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Therapy Today

October 2014

Volume 25

Issue 8

NB +++ indicates the start of a new section

Contents

Features

Bringing death back into our lives Catherine Jackson previews Kicking the Bucket, a festival of living and dying.

The changing role of the university counselling service Clare Pointon reports on the challenges facing university counselling services today.

Student–tutor conflict in counsellor training Jayne Godward explores the difficulties in the dual role of course tutor and counsellor.

A story of falling A walking accident has taught Alistair Ross a tough lesson about vulnerability.

Feedback in supervision Emma Redfern explains why feedback is essential to a healthy supervisory relationship.

Making meaning in a third language Gala Connell finds she can share meaning even if she doesn’t share a client’s language.

Regulars

Editorial

News

Columns In practice: Jeanine Connor In the client’s chair: Nina Burrowes

Talking point Jackee Holder

Dilemmas

The interview Mick Cooper

How I became a therapist Jeremy Christey

Letters

Reviews

Film reviews

BACP

From the Chair

Public affairs

BACP News

Professional standards

Professional conduct

BACP Research

TherapyToday.net

Eva Bee describes what inspired her illustrations for this issue in ‘Behind the pictures’; plus online reviews and the TherapyToday.net Noticeboard. +++ Editorial

My daughter has just applied to university to do a five-year course. If she gets in she will leave with a minimum debt of £45,000, which is a scary prospect. I wonder how well she will cope with the pressures of the course, living away from home, managing her social life and the whole transition into adulthood. There is certainly more emotional support available for students today; we are much more aware of students’ needs, and university counselling services are well established, offering all sorts of holistic support for students, helping them to cope with exam pressures or to manage their time effectively. But in many cases university counselling services themselves are under pressure because of huge increases in the number of students seeking their help.

In an article documenting how her role as a university student counsellor has changed over the years, Clare Pointon explains that one of the most significant changes has been an increase in the number of students presenting with issues that she and her colleagues are not equipped to deal with. They regularly have to immediately refer students with severe mental health problems to the NHS for long- term or specialist help. The reasons behind this increase are many and complex but include the facts that mental health problems have risen among young people in the general population, and that widening participation in Higher Education (HE) means that more young people with pre-existing mental health problems are going to university. The extent to which other factors like student debt, higher rates of family breakdown and the economic recession contribute to this increase is debatable.

Another perspective on the state of student mental health comes from one of the article’s interviewees, Alan Percy. He suggests that counselling may be developing a new form of dependency. Our society’s shift towards more child-centred parenting, he argues, may have a tendency to make some young people more emotionally dependent on their parents, so they come to university expecting to be looked after. In this scenario, he says it’s important that HE clinicians are clear about what they can and cannot offer.

Sarah Browne

Editor +++ News

Exams top student worries

Academic pressure, jobs and money are the three biggest anxieties concerning UK students today, the 2014 Endsleigh Student Survey reveals. And nearly half say they would seek help from their university counselling service if they felt they weren’t coping.

The survey of 2,128 students asked them to rank their greatest fears out of 10. The top three were keeping up with exams and academic deadlines (89%), applying for jobs (78%) and managing their money (69%), followed by physical health and fitness (62%), and their mental health and wellbeing (60%). Only 20 per cent reported homesickness as a problem but more than half (52%) worried about making friends.

Female students were more likely than men to report anxieties about these issues. On average, eight per cent more women were concerned about achieving academic success; seven per cent more were concerned about applying for jobs and 14 per cent more were concerned about exams and academic deadlines. Women were also more likely than men to talk about their worries with their family or with their friends or a partner (69% compared with 57% and 83% compared with 72%, respectively), while male students were more likely to relieve anxiety by exercising (60% compared with 50%).

Some 41 per cent of students said they would consider visiting their university counselling services; 35 per cent of women said they went shopping to relieve stress and 37 per cent of men said playing computer games helped them to relax. www.endsleigh.co.uk

Talking therapy best for social anxiety disorder

Psychological therapy is more effective than antidepressants for social anxiety disorder and has longer lasting benefits, new research suggests.

Social anxiety disorder affects an estimated 13 per cent of people. But many are not offered treatment with a trained therapist or choose medication or no treatment at all, the joint study by researchers at Johns Hopkins Bloomberg School of Public Health, Oxford University and University College London found.

The meta-analysis of 101 clinical trials found that 9,000 of the 13,164 participants in the studies received medication or a placebo pill, and some 4,000 received psychological therapy. Few of the trials tested combined medication and talking therapy, and there was no evidence that this was better than talking therapy alone.

