Therapy Today December 2015 Volume 26 Issue 10
NB +++ indicates the start of a new section
+++ Contents
Features
Regulars
Publication information
Editorial
Your views
News
Features
News feature Workplace wellbeing in a time of austerity Bina Convey reports on how employers are turning to counsellors to cut the costs of sickness absence.
Cover feature The threat to FE counselling Jane Darougar argues that cuts within FE organisations threatens the security of both counsellor and client.
Mixed race identity and counselling Nicola Codner calls on counsellors to learn more about the needs of those with a mixed race identity.
How I became a therapist Karen Cromarty
Bending boundaries in oncology counseling Caroline Armstrong describes the dilemmas in her work as an oncology counsellor in a large teaching hospital.
Peer-supported Open Dialogue Jane Hetherington introduces a model of support for people with long-term mental illness based on person-centred principles and dialogue. Mental imagery in counseling Val Thomas discusses the contribution mental imagery can make to therapeutic processes across all modalities.
Dilemmas
Letters
Reviews
From the Chair
BACP News
BACP Professional Standards
BACP Research
BACP Professional Conduct
BACP Public affairs
TherapyToday.net
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:
Behind the pictures Michael Parkin describes the inspirations behind his illustrations for this issue.
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Therapy Today is published by the British Association for Counselling and Psychotherapy monthly (apart from January and August) and is mailed to members and subscribers between 15th and 20th of the month. Design by Esterson Associates. Printed by Polestar Stones. ISSN: 1748-7846.
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42,153 (1 January–31 December 2014) +++ Editorial
The threat to FE counselling
The image of the bulldozer made its first appearance on the counselling scene eight years ago with the fight to save counselling after the arrival of IAPT. This time it is counselling services in Further Education that are being obliterated. Jane Darougar, herself a counsellor in a sixth form college, describes the importance of supporting students in FE colleges, many of whom are disadvantaged or adult learners returning to education. The massive funding cuts to Further Education have resulted in the demise of more and more college counselling services with counsellors having to support clients through abrupt endings as their services are being axed.
David Mair, the new editor of University & College Counselling, writes about the different pressures faced by university counselling services which, while not necessarily facing the cuts and closures in FE, are operating within an increasingly difficult culture. As David puts it, ‘The drive within HE to position institutions as global success stories filters down to all of us who work there… Can university and college counselling services… really play any meaningful role in countering the stress-inducing marketing slogans of our employers and wider society, and the additional pressures these create for students?’
And finally… this is my last edition as editor of Therapy Today. It’s actually hard to put into words how this feels after 13 years as editor. I was comforted a few years ago when I spoke to Rich Simon, the editor of Psychotherapy Networker, who had done 30 years as editor and is still going strong! I took over editorship in 2002 and created Therapy Today in 2005 and have witnessed many challenging and interesting times in the development of the profession. It has been a privilege to read so many inspiring articles and letters about the work that BACP members do. And it is heartening to see that in our latest readership survey 83 per cent of you find the journal very useful or quite useful to your work. I hope that the journal will go from strength to strength and continue to be an important forum for debate and sharing of best practice and new ideas.
I would also like to pay tribute to Laura Read, our Production Co-ordinator, who will be leaving at the end of the year. Laura has worked brilliantly behind the scenes putting the journal together and managing and developing TherapyToday.net for the last six years.
I wish you all well for the future.
Sarah Browne Editor
Contribute We welcome readers’ letters, original articles, feedback and suggestions for features. Visit www.therapytoday.net for contributor guidelines or please email the team at [email protected]
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Are we really making world-class minds?
David Mair reflects on the challenges facing students and their university and college counsellors today
I’m delighted to have been offered the opportunity to edit University & College Counselling journal. I’ve been working both as a counsellor in higher education (HE) and as a head of service for nearly 20 years and in that time I’ve found the articles contributed by colleagues from around the country to be immensely helpful and informative for the work that we are all undertaking, whether in further (FE) or higher education.
Our work has changed significantly over these last two decades. The main driver of change has been the massive rise in demand for counselling support from students, which has frequently not been met with an equal rise in resources. As pressures mount we have had to find ever more creative ways to deliver high quality services. In too many cases – especially within FE – these pressures have led to the closure of services. A new emphasis on ‘wellbeing’ has sometimes led to a redesignation of counsellor posts as ‘wellbeing practitioners’.
The difference between ‘wellbeing’ and ‘counselling’ may seem unimportant, but use of language is key in determining reality. ‘Wellbeing’ suggests something positive, a state we would all hope to embody. And this ties in so well with what is happening in the HE sector. In the crowded university marketplace the need to fill courses, to generate income, to rise up league tables and become a ‘global’ institution are key drivers. Alvesson1 contends that universities have become purveyors of ‘premium’ products. ‘Come to our elite institution, and you’ll have a better life’ is the underlying message behind many marketing slogans adopted across the sector: ‘Making world-class minds’; ‘Minds that Move the World’; ‘Ambitious and Smart – You and Us Both’ – all designed to convey to students – and, let’s not forget, their parents – the sense that this institution, this course, will increase their chances of succeeding in life and achieving ‘wellbeing’. HE struggles to maintain its intellectual integrity while expanding its intake of students year on year and adopting many of the characteristics of commercial companies, with highly paid executives setting the agenda and academic staff reporting ever- increasing levels of stress.
Students are not immune to such positioning and stress, and I have heard colleagues say many times: ‘I’m glad I’m not 18 any more.’ Without question, life for today’s emerging adults is more complex and fraught than it was for my generation. The anxiety that drives so many students to seek counselling is one result of living in a market-driven society, where getting a degree is now deemed necessary for all, even though simply getting a degree is no promise of either a better job or financial security. When ‘the system’ tells you that a degree, and possibly a Masters, or even a PhD, is just the starting point for selection by elite employers who hold the keys to financial security, suitability for academic study becomes secondary to the need to obtain that certificate. And whereas when I was at university in the early 1980s, getting a ‘Desmond’ (as in 2:2) was a perfectly acceptable outcome from three years of study, now students fear that anything less than a 2:1 spells ruination. But how many students are actually square pegs in round holes, hammered into an academic setting when perhaps, with genuine, properly-funded alternatives, they would be happier in a manual occupation, learning through an apprenticeship or vocational course? An educational fundamentalism has arisen in society where certain truths appear so self-evident that to question them seems perverse, even though the evidence for their assertion is mixed at best: ‘The more education the better;’ ‘The ability to perform at work is primarily achieved as a result of education;’ ‘As much education as possible must be upgraded/relabelled as higher education.’1
The drive within HE to position institutions as global success stories filters down to all of us who work there. With such powerful drives, failure becomes something shameful, to be hidden, disavowed. And yet, as counsellors, we know that for most of us world-class acclaim will remain elusive; that failure and anxiety are as much a feature of life as success. How do we maintain our personal and professional integrity within institutions that adopt ever-more inflated aims and objectives? How do we, recalling Freud, help our clients accept ‘common unhappiness’, with appropriate coping strategies, as unexceptional and commonplace? Can university and college counselling services, now typically offering between four and six sessions of therapy, really play any meaningful role in countering the stress-inducing marketing slogans of our employers and wider society, and the additional pressures these create for students?
I believe that we can, but only when we are clear in our own minds that counselling carries within it a counter-cultural ability to deal with human unhappiness, failure and hopelessness not with condemnation or a quick fix but with compassion and acceptance based on a more balanced view of what ‘success’ means. Judging from the many discussions I have had with colleagues around the country, as therapists working in success-oriented establishments we can and do work compassionately with student clients and challenge them to develop more realistic, more self-accepting life narratives. We work primarily for the good of our clients and, although most of our work will be focused on supporting students through their studies at a time of life when developmental issues are uppermost, it may also, at times, entail helping them to free themselves from overblown academic aspirations and acknowledge a different, more personally meaningful path through life.
I’m frequently awed and humbled by the levels of commitment and professionalism among counsellors in our sector who are sometimes struggling with lack of support from their institutions, facing closure of their service, or managing long waiting lists. The sense of genuinely caring for students of all ages, nationalities, genders, sexual orientations, levels of abilities, and faiths is deep and tenaciously defended. But in the face of pressures such as hostile media articles written by those with limited understanding of the context in which we operate, or posts by students and parents who use social media to voice frustration arising from unrealistic expectations of overstretched counselling services, we need nourishing and reaffirming in our work. I hope that I will be able to build on the excellent work of previous editors in providing a much-needed source of practical and theoretical support to those of us who are engaged in student counselling. The richness of experience and the wealth of expertise across the sector is hugely encouraging and I know that colleagues will continue to share this with each other through the journal. I look forward to working with them all.
David Mair is the new editor of University & College Counselling, the journal of BACP Universities & Colleges
Reference
1. Alvesson M. The triumph of emptiness: consumption, higher education and work organization. Oxford: Oxford University Press; 2013.
Personal therapy and training
Karin Parkinson argues for personal therapy in training
I am a longstanding, accredited member of BACP and proud of how the organisation has developed its battle for the recognition of talking therapies, its accessible interface with the public and its many, comprehensive learning resources. One thing, however, causes me discomfort: the value I place on personal therapy as an essential strand in the development of a counsellor or psychotherapist is no longer shared by BACP, as it was in the past.
I teach counselling skills to first year students at the Minster Centre, where personal therapy is a requirement for the duration of training. Students are embarking on an MA/advanced diploma in integrative psychotherapy and counselling that, on completion, makes them eligible to apply for accredited membership of both BACP and UKCP. However, without personal therapy throughout training, UKCP would not be an option. BACP requirements for personal development have changed over the years; today an evidencing of self-awareness, however gained, is deemed sufficient. I doubt that it is.
In training I view the three strands of theory, skills and personal development as inextricably woven. When studying theory, students inevitably think about it in terms of their own lives; the experiential nature of skills training brings further unsettling challenge. Training asks questions concerning the very essence of one’s being, in relationship with self and with others. Many trainings offer a group experience where students can actively reflect on relationship in the here and now. Not all require ongoing personal therapy. As a trainer I feel supported by the fact that the Minster Centre does. Innumerable times I have said, ‘That’s something which would be worth taking to therapy,’ or ‘You are asking me, but have you raised this with your therapist?’ Personal therapy is the place for students to take all those very intimate and personal issues that the earthquake of training throws up. And I am thankful for it. It helps keep the classroom clear for the business of training.
Personal therapy also allows students to take greater risks in the class room. Students are usually caring of each other and their fear of upsetting the peer- client can get in the way of taking considered risks. Yet where else can students courageously experiment if not in the safety of the classroom or, later, in supervision? Learning occurs through an in-depth deconstruction of the interaction. The trigger from the client, the therapist’s felt response and intention behind an intended intervention; then the perceived consequence and, in feedback, the client’s experience, are all essential to learning. I tell my students, ‘Go for it, take a risk and see what happens. You might be surprised at what your client tells you. And if someone has been touched, that is probably a helpful thing and they can take it to their therapy.’
In class they are learning about establishing a therapeutic relationship while concurrently struggling with their own. It seems that student clients have to move from an ‘observer’ position, watching and assessing how their therapist is working with them, to becoming real participants in the relationship, for their own sake. All clients come with their expectations for and perceptions of therapy, which provide material for the work. In addition to an in-depth study of self, personal therapy gives students invaluable experience and appreciation of the challenges from the client perspective.
Much, if not most, counselling and psychotherapy takes place in the cradle of a one-to-one relationship. Evidencing self-awareness obtained in any number of ways may be an inclusive gesture but is not, in my opinion, adequate for a comprehensive counselling or psychotherapy training. I find it extraordinary that BACP does not make this experience a requirement.
Karin Parkinson (MBACP Snr Accred) is a counsellor and supervisor and a trainer at the Minster Centre +++ News
Impact of bullying in schools
The impact of bullying needs to be urgently addressed with more funding for in-school counsellors and training for teachers, according to the Anti-Bullying Alliance.
In a poll of 1,496 young people aged 16-25 and 170 teachers, carried out by the Alliance, the majority of teachers (70%) said support for mental health of pupils was inadequate and over half wanted more school counsellors.
Bullying at school, plus the effects of cyberbullying, led to a host of mental health issues. Almost half of young people (44%) who were bullied reported ongoing problems with self-harm, suicidal ideation, anxiety, depression and body image issues. Long-lasting effects included difficulties in forming relationships and low self-esteem.
National Co-ordinator of the Anti-Bullying Alliance, Lauren Seager-Smith, wants greater investment in teacher training, in-school counselling and more funding in Child and Adolescent Mental Health Services (CAMHS). ‘Bullying is a public health issue. We all need to play our part to stop bullying wherever and whenever it happens – whether it’s in school, the community or online – but it’s vital that we also invest in support for children and families,’ she said.
Support for employees
Employers are to be ranked in a public index of best practice as to how they support the mental health of their staff, including the provision of counselling, online resources and resilience training.
Mind is to launch its Workplace Wellbeing Index in 2016 as a benchmark to show best practice to other employers. The announcement came as new figures released by the Health and Safety Executive (HSE) revealed that more days are taken off work in the UK due to stress, depression or anxiety above any other illness.
Injury and ill-health statistics released by the HSE reveal the average duration of time off for illness per person was 15 days but this rose to 23 days for those taking time off due to stress, depression and anxiety.
While the figures have been largely static for the last four years, Judith Hackitt, HSE Chair said that ‘more could be done’ to prevent the amount of time taken off work for illness.
The figures only reflect self-reported work-related illness, and could be much higher because of workers who give a different reason for their absence. Emma Mamo, Head of Workplace Wellbeing at Mind, said that stigma around mental health prevented workers from being open about their reasons for time off. The charity’s own research last year found that only a fraction of workers who took time off for stress gave the real reason, with 95 per cent giving another reason.
CBT behind couple therapy
People who receive couple therapy for depression are more likely to recover than if they receive CBT, according to the latest statistics from IAPT. This is the first time that the Government has released recovery data by therapy type, showing that 52 per cent of people who receive couple therapy recover from their depression compared with 44 per cent of those who receive CBT. http://www.hscic.gov.uk/catalogue/PUB19098/psyc-ther-ann-rep-2014-15.pdf
Self-doubt can help clients
Having self-doubt as a therapist can be better for your clients than being confident, according to new research.
A mix of self-doubt and personal self-compassion among 70 psychotherapists analysed in Norway was found to relate to greater reductions and better outcomes in clients. The paper, published in Clinical Psychology and Psychotherapy, identified these traits as being pivotal to the outcomes of 255 clients treated in 16 clinics who completed measures of their problems and symptom distress before and after treatment and periodically two years after the treatment.
The researchers found an interaction between therapists’ self-doubt and self- compassion and concluded that this combination paved the way for an open, self-reflective stance with a flexibility to correct the course of the work if needed.
The majority of therapists in the study used a psychodynamic approach, with just over 29 per cent humanistic therapists and 28 per cent used cognitive therapies. cCBT offers little benefit
Computerised cognitive behavioural therapy (cCBT) offers little or no benefit in treating depression, according to new research.
The research carried out by the University of York sheds light on an area of treatment in which the NHS has tried to boost access for those facing a waiting list for face-to-face CBT. The study, the largest of its kind to date, found that people did not engage with computer programmes and reported difficulties in repeatedly logging onto a computerised system when depressed.
Guidelines for treatment of depression by the National Institute for Health and Care Excellence (NICE), which endorses cCBT, are currently under review. A spokeswoman said: ‘We recommend computerised CBT as one option for treating people with mild to moderate depression, but the decision to offer it should always be based on clinical judgment and the patient’s preference.’ The ongoing review of guidelines for treatment of depression is expected to be completed in 2017.
Depression and anxiety in new fathers ignored
New fathers with depression and anxiety are largely ignored and need more encouragement from health professionals to seek help, according to a new report.
Antenatal and postnatal depression in mothers is largely recognised with women routinely asked about symptoms. But while depression around the time of a child’s birth is just as likely to hit men, few are asked directly about their mental health.
A survey by the Royal College of Nursing (RCN) of 2,000 mothers and fathers found that 27 per cent of fathers experienced depression and anxiety during or after the pregnancy, revealing an area of mental health that is less understood or explored. It was found that 64 per cent of fathers were not asked about their mental health at all during their partner’s pregnancy.
Adrienne Burgess, Joint Chief Executive of the Fatherhood Institute has called for depression in fathers to be normalised to encourage more men to seek help. ‘There needs to be a co-ordinated approach with recognition of the negative impact on the child if the father is depressed. Health professionals need to pay more attention to the father-mother relationship,’ she said.
Stigma around mental health is more pervasive when it comes to parents, according to Carmel Bagness, Professional Lead for Midwifery and Women’s Health at the RCN. She has also called for more training and time to treat the mental health of mothers and fathers.
‘Too many women and men are suffering in silence because of outdated stigmas. Too often attitudes towards mental health are not fit for the 21st century,’ she said.
Suicide rates rise with recession
A steep rise in male suicide and suicide attempts has been linked with recession, unemployment and financial difficulties. The suicide rate among men in Britain has risen significantly since the 2008 global financial crisis reversing previous trends where the rate was falling, according to new research. A report, from the Universities of Bristol, Manchester and Oxford, cited 1,000 extra deaths from suicide and 30-40,000 suicide attempts from 2008-2010 during a global financial crisis which led to the deepest UK recession since World War II, where young people experienced particularly high levels of job losses and unemployment.
Data from the Office for National Statistics, published this year, show the trend for a rise in male suicides has continued with male suicides three times higher than the female rate. Factors contributing to suicidal behaviour in the report included unemployment, disputes over benefits, wage cuts or demotions and reduced hours. The report also drew on other studies which showed that pre- existing mental health problems were a factor and concluded that vulnerable individuals became more prone to suicidal ideation during periods of recession.
To read the full report, please visit http://www.bris.ac.uk/media- library/sites/policybristol/documents/PolicyReport-3-Suicide-recession.pdf +++ News feature
Workplace wellbeing in a time of austerity
Bina Convey reports on a rising tide of workplace mental ill health and how employers are turning to counsellors to cut the costs of sickness absence
Wellbeing is more than just a popular buzzword in the corporate world right now; it has become a fast-growing business in its own right, and one in which counsellors can play a key role.
A recent flurry of activity around mental health in the workplace includes last month’s Good Day at Work Conversation – an annual wellbeing conference for business leaders – where motivational speaker John McCarthy, kidnapped and held by Islamic jihad terrorists in the Lebanon from April 1986 to August 1991, talked about bullying, survival and resilience. Meanwhile Mind is to launch a Workplace Wellbeing Index in early 2016 in which it will publicly rank employers on their efforts to tackle what has become both a moral and an economic issue.
Numerous factors have contributed to increasingly pressurised work environments over the last decade. Despite an economic upturn in the last two years, an austerity-driven economic climate has led to cost-cutting in both the public and private sectors; doing more for less has become the norm, as has a culture of high expectations linked to performance targets. Technology has also played a part in blurring the lines between work and leisure, with smartphones ensuring employees remain constantly ‘logged on’ to work, with the effect that many find it difficult to mentally switch off.1
There is nothing like an economic crisis to make business and government sit up and listen. A report published last year by the Chief Medical Officer Dame Sally Davies2 put mental health issues at work firmly on the agenda and called for ‘urgent measures’. The report revealed that mental health-related absence in the workplace is rising, with the number of days lost to stress, depression and anxiety up by 24 per cent since 2009, at an annual estimated cost of £100 billion a year in working days lost to mental ill health.
The way employers view workplace wellbeing is evolving, according to Emma Mamo, Head of Workplace Wellbeing at Mind: ‘The focus is shifting from the reactive management of sickness absence to a more proactive effort around employee engagement and preventative initiatives.’ This, says Mamo, has led to a rapid increase in employers requesting training and resources – an area where counsellors can play a vital role.
The corporate world is playing catch-up with the public sector, which has long recognised the need for employee wellbeing policies, particularly in sectors with a high-stress element such as the NHS, police and social services. Unsurprisingly, stress in the public sector is being compounded by austerity measures, with poor sleep, headaches, stress-related mental health issues and digestive problems among the problems reported by over a third of public sector workers surveyed earlier this year.3
More private companies are promoting resilience measures, from city firms, such as Goldman Sachs and JP Morgan, investing in mindfulness training for their staff, to the increasing uptake of Employee Assistance Programmes (EAPs). An EAP offers employers a package of resources, including workshops and face-to-face, online and telephone counselling. The UK EAP market, worth over £69 million, has grown significantly. According to the UK Employee Assistance Professionals Association (EAPA), the number of employees with access to an EAP has grown from 8.2 million to 13.8 million in just five years. EAP providers argue that this increase reflects a change in organisations’ human resources strategies, rather than a surge in mental health problems in the workplace.
Andrew Kinder, Chief Psychologist at OH Assist and Chair of EAPA, says the human resources function with organisations has become less about people and more about transactions between departments: ‘HR has changed; HR departments have become more strategic business partners with business objectives and less about the human elements. They have outsourced this element to EAPs with 24-hour helplines, but there are also a lot of hybrids where you will have a counsellor that has a face within the organisation.’
There may be a lingering stigma surrounding mental illness, but there has been progress in the last decade. One view is that a greater willingness to talk about mental health has given rise to a sense of wellbeing as a human right: ‘There is no stress epidemic, there is just a growing sense that people want things to be OK and are less willing to cope with the slings and arrows of life,’ says Kevin Friery, Clinical Director of Right Management Workplace Wellness
Research by Right Management Workplace Wellness found that the majority of cases of depression and anxiety among their clients’ workforces were due to personal reasons rather than work issues, although it is difficult to identify the extent to which work pressure can exacerbate a personal or family problem. However, this is immaterial, says Friery, because the result is the same: an unproductive worker who needs support to feel more motivated in life and in work.
Companies are also realising there is economic sense in being seen to do the right thing. Under the watchful eye of their shareholders, ticking the box marked ‘corporation morality’ is a must. They also need to offer an attractive package of benefits to employees that they need to retain, as well as to the talent they wish to attract.
Friery sees a host of opportunities for counsellors in the corporate environment, from delivering workshops on resilience to mediation and psychological training for managers. But he feels that many counsellors need to change their attitude and engage with what he describes as a ‘different population’ from those seeking help from the NHS Improving Access to Psychological Therapies (IAPT) services, for instance.
‘The trade of a counsellor traditionally is you and me in the room. EAP counselling involves thinking outside the box and one of my frustrations is getting counsellors to think differently and look at how their skills can be used in other areas,’ he says.
When it comes to telephone, online and face-to-face counselling, workplace provision is a very different model to that used in private counselling. Sessions are often limited to six (and sometimes just six in any 12-month period), and counsellors are required to agree specific goals with the client and detail how their progress will be evaluated. If a particular method is considered suitable, such as CBT or solution-focused therapy, clients may request this and will be assigned to counsellors with that skill set.
With increased competition in the EAP market comes the need for more efficiency measures. One counsellor with five years’ experience of working for EAPs, who asked not to be named, said that counsellors are being asked by one of the UK’s largest EAPs to try to reduce the number of sessions. ‘We received an email which asked us to finish as quickly as possible, less than the usual six sessions. It was implied that those of us who finished quicker would get more referrals.’
Whether competition is driving down quality is a moot point. ‘There is a lot of discussion about the number of sessions but what is really important is the client’s readiness to change and their motivation. It is often a view based on clinical need where you may say: “Let’s work for three sessions and then review it” rather than give six sessions,’ says Kinder.
Workplace counsellors are uniquely in a triangular relationship – with the client and with the employer, and there may also be some crossover with occupational health, when the counselling work takes as its focus how to help the client get back to work.
Being ‘organisationally aware’ is important, according to the EAPA’s Counsellor’s Guide to Working with EAPs,4 and Kinder emphasises this: ‘I do think there is a gap with some private practitioners who don’t understand the corporate world. Counsellors are in their own business and self-employed; it is vital to have some experience of working in an organisation.’
In the workplace, each employee is a commodity; it may seem harsh that cost is a major factor when it comes to wellbeing but cost may not be the only factor. A rise in telephone and online counselling in this market can also introduce a new potential client group to counselling. Says Kinder: ‘It can be about accessibility and having different ways to support people. Having a chat online and computerised Cognitive Behavioural Therapy (cCBT) opens it up to a new audience. People find it useful, not just those in crisis, but as a preventative measure.’
Working with resilience in the workplace
Psychodynamic psychotherapist Teresa Mulvena has worked as a staff counsellor and mediator in the NHS since 2008. Resilience and preventative training play a large part in her role as staff counsellor.
Mulvena believes that, no matter what the stressors are, measures can be taken to prevent stress and burnout: ‘The most effective things an individual can do is have a sense of meaning and purpose outside work and have strong connections with others. These two things make the stress of work feel smaller. At work the most effective thing to prevent burnout is the support of your immediate supervisor. So someone who listens and sees their needs is important.’ She adds: ‘It is empowering to tell people in resilience training and in counselling to focus on what they can influence and change and try not to get distressed about what is beyond their control. They might not be able to change many things about the organisation but we can all look at how we look after ourselves outside work – especially focusing on activities that really replenish you, and improving how we relate to others.’
Educating managers on the impact of stress on their workers is also a vital part of the work for therapists working in an organisation: ‘For instance, it’s useful for managers to know that support makes a high workload much less stressful,’ she says.
A firm understanding of organisation dynamics is also important, both from the aspect of how the counsellor works with the organisation and what might be going on for the client.
‘You always have to keep in mind the triangular relationship,’ explains Mulvena. ‘The organisation is also your client and this means you have to be very clear about what information is shared with whom. I think an understanding of organisational dynamics is very helpful for a counsellor. We all take our family dynamics with us and relate to colleagues like siblings and the way we react to authority is informed by our experience of our parents. Working in any organisation can make you feel like a child again having to obey the rules the adults set and this informs the counselling work too.’
Working with EAPS
Rick Hughes, BACP Lead Advisor, Workplace, says there are challenges and benefits for counsellors in the EAP market. ‘This is a tremendously rewarding sector. An EAP counsellor could typically have a huge variety of clients, from shop floor operatives to senior executives. The flexibility and adaptability required of a workplace counsellor is one of the benefits too. The feedback loop back into organisations means workplace counsellors really feel much more engaged with how and what the organisation can do to effect lasting, positive changes to the work experience of the client. ‘There can be session limits imposed on some contracts or clients, but that’s the nature of time-limited workplace counselling. Counsellors can only really work with what is clinically appropriate in the session limit given. So they need to have a good understanding of the contraindications to time-limited counselling. In some cases therapeutic assignments might be more about assessment, containment and referral on, rather than going into any real depth.
The amount of referrals can fluctuate and the fee rates haven’t really risen in over a decade. While this is reflective of competitiveness within the EAP industry, it can also be symptomatic of the demand and supply of workplace counsellors. The healthcare sector has benefited from the Agenda for Change policy which helped to set pay bands for counsellors. It would be helpful for the workplace to have this too. EAPs want good and effective workplace counsellors but they’re commercial organisations and EAP providers need to strike the right balance.’
References
1. Arlinghaus A, Nachreiner F. When work calls. Chronobiology International 2013; 30(9): 1197–1202. 2. Department of Health. Annual report of the Chief Medical Officer, 2013. London: Department of Health; 2009. 3. Dudman J, Isaac A, Johnson S. Revealed: how the stress of working in public services is taking its toll on staff. Guardian; 10 June, 2015. www.theguardian.com/society/2015/jun/10/stress-working-public-services- survey (accessed 26 November 2015). 4. Employee Assistance Professionals Association. Counsellor’s guide to working with EAPs. Derby: EAPA; 2014. +++ Cover feature
The threat to FE counselling
Jane Darougar explores how the culture of cuts and closures within FE organisations threatens the security of both counsellor and client Illustration by Michael Parkin
At a time of a rapidly shrinking state, counselling services in Further Education colleges are under threat. Many have already closed and others face big reductions or extreme reorganisations that jeopardise their ability to function. This article looks at how the changing culture within Further Education threatens the security of the counsellors and how the instability is challenging our capacity to act as secure containers for our clients.
Further education (FE) in the United Kingdom is in crisis. Whilst schools have had their budgets protected and universities have plugged the funding gaps with tuition fees, FE colleges have experienced phenomenal and catastrophic cuts, particularly to adult education. The funding systems are complex with different categories of student funded differently. The Association of Colleges give figures ranging from a 17.5 per cent cut in 16-19yrs non-apprenticeship education to cuts of 22 per cent between 2010-14, followed by cuts of a further 17 per cent in the adult skills budget.1 Sixth form colleges have far fewer adult learners so have not been exposed to the worst of this but have been affected nonetheless. These cuts have resulted in changes of priority within colleges, new and often authoritarian management styles and, sadly, the demise of an increasing number of college counselling services. In this piece I would like to say a little about the FE environment, how the cuts and anxiety about them have affected the organisations that I am familiar with, and how the knowledge of extensive service closures have affected other existing services. Historically, counselling services in FE have run on a shoestring, with a single practitioner being the most common model. Given the scarcity of resources they are vulnerable to closure if there are cuts. I am particularly interested in the challenge to counsellors to continue to provide containment to clients whose circumstances are increasingly precarious and whose hope for the future is rapidly diminishing whilst the counsellors are feeling under threat themselves.
I started working at a large inner city further education college in 2001. At that time we had approx 15,000 registered students, including part-time, evening and day-release. The college is based in a deprived area with notable indices of poverty and complexity. Its main concentration of courses were in four areas: basic skills, (including literacy, numeracy and English for Speakers of Other Languages (ESOL); vocational skills including construction, plumbing, hairdressing, beauty therapy etc; trade union education for employers across London and the school of supported learning for students with a range of disabilities including sensory impairment and/or learning disabilities. The college was deeply embedded in the community with creative and imaginative programmes to include groups normally excluded from education. We had programmes for school-refusers; ex-offenders; young people in and leaving care; mental health service users (including residents in the medium secure forensic unit); teenage parents; and the traveller community. A significant proportion of our students were asylum seekers and refugees, including unaccompanied minors and courses were run in community centres for those for whom the college environment was too challenging; we even ran courses in the local drug and alcohol service. Clearly a large proportion of our students were disadvantaged and it was accepted within the organisation that adult learners following functional skills programmes would have some reason for not having attained these skills earlier in life. Experience suggested that adult learners had frequently experienced adverse childhood experiences2 such as attachment disruption that had interfered with their capacity to engage in education. The counselling service was extremely busy, running waiting lists for much of the year. We supported a great number of students who may well have not completed their studies without this additional support.
Cuts to further education are not new phenomena. There was a tension through the previous Labour Government, with the introduction of attainment targets that seemed to misunderstand our students and the particular difficulties that they faced. Redundancies were fairly common but did not prepare us for the scale of the cuts under the coalition and the current government programme of year on year, on-going cuts under the austerity agenda. The priorities within the organisation shifted as a result of the changing political landscape and as funding changed in the direction of employability. Dartington, in his book Managing Vulnerability: the underlying dynamics of systems of care, explores society’s response to those who are vulnerable and dependent on care and the organisations that exist to support them. Within this context he quotes Rice in describing the primary task of a system as ‘the task which it is created to perform’ later becoming ‘the task that it must perform if it is to survive’.3 The primary task of the college had previously been widening participation in society, through the process of learning and the acquisition of skills. However, in the current climate of an increase in low skilled, zero hours contract employment, the soft targets of keeping people out of hospital, prison etc, and giving disenfranchised people some structure for their lives, seem to have become irrelevant. Funding streams for many programmes and support services in the college, and externally that we could refer to, have disappeared. The task now was focused on very specific educational attainment and it was clear that we might not survive as an organisation if this was not achieved. The Principal in one of his staff briefings spoke scathingly of the old culture saying, ‘We are not social services nor are we a care home, but an educational establishment, if learners are not able to learn, they do not have a place here.’ Off-site provision was closed and pre-entry level courses were also ended, reducing accessibility to education for the most disadvantaged. Staffing in the college changed with qualified teachers losing their jobs and being replaced by unqualified ‘learning mentors’ often allocated to some of the most challenging areas. Redundancy was an ever-present threat for teachers and support staff, as was the feeling of responsibility for unsatisfactory statistics and the college’s economic viability being questioned. The redundancies were extremely painful, with many staff competing with long-term friends and colleagues for ring-fenced positions. The language was brutal: ‘Your post has been deleted.’ Endings were not marked; people disappeared from view without having a leaving do. It was almost as if an annihilation anxiety response was evoked amongst the staff. Akhtar describes annihilation anxiety as fear located in the ego when there is a threat of being overwhelmed or annihilated. He explores Hurvich’s notion that annihilation anxiety originates in early infancy and that it can be re-activated later in life.4 This anxiety activates primitive defences such as splitting and projection.5 Splitting is a primitive defence against anxiety that identifies people as idealised good or denigrated bad. Foster describes how anxiety can lead to all the bad feelings being projected onto those who have been identified as ‘bad’ so that it is no longer possible to see the good in them.6 This appeared to have taken place both with staff who were not on- board with the new task being identified as part of the problem, and learners themselves being redefined from needing support and nurturing in order to achieve; to potentially catastrophic vehicles of destruction of the organisation that need to be excluded without delay. Dartington profiles a split between services and service users that ‘is enacted between the hopeful and the hopeless; between the active and the passive; between fight/flight and dependency; between resistance and acceptance; between an assumed omnipotence and a supposed impotence’.3 It was notable that there was an increase in disciplinaries and exclusions of learners and dismissal of staff. There appeared to be a disproportionate number of black and minority ethnic staff and learners affected by this. A culture of fear and anxiety was established, which seemed to encourage people to dissociate themselves from vulnerable, struggling students and the services that were designed to reach out to them.
The cultural narrative has experienced a return to wide references to ‘benefit scroungers’, the demonisation of the disabled and the classification of deserving and non-deserving poor. Dartington describes how an ethos of anti- dependency has fuelled an attack upon the vulnerable, without understanding the complexity of dependency and how appropriate it can be in certain situations and life stages.3 The dependency of our learners while they undertake the potentially transformative experience of education may have evoked a tremendous anxiety about our own potential dependency, and has made it increasingly difficult to see the individuals clearly; work creatively to meet their needs and create sufficient containment for them to engage in education. This can be understood within the context of a paranoid schizoid position, where we are unable to manage the anxiety created by contact with vulnerability.7 As a public sector worker I am continually aware of the threat of redundancy and unemployment. Through contact with my clients I am exposed daily to the distress caused by poverty and the very real difficulties faced by a significant proportion of our cohort. I can understand how, as Foster describes, survival of this anxiety may necessitate some splitting.6 However, without a container to help us to manage this anxiety, the splitting can threaten the services offered to our learners and may prevent the primary task of the organisation being met. The wider container of the organisation has become impaired as we experienced their shift to the new focus as a betrayal of our values. The resultant loss of trust was exacerbated by their combative and authoritarian style and apparent ruthlessness in the restructures and redundancies. Bloom describes in detail how authoritarian, bullying and autocratic styles of leadership flourish in organisations that are under threat as dependency grows and difference and dissent are not tolerated.2 In the midst of this chaos notifications have been coming through regularly from counselling colleagues in colleges across the country about threats to and closures of their services. In spite of repeated efforts by the BACP Universities & Colleges division to raise public awareness of the situation, it feels as though FE remains invisible. The press seem unwilling to profile any education story that does not concern schools or universities. It has made many of us feel attacked by government, our annihilation being plotted by our own organisations’ management, and our plight invisible and unsupported outside our own small community with only very recent references to FE funding in the mainstream media. I wonder if our organisations, feeling vulnerable and under threat, are distancing themselves from the service users who are likely to be most resource intensive because of fear of our scarce resources being depleted further. Hopper describes trauma as ‘always a matter of failed dependency on other people and situations for containment. Failed dependency provokes a primary fear of annihilation’.8 A recent post on Psychologists Against Austerity described austerity as ‘the systematic erosion of a person’s social and personal boundaries to leave them unprotected, completely defenceless, hopeless and in real fear of annihilation’.9 Bloom explores the emergence of parallel processes when organisations experience prolonged episodes of stress.2 Amidst the posts to the FE mail base that call for support and voice an energy to fight for our services, others are also audible… they speak of hopelessness and resignation. At times it has felt extraordinarily painful to read the despair of colleagues describing how their services are being axed and how they are supporting their clients through abrupt endings.
It leads me to question how we are able to provide the safety and containment that our clients so clearly need when we ourselves feel so undermined and under threat? Ogden describes Winnicott’s proposition that the role of the analyst is to provide a metaphorical holding function, a psychological space ‘uninterruptedly to be that human place in which the patient is becoming whole’.10 In an atmosphere of threat and anxiety it is extraordinarily challenging to provide this level of containment and holding for our clients, many of whom have experienced inconsistent and insufficient containment throughout their lives. In order for us to focus on our primary task as counsellors, it is essential that we find ways to address these challenges to maintain the contribution that we make to the empowerment and progression of our students.
I left the college that I describe above a short while before its service was shut down. It has also now lost its Mental Health Service. I feel a great sadness that the students studying there will no longer have access to the support that previous cohorts have had. I am certain, from past experience, that some will not complete without it. The investment that adult learners make when they return to education is enormous, in terms of hope, energy, financial sacrifices as well as losing out on family time. It is a tragedy when a student does not complete or achieve what they might have been capable of. For those services that are still operational, I hope that we as a community will offer our support and holding to the counsellors and psychotherapists to enable them to play their part in the empowerment of students who have so often been failed before.
Jane Darougar is College Counsellor at Leyton Sixth Form College. She has taught a variety of counselling courses and workshops and has an MA in Working with Groups from the Tavistock & Portman NHS Foundation Trust. Jane is also deeply committed to widening participation in education as a means of challenging social exclusion and has a particular interest in the emotional barriers to learning. Email [email protected]
This article is based on an article published in University & College Counselling (September 2015). Visit bacpuc.org.uk
References 1. https://www.aoc.co.uk/sites/default/files/College%20Funding%20and %20Finance%201%20May%202014%20FINAL_0_0.pdf 2. Bloom S, Farragher B. Destroying sanctuary, the crisis in human service delivery systems: Oxford; 2011. 3. Dartington T. Managing vulnerability, the underlying dynamics of systems of care. [24, 46]: The Tavistock Clinic Series; 2010. 4. Akhtar S. comprehensive dictionary of psychoanalysis. [22]: Karnac; 2009. 5. Klein M. Envy and gratitude and other works: new York: Delacorte Press; 1946. 6. Bishop B, Foster A, Klein J, O’Connell V. challenges to practice, practice of psychotherapy series: book one. [93] Karnac; 2002. 7. www.melanie-klein-trust.org.uk/paranoid-schizoid-position 8. Hopper E (ed). Trauma and organisations. [54] Karnac; 2012. 9. Psychologists Against Austerity. https://psychagainstausterity.wordpress.com. 10. Ogden T. On holding and containing, being and dreaming. In: Winnicott and psychoanalytic tradition: interpretation and other psychoanalytic issues. [80]: Karnac; 2007. +++ Mixed race identity and counselling
Nicola Codner describes her own identity as a mixed race woman and calls on counsellors to learn more about the psychosocial needs of our third largest ethnic minority group
I felt compelled to submit an article to Therapy Today because I’m aware that, as a mixed race woman (of black Jamaican, Nigerian and white British heritage), every time I pick up a copy of the journal I’m scanning for articles on mixed race identity and counselling/mental health. I rarely find anything on the topic and when I do it tends to be a mere few lines or paragraphs that only acknowledge the lack of attention paid to this group. This is disappointing and frustrating. Mixed race identity and issues are so invisible in the counselling world, despite the fact that this section of the population is the fastest growing and the third largest ethnic minority in the UK.1
Dialogue around issues affecting mixed race children, adults and families, is increasing slightly in the UK but it is still insubstantial. I notice in the US (where the mixed race population is also quickly increasing) this is a different story. Research on the mixed race population is more abundant and counsellors are being made aware that they need to be able to consider the needs of this part of the population and be able to show specific competence in working with this group. Research in the UK is minimal and counselling books that focus exclusively on mixed race people are absent. As noted by Yasmin Alibhai-Brown,2 social policy makers are taking a slow-paced approach to including mixed race Britons, despite the fact we are the country with the most mixed relationships in the developed world.
It was only in 2001 that the racial category of mixed race was added to the National Census of Population.3 The term is most commonly understood as applying to people who have one white parent and one parent from an ethnic minority. However, this traditional understanding of the term excludes those who have parents of different races where neither parent is white. Again, there is more dialogue around this in the US where it is more commonly acknowledged that our general understanding of who is included in the mixed race category needs to broaden. It’s also important to acknowledge that not all people who have parents of different races will identify as mixed race, which means the mixed race population could be larger in the UK than is currently observed (as an example, some people of black and white parentage may choose to identify solely as black). In addition some mixed race people are of more than two races which is often ignored.
A largely ignored group
Both black and mixed race people are over-represented in the mental health care system4 and in prisons5 in the UK. Mixed race children are the most likely to be put into care and also over-represented in youth justice and child protection systems.6 Mixed race people have been reported as more likely to be the victims of crime.7 However, discussion around mixed race mental health is seriously lacking. Why is this? This invisibility only further demonstrates the way mixed race people are largely hidden and ignored in our society beyond superficial recognition. This superficial recognition is usually attached to perceived attractiveness and is nothing more than a form of objectification that only further stereotypes a group with no significant social capital.
I have only recently completed a person-centred diploma in counselling and one of the things I notice as a new person coming into the counselling world is how the topic of race in general can be sidelined because it is such a complex and emotional topic for people to talk about. On my counselling course people were able to learn a bit about mixed race identity and black identity but only because I and a few other class members felt the pressure and responsibility to educate them. What if we hadn’t been on the course? And why should this obligation have fallen to us? What if we hadn’t felt like educating? Who is to say the work we did was even helpful? Shouldn’t training on race and culture be a crucial part of the training, regardless of who is present in the student population? My group was also typical of those in counsellor training in that they were anxious and avoidant when it came to having anything more than a shallow conversation about race. This has obvious implications for counselling practice. Isha Mackenzie-Mavinga explores this common trend in her book Black Issues in the Therapeutic Process.8
Issues for counsellors to consider
We urgently need books on mixed race counselling as well as guidance and support for counsellors. It was only in 2014 that Mooney published the first empirical research in the UK into how mixed race identity is navigated in counselling.9
I can speak from my own experience and say that finding a counsellor who can work effectively with mixed race issues can be an extremely arduous task. I had to go through several counsellors (of different races) to find adequate support. Some of the difficulties I faced were counsellors defending against hearing about my experiences of racism and making assumptions about how I should see myself as a mixed race individual based on their own personal opinions and prejudices. After these negative experiences, if 20 hours of counselling had not been a requirement for the course I was doing, I would not have been returning for further counselling.
As a client from an ethnic minority it can be difficult to bring up the issue of race any time in counselling because it is easy to become deterred by concerns about the counsellor’s level of competence in supporting your explorations. The client is the one left under pressure to broach the topic and it is naively assumed that they will raise the issue if it is important to them. This assumption is made while ignoring the fear most people have of discussions around race, the fact that mixed race people are generally ignored as a group in society so may not feel empowered to start the conversation, and the fact that counsellor competence, skill and comfort (which counsellor training does not tend to instil) is crucial in this area for there to be any therapeutic benefit. According to research by Pope-Davis and colleagues (as cited by Mooney9), it has also been shown that clients modify what they say to the skill-set of their counsellor. It has also been argued by Cardemil and Battle (also cited by Mooney9) that counsellors who do not attempt to facilitate discussions around race in counselling and simply wait for the client to raise it may not actually be performing as helpers. I would agree that counsellors need to address obvious issues of difference in the counselling room and make it known they are capable of working with issues connected to race, should the client need to explore them.
Currently counsellors do not have to show any meaningful level of competency in their ability to work with racial diversity. Counselling courses usually do address the topic of race, ethnicity and culture at some stage but it is generally dealt with at a facile level, and Watson notes10 that tutors are not given any specific training for working with students in this complex area. This leaves all students in a difficult situation (which some students may be unconscious of) when it comes to their own counselling practice and race. It also leaves clients from ethnic minorities likely to be exposed to further discrimination and misunderstanding.
In her paper Mooney9 argues: ‘Counselling psychologists must have an awareness of the needs that British mixed race clients have in terms of identity and personhood. In doing so, the practitioner may minimise their assumptions and biases, thus forming a therapeutic alliance based on knowledge of how mixed race people manage therapy and construct identity’ (p10).
What does this mean for those of us who are not counselling psychologists? How do we make sure that we are working with mixed race clients in meaningful ways?
Mooney9 also argues that we need to be less eurocentric when working with mixed race clients, and we need to work from a more multicultural and intersectional perspective where we acknowledge how all facets of a person’s being influence their life, including race, gender, age, sexual orientation, mental health issues and so on. This is the approach adopted in the US, where specific knowledge is also required of issues affecting the mixed race population, such as racism within the family/from partners, lack of community/issues to do with belonging, rejection by mono-racial groups, stereotyping and being exposed to disparaging comments in relation to all sides of their racial identity. This is not an exhaustive list of the potential issues. It is also a required part of competence in the US to be aware of models of identity development for this group.
Developing an integrated identity
I want to share some of my own experience of developing an integrated identity as a mixed race woman while having person-centred counselling. I did have to find a counsellor with some specific knowledge of mixed race identity in order to support this integration as well as do a large amount of work on this alone, including a great deal of reading (which mainly included US research).