Individual CBT was the most effective talking treatment – better than psychodynamic, interpersonal and supportive therapy and mindfulness. For patients who didn’t want or couldn’t access talking therapies, selective serotonin re-uptake inhibitors (SSRIs) were the most effective medication.

Based on these findings, the researchers say that medication should only be used if a patient has refused talking therapy. ‘Greater investment in psychological therapies would improve quality of life, increase workplace productivity, and reduce health care costs,’ said lead researcher Dr Evan Mayo-Wilson. ‘Now that we know what works best, we need to improve access to psychotherapy for those who are suffering.’

Lancet Psychiatry

Mentally ill denied non-medical care

Fewer than half of people receiving community mental healthcare say they have been offered non-medical treatments, a survey by the national Care Quality Commission has discovered.

In its annual national survey of more than 13,500 people with severe mental illness in the care of community mental health services, just 47 per cent said they had received any treatments or therapies that did not involve medicines and 26 per cent said they would have liked them.

The survey also found that fewer than half the respondents felt that the NHS mental health staff they saw always understood and helped them with what was important to them, and always helped them to feel hopeful about the things that were important to them.

The CQC says effective care for mental health conditions can include many treatments other than the medications and psychological therapies recommended by NICE, such as relaxation and art therapies, massage and acupuncture.

‘As it is a government priority that more people should benefit from psychological therapies, we hope that future surveys will find a greater proportion of people receiving therapies other than, or in addition to, medicines,’ said Dr Paul Lelliott, Deputy Chief Inspector of Hospitals and CQC lead for mental health. www.cqc.org.uk

IAPT 2013/14 waiting times

Huge regional variations in waiting times are revealed in the 2013/14 data on access to IAPT psychological therapies from the Health and Social Care Information Centre.

Nearly a million (947,640) people were referred to IAPT services in 2013/14 with anxiety and depression. Overall 61 per cent were seen within 28 days of referral, but this varied by Clinical Commissioning Group (CCG) from 96 per cent to just three per cent. Most (89%) were seen within 90 days.

But, of the 40 per cent of referrals recorded as having completed treatment, 37 per cent never saw a therapist for an assessment or treatment at all, and 24 per cent ended treatment after just one assessment and one treatment session or just an assessment.

The majority (63%) of referrals were women and the largest user group was aged 25–29. The most common diagnosis was ‘depressive disorder’ (a quarter of new referrals), and cognitive behavioural therapy (CBT) was the most frequent treatment (38% of appointments). The average number of sessions was six, although 20 per cent received just two. Of the 364,343 referrals that finished a course of treatment, 60 per cent were recorded as showing ‘reliable improvement’, and 13 per cent of those prescribed and taking medication at the start of treatment were no longer taking it when their course of treatment ended.

The Liberal Democrats have said they will include the first ever waiting time targets for access to talking therapies in their manifesto for next year’s election: six weeks for 75 per cent of referrals and 18 weeks for 98 per cent. www.hscic.gov.uk/pubs/psycther1314

Irritable bowel syndrome

Psychotherapy can be helpful for people with irritable bowel syndrome (IBS), a review of published studies has found.

The review analysed 48 randomised controlled trials of treatments for IBS. The studies included comparisons of psychological therapies with a control therapy or usual care, antidepressants with placebo, and combined psychological therapy and antidepressants with placebo.

Antidepressants were only very slightly more effective than psychological therapies. In the psychological therapy trials, cognitive behavioural therapy, hypnotherapy, multi-component psychological therapy, and dynamic psychotherapy all had similar success rates.

The American Journal of Gastroenterology

Antidepressant use in Scotland

One in seven people in Scotland are now taking antidepressants, according to Scottish Government figures.

Prescriptions rates in Scotland for antidepressants, antipsychotics, drugs for ADHD and drugs for dementia have all increased sharply in the past four years.

A total of 778,180 patients were dispensed at least one antidepressant during 2013/14, an increase of 4.2 per cent from 2012/13. Women and people aged 45–49 years were most likely to be prescribed antidepressants, and those living in urban deprived areas – the highest prescribing rates were found in Greater Glasgow and Clyde and Ayrshire and Arran.

A Scottish Government spokeswoman said it is ‘also committed to improving access to alternatives, such as psychological therapies’.

Go to work on your feet, study says

Walking or cycling to work is better for people’s mental health than driving, according to new research by the University of East Anglia and the Centre for Diet and Activity Research (CEDAR). The researchers say the benefits are both physical and psychosocial.

The research team studied 18 years of data on almost 18,000 commuters in Britain aged 18–65 to gauge levels of feelings of worthlessness and unhappiness, sleepless nights and feeling unable to face problems in relation to their mode of getting to work.