While it’s true that any group in society can face difficulties in developing a whole self, it is thought that mixed race people are more at risk because of society’s construction of race in overly simplistic binaries and the responses mixed race people receive. If certain aspects of racial identity are not accepted externally, this can lead to a fragmented or split off self for mixed race individuals as described by Mooney.9 The legacies of colonisation, slavery and current events concerning race can also affect how mixed race individuals view their identities and how they feel about their wholeness.
We cannot assume that every mixed race person who comes for counselling has issues around their mixed race identity. Some mixed race individuals will grow up in environments where they are actively encouraged and supported to develop an integrated and healthy identity. However, all mixed race individuals in the UK will have to negotiate living in a society where their identity is only recognised superficially at a societal level and where race is still largely constructed in binaries that often deny their existence and uniqueness. Mixed race individuals commonly experience misrecognition of their identities when people make assumptions around or interrogate their identities. In my own experience, I was often bombarded with not only negative mixed race stereotypes but black stereotypes as well, which had a negative effect on my developing self-esteem.
In terms of person-centred theory, an individual who is out of touch with their authentic self (their organismic valuing process) due to a lack of appropriate empathy, unconditional positive regard and congruence in childhood, is likely to develop conditions of worth based on others’ desires and needs. This means that mixed race people who are not in touch with their true selves may experience distress in connection with their identity as they will struggle to dispel the racialised projections others make upon them and to face the constant questioning they receive around their identity.9
In my personal exploration while studying on my person-centred course, I found it useful to explore my racial identity in terms of the configurations of self from person-centred theory. I discovered I held three different racial identities that I had to work on integrating more fully. I realised I had a black, a white and a mixed race configuration. It was clear when I looked back over my life that, externally, my white heritage, followed by my mixed heritage, had been over-valued at the expense of my black heritage, because of the environment I grew up in. The black and the mixed race configuration had to be examined and healed in terms of racist experiences. I did this partly by reading the stories of black and mixed race women and using affirming pictures of black women in particular (because I had grown up so aware of society’s racism towards them and experienced this as personally toxic for my own identity) to bolster my self-esteem. Having grown up with a white mother and black father I missed out on having role models to whom I could fully relate and who could empathise with my experiences as a female of colour. As an adult I had to compensate for missing out on this empathy in my therapy. This is not to say mono-racial parents can’t successfully raise mixed race children; however, some may need additional support and guidance. My white identity became less acceptable to me as I explored the harm done to my mixed and black identities. I was rejecting of this aspect of self. While I was feeling rejecting of this aspect of self I did, however, maintain a good relationship with my white counsellor, which I feel is because she was offering me the appropriate level of understanding and empathy. Later I had to do work on accepting and working to integrate my white identity, which I did by thinking about the positive aspects of being part-white British. Occasionally I have experienced racial prejudice for this aspect of my identity as well and this also had to be worked through in therapy.
While exploring my different configurations of self I uncovered several tensions between my black Jamaican identity and my white British identity. This was partly due to the history of slavery and colonisation by the British in Jamaica and the relationship between my parents but also due to cultural differences and clashes that I saw between these identities. I realised I had a stereotypical British identity that was reserved, polite and overly accommodating but that this was also in dramatic conflict with what I perceive as my Jamaican identity, which is more expressive and direct, and sometimes outspoken. This Jamaican aspect of self has come up against very harsh judgment in British culture. I had to work on finding a balance between these two identities so I could stop veering between them and being confused about what my personality really was. I also became more positive about my expressive Jamaican side and more critical of the British characteristics, which have held me back in life in many instances, particularly in conjunction with my identity as a woman. Our socialisation as women is often partly about pleasing others and putting others first, to our own detriment.
In addition I had to do a great deal of work on exploring my black Jamaican, Nigerian and white British father’s racial identity, issues and upbringing, in order to understand his influence on me. This was the most significant and complex piece of work I had to do. Because I had had a difficult relationship with him, this has also affected my relationship with the black part of my identity. I had to work through a large amount of anger as I began to understand the impact of racism and a history of slavery and colonialism on my family at large.
I came to acknowledge my Jamaican and Nigerian identities were poorly developed due to a lack of exposure to Jamaican and Nigerian customs and culture. I’ve never been to either country. I never had a relationship with my Jamaican-born grandfather, and my Nigerian and British grandmother died when I was a young child. Most of what I know about both countries is through reading. Acknowledging this disconnection awakened a process of mourning in me and I have still not found a satisfactory way to fill this hole. Being more aware that it is there and that it causes some sadness is at least a beginning.
It has been particularly healing for me to think of the strengths of having a mixed race identity, such as being comfortable with diversity, having a rich background and being open to broad perspectives and experiences in ways that I see many others are not.
Counselling mixed race clients
I think working with theory to help clients understand their racial identity is very helpful but it is not something I have ever heard of outside my own work on this. The difficulty here will potentially be the counsellor’s lack of knowledge and competence around race and cultural issues and their ability to facilitate the client’s understanding of themselves in a non-defensive way. It’s important to note that the work I did on configurations of self was born from my own initiative in my counsellor training and then from reading books from the US on mixed race identity and counselling. I found Biracial Women in Therapy by Gillem and Thompson11 particularly useful (it was one of the only books I actually found on counselling mixed race people). Although my exploration of configurations of self did not develop out of therapeutic work with a counsellor, I did take my findings to counselling later to discuss. I think I was privileged here in the depth of understanding I could develop around my identity by myself and I wonder how much counselling practice alone, as it presently stands, can facilitate significant and meaningful reflection on identity for mixed race clients. I found using identity development models enormously useful, as well as thinking about how other aspects of my identity affected me as someone of mixed race, particularly with regards to gender and class oppression.
In summary, it is important to remember mixed race identity is fluid and may change over time and in different geographic locations, because of different current events and so on. I personally know I will have to keep exploring my identity as a mixed race woman for the rest of my life.
I’m not sure if this article will have any impact but I would love to see more dialogue around mixed race issues in the counselling world. While it is true that working with mixed race clients on issues of race may not necessarily be commonplace at the moment for many therapists, this may well change over time and mixed race clients deserve appropriate support when they do come through the door of the counselling room. In my short experience so far as a counsellor, I have already worked with a mixed race client as well as several women from mixed race households. We need to make sure we are not failing this group of people because in many cases they have already been failed enough. Successfully integrating a mixed race identity and navigating mixed race relationships in a world that constructs race in rigid binaries and where racism is still a considerable problem is a real challenge and can bring up a wealth of difficult emotional and psychological issues. I do not think counsellors in general are even scratching the surface right now in this area.
Nicola Codner has just completed a person-centred diploma in counselling and is currently a volunteer bereavement counsellor. She is specifically interested in the areas of race and culture, class, sexuality and gender. She has a degree in psychology and English literature and enjoys writing on social issues. References
1. Smith L, Mixed race in the UK: am I the future face of the country? The Telegraph; 8 November 2014. 2. Alibhai-Brown Y. Mixed feelings: the complicated lives of mixed-race Britons. London: The Women’s Press Ltd; 2001. 3. Parker D, Miri S. Rethinking ‘mixed race’. London: Pluto Press; 2001. 4. Five-year plan fails to help black people in the mental health system. News. Therapy Today. 22 (4); 2011. 5. Institute of Race Relations. Criminal Justice System Statistics. http://www.irr.org.uk.research/statistics/criminal-justice/ 6. Mixed race children’s needs. News. Therapy Today. 25 (3); 2014. 7. Ministry of Justice. Statistics on race and the Criminal Justice System. https://www.gov.uk/government/statistics/statistics-on-race-and-the-criminal- justice-system-2012. 2013. 8. Mackenzie-Mavinga I. Black issues in the therapeutic process. London: Palgrave Macmillan; 2009. 9. Mooney AM. ‘The elephant in the room?’: an exploration into how clients construct and manage the role of being mixed race within therapy. University of Roehampton; 2014. 10. Watson VVV. The training experiences of black counsellors. University of Nottingham; 2004. 11. Gillem AR, Thompson, CA. Biracial women in therapy: between the rock of gender and the hard place of race. New York: The Haworth Press Inc; 2004. +++ How I became a therapist
Karen Cromarty
Attending school governor meetings made Karen Cromarty realise that therapeutic intervention could help children and young people
My decision to become a therapist was as a direct result of my work as a school governor. I regularly sat on Exclusion Panels and heard narratives of young people in school whose behaviour was so ‘bad’ that they were going to be disallowed from attending school – either temporarily for an extended period, or permanently. Now whilst the staff in schools had ostensibly done their best to contain these pupils, these young people NEVER had any opportunity to reflect on their behaviours or on what might have caused them, and how they might respond differently in the future. I wanted to bring some therapeutic skills to this potential client base, in the hope of preventing more such exclusions in the future.
At the time, and this was 1997, my judgment that counselling might help children at risk was based upon a ‘gut reaction’ and a knowledge from the evidence base that counselling helped adults. Of course since then times have changed; BACP has worked on many and varied research projects that have studied young people’s counselling, especially in secondary schools, and the emergent evidence base is really highly positive. School based counselling is associated with significant positive change. So I had a sense that counselling in schools would help, but now we have the studies to show this. And it’s these studies that convince the politicians and opinion formers to invest in even more resource to support cyp mental health. I’m now involved far more in presenting the case for counselling at this level, which is daunting and exciting in equal measure.
I think being a therapist is probably a vocation, and my personal view is that it’s not rocket science! Someone who genuinely believes people are trying their best and can do with a helping hand sometimes – a simple ‘two heads are better than one’ approach – understands the basis of the therapeutic relationship.
The best advice I have received wasn’t actually about therapy, and maybe it was a maxim rather than advice, but it relates to the children and young people sector very well. A great friend of mine, a post office manager and Dad of two, told me when my children were young, that he thought all children went through every ‘stage’ at some point in their formative years. So that you may as a parent get a placid baby – but my, they might really test you in their teenage years! On the other hand, the young extroverts, who love to put on a show when they’re little, will almost certainly go through an uncommunicative phase when they will hardly be able to face anyone. Seems simple really, but it helped me a lot, especially when working with school staff who can sometimes think that the age of the child accurately describes their developmental stage.
Personal values are really important to me, as they can be the boundaries and touch stones in everything we do. One that stands out above the rest for me is integrity – being true to my own code. Being honest but kind is important to me as well. Doing my best is up there alongside working hard. Trying to help others as well as I can, whenever I can; being as good as I can be. Influencing what I can, to the best of my ability, and letting go of things over which I don’t have control.
I don’t do much ‘theraping’ these days – but when I did I felt privileged to be trusted by others who were feeling vulnerable. And to see people change in ways that suited them was always highly rewarding.
I find my biggest challenge is that there are only 24 hours in every day. There’s so much interesting and exciting work to be done, I could easily fill another 24 hours. My leisure time has to be guarded fiercely. I wouldn’t say I’m a great reader, but music I find is very inspirational both through playing (the guitar) and having an eclectic taste in music from classical to Runrig.
Becoming a therapist, even studying a basic counselling training, can be life changing, and I would recommend it to many. A six evening counselling skills course was a game changer for me in terms of self-awareness, and I became really hungry for more of that. Once you begin to become self-aware then it’s hard to stop. You can’t not know what you know! I just wish more people would go in for it. It has also been an absolute privilege to have individual clients and supervisees trust in me and that is humbling.
Karen Cromarty is BACP’s Senior Lead Advisor and holds the portfolio for children and young people within the Association. Although Karen currently has only a very small private practice, she has been a school counsellor, supervisor and manager; and she now uses her ample experience to focus on children and young people’s mental health as an author, researcher and media spokesperson. +++ Bending boundaries in oncology counselling
Caroline Armstrong describes the unique dilemmas raised by her work as an oncology counsellor in a large teaching hospital Illustration by Michael Parkin
Imagine you’re in hospital and you’ve been telling the ward counsellor that you are scared that the excruciating pain in your head may be a progression of your cancer. You feel the counsellor listens carefully and seems to understand, and you feel a bit calmer by the time she leaves. Later the consultant comes round and confirms your worst fears: the cancer has spread to your brain. How, then, does it affect your feelings towards the counsellor when a chance remark makes it clear that she already knew the results when you were both speaking earlier?
This may appear to be extreme, but it can happen. Most ward-based referrals come from attending ward hand-over meetings. As a result the counsellor becomes privy to personal information without the person choosing to share it, and they themselves may not even be aware of some of it. This raises all sorts of dilemmas, ranging from how to respond when the client’s story differs from other versions you have heard, to anticipating the delivery of bad news. Perhaps you decide to ignore the additional information and meet the client with the material they bring. Or maybe subtly you choose to encourage reflection on the possibility of bad news. Perhaps you delay your visit until the bad news has been given. Whatever choices you make within the therapeutic context, it will affect the relationship.
As an oncology counsellor in a large teaching hospital, I work alone in an office close to the main oncology ward. I provide short-term counselling for outpatients, as well as providing emotional support to patients on the wards. It was a situation similar to the one above that led me to reflect on the strange environment in which I work and the many ways in which boundaries and ethics can become live issues. These issues are not unique to the hospital setting; nor is it possible in this article to provide definitive answers to the many dilemmas that can arise. What I hope to achieve is to increase awareness around some of them, so that all of us who find ourselves in similar situations can make conscious ethical choices. There are many lone counsellors working in isolation in hospital units, with no one but their clinical supervisor to understand their work fully, and this is directed in part to them and to anyone considering a job or placement in a hospital. The issues are also likely to have resonances for people working in other settings.
Information and confidentiality
To some extent information contamination – that is, information that has not come direct from the client – is inevitable. Some people may suggest avoiding the professional meetings and minimising additional information. However, that risks a lower professional profile on the ward and fewer referrals. Nor does it fully avoid exposure: the wards operate in a culture of information exchange within the multidisciplinary team and, while it is accepted that the counsellor will not share the content of his or her sessions, it would be a big challenge for the counsellor to avoid all exposure to information from other professionals.
Another area of flexibility can be confidentiality, depending on where people are seen. In the counselling room the environment can be controlled: a contract lays out the ground rules; conversations are private (other than those where there is risk of harm to self or others); notes are kept separately and can only be accessed by the counsellor (or the client, with notice), and any statistical data are anonymised. In other words, it is very similar to the standard community-based counselling service, although it is expected that any referrer is notified that a service is being provided.
In contrast, work on the ward is more fluid. If someone can walk and they are well enough, it may be possible to access a quiet room for a counselling session. However most visits are carried out at the bedside, often surrounded by curtains that give an illusion of privacy but through which conversations can be heard. There can be interruptions, which are often not controllable, by people or activities in the immediate or adjacent areas. There is no contract and the extent to which people share experiences under these conditions is left to them (albeit with the occasional reminder about the absence of privacy). Add in that people on wards are frequently asked personal questions by other staff so they can become disinhibited and subsequently feel exposed. It is important to ensure that people have real choice about whether to speak with the counsellor or not. Most people are ill, vulnerable and scared, and many are keen to be seen as a ‘good’ patient. In those situations they could comply when they would really rather not.
Flexibility
Thinking back to my early days when I was training to become a counsellor, I remember certain ‘givens’: always start and end sessions on time; expect regular attendance, and explore the meaning of absences with the client as part of their process; be circumspect about the use of touch; keep things consistent – eg time and day of meeting, and where the meeting takes place. In fact I have always aimed to maintain the first of these, keeping the allocated sessions to time. Anyone who works or has been a patient in a hospital will know just how different this is to the prevailing culture. To see how the rest of the given rules can be affected, consider the following case.
D was a 46-year-old black British woman who came for one-to-one counselling midway through receiving chemotherapy for the second time, following a relapse of her bowel cancer. She was understandably frightened, both of the potential side effects of the new treatment and of the implications of relapse. Sessions were arranged to avoid her worst symptom days within the three-weekly cycle of treatment. We did not always meet on the same day each week, although we managed to keep to the same time of day. When she rang to cancel her second session due to ill health, I accepted it at face value, and we confirmed the next appointment. This is not unusual for people receiving chemotherapy. Over the following three weeks she turned up late twice; the reasons could all have been legitimate but I took the decision to explore them. What emerged was her fear of facing the ‘inevitable’ discussion about dying. I reassured her that we would only move at her pace and discuss what she brought. On the strength of that she felt comfortable to extend her sessions. Some time later she announced, ‘I’m ready to talk about dying now,’ and we explored this over several weeks. Towards the end she realised that she had probably explored as far as she could, mainly because she could now see that ‘there’s still life to be lived’ and that at least one more form of treatment was available to her should she relapse again.
That may have been the end of the story but some years later I noticed that D was an inpatient on the ward. This time, I heard, she was dying. I was unsure whether she would want to see me on the ward, since no one would have known she had seen me previously. I asked one of the senior nurses to let her know that a counsellor was on the ward (giving my name), and to ask her if she would like to talk. She was very happy to see me and had no qualms about the confidentiality of her previous contact with me, but said she tired easily. She was candid about her current predicament, but seemed accepting of it until she started having a coughing fit and struggled to catch her breath. Having alerted the nursing staff I stayed with her. She was clearly scared so tentatively I put a supporting arm around her shoulders, unsure if physical contact was appropriate, although it felt the right thing to do. At this point she leant into me and both of us remained there while the staff gave her the medication she needed and the fit passed. She died peacefully a few days later.
Talking this over in clinical supervision, what made most sense was that, at that point of placing an arm around her shoulders, I stopped being her counsellor and became one human being caring about another.
The experience with D illustrates not only how boundaries can be affected but the importance of checking things out. The changes in days could have caused confusion, but they did not. The lateness could have been genuine, but by looking at it together we uncovered some very potent material and prepared the way for its exploration once she was ready. In hospital it is common to see someone for counselling and then meet them out of context. Some people can be upset by recognition, others by a lack of it. It was possible to check with D but in other contexts of course you can only do your best, and perhaps wait for them to make the first move.
Medical culture
Perhaps the greatest challenge to a lone counsellor working in a hospital is the medical setting itself. The professional paradigm around you is one of being the expert and problem solving. This can be a seductive trap for the therapist, and yet clients feed back that they really value the counsellor being outside the medical model – an independent ear who nonetheless knows the territory. Being seriously ill can leave people feeling extremely vulnerable and powerless; being accompanied by someone who encourages them to reconnect with their own agency can be transforming. In this context counselling is a space where people with serious illness can stay with whatever difficult emotional rollercoaster they find themselves on without it being seen as another problem to be solved. This is not to say that the specialist expertise of the counsellor is redundant. Many people need help to develop tools for managing anxiety and depression. Similarly there are several points at which it is recognised that people facing cancer, for example, can become particularly affected psychologically by predictable concerns.1 This is about knowing the territory. The challenge is to accompany someone through the terrain while respecting their unique experiences and abilities. It can be difficult to stay in contact with that approach in a ‘problem/fix’ culture.
Another issue where I found myself drawn into the dominant culture for a while was access to and use of patient notes. In the hospital access to information is always on a ‘need to know’ basis, but in the case of a lone worker such as the counsellor this is left to the judgment of that professional. I have access to personal patient records in two ways: electronic data and ward files. On the wards, all members of the multidisciplinary team read through the notes of the patients they are about to meet and I followed suit. It told me their diagnosis, who else was involved in their care, occasionally some comment on their emotional state, and what treatments they might be receiving. I would also write a single line, simply to say that I had visited and whether or not those visits would continue. One day in supervision I mentioned reading information in someone’s notes and was shocked by my supervisor’s response. She felt very strongly that she would object to that, were she the patient, and challenged me to think deeply about my ‘need to know’. This expanded to a reflection on the electronic data to which I had access. The whole process had become so ‘normal’ to me by this stage that it took this shock to make me look at it afresh and question my practice. Initially I wanted to defend my actions by listing the perceived benefits. That led me on to explore how else I might gain that information, whether I needed it and what I might need to know beyond the information provided by the person themselves. I decided to experiment, and refrain from reading any notes for a period. The surprise is that it made very little difference to my actual work with clients, and by dealing only with the information that they chose to share I felt closer to their experience. This episode was a huge learning curve for me, and now I only access the hospital patient records to collect the non-identifying demographic data on which I base my quarterly service reports.
Support and exchange
People’s views on the various boundary issues outlined in this article are likely to vary according to their counselling modality, the levels of support that are available, the pressures on the service, and any number of other factors. It is important to be aware of the choices you make, though, as your decisions are bound to impact on the client. For isolated practitioners, regular clinical supervision and reflective practice are invaluable, provided they are used effectively. This can be augmented through networking with other practitioners in similar situations, such as local counsellor networks. These may bring together counsellors from different specialisms within one hospital, or counsellors working in one specialism across several hospitals. I have facilitated both, formally and informally. I hope this article will also spark debate and ideas more widely.
Conclusion
In the context of hospital-based counselling, many boundary and ethical issues can arise. This article highlights a few: information contamination; confidentiality, and the challenges to maintaining it; the need for flexibility that is based on a foundation of established good practice, and maintaining a helpful distance from the dominant culture of the medical model. There are no absolute answers to many of the issues raised here, and I would suggest resisting the urge to legislate too tightly on any of them. Conditions and workplaces vary too greatly for that to be anything other than a misguided effort to establish safety and certainty in an uncertain world. Instead I would suggest continuing dialogues that are guided by the principles of the Ethical Framework.
As someone who came into the NHS from the outside, I had little preparation as to the kinds of challenges that this particular way of working would pose. It would have been helpful to have been aware of some of the cultural and practical issues that I was likely to face. I hope this article both offers food for thought for others who may be considering a similar career move and provides a reminder to those already working in this and similar settings of the issues that surround us daily and to which we can become blind through familiarity.
Caroline Armstrong MBACP has been an accredited counsellor since 2002. She is a trained supervisor and worked in a variety of counselling settings prior to her eight years as an oncology counsellor in a London teaching hospital. She has a special interest in mindfulness. Email [email protected]
Reference
1. Burton M, Watson M. Counselling people with cancer. Chichester: John Wiley & Sons Ltd; 1988. +++ Peer-supported Open Dialogue
Jane Hetherington introduces a new model of support for people with severe and long-term mental illness that is based on person-centred principles and dialogue
‘The paradox of dialogue may be in the simplicity and complexity of it on the whole. It is as easy as life is, but at the same time dialogue is as complicated and difficult as life is. But dialogue is something we cannot escape, it is there as breathing, working, loving, having hobbies, driving a car. It is life.’1
I am a principal psychotherapist working in the NHS for the Kent Early Intervention Service (EIS). I trained as an integrative psychotherapist 15 years ago after careers in law and industry. My interest in psychotherapy was sparked after volunteering at London Lighthouse (an organisation working with people with an HIV diagnosis) and I moved from a basic counselling skills course, through various trainings, to the Masters in Integrative Psychotherapy at Metanoia and a radical change in career.
In Kent we are currently participating in an exciting and innovative project that is piloting Peer-supported Open Dialogue in the NHS in England. I am aware that not all Therapy Today readers work in the NHS but this pilot has long- term implications for treatment in both statutory and voluntary sector services, and for practitioners in the private sector. The training discussed in this feature is currently only available to NHS employees but a three-year training will soon be available for practitioners working outside the NHS.
Open Dialogue
Open Dialogue was originally developed in the area around Tornio in Western Lapland, Finland, in the 1980s when the psychiatric services were in a state of disarray. It initially offered an alternative to treatment as usual (TAU) for psychosis but is now the only model for all mental health treatment in this area. This has allowed the system to develop a comprehensive approach that integrates inpatient and outpatient mental health services with social care and external agencies. They now have the best documented outcomes in the Western world. At two-year follow-up 82 per cent had non-visible psychotic symptoms compared to 50 per cent in the comparison group. Patients also had better employment status with 23 per cent on disability payments contrasting with 57 per cent in the comparison.2 Open Dialogue has since been introduced to a number of countries, including most of Scandinavia, Russia, Germany, France and some states in the US.
Open Dialogue perceives psychosis from a social constructionist perspective where ‘psychosis is a temporary, radical, and terrifying alienation from shared communicative practices: a “no man’s land” where unbearable experience has no words and no genuine agency’.2 Open Dialogue recognises the lack of adequate provision for service users and their families in both community teams and inpatient units. Unfortunately the NHS is currently structured in serial or parallel services, which results in an incompatibility between treatments offered, lack of consistency and poor communication between the various sectors.
Open Dialogue encompasses a number of theoretical approaches, including psychodynamic theory, systemic family therapy, dialogical theory and social constructionism. The model involves a psychologically consistent model in which the service user, their family and their social network participate in regular network meetings where the thinking and decision making about their care and treatment takes place. These meetings are facilitated by specially trained team members, and this is fundamental to the therapeutic process. This model encourages service users, their families, social networks and support workers to be pivotal to the provision of care. The empowerment of the client and their family is at the heart of the therapeutic model, resulting in an enhanced experience of comprehensive support. In addition, improved agency and awareness may lead to a longer-term reduction in chronicity and reliance on services.
Peer-supported Open Dialogue (POD) is the variant of the Open Dialogue model which we will be piloting in England. It involves the inclusion in the treatment team of peer support workers trained in Intentional Peer Support (IPS). Peer support workers are currently already working in some NHS teams and are seen as experts in their own right through their lived experience. IPS involves a training in crisis management and holistic, person- centred models of care that is wholly compatible with the Open Dialogue approach. Within the treatment teams, staff and peer workers will be trained together, and peer workers will be encouraged to develop a supportive peer community. POD has been developed in the US, where the New York boroughs have been evolving the model. Parachute NYC is a POD project that offers alternatives to hospitalisation for people experiencing emotional crisis. In the UK the service will evolve with a uniquely British flavour that is influenced by the demographics of the pilot site areas and a range of cultural variants.
Seven basic principles
POD is built on seven basic principles.
1. Immediate help The first meeting with the team occurs within 24 hours of receiving the referral. We are attempting to comply with this through the introduction of a single point of access. All participants in the team are there from the outset and the psychotic stories are discussed in Open Dialogue with everyone present.
2. Social network perspective Those who define the problem are included in the treatment process. The team discusses and decides together who is aware of the problem, who could help and who should be invited into the network meeting. Participants could include family, friends, relatives, fellow workers and other agencies, including the police, social workers, or substance misuse services if relevant. If a network member lives some distance away they can be involved through Skype, conference calling etc.
3. Flexibility and mobility The response from the service is adapted to need and is flexible in relation to the evolving requirements of the service user and their social network. The location for the network meeting is jointly agreed, although the family home is the preferred choice.
4. Responsibility The team member who is first contacted is responsible for organising the initial meeting. The team takes charge of the whole process, regardless of the place of treatment (including inpatient admission). All the treatment options and concerns are discussed openly between the doctor with clinical responsibility for the person and the team.
5. Psychological continuity The team is integrated and includes outpatient and inpatient staff (if required). The meetings occur as often as necessary – normally more frequently in the initial stages of treatment. The meetings last as long as required, which in our experience can be up to two and a half hours. If there is a further crisis the core of the team will remain constant where possible.
6. Tolerance of uncertainty The model is designed to tolerate uncertainty in order to create an environment that can facilitate a safe enough process. The aim is to encourage the service user and those closest to them to develop their psychological resources so they are able to remain with the uncertainty and avoid premature decision making and treatment plans.
7. Dialogism The emphasis of the network meeting is to generate dialogue, not primarily to promote change. The aim is to discover a language to express experiences that remain embodied in the individual’s personal language and inner disturbance and to recognise the multiplicity of voices within the meeting – what Bakhtin identifies as ‘the polyphony’.3
Current POD training
The POD programme is evolving but currently the initial stage involves a year of part-time training, which we are two-thirds of the way through. A multi- disciplinary team has participated in a programme involving a partnership between North East London Foundation Trust (NELFT) and Gjovik University College, Norway. The course comprises four week-long modules covering an introduction to family therapy and systemic practice, social constructionism, family life cycles, reflecting process, research, and Open Dialogue as an approach and attitude to working with families. It also includes recognition and response to trauma, working with adolescents, the ethics of working with families and networks, exploration of the recovery model and the therapeutic relationship. There is a strong emphasis on the humanistic approach espoused by Carl Rogers. The core conditions of empathy, congruence and unconditional positive regard underpin this model, making it ostensibly a simple, kinder and more optimistic approach to working with complex mental health issues. There is also an emphasis on the spiritual aspects of mental health to which Rogers returned and which he explored further in the latter part of his life.
The use of self in the therapeutic alliance is examined and this, together with the reflecting process and the high level of self-examination, has been difficult for many on the course. This is partly because of the intensity of the training but another factor has been the dominance of the medical model that underpins the core training of some practitioners. Nurses, occupational therapists and doctors have not traditionally been required to examine their own process and reflect on their choice of career, personal history or family of origin, and this has proved to be an emotional journey for the team. Because of the level of personal development and awareness this approach requires, we have also been encouraged to monitor ourselves and to use yoga and mindfulness, which are components of the training. In Kent we have factored in additional supervision and support where required, as we are aware of the possible impact of the programme on our practitioners.
The team is encouraged to discuss the logistics of creating the new services that we will be forming. We are also exploring the personal and professional obstacles that we may encounter in developing client-driven, dialogic services and establishing greater levels of acceptance, attunement and compassion in our professional practice.
Implications for services
It is difficult to conceive how revolutionary the establishment of these services will be. When you explain and expand on this approach with colleagues in mental health services, they say, ‘But this is what we do already.’ Unfortunately we do not do this often enough, or consistently. Rachel Freeth, who originally trained as a psychiatrist, then as a person-centred therapist, discusses openly in Humanising Psychiatry and Mental Health Care the dilemmas and constraints that she encounters in her attempts to be a person- centred clinician in the context of the NHS.4 We clinicians often do not listen well and in a dialogic manner: ‘In the professional world within which we currently dwell, a disengaged way of thinking, that we think of as rational, holds sway. But in this form of thought, we find ourselves assuming that there are “things” which are separate from something else, and this is not, as will become clear, how dialogically-structured activities – as an aspect of our Nature at large – actually work.’5
Many participants on the course have had their own personal experiences of mental health services as users or family members, in addition to their professional training. Jung’s construct of the wounded healer is relevant to us as a team. The idea is thought to have foundations in Greek mythology and pertains to the centaur Chiron, who was hit by one of Hercules’ poisoned arrows and suffered a wound that would never heal. It relates to the notion that many of those in the caring professions have experienced some levels of psychological distress that has influenced their choice of career. We as a team are, therefore, enthusiastic and evangelical about the aim of services being radically improved: ‘I really believe this is the way mental health services should be. Transparent, caring, open, honest and truly person centred. All these things that services claim to be, but often fall very short from the mark’ (Lauren Markham, trainee POD worker, 2015).
Developing the pilots
The initial NHS pilot for POD involves four trusts: North East London Foundation Trust (NELFT), Kent & Medway NHS and Social Care Partnership Trust (KMPT), Nottinghamshire Healthcare Trust and North Essex Partnership University Foundation Trust. They will be funding the setting up of POD services over the next few years. These pilot POD services will enable the NHS to evaluate and expand on the evidence base in order to inform the NICE guidelines on the treatment of severe and enduring mental health problems and promote more wide-scale take-up if the improvements in outcomes and cost reductions remain positive. The evolving plan is to apply for a grant for a multi-centre randomised control trial and to undertake further qualitative research.
The situation in Kent has evolved from the original plan and workers from several teams – principally Early Intervention Services (EIS) – have volunteered to be part of the programme. We currently plan to train a second wave of practitioners to add to the original cohort of 15 and to create a stand- alone team based in one of the Kent community mental health divisions. Kent EIS has already established the peer support role but additional peer support workers will be trained in the second cohort. There is also an aim to embed the model in the various teams involved in order to disseminate the POD principles. Once the Kent team is established, they will start collecting data from the service and, with the other pilots, contribute to the multi-centre study. Should POD consistently demonstrate sufficient clinical improvement and reduction in medication and hospitalisation costs, then an argument could be made for a more widespread roll-out, both within every mental health trust as well as nationally, via commissioning, government and clinical guidance authorities.
The pilots are potentially the first step in what could ultimately become a radical shift in national mental health services and this is what I consider to be so exciting about these developments.
Using Peer-supported Open Dialogue
I find myself working more dialogically
‘There are challenges attached to Peer-supported Open Dialogue. First, not being from an outright educational background or having training, I was wondering how I would be able to cope with the training and meeting the demands. I was also very wary on the first day during the introductions, being in a room full of doctors, therapists, psychologists and the like. I was sitting there thinking, “I am only a support worker.” Initially, however, I was wondering if I was important enough, almost, to first undertake the training and second to practise, which I have now started doing.
‘Second, something I struggled with after the initial week in Birmingham was the idea of roles and how the role of STR worker fits within an Open Dialogue framework. My role is very much ‘to do’: a referral comes for an STR and a plan is formulated (this person needs support with shopping/accessing the community/finding work) and it is my role to facilitate that. This seemed a million miles away from POD, where things are talked through, the client and their network are the centre of everything and come up with the ideas. I saw myself as having two roles: my STR role and my POD role. I did realise, however, that these two co-exist and, although, I can suggest things in order to achieve goals, all of this will be formulated in network meetings and the support will still happen in between the network meetings. I am also finding myself working more dialogically overall in my work, not just at network meetings, which is the way it should be.’
Lauren Markham, STR worker
Just being listened to
‘It’s difficult to feel and openly say you have a point of view or perspective on the experiences and events that led up to and surround mental illness affecting someone close to you. Open Dialogue involves you and validates your thoughts and feelings. What begins to happen is a unique understanding of how we all relate to and affect each other, how we can all better support each other by talking, and that in turn gives everyone another way of looking at the situation. You begin to hear the emotions of the person suffering, and you hear yourself expressing yours and this creates surprising reactions, always supported by a team.
‘At times it feels like nothing is happening and that if it was just a matter of sitting and talking, well, can’t we do that without any outside interference? I think that the point is we don’t; we think these things but daren’t say them for fear of causing more distress.
‘When someone is ill it affects everybody. This is inclusive – just being listened to when it’s needed most, allowing these hopes and fears to come to the surface, and feeling as if in you are in safe hands.’
Amanda Francis, carer and crisis team worker
References
1. Seikkula J. Becoming dialogical: psychotherapy or a way of life? The Australian and New Zealand Journal of Family Therapy 2001; 32(3): 179–193. 2. Seikkula J, Olson M. The Open Dialogue approach to acute psychosis: its poetics and micropolitics. Family Process 2003; 42(3): 403–418. 3. Bahktin MM. The problem of Dostoevsky’s art. Leningrad: Priboj; 1929. 4. Freeth R. Humanising psychiatry and mental health care: the challenge of the person-centred approach. Oxford: Radcliffe Publishing; 2007. 5. Shotter J. On being dialogical: an ethics of ‘attunement’. Context 2015; 137: 8–11. +++ Mental imagery in counselling
Val Thomas discusses the important contribution that mental imagery can make to therapeutic processes across all modalities
This article considers how talking therapies have made use of clients’ mental imagery and reflects on how the patchwork development of this practice has been shaped by wider historical and cultural contexts. It will argue that it is time to develop more inclusive theory and practice that supports a deeper integration of mental imagery into therapeutic work.
The genesis of my research interest in mental imagery lies in my experience during the 1990s of working therapeutically with substance misusers in crisis. It was my practice to ask these clients to translate their sense of self into an image of a building. Unsurprisingly, people produced a whole variety of images of structures that were, in general, in a poor state of repair, often abandoned and derelict. Then, in the mid-late 1990s, I started to notice a new pattern that corresponded with an epidemic of crack cocaine misuse in London. As with the heroin and alcohol misusers, the clients with crack cocaine habits reported a wide range of building images but these all had one thing in common: there was significant damage to the roof.
I was intrigued that mental imagery appeared to have the capability to disclose misuse of specific drugs and I started to search the literature for similar reports from other clinicians. After an exhaustive search I found no other examples of this type of work. But I did discover that, although there was a great deal of literature on working with mental imagery, in the main it comprised accounts of two types of work: either techniques and procedures developed within particular schools, or idiosyncratic image-based approaches developed by innovative clinicians. There appeared to be very little interest in developing more inclusive approaches. I found this puzzling: the therapeutic potential of mental imagery has been recognised ever since the inception of psychotherapy so why has it not moved in a more trans-theoretical direction?
Therapeutic use of mental imagery
A very brief overview of the therapeutic use of mental imagery in talking therapies shows the piecemeal nature of its historical development. Over the course of the 20th century different schools came to the fore and contributed mental imagery techniques and procedures informed by particular therapeutic approaches and paradigms. Psychoanalysis was developed within the particular historical and cultural context of continental Europe during a period of increasing interest in studying altered states of consciousness, dreams and visions. Clinical observations and experimental investigations were starting to indicate that people’s mental images represented communications from a non-conscious part of the mind. Influenced by his teacher Charcot (1826–93), Freud experimented by pressing his patients’ heads in order to stimulate mental images.1 However, as he started to develop his theories about the defensive, warding-off function of mental images, he then shifted to word- based free association.
As Freud’s initial interest in eliciting his patients’ mental imagery lessened, another pioneering genius came to the fore – Carl Jung, whose contribution to this field can hardly be overstated. Jung developed a radically different view of the nature and importance of his patients’ images and symbols.2 Their images were not to be interpreted through the therapist’s frame but were instead viewed as communications in their own right arising from the personal and collective unconscious. In order to allow more access to the unconscious, Jung developed his influential method of active imagination whereby the client is encouraged to amplify the original image.
In the 1970s there was a period of intense interest in imagery, particularly within humanistic schools and transpersonal approaches such as psychosynthesis. These schools drew on Jung’s pioneering work with symbols and active imagination but their methods were characterised by a more dynamic and interactive approach to clients’ mental images. In addition, throughout this time and running in parallel to the main schools, there has been a varied range of idiosyncratic image-based therapies developed mainly in Europe by innovative clinicians such as Leuner3 and Desoilles.4
Towards the end of the 20th century the flowering of interest in mental imagery began to fade as the relational turn in counselling and psychotherapy shifted attention away from methods that worked with the client’s subjectivity. However, while most of the field lost interest in mental imagery, one school – contemporary cognitive behavioural therapy (CBT) – went in an opposite direction and is now at the forefront of developing imagery as a therapeutic intervention. The increasing importance attributed to emotion and a recognition of the limitations of verbal language to access preverbal and/or traumatic memory have combined to drive practice and research into investigating the potential for imagery to be a therapeutic tool. Whole approaches based on imagery have recently been developed such as imagery rescripting techniques for intrusive traumatic memories. As would be expected, these procedures are instrumental and goal-oriented, but there is increasing interest in adapting humanistic imagery approaches – Gestalt dream work, for example, is being reprised as a masterful example of guided discovery. Hackman and colleagues5 sum up the change within this school: ‘50 years ago, in the heyday of behaviourism, imagery was not considered worthy or appropriate for experimental investigation, though interestingly it was incorporated into behavioural treatments such as systematic desensitisation. Now the empirical study of imagery links clinical research, cognitive psychology, neuroscience and clinical treatments, creating a body of knowledge that strongly suggests the rich potential of imagery-based interventions in therapeutic practice’ (p204).
The imagination and healing
So how can we explain the way that mental imagery has been and still continues to be developed within the constraints of particular schools? I think we need to step outside the relatively short history of psychotherapy and counselling in order to grasp the bigger picture. The disciplines of counselling and psychotherapy are shaped by wider historical and cultural contexts. A consistent theme that I have noted in different clinical contexts is that clients in general initially find it difficult to take their imagination seriously. In particular, most people find it hard to accept that the mental image is a reliable source of valid information about themselves: ‘But I’m just making this up!’ is a common expression. Where does this widespread resistance come from?
I would suggest that this unreflective attitude towards the imagination is a consequence of the Cartesian mind–body split. I realise that this is a common explanatory trope for a range of problematic issues in Western culture – therapists will be familiar with this explanation for the marginalisation of the body in psychological therapies. However, perhaps what is less well known is the profound impact of Cartesian dualism on Western understanding of the role of imagination in healing. In the pre-modern period imagination was viewed as operating in both mind and body, and it was implicated in the cause of illnesses and also used as a treatment. My example at the beginning of this article (of different patterns in mental imagery linked to the use of different drugs) would have been consistent with the pre-modern world view. The early Greek physician Galen (130–200 AD) wrote about the use of dream images as diagnostic criteria for certain health conditions. However, this possibility was removed by Descartes’ philosophical writings in the 17th century, which separated mind from body: once the faculty of imagining was understood as solely a mental phenomenon then it could not possibly affect the physiological system. ‘In the predualistic era the expression “It’s all in your imagination” signified a key medical principle. In the modern era it came to signify justification for dismissing the patient as untreatable.’6
But something more happened at this point, which I contend is still influencing the way Western culture disregards the validity of imaginal processes: imagination was compared unfavourably with rational thought. Influential post- Cartesian philosophers launched a devastating attack on imagination, and Hobbes’ (1588–1679) argument that imagination was an inferior type of thinking was buttressed by other philosophers such as Locke (1632–1704), who defined imagination as a ‘decaying sense’. During the following centuries, informed by the Anglo Saxon empirical philosophical tradition and the great technological progress brought about by applications of rational thought, imagination became conflated with illusion in the popular mind. Treated contemptuously by modern science, it was only in the mid 20th century that psychology began to accept that people’s imagination and their mental imagery in particular were worthy of investigating.
Why use the imagination in therapy?
Does this matter? Despite the way that imagination has been sidelined in Western culture, its therapeutic potential has always been acknowledged in counselling and psychotherapy, each school contributing to the repertoire of mental imagery procedures and techniques. So why should we attempt to develop more trans-theoretical approaches to the therapeutic use of mental imagery? The first reason is a general pragmatic one. A great wealth of knowledge, procedures and techniques has been developed within the different schools and image-based therapies; more inclusive frameworks for practice would allow integrative therapists to draw on all of these. The second reason is that it is time to take on board that other disciplines are generating new ideas about the embodied nature of cognition. These empirically- grounded theories lend support to the long-held understanding in psychotherapy that imagery accesses non-conscious parts of the mind. In particular, Lakoff and Johnson’s important theory of conceptual metaphor7 provides a compelling explanation of the way in which mental images can shed light on how the person is cognitively structuring his or her perception of the world.
My example of imagery work with substance misusers is an illustration of a particular conceptual metaphor: ie the self is a building (small capitals are the accepted convention for conceptual metaphors). Lakoff and Johnson argue that these deep-level conceptual metaphors (non-verbal experiential gestalts) emerge directly out of embodied experience. Gibbs and Berg8 go on to make the case that representing a conceptual metaphor as an image will not only reveal the person’s sense of self, it will also disclose their experience of their embodiment. This was confirmed for me in the case of the crack cocaine users, where damaged roofs appeared to represent the impact of taking a particular physical substance into the body as well as the concomitant psychological processes.
The implications for counselling and psychotherapy are that, by viewing and interacting with image-based representations of conceptual metaphors, we can gain more direct access to the cognitive processes (and associated embodied aspects) involved in therapeutic processes. Conceptual metaphor theory would support the idea that changes in the metaphor would be mirrored in changes in how the person experienced his or her self. I saw that in action when I used imagery interventions to help crack cocaine misusers deal with the problematic psychological conditions that arose after stopping taking the drug. One procedure involved temporarily securing the damaged roof by visualising a tarpaulin covering the hole. This change to the image usually resulted in an immediate reduction in self-reported paranoia – a classic crack-cocaine related state.
Going forward
I have argued that it is time to move towards more trans-theoretical perspectives on the practice of mental imagery, but how can this be achieved? I think there are three ways forward. First, it is important to develop the evidence base. Mental imagery has suffered until recently from a lack of research interest in the counselling and psychotherapy field. One of the advantages of CBT being the current driver of developments in this practice is its commitment to empirical evidence for interventions. This commitment is evident in the increasing range and volume of research studies being carried out into the efficacy of therapeutic applications of mental imagery. The findings often confirm long-held clinical assumptions about effective practice. One such example would be Holmes and colleagues’ study, cited in the study by Hackmann et al,5 which seems to support clinical observations that therapeutic work is more effective when clients view their mental images from a first person rather than third person perspective.
A second way forward would be to develop trans-theoretical frameworks for the practice of mental imagery. This could take the form of generating something similar to Clarkson’s five relationship modality framework,9 which allows a means of drawing on differently theorised approaches to mental imagery. An integrative practitioner could then use techniques and procedures developed within different schools in a way that responded to the ever- changing requirements of the therapeutic process. Another possible approach could involve a search for commonalities in its practice in different schools. An example of the latter would be a research study that identified a range of common functions in the way that mental images operate as agents of communication between the conscious and non-conscious aspects of the self.10
And third, we can start to develop practices whereby mental imagery is viewed as an integral aspect of talking therapies. Such practices would mirror the way that mental imagery is increasingly understood to be fundamentally implicated in embodied cognitive processing. Rather than being an add-on, such as a technique or something separate such as an image-based approach (this is not to disparage the usefulness of these), the client’s mental images would be more deeply interwoven into the fabric of the therapeutic work.
In the following very brief vignette (all identifying details have been changed to protect anonymity), I give an example of how this can work. In this case, the building image is being used throughout the therapy as a site for ongoing work and meaning-making.
Vignette: Vicky
When Vicky first came for therapy, her presenting issue was her sense of hopelessness and despair. She reported that she had never managed to establish a fulfilling life. Initially she was shocked when she produced a representation of her self-structure in the form of an abandoned, moss- covered hut. However, on reflection, she reported that its flimsy nature resonated with her fragile sense of self and she linked its abandonment to the ending of a dysfunctional relationship 20 years previously.
Vicky said that she was ready to focus on strengthening her sense of self. From clinical experience, I was aware of the importance of creating a sense of containment while clients engaged on working on their self-structure. So I recommended that she visualised a little caravan parked up by the hut, which she could use as a temporary base. During the first couple of months of the therapy, Vicky visualised being inside the site caravan and gazing out of its window at the abandoned hut. Through this activity she was able to reflect on and come to terms with the negative long-term impact of the relationship on her life.
As the therapeutic work deepened, Vicky started to revisit her childhood and this corresponded with her first tentative explorations of the inside of the hut. Here she began to realise that it was poorly constructed and the floorboards were rotten. She felt that there was something bad that was emitting noxious fumes underneath one corner of the floor. Imagining herself prising up one of the rotten floorboards triggered a difficult psychological process of uncovering repressed memories of childhood sexual abuse. This painful process unfolded over several months as Vicky used the safety of the therapeutic sessions to begin to recall incidents from her childhood. Every now and then I would encourage her to return to the building image to anchor and monitor the therapeutic work. At points when the process felt overwhelming and threatening, Vicky would be reassured by the concreteness of the metaphor of the building and the security offered by an exterior perspective, symbolised by the caravan.
By the end of the first year the rotten floorboards and the noxious contents from under the floor had been removed. Although Vicky’s sense of self was still, understandably, insecure, she reported that she no longer felt so despairing – the image of the hut ready for new foundations gave her hope for the future. (Readers who are interested in using mental imagery in this way are referred to my published guide.11)
Conclusion
Counselling and psychotherapy have used the therapeutic potential of clients’ mental imagery in a range of ways, but its development has remained harnessed to the paradigms of different therapeutic approaches. Now is the time to recognise the fundamental importance of mental images in cognitive processing and move its theorisation and practice beyond the limits and partial perspectives of particular schools. A deeper integration of mental imagery within talking therapies is long overdue and would resonate with wider historical and cultural processes that are moving beyond Cartesian dualism and its unhelpful deprivileging of imagination in healing processes.
Dr Val Thomas is a counsellor, supervisor and trainer. She was formerly course leader for counselling training at Anglia Ruskin University. She currently works at The Minster Centre developing post-qualification programmes.
References
1. Breuer J, Freud S. Studies on hysteria. In: Strachey J (ed). The standard edition of the complete psychological works of Sigmund Freud, vols 4 & 5. London: Hogarth Press; 1955. 2. Jung CG (ed). Man and his symbols. New York: Dell Publishing; 1968. 3. Leuner H. Guided affective imagery: mental imagery in short-term psychotherapy: the basic course. New York: Thieme-Stratton Corp; 1984. 4. Desoille R. The directed daydream. New York: Psychosynthesis Research Foundation; 1966. 5. Hackmann A, Bennett-Levy J, Holmes EA. Oxford guide to imagery in cognitive therapy. Oxford: Oxford University Press; 2011. 6. McMahon CE, Hastrup JL. The role of imagination in the disease process: Post-Cartesian history. Journal of Behavioral Medicine 1980; 3(2): 205–217. 7. Lakoff G, Johnson M. Metaphors we live by (2nd ed). Chicago: University of Chicago Press; 2003. 8. Gibbs RW Jnr, Berg EA. Mental imagery and embodied activity. Journal of Mental Imagery 2002; 26(1–2): 1–30. 9. Clarkson P. The therapeutic relationship (2nd ed). London: Whurr Publishers; 2003. 10. Thomas V. The therapeutic functions of mental imagery in psychotherapy: constructing a theoretical model. In: Goss S, Stevens C (eds.) Making research matter: researching for change in the theory and practice of counselling and psychotherapy. London: Routledge; 2015 (pp106–121). 11. Thomas V. Using mental imagery in counselling and psychotherapy: a guide to more inclusive theory and practice. London: Routledge; 2015. +++ Dilemmas
Confronting challenges in the supervisory relationship
This month’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 note that opinions expressed in these responses are those of the writers alone and not necessarily those of the column editor or of BACP. You can read additional responses to this month’s dilemma at TherapyToday.net.
Refer to the original contract
James Rye Counsellor, psychotherapist, supervisor, and trainer working in King’s Lynn
I found it helpful to approach this problem by considering three areas: the original supervision contract, the dissatisfaction with the supervision service, and the limits on the responsibility of care. Therapists know that problems with clients can sometimes be helped by reference to a good contract. The same is true with supervision problems. Did the initial contract contain information on these key areas? Was there a clear understanding about contact between sessions? Was such contact permitted and, if so, under what circumstances? Was there any reference made to intended response times on behalf of the supervisor, how disagreements might be resolved, or how the contract might be modified if necessary? It is clear that Pat is dissatisfied with parts of the service he is receiving. He has expectations that Sylvie will respond to his contacts within a certain timeframe and will remember details of all the clients that he brings to supervision. The supervisor may or may not think that those expectations are reasonable, and reference to a good written contract, or an updated and re- negotiated one, might resolve the issue.
Pat is assuming he understands the reasons for Sylvie’s behaviour. Although he has been talking to Sylvie, it seems that he has largely framed the issue in terms of her growing old (which makes it personal, and perhaps inappropriate), rather than in terms of the professional issue (his concerns about aspects of his experience of being supervised). Pat may have grown close to Sylvie over the 10 years, and feel responsible for part of her care. However, it is not the supervisee’s job to take responsibility for the supervisor’s health and fitness to practise. The supervisor’s supervisor should be monitoring that. At the heart of this problem there is a professional disagreement about the quality of service being provided. It feels as if that is in danger of getting lost.
In my view Pat should seek to raise the issue with Sylvie, framing it as a professional dissatisfaction and, if possible, refer to the current understanding about what and how supervision should take place in this professional relationship by referring to the written contract or initial discussion. It may be that Sylvie is happy to make changes in her behaviour and revise the contract. It may be that she feels Pat’s expectations are unreasonable.
If Sylvie is not willing to accommodate the changes Pat requires, Pat either has to accept that or thank Sylvie for her work over the years and seek a new supervisor. Some would argue that a new supervisor after such a long time might be a wise move anyway. If Pat feels genuinely concerned about Sylvie’s apparent condition, he can express that to her, but he must leave her (and her supervisor) with the responsibility of considering the validity of that judgment and of caring for herself.
Other supervision is needed
Mary Russell MBACP (Snr Accred) counsellor and supervisor in private practice
On the face of it there is a clear answer to this dilemma as far as Pat is concerned. In various ways his supervision with Sylvie is no longer meeting his needs and therefore those of his clients, and other supervision is needed. The fact that he may retire in a couple of years is beside the point as the needs of the clients he will see in that time are obviously as important as those of the clients he saw earlier.
If we look at the reasons this supervision has become problematic, the strongest indicator is that Pat has tried to talk to Sylvie about his issues but ‘his efforts have landed on deaf ears’. This indicates that, in this area, she is at present unable to show the reflectiveness and curiosity essential to our work as counsellors and supervisors. There may also be a problem with Pat’s ‘gentle’ approach. The knowledge that he is moving towards retirement himself may mean that he feels less robust and has less clarity about his supervision needs. He also needs to explore this in supervision. A robust review in which both Pat and Sylvie explore their work together, as well as re- visiting their contract (including supervisor availability), is essential.
The other problems mentioned are Sylvie’s difficulty remembering Pat’s clients and her failure to reply to his need for support in a timely manner. Neither of these in themselves proves a cognitive decline, which might necessitate retirement. Our practice at any age is influenced by life events and these are also in play here. We will all have periods, such as holidays, when we are unable to meet the needs of clients and supervisees. As we grow older we sometimes use notes more than we did previously. This may be easier with short-term rather than long-term work. Arguably we should all have more than one source of supervision, even though we have a lead supervisor. This means that we have supervisory support at all times, and also additional support in specialist areas when this is appropriate.
As far as this supervision is concerned, we do not know how useful Pat continues to find it in terms of his client work. If his work continues to benefit from Sylvie’s supervision he could consider continuing to see her while also seeing another lead or supplementary supervisor. This arrangement would need to be transparent to the practitioners involved. If Pat has concerns about Sylvie’s continued ability to practise, and evidence of this, then there is a further ethical dilemma as to how she may be encouraged towards retirement. Sylvie’s supervisor should also be involved in this. The only formal mechanism we have at present is a Professional Conduct Procedure. A ‘capacity’ stage before this, with assessments, would be useful here. It would be helpful to have more support and guidance from BACP when we come to an age where cognitive decline is more likely.
Why maintain the status quo?
Helen Tattersall Person-centred counsellor and supervisor working in private practice and in an NHS IAPT counselling service
It sounds like the boundaries in this supervisory relationship have become blurred due to a personal element developing over time, which appears to be unacknowledged. It feels like Pat is having difficulty separating how he feels personally for Sylvie from his needs as a supervisee. He appears to be struggling with being fully congruent with her because he cares about her and doesn’t want to be critical of her, and can also identify with issues that may be age related. He also appears protective of her, being aware she is experiencing a difficult time personally. Unfortunately Sylvie does not seem to have awareness of these issues and the effect they are having on Pat, and is not picking up on his attempts to communicate his concerns. Another element is Pat’s reluctance to start afresh with a new supervisor. His reluctance to address the issues more openly with Sylvie may be related to his fear of fracturing the relationship, which could result in him having to change his supervisor.
It may be helpful for Pat to reflect on his reluctance to be more challenging with Sylvie and explore what need is being met in him by staying with the status quo. As our behaviour is motivated by our needs, Pat could benefit from becoming more aware of what emotional need is behind his current dilemma. He seems to be reluctant to leave the security of the longstanding relationship, despite the change in the nature of it with regard to his needs as a supervisee being fully met. An open discussion with Sylvie, owning his reluctance to challenge her but clearly sharing his concerns in a direct way and how they are affecting him, may help Sylvie be more open to hearing his concerns and addressing them. Ultimately Pat is going to have to decide what is more important to him: the personal relationship that has developed or his desire to have a supervisor he feels fully confident in and who has the capacity to be consistent and fully present in her role as a supervisor.
Separate friendship from the contract
Jim Holloway MBACP senior accredited supervisor, partner in Cambridge Supervision Training and co-author of Practical Supervision (JKP, 2014)
First of all, what’s this anxious feeling in my gut? The tale of Pat and Sylvie has got me squirming a little. I haven’t experienced their situation in reality but can recognise myself in both of them. I guess my gut is saying: this could all too easily happen to me, so be careful. And I am worried about Sylvie. Assuming she is providing counselling or therapy and not just supervision, how risky has her forgetfulness and unreliability become in her contact with clients? Pat’s concern is presumably shared by her other supervisees, who might also feel their caseloads are inadequately supported. Sylvie’s decline, to put it bluntly, is probably adversely affecting a large number of people in her direct or indirect care. I wonder what her supervisor is doing about this.
Pat’s dilemma stems largely from his dual relationship as a fond friend and professional colleague. Such a relationship can be wonderfully restorative; it can also completely flatten collegial rigour. He has been a good friend by telling her honestly what he has noticed in her behaviour but, significantly, his words have ‘landed on deaf ears’. Putting aside the fact that at her age Sylvie is likely to have actual hearing loss, this phrase is telling. I imagine she has profoundly enjoyed her work for decades; surviving her extreme personal difficulties has deepened her passion for it even more. She might feel invincible, believing she will work till she drops. If so, the challenge for her to unlock her denial and enter a new phase of life outside her profession could be huge. However, if she seems mostly unaware of her memory loss, the challenge might be more to do with Alzheimer’s disease. Pat could discreetly ask one or two people who also know Sylvie well if they have noticed the same uncharacteristic changes in her that he has. He will be reassured if he knows that someone else is also respectfully confronting her.
He has spoken to Sylvie ‘gently’ about things. Understandably, he doesn’t want to hurt his friend or damage his highly valued supervisory relationship by speaking more forcefully, but he has an ethical duty to put his professional commitments – to himself and his clients – first. Compassion is the toughest of all the virtues. I want him to step up a gear and be firmer with her, face to face. Then he could also write his concerns in a letter (I mean a proper old- fashioned letter, not an email), as she might be able to ‘hear’ him more acceptingly in a tangible form like that.
Pat must change to another supervisor – specifically someone who does not know Sylvie – for the last two years or so of his career. This would remove the risk to his practice presented by Sylvie’s cognitive impairment (albeit as yet medically undiagnosed). His ethical task is to separate his personal friendship with Sylvie from his supervisory contract with her. Pat would then be free to be wholly her friend without compromising his professional integrity.
Individual action is not a solution
Roslyn Byfield Counsellor in private practice
It’s interesting that this dilemma is the subject of Anne Power’s article in the same issue of Therapy Today, and of her recent book Forced Endings in Psychotherapy and Psychoanalysis: attachment and loss in retirement. Although Anne interviews a number of therapists at various stages of closing their practices (and what she discusses about therapists can equally apply to supervisors), awareness of need and/or desire for closure has obviously preceded the decision. We have to wonder how many such supervisors and therapists could be practising apparently unaware there is anything amiss.
As Pat has benefited from this relationship for so many years it is understandable that it would be hard for him perhaps even to question, let alone address, what is happening in terms of Sylvie’s apparent decline. Pat is also aware that Sylvie has had difficult issues to deal with and this could enable him to believe that the situation could revert to ‘normal’ after a while. Feelings of attachment and loyalty will be a strong influence, but as Anne’s article clarifies, such cognitive decline (‘crumbling therapist’) could go unseen by the supervisor’s own supervisor, since difficulties can be glossed over during a relatively short meeting.
If it’s not the supervisor’s job to pick up on and address such cases, does it then become the supervisee’s? There seems no clear answer to this at present but issues Pat may want to reflect on, perhaps in his own therapy, if he has it, include being in the ‘latter stages’ of his own career, possibly leading to uncomfortable thoughts about his own decline; a defensive reluctance to let go of a strong attachment (ie wanting to continue ‘if possible’) in order to avoid the situation he is confronted with; and boundaries, as it sounds as if the relationship has become as much friendship as supervision. It seems Pat hopes it will get better of its own accord but if not he may have to face a potentially difficult choice without much support.
Anne points out the lack of a policy on retirement: having also no compulsory retirement age as exists in other professions such as the judiciary (although this would not necessarily be a solution), is another by-product of an unregulated profession. It could be argued that workable policies and procedures need to be developed to remove unfair responsibility from individual supervisees, and because individual action is not a solution.
He may need to put his affection and loyalty aside
Leon McCarthy Counselling diploma student, West Herts College
Pat needs to acknowledge that this is a professional supervisory relationship between two experienced practitioners who need to take joint responsibility for any difficulties within the supervision. It is not a therapeutic relationship, although there will obviously be elements of both transference and countertransference within it for both parties. While one can be sympathetic to Pat’s wish not to change supervisors at this point in his career, he has to accept that he needs to tackle the current difficulties with his supervisor.
At this point Pat needs to raise the issues with Sylvie very directly and clearly, albeit in a gentle but persistent way. If Sylvie is able to recognise and acknowledge any of what he is saying, and to think about possible solutions, then it may be possible to continue the supervisory relationship if things improve. However, if Sylvie is defensive, dismissive or denies that there is a problem, then the supervisory relationship cannot continue, as Pat is not getting what he requires for his professional practice. Soldiering on for another couple of years with supervision that Pat considers inadequate would be doing a great disservice to the process and could have an adverse effect on his client work.
Perhaps they might spend some time together looking at strategies that may help them to continue their working relationship. After 10 years working together, perhaps it is time to renegotiate their contract. Could they allow more time for note taking during the sessions to help Sylvie recall details? Or maybe agree a regular time slot in which Pat might call her should he have a pressing client issue?
If Sylvie remains unreceptive to her supervisee’s suggestions, perhaps it is a sign to Pat that he may need to move on and find someone new. This does not exclude a personal relationship continuing, although that may be difficult if Sylvie cannot acknowledge there was an issue with their work together. Even though Pat is an experienced counsellor and in the throes of winding down his career, the support of a competent supervisor remains essential to underpin both his client work and his wellbeing. Pat may need to put his feelings of affection and loyalty aside to ensure he gets a more adequate level of protection and support in future.
Febuary’s dilemma
Anton is the counselling co-ordinator for a substance misuse charity where he supervises qualified members of staff and student counsellors on placement, as well as holding his own client caseload. Following the Savile Inquiry, the charity introduced a policy that requires counsellors working with clients who disclose historical sexual abuse to encourage them to disclose the name of the perpetrator, if they are still alive, and collect as much information as possible with a view to the client then sharing this information with the police.
In addition to his paid employment, Anton also volunteers for a local counselling centre where the approach is psychodynamic. He has asked his supervisor and the centre director whether this same approach should also be followed there and has been told it shouldn’t. He is currently working with a client who is a survivor of sexual abuse and who has given him the name of his abuser, and he is concerned about the ethics of not working with him in the same way he would if he was in his workplace. He is particularly anxious about the possibility that he may be the only person that this client has told, and the risk that, as the perpetrator is still living, other children may be being abused.
What should Anton do?
Please email your responses (500 words maximum) to John Daniel at [email protected] by 20 January 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
We can’t ignore politics
I am shocked by Denise Pickup’s letter requesting less coverage of political, social and international issues. Surely the individual cannot exist in a vacuum outside his/her social, cultural and political context? If we opt out of political, national, international and social issues, what kind of therapists and human beings can we be?
Has it not occurred to Denise that the lack of funding for Relate in Lincolnshire and the reason why it had to close might be related to cuts in government funding for local government? Government policies on welfare have also been the cause of many of the mental and physical health difficulties which drive our clients to seek our help.
I think this individualistic and solipsistic stance, in which counsellors and therapists separate themselves from the ‘political’ (which has also often played a big part in the formation of our inner psyches as well as our values and meanings), gives the whole therapeutic project a bad name.
I welcome the fact that Therapy Today is not insular and, while addressing national and local ‘therapeutic’ issues, also covers practice with refugees and people in China.
Val Simanowitz MBACP senior accredited counsellor and supervisor
Walking the walk
I am writing in support of Frances Bernstein’s view (‘Personal therapy is important,’ Letters, November Therapy Today) concerning the importance of personal therapy in this work – a wider issue than that of distinguishing psychotherapy from counselling. Frances states that she was required to be in personal therapy for the duration of her five-year training. It was the same for my three-year MSc, and this was not just any therapy – as the training was psychodynamic the therapy also needed to be weekly and psychodynamic or psychoanalytic. I would go further and suggest that, as learning is continuous throughout life and our formal qualifications are steps along a journey rather than a completion, we benefit from continuing our own therapy.
Worryingly but not surprisingly due to lack of regulation, it seems there are now many courses that require no therapy, or a minimal amount (eg six sessions). This is, perhaps, compounded by the absence of any requirement for therapy in NHS CBT trainings for roles in IAPT services. Besides potentially encouraging omnipotence, this could carry the damagingly normalising message that we don’t ourselves need to experience what we are expecting our clients to experience.
I believe it is ill-advised that BACP some time ago removed the requirement for personal therapy, as it represents an omission in itself and also has implications for the profession’s status, linking with the relatively low pay (compared with other professions) that many practitioners complain of. I don’t think other kinds of personal development, beneficial though they may be, can be substituted for undergoing the kinds of journeys (at times painful) our clients are taking with us.
I agree with Frances’ view that ‘personal therapy is as important as ongoing supervision for working in depth and for working with complex need’. CBT doyenne Christine Padesky’s words, quoted in a review of a book about self- reflection for CBT practitioners (‘Experiencing CBT as a therapist,’ Reviews, November Therapy Today) could well apply to personal therapy: ‘Your credibility, the therapeutic alliance and client adherence are enhanced when you have “walked the walk”.’
Roslyn Byfield Counsellor in private practice. www.roslynbyfieldcounselling.co.uk
Why a Christian counselling centre?
I was interested in the responses to the dilemma discussed in November’s Therapy Today. Much of what was covered was excellent.
I was wondering, however, about the little bit of information that nobody picked up on, other than the oblique comment that Avril might have support ‘from her Christian Counselling Centre’ – about the setting being a Christian counselling service. This is a particular kind of information. It might have been a ‘large city centre’ service, for example, which would have prompted me to think about people possibly going there hoping for anonymity, or that parking might be an issue. It is one sort of information. But the reference to Christian sets a frame for thoughts and fantasies about certain sorts of beliefs and values, or our ideas about them. It could well have some bearing on why a counsellor might want a voluntary placement there, or why a couple might look for therapy there. Whatever the counsellor’s stance, it is bound to have an influence on what the clients think, either knowingly or unconsciously. And should therefore be part of a background discussion about what a couple are hoping for and what might be acceptable to them.
What if the people had Muslim names and the counselling centre had been described as Islamic; would that also not have been mentioned?
Your respondents’ comments were all valid and pertinent. But it did feel to me like the Christian bit was an elephant in the room!
Annie Hargrave Retired psychotherapist
Lincolnshire Relate
Relate would like to reassure readers of Therapy Today that by the end of November the ongoing relationship support needs of people in Lincolnshire will be being met. This follows a letter in the November issue of Therapy Today (‘Relate branch closed’) from a reader who was understandably concerned following news of the closure of Relate Lincolnshire.
Relate is a federation with a central national charity and 59 centres, which are all separate charities and separate limited companies. We all rely on funding from various sources to subsidise the services we provide for clients. We were very sorry to see Relate Lincolnshire close in October after 53 years of supporting local couples, families and young people. The centre had experienced financial difficulties caused by a number of factors, including the loss of a major contract.
We apologise for the short gap in service delivery and any inconvenience and upset caused to clients and our dedicated staff. Relate as a national charity is committed to continuing to provide services for the clients and communities of Lincolnshire and we acted quickly to ensure clients were offered telephone and email counselling while services were re-established. We are pleased to say that the full range of services will be up and running again by the end of November, provided by Relate as a national charity but delivered locally.
The way people want to access relationship support is changing and Relate, like all providers, needs to constantly review how we provide services in the most accessible and affordable way for our clients. That is why, in addition to our commitment to provide face-to-face counselling, we have also developed online support counselling services using web-cam and email. Our innovative Live Chat service also provides clients with a one-off, 30-minute, targeted support session with our trained counsellors.
Despite tough economic times we know that the demand for relationship support is growing. As such, we are determined to make sure that relationship support is available across the country. Relationship breakdown costs the economy an estimated £47 billion, which is why Relate and other organisations are calling for the Government to triple to £22 million its promised £7.5 million for relationship support. This will provide much-needed investment for interventions that we know make a difference.
Chris Sherwood Chief Executive, Relate
Integrity, not qualifications I refer to the recent correspondence attempting once again to differentiate counsellors and psychotherapists – a continued debate that is both anachronistic (witness BACP’s own guidance on the subject) and demeaning to the profession, judging by the nature of some of the correspondence. There is surely a simple and dignified answer: the difference lies in the nature of the work and the integrity of the practitioner, rather than the person and their qualifications.
David Sherborn-Hoare MNCS (Accred), MBACP Reg. www.cheltenhamcounsellor.co.uk
Personal work integral to CPD
Reading Frances Bernstein’s letter (Therapy Today, November 2015) about the importance of personal therapy – ‘in my view having had personal therapy is as important as ongoing supervision for working in depth’ – I would add that in-depth personal work is integral not only to both counselling and psychotherapy training but also to continuing personal development; that being fit-to-practise includes recognising the value of further therapy, even or perhaps especially when not deemed ‘necessary’.
Jane Barclay AHPP (Accred), UKCP Reg psychotherapeutic counsellor, Exeter
Counselling and CBT?
Someone I know recently had a screening interview with one of the London NHS Psychotherapy Services. He had asked for counselling via his GP due to depression. At the end of the interview he was asked, ‘What would you prefer – counselling or CBT?’ He was told that CBT has a good track record. He said he’d prefer counselling. It doesn’t seem right that they seem to have been put into two quite separate categories.
Pam Laurance Counsellor in private practice (who uses some elements of CBT)
IAPT ethnic imbalance
With regard to Gillian Proctor’s article (Therapy Today November 2015), I would add that there remains also an often unreported factor in the delivery of the IAPT initiative – the ethnic imbalance between those delivering IAPT and those receiving it, along with disparities in ethnicity between those who actually do get referred to and receive the service, and those who do not.
Richard Bryant-Jefferies Retired counsellor First, do no harm
‘First, do no harm’ is the primary maxim of every physician, and should also be ours as therapists as we seek to adhere to the ethical principle of non- maleficence. In light of this, therapists should be made aware that there is another side to a short news item in November’s Therapy Today, ‘CBT could help ME’. The article rightly says that The Lancet published research carried out by Oxford University which found that sufferers of Chronic Fatigue Syndrome or Myalgic Encephalomyelitis (ME) may be helped by CBT and GET (Graded Exercise Therapy), and that after two years, sufferers found significant improvement in their symptoms.
A closer reading of the study however, reveals that the findings were quite different to what has been reported. The abstract of the study published in the Lancet Psychiatry, 27 October 2015 says this: ‘There was little evidence of differences in outcomes between the randomised treatment groups at long- term follow-up.’ This means that those in the GET and CBT groups had no greater improvements, long term, than those following a different form of treatment, and those who did nothing at all. The authors hypothesised that the reason for the lack of different outcomes could be because those in the non GET groups did Graded Exercise after the study. However, they have no data or evidence to suggest that this is the case.
The study was a follow up to a previous study, the PACE trial, which itself was found to be significantly flawed. Six scientists from American and English universities sent a joint letter to The Lancet calling for an independent re- analysis of the PACE trial data, due to what they feel were multiple flaws in the research methodology. The open letter (http://www.virology.ws/2015/11/13/an-open-letter-to-dr-richard-horton-and- the-lancet/), states: ‘The PACE study was an unblinded clinical trial with subjective primary outcomes, a design that requires strict vigilance in order to prevent the possibility of bias. Yet the study suffered from major flaws that have raised serious concerns about the validity, reliability and integrity of the findings.’ The letter summarises the main flaws of the trial, and concludes: ‘Such flaws have no place in published research. This is of particular concern in the case of the PACE trial because of its significant impact on government policy, public health practice, clinical care, and decisions about disability insurance and other social benefits. Under the circumstances, it is incumbent upon The Lancet to address this matter as soon as possible.’
If it is true that the NICE guidelines are misleading, this matters for clients who may seek the help of a therapist, asking for GET. The ME Association reports (http://www.meassociation.org.uk/wp-content/uploads/2015-ME-Association- Illness-Management-Report-No-decisions-about-me-without-me-30.05.15.pdf) that 74 per cent of ME patients are harmed by GET, leaving some permanently disabled. As therapists, we can’t be expected to question every piece of research that dictates best practice for the way we work, especially those published in highly reputable medical journals like The Lancet. However, if we are to be practitioners who first do no harm, we do need to consider this one.
Stephanie Bushell BACP Accredited integrative counsellor and supervisor in London
Counsellor training and therapy
It is not true, as Frances Bernstein implies (Letters, Therapy Today, November 2015), that counselling training does not require trainees to have personal therapy, and I am surprised to read this from a qualified supervisor. Some courses do not have this requirement – a mistake, in my view – but many do. I trained as a counsellor at Re-vision, the Centre for Integrative Psychosynthesis, and we were required to have personal therapy for the duration of the three-year course. I found this an invaluable experience, which enabled me to integrate the learning from the course, and especially to learn from my own experience about the value of a relational stance in working with clients. Many of us continued with our personal therapy for some time after the course, and continue to return to it as a resource in times of personal or professional need.
Maeve Allison MBACP (Accred) Registered Counsellor and EMDR Europe Accredited Practitioner
On the wrong list
In 2006 I applied to a charity that was looking for new trustees. In return for my counselling expertise, I gained the experience of being a trustee. I resigned in 2008, not realising that my confidentiality was already breached.
Two years later, at a family party, people were googling each other’s names to see what could be gleaned about them from the internet. When it came to my turn, I was astonished to be told that my postal address, phone number and date of birth were freely available. I had no idea how Google had accessed these details and made strenuous attempts to get them removed but with no success.
When Google started to help individuals who wanted their out-of-date information erased, I discovered that the charity had mistakenly listed me as a director and so my name and address had been placed on the Government’s Companies House website. The only way to get my details removed was to prove that my life was in danger. However, my name and date of birth would remain on the site for ever, even if my address was removed. If I wanted to be delisted, I had to pay £55 for each incorrect listing, enclose a letter from a police inspector in support of my application, and provide an alternative address. In 2014 I decided to pay £165 and submit all the required paperwork. Fortunately my application was successful. As soon as I heard from Companies House, I googled my name and found that nothing had changed. There was one further problem. Companies House had sold my details to other websites. I had to contact each one and apply to be delisted. This took until the end of March 2015. Therapists, beware of getting on the wrong list!
Bella Hewes
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
Fear of climate change
Environmental melancholia: psychoanalytic dimensions of engagement Renee Lertzman, Routledge, 2015, 221pp, £90, isbn 978-0415727990
Reviewed by Anne Gilbert
In recent times it has become fashionable to argue that we do not take action to safeguard the environment because we are apathetic. In this delightful and original text the author uses psychoanalytical theory and psychosocial research to explore issues of public engagement and apathy in relation to environmental issues.
The opening section, ‘Why psychoanalysis matters’ sets the scene and explores the arguments for applying psychoanalytic concepts to environmental issues. Qualitative research undertaken by the author is outlined, together with a detailed rationale for the research methodology selected. The author describes the in-depth interviews with respondents she conducted in Green Bay, Wisconsin about their responses to the degradation of their local environment.
In ‘Psychic Dimensions’, she presents the research findings and analysis. Chapters 4–6 cover themes of loss, mourning, melancholia and ambivalence that emerge. Lertzman concludes that far from being apathetic, her research subjects are stuck in what she labels environmental melancholia, a chronic form of mourning for environmental losses. The sense of loss experienced is so profound that it is difficult for participants to make sense of. She also concludes it is the situation of stasis from their grief that prevents respondents moving on to anger and action, rather than that they are apathetic. Chapter 7, the final one, explores ways of moving from loss to engagement in local communities, by inviting creativity. The lengthy appendices provide more detail of the research respondents and methodology.
Although this is a densely written text, I found it novel and very thought provoking. It will be of interest to those wishing to apply therapeutic frameworks to wider social issues. A couple of caveats: I really wish the photographs were colour rather than black and white in order to provide a more vivid depiction of the local terrain. Also, this is a very slim volume and it is difficult to understand why it costs £90.
Anne Gilbert is a Gestalt psychotherapist and supervisor
A therapy novel
The training patient: a novel Anna Fodorova, Karnac, 2015, 242pp, £9.99, isbn 978-1782202202
Reviewed by Anne Power
I never tire of novels about therapy and I found this one both enjoyable and interesting. Whilst not the strongest in terms of the depth of the therapeutic dialogue, the book breaks new ground by focusing on the experience of a trainee. The story is set in a psychoanalytic training so our novice therapist needs first to find herself a patient who will come twice a week and the treatment is conducted within a classical frame – or at least is meant to be.
Like almost all therapy novels the story involves some suspension of belief – in this case the therapist plays fast and loose with the frame in a way that detracts considerably from veracity. She becomes in effect a stalker to her patient – a narrative that fits with the patient’s presenting problem of being followed. The therapist’s countertransference and its enactment thus form a major part of the book.
Another theme explores the protagonist’s weekly visits to her benign supervisor. Here we see her struggle to admit the muddles she is getting into with the frame. We also see her with her own therapist, or rather with two successive therapists where she experiences two different types of transference.
The story includes many of the aspects to training which I have not seen covered in fiction: relationships with peers, the struggle of different trainees to keep going and the group’s interactions with their tutor. An important subplot is the death of a therapist. It was very good to see this explored in fiction as this is a remarkably common experience and, as in the real world, no one was available to protect the interests of patients by putting the case for responsible retirement.
For those whose training is psychodynamic the world described in this story will be very familiar. For those of other modalities it may be interesting to take a look at a different process. In terms of literary style, the book is mixed. There are some moving passages, but sometimes the effort to describe and convey this rarefied world results in rather heavy writing. For me the interest in the story overcame the awkwardness in style.
Anne Power is an attachment-based psychotherapist and author
Understanding the Muslim client
Islamic counselling: an introduction to theory and practice G Hussein Rassool, Routledge, 2015, 296pp £29.99, isbn 978-0415742689
Reviewed by Myira Khan As a Muslim counsellor, trained in psychodynamic counselling, I approached this book with much curiosity, wishing to further my understanding and knowledge of working with Muslim clients using a faith-based model. I found the range and depth of topics that the book explored quite staggering and beyond my expectations. In Part One, the book presents Islamic context (theory), covering basic principles in Islam, spirituality, personal development, cultural and religious influences upon mental health, working with Muslim clients and Islamic ethics relating to counselling. I would recommend that for any counsellor this is essential reading to develop understandings of Muslim clients and their context of religious and cultural dynamics. It underlines how these impact upon accessing counselling and of how clients may perceive the ability to change through counselling.
Rassool goes on to present an 11-step practical model using directive and non-directive techniques, skills, guidance and spiritual interventions. This is derived from an integrative theoretical modality of Islamic counselling, which includes elements from mainstream counselling theories that are congruent with Islamic principles, such as the core conditions. This illustrates how many mainstream principles/values/ morals are shared with the Islamic understanding of ‘good’ characteristics and principles. Rassool also explores how to use an Islamic counselling perspective for client assessments and working with particular presenting problems, ie addictions and alcohol problems. Throughout the book he does not claim his model to be a fixed template for practice but as a “preliminary mapping exploration” for further development (p219), which reflects a robust yet flexible foundation for counsellors to use and build upon.
Rassool identifies that the challenge facing counsellors is fundamentally to be ‘responsive’ to clients’ health beliefs/practices and their religious-cultural needs. Although subtitled ‘An introduction to theory and practice’, the topics covered are more far reaching than implied by ‘an introduction’ and it is essential reading for all counsellors working with Muslim clients. The flexibility it offers, to use theory and/or practice to develop culturally-competent counselling, allows us to incorporate elements which we feel would best support our clients in accordance with their religious-cultural beliefs. As the first mainstream textbook on Islamic counselling, I think Rassool has successfully created a comprehensive resource to further develop culturally- competent counselling for Muslim clients as well as providing a faith-based practice model for counsellors who are looking to offer Islamic counselling.
Myira Khan is a counsellor in private practice and founder of the Muslim Counsellor and Psychotherapist Network
Freud’s history
The hidden Freud: his Hassidic roots Joseph H Berke, Karnac, 2015, 245pp, £25.99, isbn 978-1780490311
Reviewed by David Goldstein Throughout his life Freud dissimulated and denied his Jewish roots, in an attempt to re-create himself as a Viennese professional and to protect his creation, psychoanalysis, from the anti-semitic charge of being a ‘Jewish science’. Despite this, he joined the Vienna B’nai Brith in 1897, shortly after his father’s death, and (by administration of morphine) chose the Jewish Day of Atonement, Yom Kippur, as the day of his death.
In this intriguing and rewarding work, Berke examines Freud’s family history and Jewish education, tracing his line back to his grandfather, Shlomo, an Orthodox Hassidic Jew living in a Galician shtetl. Most of Freud’s circle and followers were Jewish, and many were descended from notable rabbis and scholars.
The book does not read as a coherent argument and is perhaps best considered as a collection of essays or ‘free associations’, weaving together ideas from psychoanalysis and explorations of the lives of Freud and other psychoanalysts, with themes from Kabbalah and Hassidus and Berke’s own original psychoanalytic and Jewish mystical interpretations.
I found the chapter on ‘Lowness of spirit’ of particular interest. Hassidic thought distinguishes four kinds of what we commonly call depression. Three, nemichat ruach (lowness of spirit), lev nishbar (contrition, broken- heartedness), and merrirut hanefesh (bitterness of soul) are seen not as pathologies but states of spiritual falling-short and calls to renewed effort. These are important distinctions to be made in clinical work.
Similarly, the chapter on ‘Reparation’, comparing Klein’s concept with Jewish ideas of t’shuvah (repentance, return) and tikkun (repair), also has the potential to deepen our work with clients.
In his enthusiasm to establish Freud as an essentially Jewish thinker Berke is sometimes guilty of hyperbole. A conversation with Rabbi Safran (a future chief rabbi of Romania) becomes ‘several meetings’ (p104) and a consultation from the Hassidic Rebbe Rashab ‘must have brought Freud back to his Jewish roots’ (p19). Must have? Annoying as it is, this tendency is forgivable given the overall quality, depth and interest of Berke’s writing.
As counsellors and psychotherapists we need to be able to respond to our clients’ (as well as our own) strivings for meaning, spiritual depth and wholeness. This book reveals some of the spiritual sources of psychoanalysis and is a valuable resource for any who choose to delve into it.
David Goldstein is a counsellor
Refugee children
Handbook of working with children, trauma and resilience: an intercultural psychoanalytic view Aida Alayarian, Karnac, 2015, 205pp, £24.99, isbn 978-178220193
Reviewed by Jeanine Connor
Aida Alayarian has almost 30 years’ clinical experience and is the founder, Clinical Director and CEO of the Refugee Therapy Centre (RTC) in London. Her book combines research, theory and practice, focusing on the experiences of refugee and asylum seeker children, with the explicit aim of examining the impact of torture.
The opening chapter reminds us that one quarter of asylum seekers are children and that the trauma they endure is threefold; encompassing stressors endured in their country of origin, their flight to safety and their new environment. The author acknowledges her feelings of pain and anger in response to the children’s narrative but acknowledges also that this will not help them and is not what they need. The book contains many clinical vignettes depicting the horror of refugees’ experiences. It is difficult not to be pained or angered by them, providing a stark example of the challenge of working with this client group.
I found Alayarian’s no-nonsense style of writing appealing. She draws on a wealth of psychodynamic literature including Freud, Erikson, Bowlby, Stern and Ainsworth. Readers without a psychoanalytic background may find this a challenging read, although Alayarian does a sterling job of making the underpinning theory accessible.
She identifies post-trauma anxiety and depression as normal responses to environmental stress rather than signs of mental illness. Similarly, the importance of recognising adaptation strategies as a sign of health is illustrated, for example, by identifying ‘healthy dissociation’, which moves the focus away from trauma and provides a much needed psychic break.
The ‘resilience’ part of the RTC model encourages a shift away from the traditional ‘deficit, disorder, problem-behaviour’ paradigm and instead encourages a focus on competencies, capacities and resources; in other words, the emphasis is on the haves rather than the have-nots.
Alayarian’s caution against pathologising and the provision of medication is refreshing. She advocates a systemic approach that considers the multiple factors and needs of the children themselves, as well as their families and schools. If only the services of the RTC were available nationally and for all refugee children! An excellent and timely publication.
Jeanine Connor works as a child and adolescent psychotherapist in private practice and CAMHS, and as a writer, supervisor and trainer
The pleasures of life
Unforbidden pleasures Adam Phillips, Penguin Random House UK, 2015, 198pp, £14.99, isbn 978- 0241145791
Reviewed by Jane Cooper
Is it only nice if it’s naughty? Adam Phillips thinks not. This slim volume, originally delivered as interdisciplinary lectures, is a plea for the ordinary pleasures of life to be allowed a place. ‘It is extraordinary,’ Phillips argues, ‘how much pleasure we can get from each other’s company, most of which is unforbidden’ (p195).
We have been brought up to split the world in two – what is allowed and what is forbidden, with the latter held centre stage. The pleasure and affection one might feel, say, in having coffee with a friend, is seen as a poor cousin to the illicit pleasure of the forbidden affair.
I like the way Phillips describes the therapeutic process as a reassessment of the forbidden and the unforbidden in our lives. This process often reveals that we are ‘the casualty of forgotten obediences’ (p82) and Phillips makes a helpful distinction between two kinds of obedience – the pathological kind that he suggests stems from a tantalising mother and what he calls a more promising obedience that acknowledges reality.
So what would a society based on unforbidden pleasures be like? Phillips draws on the evidence of an unusual traffic experiment, which took place in the Netherlands in 2003. Traffic lights were removed from busy intersections, leading to an improved flow of traffic and fewer accidents as drivers rediscovered the unforbidden pleasures of co-operation and attentiveness, which Phillips likens to the kinds of attunement witnessed between mothers and babies when things go well.
The chapter I found most useful for my work as a counsellor is his treatise ‘against self criticism’, available for free as an LRB podcast at www.lrb.co.uk/v37/n05/adam-phillips/against-self-criticism
We are invited to imagine the superego as a person to whom we get chatting at a party and soon realise is living in the aftermath of a catastrophe. He’s accusatory, narrow-minded and ‘like the referee in football, always right even when he is wrong’ (p109). Phillips makes a valuable suggestion as to how this cruelty can be moderated with a return to the ego ideal, the forgotten part of the Freudian superego. This is ‘inner critic’ work at its best.
Jane Cooper is a counsellor and supervisor
Shelf life
The ‘Shelf life’ feature has been extended to include books that readers would recommend as long lasting good reads relevant to counselling and psychotherapy, as well as classic and much loved books already on their shelves.
Junkie Buddha: a journey of discovery in Peru, Diane Esguerra, Eye Books, 2015, 256pp, £8.99, isbn 978-1903070994
Reviewed by Deborah Keays
Whether it’s due to a lack of time or inclination I rarely get to read a book which a client of mine has enthused over. I’m pleased, in the case of Junkie Buddha, that I made an exception. The dichotomous title intrigued me; a few pages in and I was hooked.
A year after discovering the body of her half-Colombian adult son following his accidental heroin overdose, the author travels alone to Peru to scatter his ashes at the Inca citadel of Machu Picchu – a place to which the young man, who had walked the Inca Trail and loved travelling in South America, had longed to revisit.
It isn’t long before she discovers that Peru’s stunning landscape and anguished history mirror her son’s troubled psyche. This provides the backdrop for her attempt to come to terms with the fraught journey they had shared and its heart-breaking conclusion.
The mystery and awe-inspiring beauty of the country help to reconnect her with life. She befriends several Peruvians who have also been closely bereaved – a son who has lost his mother and a mother who has lost her son, which prompts her to stop asking ‘Why me?’ and to start asking ‘Why not me?’
Whether she is flying over the Nazca Lines in a wobbly plane, meeting an Inca witch, rowing out to floating islands, or finding herself in the middle of a soap opera film set, Diane Esguerra’s eloquent writing and self-deprecating humour make this a surprisingly rewarding and uplifting read. I was able to gain a deeper understanding of the beneficial nature of ‘continuing bonds’ and also of loss-induced post-traumatic growth – which, she believes, has made her a more empathic psychotherapist.
The journey is a courageous one; so, too, is her willingness to share raw emotion with her reader and her determination to create both meaning and value out of some truly heart-breaking life experiences.
Deborah Keays is as a CBT/EMDR therapist and supervisor
Film review: The Lady in the Van
Chris Rose reviews The Lady in the Van, a film that makes you question your own sense of tolerance The lady in the van is the person most of us would avoid – cantankerous, irrational, ungrateful and filthy, with an overpowering odour of urine dusted with Yardley’s lavender talc. Her arrival and subsequent 15-year stay in Alan Bennett’s drive is by now a familiar story, and Nicholas Hytner’s film movingly recreates both the humour and the squalor. ‘Caring is about shit,’ Bennett (Alex Jennings) sagely observes as he treads in it once again on his drive.
The smell seems to waft from the screen to where I sit, certainly challenging my own sense of tolerance. How did Bennett manage this for 15 years? The film presents us with two versions of him – the one who lives in the house and the one who writes about it, and their witty, waspish dialogue questions the nature of this tolerance. Is it indolence, compassion, timidity, guilt for having put his own mother into a care home?
Whatever his motives, it made me think about who and what can be tolerated. As counsellors and psychotherapists we might pride ourselves on our tolerance, but for all of us there is a point where it runs out. Disgust, anger, fear, revulsion – these are some of the things that can erode our capacity to stay in relationship with the other. Appropriately or not, we draw boundaries to protect our limited capacities to relate.
Bennett protects himself in part by turning Miss Shepherd into a subject for his writing, but nonetheless, 15 years of tolerance is a remarkable feat. Yet the story goes beyond Bennett himself. The community of neighbours that the film gently mocks are also tolerant to a degree that I doubt would be the case today. The contemporary culture demands that those who challenge our emotional security are ‘fixed’, quickly and cheaply, or removed from our particular back yard. The film is set in an era when it seemed more possible and acceptable to provide long-term consistent support for those whose problems were not ‘solvable’.
The film shows how, in a very English, restrained manner the relationship between the characters develops in the context of this long-term consistency. We are rewarded with a glimpse of who this woman might have been in other, kinder circumstances. Miss Shepherd is revealed as an accomplished pianist, fluent French speaker, motoring enthusiast, and wartime ambulance driver. In a remarkable performance, Maggie Smith brilliantly transforms an unbearably filthy and untouchable character into a multidimensional human being capable of charming us. She becomes, bit by bit, tolerable. As we become able to see her vulnerabilities, her capacity to laugh, her childlike delight in painting her vehicles custard yellow or freewheeling down the street in a wheel chair, the smell becomes less overwhelming. At the end of the film she is at last bathed, hair washed and dressed in clean clothes. Now she can ask Bennett to hold her hand. ‘It’s clean,’ she tells him. The transition from intolerable to touchable is complete.
Chris Rose is a group psychotherapist, writer and Therapy Today Reviews Editor. If you would like to write a film or theatre review, email [email protected] Reviewed on TherapyToday.net
Individual, societal and ecological wellbeing
Happier people healthier planet Teresa Belton, Silverwood Books, 2014, 372pp, £13.95 (paperback), ISBN 978-1781322604
Reviewed by Charles Gordon-Graham
This book offers an uncompromising indictment of the consumerist culture that underpins Western (and increasingly other) society and economics. Belton’s is a two-pronged approach, focusing both on the effects of consumerism on individual welfare and on the impact of consumerism on the environment, addressing society at large in the process.
For those who are concerned about issues of individual, societal and ecological wellbeing this book is not a comfortable ride, but neither is it a doomsayer’s almanac that could only lead to despair. While providing a devastating critique of the consumerist system, she also offers many examples of individuals who have tried in their own different ways to lead a lifestyle based on reducing consumption and who live very fulfilling lives. Those individuals, male and female of all age groups, have focused on, for example, growing their own food, developing craft skills and enriching their lives through relationships, community activities and creative, artistic pursuits.
The book covers the sources of wellbeing and how material consumption does not make us happier. Also discussed is the issue of experiences that can influence the extent to which one might be inclined to a high, moderate or low level of consumption. Belton looks at the important role of values and also at such areas as creativity, spirituality and spending time in natural surroundings (and the importance of this in education). The book is very well researched with many pages of notes with references.
Belton says at the outset that she focuses on the UK, but to be honest I would have liked to read some examples from other countries, including non- Western societies. So saying, I would consider this book a welcome addition to reading for psychotherapists, as – like and Wilkinson and Pickett’s The Spirit Level – it links individual wellbeing to the wider societal and world issues that confront us, and it does give a positive message that change is possible, which is also typically the therapist’s message.
Charles Gordon-Graham is a lecturer, counsellor/psychotherapist, poet and writer +++ From the Chair
Andrew Reeves reflects on counselling as a political activity
I went for a coffee with colleagues recently and we were chatting about everyday life, passing the time, as you do. The conversation moved to the current state of counselling which, in turn, moved us on to the wider positioning of counselling and its place in society. At this stage we realised that the caffeine was really beginning to kick in, and the juices started flowing and we found ourselves in a conversation that really began to energise.
We were thinking about counselling as a political activity; political with a small ‘p’ – although perhaps the small ‘p’ informs the bigger ‘P’ at some level, but it was the small ‘p’ that was grabbing our attention. The discussion resonated for me because I had just recently finished writing last month’s Chair’s column, in which I was talking about the importance of the role of advocacy as part of being a counsellor: to advocate for individual clients, with their consent, but also to advocate for change when we encounter wrong-doing, or oppression, or discrimination, and so on.
When I trained as a social worker my motivation was to be part of societal change. This was before the advent of ‘community care’ and what became known as the ‘purchaser-provider’ split in social care services: where one part of the system assessed and purchased care from the other part of the system. I was very clear that my role was on the ‘provider’ side in delivering the best quality mental health and therapeutic services, and that while I was not diminishing the importance or skill of the purchasers, that really was not my bag. However, I quickly moved into becoming a counsellor because it seemed to me that social work was becoming less about social change and more about social facilitation. Counselling, it seemed to me, had grown from communities and networks and provided a real opportunity to make a difference.
I am now minded to reflect on the nature of the difference counselling makes. I am entirely convinced, and the evidence supports this, that counselling can really make a significant difference in many people’s lives. For over 25 years I have seen people who have attended counselling and have left feeling very differently about themselves. I truly believe in the value of counselling and the things that can be achieved. How much might we also contribute, however, to helping people think about the bigger picture? If we see clients living in crushing poverty and deprivation, with systems preventing them from finding escape from those difficulties, we can support the individual in that situation but could we not do more? If we help people who encounter discrimination on a daily basis because of age, disability, culture or sexuality, for example, we can help those individuals tend to those emotional and psychological wounds, but could we do more? This is where the discussion over coffee really got going. If we witness a pattern of discrimination across clients but do not take that observation beyond the confines of the counselling space, do we not run the risk of colluding with it? Indeed, we run the risk of becoming silent witness to the anguish of many, unless we find a collective voice to advocate for those who are in a position of not being able to do that for themselves.
I think we have much to learn from those cultural perspectives that place the individual in the context of group: family, community and society. As counsellors we need to be trained to think from a systemic perspective, both for the individual client and for the wider issues that present in our counselling rooms. In locating our own authority and finding collective ways of representing what we know, we can become formidable agents of change. Either that, or I start drinking decaffeinated coffee and go for a quieter life.
Officers of the Association
Chair Andrew Reeves
Deputy Chair Elspeth Schwenk
Chief Executive Hadyn Williams
President Michael Shooter
Vice Presidents Sue Bailey John Battle Robert Burgess Bob Grove Kim Hollis Lynne Jones Martin Knapp Juliet Lyon Glenys Parry Julia Samuel Pamela Stephenson Connolly +++ BACP News
Recognition and evolution
Our AGM took place last month, and with it the opportunity to reflect on the achievements of the past year and to look forward to the new direction we’ll be taking in 2016. Andrew Reeves captured these themes of reflection and change in his Chair’s Address, in which he gave an overview of the Association’s work in 2015, as well as a taste of the exciting things to come.
Andrew looked back on the work that has already been done on the new Professional Conduct Procedure, Ethical Framework and strategy. These three key elements of our work will be launched next year and each has been facilitated through comprehensive consultation with our members. Andrew acknowledged this, saying, ‘Each and every one of us is able to provide our own influence through challenge, debate, encouragement, affirmation and advocacy.’
The AGM also saw the election of a new member of the Board of Governors. Eddie Carden is CEO of Renew Counselling in Essex and an ordained minister in the Church of England. He brings with him a wealth of knowledge in the field of mental health. Two more Governors, Fiona Ballantine Dykes and Elspeth Schwenk, were congratulated on their re-election. Andrew expressed at the AGM his aim of raising awareness of the way the Association is governed among our members. The intention he said, was to ‘promote further engagement with governance so that those who steer the direction of BACP represent the diversity that is found in the membership’.
Andrew described BACP’s new strategy as one that ‘speaks to the heart of what counselling is fundamentally all about’. He added: ‘There is no doubt that the membership of BACP is our most important resource in facilitating change.’
We look forward to announcing details of our new strategy soon, and continuing to work with you as BACP enters this exciting new stage of its development.
Counselling MindEd
Those of you who work with children and young people will already be aware of the Counselling MindEd e-portal. This project, funded by the Department for Health and managed and delivered by BACP, provides free online resources on children and young people’s mental health for practitioners working in the CYP sector.
A wealth of counselling knowledge is available to support the training of school and youth counsellors and supervisors working in primary, secondary, tertiary and community settings, and in the independent sector. An independent evaluation of the Counselling MindEd e-portal was completed earlier this year by Cathy Street & Associates and Youth Access. One of the key conclusions is that Counselling MindEd has been generally welcomed by practitioners and is seen as having the potential to build knowledge and understanding of children and young people’s mental health and emotional wellbeing across all services that work with these groups. Recommendations for improvements and further developments are also made and these are being addressed as part of the next stage.
You can read the full evaluation report online on the ‘Resources’ pages of the MindEd website at www.minded.org.uk, where you can also access Counselling MindEd’s 46 e-learning sessions.
We look forward to bringing you further updates on this project as it evolves.
CPR journal to go online in 2016
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.
Good Practice in Action
We’re working on a series of Good Practice in Action resources to support you in your work. The first 10 of these new resources are available now and are free for BACP members to view and download from www.bacp.co.uk/ethics/newGPG.php.
With subjects ranging from choosing a supervisor to confidentiality and ethical decision making, these documents are a valuable addition to your counselling toolkit. Presented in a range of formats, including FAQs, fact sheets and legal resources, these 10 documents are just the beginning of a comprehensive online library of publications that will support you in your practice. We’ll keep you updated as more resources are added.
As part of this work, we’re looking at producing further resources to support you in making ethical decisions. It would help us if you would complete this short survey at https://www.surveymonkey.com/r/N5GF66D to tell us more about how you currently make ethical decisions. Your feedback will help us find out how we can best support you.
A very big thank you to all of you who have given your time by offering feedback and reviewing new resources – your input is vital in making our publications as relevant and useful as possible. If you are interested in joining one of the focus groups to offer feedback and review forthcoming publications, email [email protected] and let us know the topics that would interest you most.
BACP registration deadline
As the 31 March 2016 registration deadline for MBACP members approaches, places are filling fast on the free Certificate of Proficiency (CoP) assessment days early in the New Year.
If you still need to sit an assessment, we’d advise you to check availability at your closest venue by going to the BACP Register website at www.bacpregister.org.uk. You can book online or call us on 01455 883300.
Around 13,000 members have already passed the CoP. Despite some initial concerns, many have found it a good experience and a fair evaluation of therapy skills and practice. You can watch members talking about their experience on a new video on our YouTube channel.
Accredited members, or those who have passed a BACP accredited course, can still join the Register just by signing up to its Terms and Conditions. You can do this online or call us for a printed copy.
If you’ve recently passed the CoP, don’t forget you also need to sign the Register’s Terms and Conditions to complete your registration.
Some members have queried their eligibility for the BACP Register because they are not ‘in practice’. We define practice as including practice management, training, supervision and research, as well as actually seeing clients. So you can register if you have done any of these in the last three years.
If you are not practising, you could move to our new Retired Member category, which does not require registration. Please call us if you are unsure and would like to discuss the options.
Have your say about BACP membership
Early in the New Year we’ll be emailing you with a survey looking into your experience of membership, what you value most about being a BACP member and in what ways you think we can improve. Your feedback will be absolutely vital to us as we look into the services and benefits we offer, and will help us focus on what’s most important to you. There will be an added incentive to take part in the survey, so keep an eye on your inbox in the New Year for the details.
Editor for University & College Counselling
We are delighted to welcome David Mair as the new editor of University & College Counselling journal. David has a wealth of sector experience and is currently Head of Counselling and Wellbeing at the University of Birmingham. He joins our other divisional editors, subject to contract, on 1 December.
University & College Counselling is a quarterly professional journal for counsellors and psychotherapists in further and higher education, which is free to members of BACP Universities & Colleges. For more details, please visit www.bacpuc.org.uk
Log-in issue on TherapyToday.net website
Apologies to readers experiencing problems logging on to the TherapyToday.net website or accessing specific articles. We are working on resolving this and currently all articles on the site are free for everyone to read.
If you find that you still can’t access a specific article then please email [email protected] with ‘TherapyToday.net article’ in the subject line. Include in your email the title of the article, the author(s), and the month and year the article was published, and we’ll send you the article as a Word file as soon as possible.
Skills needed to support employees
Employee counselling is a fast-growing sector, with thousands of you working as affiliates for EAPs and/or staff counselling services in the public and private sector.
Counsellors play a vital role in supporting the mental health of employees at work, but the feedback from EAPs and recruiters is that qualified practitioners need further skills and competencies, beyond their initial training, to meet the specific needs of this emerging sector.
Rick Hughes, BACP’s Lead Advisor for Workplace, puts it like this: ‘Counselling in workplace settings is a complex task because, as well as the traditional client-counsellor relationship, therapists need to appreciate the role, relationship and responsibility of the organisation in the process.’
BACP Workplace is our specialist division for members working with employees, employers and EAPs. Through this division, we are developing a range of resources to support you in understanding the complexities of employee counselling and to expand your competence and skills within the sector. At the Practitioners’ Conference next spring we’ll be offering learning opportunities specifically tailored to those of you who would like to build your practice and develop skills fit for today’s workplace.
Find out more about the BACP Workplace division at www.bacpworkplace.org.uk
Affordable, accessible learning
When it comes to CPD in 2016, we’re focusing on offering you access to the best possible learning opportunities using methods you will find both affordable and accessible. With this in mind, we’ve got a couple of webcasts already planned for 2016 that really fit the bill.
In April we’re offering a live webcast of the OCTIA 2016 conference, which will look into Relational Depth and Emotional Connection in Online Therapy. The conference is aimed at practitioners who are working in or interested in online counselling and a range of speakers will present their varied experiences of working with clients online.
A couple of weeks later we’ll be broadcasting day one of the UKESAD conference. This webcast is designed for practitioners who work with clients with addictions, or are interested in this field. Throughout the day a studio panel will conduct interviews with guests in the studio, as well as engage in discussions with delegates online.
For more information about these events and to book your place, visit www.bacp.co.uk/webinar ‘
Pick and mix’ conference
Do you see clients presenting with a broad range of issues? Does your practice span a number of settings? If so, the BACP Practitioners’ Conference on Saturday 30 April in London is a tremendous opportunity to gain CPD on a wide variety of pertinent topics.
There will be a packed programme of guest speakers and practical workshops, as well as networking opportunities. You can create your own ‘pick and mix’ programme, tailoring your learning to suit your professional needs. You can meet practitioners from different sectors, share ideas and experience a range of perspectives. You can network with peers working in similar settings and review current thinking in your specialist area of practice. This conference is ideal if you work in workplace, healthcare and coaching, have a portfolio of work spanning a number of settings, have a range of CPD requirements or wish to network with a wide variety of different practitioners.
To register your interest and be first in the queue for future updates, email [email protected] +++ BACP Professional Standards
Newly accredited counsellors/psychotherapists
Nancy Ajavon Denise Askew Fiona Astbury Keith Bales Sue Baxter Alison Bean Rowan Bolland Gill Brennan Tracy Buckle Margaret Buckley Sadie Cissell Elaine Craig Nelson Davis Gareth Desmond Tabitha Draper Katrina Durant Daniel Fensom Lisa Gee Ramona Haetzer Sarah Hamilton Jane Harris Charlotte Hastings Tamara Howell Zsuzsanna Hutchinson Elizabeth Jakeman Sarah Jump Alison Kennedy Vida Kennedy Sharon Lascelles Lisa Lau Galit Levy-White Natasha Lumley Sarah McCowen Lucy McDonald Rachel Mckechnie Anne McKinley Philip Meek Helena Michaelson Catherine Millican Miriam Mitchell Denise Monet Michael Montgomery Jacqueline Moran Sarabeth Morrison Nuala Moseley Abbie O’Connor Elizabeth O’Connor Elizabeth Oliver Lei Myo Oo Nicola-Jayne Parker Antonia Phillips Trevor Pierce Kara Rogers Jackie Rogers Janet Seabrook Charlotte Simpson Diana Simpson-Hinds Emma Skala Paul Smith Sarah Soden Margaret Stickland Cigdem Tas Paul Thorley-Ryder Claire Turner Helen Walker Jan Willmott Siobhan Wilson Julie Wray
Newly senior accredited counsellor/psychotherapist
Christine Wells
Newly senior accredited supervisor of groups
Kathleen Nisbet
Organisations with new/renewed service accreditations
Brunel University London Wimbledon Guild
For a full list of current accredited services, visit the service accreditation webpages
Members not renewing accreditation
Susan Ashmole Ann Boyle Margaret Cairns Christopher Carroll Chris Coburn Shirley Crookes Clair Dinsdale Patricia Elliot Helen Evans Christine Gander Angelina Gibbs Patience Gray Janet Grimes Jenny Hall Selina Hoey Diana Jack Nigel Law Elizabeth Leese Catherine Ma Carole Marco Wendy Morrison Diane Phillips Trevor Plumb Susan Popplewell Andrew Stanton Katharine Taylor Pat Thompson Helen Voller Nina Wright Susan Wyld
Member whose accreditation has been reinstated
Diana Simpson-Hinds
Member whose accreditation has been restored
Dorothy Ramsay
The above details apply for 1–30 October 2015 and are correct at the time of going to print. +++ BACP Research
Putting PRaCTICED into practice
Sally Ohlsen, Kate Ashley, David Saxon and Michael Barkham report on some of the practical challenges of running the PRaCTICED trial
In June 2013 Therapy Today interviewed Professor Michael Barkham about embarking on a large-scale randomised control trial (RCT), funded by the BACP Research Foundation and based at the University of Sheffield, that aimed to assess whether counselling for depression (CfD) was non-inferior to CBT for patients with moderate to severe depression when delivered in IAPT services. The trial is being conducted in partnership with the Sheffield IAPT service. Two years into the trial members of the research team provide an update on some of the in-practice challenges that have arisen in conducting an RCT within a local IAPT service and the solutions that, it is hoped, will overcome them.
The PRaCTICED trial
The acronym for the trial is PRaCTICED – Pragmatic Randomised Controlled Trial assessing the non-Inferiority of Counselling and its Effectiveness for Depression. Its aim is to gain robust evidence for the effectiveness of CfD relative to CBT. CfD is one of the four NICE-approved psychological therapies for the treatment of depression, other than CBT, offered within IAPT services.
The trial design is simple. Patients presenting with depression to IAPT services will typically first be seen at Step 2 by a psychological wellbeing practitioner (PWP). The PWPs are the gatekeepers to the trial as they are responsible for informing those patients about the trial who are likely to be stepped up to a high-intensity counsellor or CBT therapist. A patient presenting with depression requiring a high-intensity therapy is invited to a screening interview carried out by a member of the research team or one of the NHS clinical support officers (CSOs). If the patient meets the trial criteria and consents to take part, they are randomised to receive CBT or CfD. Hence PWPs have a crucial supporting role.
To date the research team has recruited over 150 patients to the trial; the target is to secure 275 in each of the CfD and CBT arms. However, while the design is simple, the implementation of a trial set within an NHS clinical setting is complex and challenging. It is a continual process of solving puzzles (where we have some warning of impending problems) and firefighting (when we don’t).
Developing a strategy
Most of the problems we have encountered concern bridging the gap between research and practice. While the agenda and language underpinning PRaCTICED is rooted in the world of research, the priorities of practitioners within IAPT services are determined by a combination of patients’ needs and NHS targets.
The key issues faced by the team include: 1) securing a sufficient number of referrals on an ongoing basis; 2) building bridges with the IAPT service, and 3) securing a priority for the trial and maintaining its integrity amid the relentless pressures placed on IAPT services from ever-changing NHS and Department of Health targets. In light of our experiences, we have developed and implemented a strategic approach to resolving these issues.
Following the move of our full-time research assistant to another project, we had to decide whether to fill the post with a further research assistant or adopt a different model. We had become increasingly aware of a gap in our knowledge of the intricacies of the IAPT service. Coincidentally, in January 2015 Sally Ohlsen joined the wider research group in the School of Health and Related Research (ScHARR) at the university and initially provided support at the front end of the trial: namely, by supporting PWPs in securing patient referrals. What became apparent was that her knowledge of the NHS, drawn from being an occupational therapist, gave the team access to the finer details and nuances of NHS ways of working and provided an immediate down-to-earth point of contact with PWPs.
As we saw connections and communications being built up, we realised that we needed to provide a more permanent link between the trial and the IAPT service. The PWPs already provided the gatekeeping function for referring patients and seemed to be key in building the bridge between research and practice. However, adding further demands to their workload would simply create an additional burden given the pressures already placed on PWPs.
In April 2015 our solution, in partnership with the Sheffield IAPT senior management team, was to second three PWPs for half a day a week each into the research team for six months to work specifically on supporting referrals and encouraging other PWPs to make appropriate referrals to the trial. The PWPs knew the individual GP practices across the IAPT service (there were potentially over 90 of them) as well as all the PWPs in the service.
The strategy of embedding NHS expertise within the trial bore fruit with an almost immediate increase in referrals, suggesting the potential for filling the research assistant post with a half-time PWP seconded from the IAPT service. With the endorsement of the IAPT senior management, we took the decision to advertise a 12-month seconded half-time post for a PWP to work with the research team. The tasks of the post would cover both the front end (referrals) of the trial and the back end in terms of securing follow-up data. In October this year, we appointed one of the original seconded PWPs (KA) to the 12-month post. In addition, a further PWP took up a new six-month post working half a day a week. The remainder of this article presents examples of how this NHS expertise embedded in the research team is helping to resolve key challenges for the trial. The difference made by the NHS expertise can probably be grouped into three main components: 1) knowledge and expertise concerning the NHS and local IAPT service (ie systems); 2) a shared IAPT language with colleagues (ie personnel), and 3) direct access to the secure and confidential IAPT database system (ie IT). Two other factors are being innovative and responsive and a developing system of communication pathways.
Knowledge and expertise
While Sheffield IAPT is a single service, there are four geographical sectors that operate in differing ways and that vary considerably in terms of their levels of economic wealth and deprivation as well as cultural mix and ethnicity. An added complexity is that not all GP surgeries have a dedicated CBT and CfD practitioner. For the non-NHS research team, it had been an all-consuming task to collect the information that was also constantly changing. Whereas previously it was a little like trying to complete a jigsaw puzzle in which many of the pieces kept changing, the embedded PWPs in the team gave us immediate and inside knowledge about who worked where, when they worked, and how best to engage IAPT staff with the trial. This organisational knowledge has been crucial.
Shared IAPT language
Sheffield IAPT employs a large workforce of approximately 130 practitioners comprising PWPs, counsellors (both CfD and non-CfD), and CBT therapists. Having members of the research team who understand the language of IAPT and the tacit knowledge and context of the organisation has encouraged members of the IAPT service to have conversations with us about aspects of the trial and we have also seen their confidence within the research setting begin to grow, as well as the number of patient referrals. Potential issues have been highlighted earlier in the process and solutions derived collectively with IAPT staff.
IAPT data system
The local IAPT database captures service level data from which we can learn the status of a patient’s therapy (ie number of sessions so far, whether they have completed therapy etc). The embedded PWPs and CSOs have access to this system, which has enabled the research team to keep the trial data up to date, especially in relation to managing waiting times for each therapy at the different surgeries. It has also been invaluable in allowing us to rapidly update the IAPT system with any information gathered from contact with the trial, such as any risk highlighted during the screening appointments.
Being innovative and responsive
During the course of the trial we have had to balance adhering to the trial protocol with the reality of the practitioners delivering an NHS service – this is the nature of a pragmatic trial. Innovations have included using previous anonymised local data to identify the natural rise and fall of referrals due to staff and seasonal changes (ie school holidays). We have also created a core team of referrers at sites where both CfD and CBT practitioners are available to encourage a steady flow of referrals. And we have initiated a central waitlist and city centre venue, allowing access to the trial for patients who would not have had that option due to lack of resources in their local GP practice.
Communication pathways
Underpinning all of the above has been a developing system of informal and formal communication pathways between the IAPT service and the research team. Beyond the informal pathways established by the seconded PWP, there are also pathways with the lead CfD and CBT practitioners, and all are members of the Trial Management Group that is responsible for the trial’s operational running. Their contribution sits alongside other members who bring their expertise in the form of lived experience of depression and represent public and patient involvement. In addition, there is a clear communication pathway to the IAPT Head of Service and the IAPT senior management team. This involvement of senior management has been crucial; without it, the trial simply would not be possible.
Recommendations
Our overall strategy of embedding NHS personnel and expertise within the team reflects the trial’s pragmatic design. It has also given a small number of PWPs the opportunity to develop their skills and experience within a research environment and has engaged CfD and CBT practitioners with the potential for future collaborative research. Crucially, it is also a reflection of the commitment of the IAPT senior management team to the trial and their collaboration with the research team.
In sum, the lessons learned from our experience are two-fold: first, to factor in seconded staff from the service environment within which the trial (or study) is taking place; second, to start the process of inputting service knowledge from practitioners, as well as managers, at the design stage of a trial. As we have so often found, the devil is in the detail and seconded staff embedded within the trial or study are best placed to identify, address and resolve such issues.
Sally Ohlsen is a research assistant and occupational therapist supporting the PRaCTICED trial. Kate Ashley is a psychological wellbeing practitioner seconded part-time into the trial. David Saxon is the PRaCTICED Trial Manager, and Michael Barkham is Professor of Clinical Psychology and Director of the Centre for Psychological Services Research at the University of Sheffield. The authors would like to thank members of the PRaCTICED research team and all staff in the Sheffield IAPT service for their ongoing support.
Learning from research
Andy Hill talks to BACP PhD scholar Emma Broglia about her research and where she hopes it will lead Andy Hill: Tell me a little about yourself and your academic interests.
Emma Broglia: I have quite a broad academic background. Initially I was interested in psychology and worked on various projects from cognitive function to sleep disorders, and learnt about lifestyle factors and their impact. My main interest was in understanding why things go wrong and what can be learnt to prevent them recurring. I think more face-to-face contact rather than computer experiments helps people. I’m now in my second year and thinking about my third year.
AH: What attracted you to the BACP PhD scholarship? Why were you interested in this area?
EB: I was drawn to the scholarship as I wanted to be part of BACP’s research. I wanted to include everything I learnt from working with different services. My interests were improving psychological functioning and the need for embedded psychological services – this was exactly the challenge I was looking for.
I worked at Birmingham University for seven years, with various lecturers in the psychology department, and wanted to become more involved in counselling and therapeutic services with schoolchildren or university students. I wanted to be a mediator between doing the research and being involved in clinical practice; the BACP scholarship made this possible.
AH: Can you tell us in a nutshell what your PhD is about, perhaps outlining a) the work undertaken thus far and what you have found and b) your plans for the remainder of the scholarship?
EB: My PhD broadly aims to explore clinical academic and institutional outcomes from university counselling and to develop an evidence base to help support services. I also want the work to inform a design for a RCT trial to make an impact and get an evidence base to show counselling is effective in keeping students in university and helping clinical outcomes.
I started with a systematic scientific literature review to see what types of research in terms of design had already been done. I wanted to map the different university counselling services and do an annual survey of 113 services. Second, I wanted to explore the technology with heads of service – this is very popular but also potentially risky. Third, we did a pilot study and initial evaluation of student-specific clinical measures in comparison with CORE-10, as the annual report revealed a lot of embedded counselling services were using CORE but not measuring academic stress, family distress, alcohol misuse etc. We were able to embed this student-specific clinical tool alongside CORE in two UK universities, with encouraging results. We now have another eight to 10 services on board and hope to repeat this next year. Mobile phone apps are being recommended without knowing the risks or quality or potential benefits, so we would like to do some focus groups with clients/counsellors to see what their experiences have been.
Then we would like to use the results from all the work to inform the design of a feasibility trial – the main aim being to explore the possibility of integrating or supplementing face-to-face counselling with embedded counsellors using online support or mobile phone apps to promote self-monitoring, goal setting and homework. We want to explore the technical component of this and also encourage counsellors to work more flexibly to see if face-to-face working can be supported by other means, because what came out of our research so far is that drop-out and engagement rates with students in therapy is a big issue as students want support outside office hours and at weekends. So we would like to inform the design of something like a mobile phone wellbeing app, drawing on the contextual experiences that embedded counsellors have to improve engagement between the client/counsellor. This feasibility trial is the main project left to do on the PhD so I have set a year aside for this work.
AH: What has been your experience of the scholarship so far?
EB: It has been absolutely fantastic and exceeded my expectations. I have worked with many people who have inspired me to want to do good quality research. I had thought there would be resistance, but it’s been quite the opposite: university heads of counselling services, counsellors and even clients have been very excited about being involved. I’ve also felt incredibly supported by BACP.
AH: It’s good to hear that your experience of practitioners is that they are interested in research. This is a shift in recent years really. What do you think will be the implications of your work for the counselling and psychotherapy field? What will be its legacy?
EB: I hope my work inspires services to get more involved with research by demonstrating how simple it can be and how quickly services can benefit by collaborating with each other and sharing experiences. In terms of legacy, this work will hopefully result in the development of UK norms in student counselling services.
AH: Do you have any thoughts about a full-scale trial based on your design?
EB: Yes, we have a few initial designs; a lot will emerge from the final feasibility trial, but one important thing is looking at the use of outcome measures and developing student-specific versions. Not just using clinical outcome measures to keep management happy or as a form filling exercise but using them as student-specific tools to help facilitate discussion between clients and counsellors to improve the therapeutic alliance. AH: Thinking about the future, is this something you would be interested in, getting funding to scale up the project into a fully scaled trial?
EB: Yes definitely; we’ve already thought about that. We are trying to see what would appeal to potential funders for next year to support a full-scale randomised controlled trial based on what we have found so far because I think we’ve got some really exciting data and have a good chance of securing a funding bid to design a full scale RCT.
AH: What plans do you have for yourself and the end of the scholarship?
EB: Outside of academia my main hobby is running and I quite like the idea that, by the end of the PhD, I will be able to run my first mountain marathon. It has really helped me cope and I have run a few half marathons so I’m looking for the next challenge.
AH: So you like to challenge yourself physically as well as mentally?
EB: I think it helps me cope!
AH: What has it been like to work across different organisations and stakeholders?
EB: I’ve never worked with a professional organisation like BACP before, so I didn’t know what to expect, but looking back I’ve been very grateful for their involvement; it’s driven me to do bigger and better research. Everyone involved in research wants to make a difference and my aims are in line with BACP’s to make a wider impact on services. Having BACP involved has definitely helped get people on board because they realise BACP is really trying to help the sector.
It’s been difficult managing different individuals’ expectations while also ensuring that our research aims are portrayed realistically. It is only a three- year PhD so we need a focused approach but we don’t want to exclude other professional affiliations, who may feel daunted because of BACP’s involvement and want to influence the sector as a whole rather than a professional body. It’s a wider agenda than just BACP’s, and it covers the whole sector. I’m based at Sheffield University and having the Head on board, who is affiliated to the UKCP, has helped broaden the outlook.
AH: I think that’s true. It’s the kind of work that will benefit the field as a whole. Even though BACP is funding the initiative, the overall intention is about promoting research across the whole professional field. I think it’s really good that you are presenting the work in this broad way. Now to the last question: do you have any advice for BACP about funding further PhD scholarships? Should they continue to provide such opportunities?
EB: Well the main observation is that services have responded really well to the research so far and are keen to participate, but the main issue is that there isn’t enough capacity in the sector to have a research area linking together and supporting evidence-based practice. We have had such a good response to our work so far, with people saying it’s great that your PhD is addressing these issues. It’s been a long time coming.
My advice would be to keep offering PhD student scholarships because it has been a fantastic research opportunity but also, from the perspective of university counselling services, it has done a lot of good.
AH: It’s been a pleasure having a chat with you, Emma. Thank you.
Feedback on CHI paper
Mick Cooper (University of Roehampton) and John McLeod (University of Oslo) are seeking feedback on a draft paper on how to conduct a Client Helpfulness Interview (CHI) study.1
CHI is a type of ‘psychotherapy process research that asks clients, directly, what it is that they found helpful and unhelpful in their counselling and psychotherapy; and also, potentially, their perceptions of the process of change’.
A recent audit of BACP’s dissertation database by Jennifer Loy found that just 15 per cent of post-graduate research concerned clients’ experiences of counselling and psychotherapy. Cooper and McLeod are keen to see this increase.
One of the main advantages of CHI research is that it really tries to listen to the voices and experiences of clients, rather than perceptions of therapists or observers. It is hoped that the CHI method will provide researchers with an opportunity to contribute to the development of the counselling and psychotherapy profession by focusing on the experience of service users.
The paper is free to download from http://tinyurl.com/pqlpeaw. Professors Cooper and McLeod would welcome feedback on the working draft of this paper.
Reference
1. Cooper M, McLeod J. Client helpfulness interview studies: a guide to exploring client perceptions of change in counselling and psychotherapy. Working paper; 2015. https://www.researchgate.net/profile/Mick_Cooper Last call to apply for awards
BACP Outstanding Research Award
If you have completed or written up a piece of counselling/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 for counselling, psychotherapy and its guiding principles; improving the overall quality of counselling and psychotherapy research by example, or 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.
CPR New Researcher Award
Submissions are being invited for the CPR New Researcher Award, sponsored by Wiley. The winning entry will receive £100 worth of book tokens. To be eligible for consideration you must currently fulfil one of the following criteria: 1. a current student who has completed a research project in counselling and psychotherapy, or 2. graduated in the last 24 months and have completed a research project in counselling/psychotherapy as part of your course, or 3. had a paper accepted for publication in Counselling and Psychotherapy Research (CPR), which will be your first publication.
Submissions are in the form of a research paper and the applicant must be the first author. They must not have had work published in any journal previously.
The deadline for submissions for the above awards is 29 January 2016. For details of how to apply, go to www.bacp.co.uk/research/resources/awards.php or email [email protected]
Thank you from Research
BACP Research would like to thank the many people who contributed to our work in 2015. Over the past 12 months we had the pleasure and the benefit of working closely with many people who kindly gave their time and expertise to further research at BACP, for which we are very grateful.
We would like to mention the people below for a special thank you, although the list is not exhaustive. Please forgive us if we have unintentionally missed anybody out. Michael Barkham, Jennifer Beecham, Emma Broglia, Mick Cooper, Sir Cary Cooper, Richard Davis, Andy Fugard, Susan Hajkowski, Catherine Hayes, Anthony Hickey, Trish Hobman, Stephen Joseph, Chris Kelly, Michael King, Thomas Mackrill, Nick Midgley, Naomi Moller, David Murphy, John Norcross, Glenys Parry, Peter Pearce, Jo-Ann Pereira, Gillian Proctor, Kaye Richards, Maggie Robson, Anthony Roth, Aaron Sefi, Roz Shafran, William B Stiles, Ladislav Timulak, Andreas Vossler, Panos Vostanis and Jeannie Wright.
With best wishes for a happy and healthy 2016 from the BACP Research team. +++ BACP Professional Conduct
Sanction compliance, Carol Gordon, Reference No: 519410 Surrey CR0
BACP was satisfied that the requirements of the sanction have been met. As such, the sanction reported in the June 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, Susan Campbell, Reference No: 541500 Sheffield S8
BACP was satisfied that the requirements of the sanction have been met. As such, the sanction reported in the June 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.
BACP Professional Conduct Hearing
Findings, decision and sanction, Stephen Hockett, Reference No: 624046 Essex SS9
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 Mr Hockett was responsible fell below the standards that would reasonably be expected of a practitioner exercising reasonable skill. The Panel found that Mr Hockett was incompetent and provided inadequate professional services.
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, Yvonne Builth, Reference No: 541446 Staffordshire DE13 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 in that the service for which Ms Builth was responsible fell below the standards that would reasonably be expected of a practitioner exercising reasonable skill in that she was incompetent, reckless and provided an inadequate professional service.
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 Public Affairs
School-based counselling
The Youth Select Committee Inquiry into Children’s and Young People’s Mental Health has published its recommendations to the Government for ways in which to improve the mental health of children and young people in the UK.
BACP submitted written evidence to the Youth Select Committee of 11 young people aged 13–18 years, who launched an inquiry into ways in which the UK Government could improve the mental health of children and young people. The committee invited BACP to provide oral evidence in Parliament in June, to elaborate on the written evidence, which highlighted the role of school- based counselling. BACP wrote that school-based counselling is effective in improving the mental wellbeing of young people by being both easily accessible and a quick response treatment, allowing a counsellor to intervene early before the young person’s mental health deteriorates further, and onward referral to more specialist support if required.
BACP’s Children and Young People Lead Advisor Karen Cromarty, who represented BACP at the committee hearing, said: ‘Our research shows that counselling can lower levels of distress in young people. It can help them to attain better results in school. Young people tell us it helps them with their learning. Senior school staff – deputy heads and head teachers – tell us that young people who have been to counselling work better in class; they do better in their studies; they attend school more often.’
The committee’s final recommendation, published in mid-November, was that a trained counsellor should be available in all schools.
The committee also said funding for young people’s mental health services should be proportionate to that of physical health to achieve parity of esteem; that there should be compulsory training for GPs on young people’s mental health; that teachers should be provided with training on mental health issues, and that more work should be done to mitigate the negative impact of cyber- bullying through social media.
The committee is now awaiting a response from the Government to its recommendations.
Westminster debates gay conversion therapy
Westminster recently saw a debate on gay conversion therapy, led by MP Mike Freer, who called on the Government to explore ways in which gay conversion therapies can be banned. Freer raised his concern that people who might be confused about their sexual orientation might potentially be referred on by an NHS professional to see a psychotherapist for ‘treatment’.
BACP welcomed the debate as we oppose any psychological treatment, such as ‘reparative’ or ‘conversion’ therapy, that is based on the assumption that homosexuality is a mental disorder, or on the premise that the client or patient should change their sexual orientation. BACP published a statement saying: ‘We believe that socially inclusive, non-judgmental attitudes to people who identify across the diverse range of human sexualities will have positive consequences for those individuals, as well as for the wider society in which they live. There is no scientific, rational or ethical reason to treat people who identify within a range of human sexualities any differently from those who identify solely as heterosexual.
‘BACP, along with 13 other organisations, is a signatory to a Memorandum of Understanding (MoU) on Conversion Therapy in the UK. Supported by NHS England, NHS Scotland and the Scottish Government, the MoU sets out an agreed framework for activities to help address the issues raised by the practice of conversion therapy in the UK.’
In response to the debate, Public Health Minister Jane Ellison MP said that the Government does not believe that being lesbian, gay, bisexual, or transgender is an illness to be treated or cured. Jane Ellison continued by saying she will ‘continue to challenge the Government to go further on this issue’.
Consultations
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 to governments, parliaments and non-political organisations.
BACP has recently been responding to the Northern Ireland Public Health Agency’s consultation on the Lifeline Crisis Intervention Service. Lifeline is a free-to-call, 24/7, confidential telephone helpline for people in Northern Ireland who are experiencing an emotional crisis and are at risk of self-harm or suicide.
The Public Health Agency was calling for views on the proposed future of the Lifeline service and associated suicide and self-harm prevention services beyond 2015. One of the primary thrusts of the new proposal is to replace the existing helpline service, currently staffed in part by counsellors, with a telephone crisis helpline delivered directly from the Northern Ireland Ambulance Service.
While the proposed new helpline would still refer people on to trained therapists, BACP opposed changing the helpline staffing model as we felt it would compromise the service being provided to people in crisis. To read BACP’s full response to the Lifeline consultation, see www.bacp.co.uk/policy/consultations/
If you wish to contribute to any of BACP’s consultation responses, email the Public Affairs team at [email protected] and we will add you to our consultation experts database. +++ Behind the pictures
Illustrator Michael Parkin describes his creative process and what inspired his illustrations in our December issue
Do you consider yourself to have a trademark style? If so, how would you describe it?
I think over the last year, since graduating, my work has definitely fallen into more of a distinct style. I approach each project in the same way and build up the illustrations through a process of drawing, making textures and compiling digitally. Once all of these processes come together, the style seems to sort itself.
How would you describe the creative process you go through when working on your illustrations or does it vary?
The ideas are the most important part for me and I can spend quite a bit of time coming up with them. I will go through a lot of rough drawings before I start and focus on the ones I like the best. Often I have a vision for how I want things to look and this helps to get started. Also I find it helps to take time away from my work to clear my head and declutter my thoughts.
How do you come up with your ideas and what inspires you?
I come up with most of my ideas in bed at night when there are no other distractions. I always make sure I read the article I’m working on in the evening and that helps to keep it fresh in my mind. The ideas then seem to naturally evolve and the next day I can explore them further. I also find talking about the article with another person helps massively – much to the annoyance of my girlfriend, who gets frantically talked at a lot!
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?
At first I found the articles quite daunting, as they were about such big subjects, and there were three articles to read and come up with ideas for. Eventually I tackled one at a time, writing down key points that I came across when reading each article. I then took these and started thinking of ways to visually back up the article. This process took quite a while and developed over a few days.
Can you describe what inspired your Therapy Today illustrations? When reading the articles I found myself visualising parts of the text. None of these ‘visions’ became the final images, but they really helped to bring the article alive and spark ideas. As mentioned earlier, I got a bit stuck when it came to developing ideas, and a walk round Richmond Park really helped to focus my thoughts and get ideas flowing.
Did illustrating these particular subjects throw up any challenges? If so, what were they?
All of the articles tackled big subjects and it was tricky trying to come up with ideas that backed them up and summarised the key themes, whilst avoiding clichés. I spent a lot of time sketching and developing ideas, many of which ended up straight in the bin before I settled on the final ideas.
Can you describe in a nutshell what you were trying to convey with each image?
For the first two illustrations (about Further Education counselling) I was struck by how many people would be affected by cuts. I wanted to get across how counsellors offered a lifeline to people trying to get their life back on track, and how cuts and closures were leaving clients with no options. I think the mountain illustration gets this point across, with the ropes and ladders being pulled out from beneath clients. The cover illustration evolved over the course of a week. The idea started as a locked cupboard full of old scrolls and trophies, but after discussing this with the Art Director (Laura Read) we decided it was too focused on achievement. This then changed to a classroom viewed through a lock, but it still wasn’t working and eventually I decided to focus on the threat of the closure and went with the demolition machines ominously hanging outside a classroom window while everyone inside seemed oblivious.
The illustration for the hospital-based counselling article came to me pretty quickly. I was really hit by the opening of the article: I had no idea that a counsellor could be put in the position of helping support a patient whilst also covering up the fact that they knew more about their patient’s prognosis than the patient did. I knew I wanted to have the counsellor looking at notes before visiting the patient and the rest fell into place.
The final illustration for the article about mixed race was a tricky one, as it was a large issue that needed to be approached delicately. After a long time thinking and sketching ideas I thought that it didn’t need to be as complex as I was trying to make it, and the final illustration idea just popped in to my head.
How do you feel about your finished work and do you have a favourite image? I am really happy with the illustrations and enjoyed the whole process. It is always good to work with challenging articles, especially when they are so informative on areas that I don’t know much about. I think out of all of the images the cover is my favourite, as it was the one that I battled with the hardest, and to see it finally come together was really rewarding.
Apart from Therapy Today, where else might we see your work?
I have worked for a variety of clients since graduating last year, including The New York Times, The Wellcome Trust, The Independent and The Telegraph.
Michael Parkin graduated from Kingston University last year and is based in Kingston Upon Thames. Currently he is working in-house on a book at Penguin and also freelancing. Next year he hopes to spend more time working on his graphic novel. To see more of his work, please visit www.parkinparkin.com. Email [email protected] +++ Noticeboard
Find a supervisor or supervision group in your local area or online
Altrincham/Manchester/Stockport Registered Member MBACP. Experienced in multidisciplinary clinical supervision. NHS, private practice and third sector. Also services for persons experiencing homelessness, personality disorder, asylum seekers. Contact Nigel 07525 374062; www.nigeldawsoncpc.co.uk
Beckenham, Kent Experienced Member MBACP (Snr Accred). Person centred/integrative counsellor and supervisor (Snr Accred). Reduced rates for students. Contact 0208 658 8743; 07900 076732; [email protected]
Cambridge Supervision with psychodynamic counsellor/psychotherapist, experienced in NHS and University settings. Small amount of low cost/free of charge spaces becoming available whilst continuing supervision training at BPF. Contact [email protected]
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
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]
Kingston Bereavement Service seeking a qualified and experienced clinical supervisor to facilitate a supervision group for bereavement counsellors. Every three weeks on a Wednesday morning. £30 per hour. Contact [email protected] with CV; 0208 547 1552
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]
London SE Experienced integrative supervisor for individuals and groups. Support with building business and those starting out in private practice as well as for more experienced practitioners. Contact Fiona 0208 699 7288; [email protected]; www.innerway.co.uk
London SE27 Accredited integrative counsellor offering reduced rate supervision whilst on supervision diploma. I have fifteen years experience of long and short term therapy in both private practice and within services. Contact Nicola 07841 420067; [email protected]
TW15/TW20 Registered Member MBACP, person centred practitioner offering reduced rates for trainees and those on a low income whilst in supervision training. For more details contact Rayner 07982 978555; [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
London CBT and EMDR practitioner opportunity. Pinnacle Therapy offer psychological resilience consultancy. We are currently looking to recruit a CBT and EMDR practitioner to work in a corporate setting in Staffordshire. Send CVs to [email protected] by 5th December.
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
East/West Sussex/Surrey YMCA Dialogue is recruiting for honorary counsellors for volunteer placements working with children and young people in secondary schools and the community. For more information, contact [email protected]
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
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 discrimination under The Equality Act 2010, Schedule 9 Part 1
London, East London. Domestic violence counselling service seeks volunteer female trainee/qualified, person-centred/humanistic counsellors. Free fortnightly supervision. All Woman’s Trust positions are open to women only and are exempt from discrimination under the Equality Act 2010 Part 1, Schedule 9. Contact Maya 020 7034 0303; [email protected]
Stockport Person centred counselling placement in young people and family substance misuse service for second year diploma students (or equivalent) with prior placement experience. Post qualified applicants welcome. Training available to support role. 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] Research
Help researchers with their studies by participating in research
The pregnant counsellor Seeking practitioners (qualified or trainee) who are currently pregnant to share their experiences of working during this time. One hour interview, location flexible. Contact Clare Bhugon [email protected]
Call for MA research participants Seeking counsellors/therapists aged 40 or under who have worked with two or more clients aged 65 or over. Must be qualified or in final year of training. Contact [email protected]
Research participants I am carrying out a research on how psychotherapists experience the termination of therapy when it is initiated by long term clients. If you are interested please contact me at [email protected]
Relational spirituality Do you recognise a time in counselling/psychotherapy as a counsellor or as a client, when there is an aspect of the relationship that you would describe as ‘spiritual’. If you would answer a set of questions on this contact Jeff [email protected]
Doctoral research: Did you, or do you know anyone, who relinquished a child for adoption during the 60s-80s and subsequently tried to contact your child. If so, I would love to hear your story. Contact www.birthmothers.me.uk; [email protected]
Are you a psychosexual/sex therapist with experience working with adult survivors of childhood sexual abuse? I am undertaking a research project in how you have modified your approach. Please contact [email protected] for more information
How do counsellors perceive and work with attachment when working with bereaved clients? I invite counsellors (trainee and qualified) to take part in one semi-structured interview to explore their experiences. Please contact Melissa [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
Cumbria, Penrith Person centred group meets every month to discuss therory and practice. If you are a qualified counsellor, would you like to join us? Please contact Sue Fox 01768 341861
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]