They found that the more time commuters spent in cars, the worse their psychological wellbeing. Conversely, the longer their walk to work, the better their mental health. Commuters also reported feeling psychologically better if they travelled by public transport.

‘As buses or trains also give people time to relax, read, socialise, and there is usually an associated walk to the bus stop or railway station, it appears to cheer people up,’ said lead researcher Adam Martin.

According to the 2011 census, 67.1 per cent of commuters use cars or vans as their usual main means of getting to work, compared with 17.8 per cent who use public transport, 10.9 per cent who walk and just 3.1 per cent who cycle. www.cedar.iph.cam.ac.uk +++ In practice

Thinking about dying

Jeanine Connor

I live in a small town close to a slightly larger town in a semi-rural part of the UK. Yet, despite my whereabouts, I can’t travel far without passing an impromptu shrine apparently marking the site of a recent fatality, forcing personal loss into the public domain.

I write this piece in the wake of the actor Robin Williams’ suicide, with images bombarding our screens of floral tributes outside his Californian home, on the Hollywood Walk of Fame and at various film locations around the US. Meanwhile the social media are awash with homages to the ‘acting genius’, mostly from people who never met him. There is no escaping Public Displays of Grief (capital letters merited), the most striking example of which followed the death of Princess Diana in 1997. Images of waist-deep stacks of bouquets remain indelible in the minds of all who witnessed them. This seemed to set a precedent and signify a new cultural norm, but to what end?

Grief is a deeply personal emotional state, so the desire to demonstrate it publicly seems paradoxical. Perhaps the laying of floral tributes externalises, and therefore splits off, those feelings of personal grief that are too painful to contain. Maybe the shared mourning of a celebrity creates a socially acceptable outlet for the expression of individual loss, discouraged in our typically buttoned up society.

We have heard much about Robin Williams’ struggle with depression, which is in contrast to the more familiar face of the ‘comic legend’. Millions of people identify with this and with the urge to self-harm or to attempt suicide. When someone takes their own life opinion rages, and those who do so are branded as brave and tormented or insensitive and selfish. And all this occurs in the context of another debate currently being contested in the public sphere – that of assisted dying. The associated moral, ethical and legal considerations are too vast for the constraints of this column, but they do highlight issues that cannot be avoided: issues about how we manage death, personally, publicly and in practice.

Benjamin Franklin wrote in 1789: ‘In this world nothing can be said to be certain, except death and taxes.’ Death is certain of course, but the where and when and how are rarely known about in advance. How could we live with certainties about our own demise despite knowing, cognitively, that we and our loved ones are mortal? Some of our patients have fewer unknowns: those who live with terminal illness, whether their own or that of someone else in their family, and those who are contemplating assisted dying or suicide. This raises a further paradox in that, although these issues are in the public domain, personal suffering too frequently remains hidden: for example, few spoke about Robin Williams’ depression prior to it being cited as the cause of his death.

In my psychotherapy practice, I have worked with many patients for whom death is an ‘alive’ reality. Their ages and circumstances vary enormously but all are beset by physical and/or psychological pain, often accompanied by a heavy dose of shame. Talking helps. Having a space to verbalise fears, fantasies, what-ifs and if-onlys helps. Not being judged, persuaded, discouraged or emotionally blackmailed helps. Humour helps. Of course I have an urge to keep my patients alive physically, but the crux of my work is to facilitate psychological aliveness. I have witnessed transformation in the most fragile individuals as they gradually become more robust. I have rejoiced as, after numerous overdoses, a client begins to make alternative, safer choices to manage their despair. I have reflected on life after death with children whose parents have completed suicide and who thought there was no alternative for them. I have explored treatment choices and decisions to terminate treatment with those who are terminally ill. I have helped manage the psychological ache of termination. One very ill young man summed up our work with a metaphor: ‘There’s a ton of bricks hanging over me. You haven’t taken them away, but you’ve climbed under here with me and are helping me hold the weight. I’m ready now. I’m ready to go.’

Jeanine Connor MBACP works as a specialist child and adolescent psychodynamic psychotherapist in private practice and in specialist Tier 3 CAMHS and is also a writer. Events and individuals described here are anonymised and are not identifiable. Visit www.seapsychotherapy.co.uk +++ In the client’s chair

Gaining the courage to be me

Nina Burrowes

I am a psychologist who uses cartoons to help people understand how the human mind and emotions work. The Courage To Be Me is an illustrated book for people who are in the early stages of disclosure of sexual abuse. I wrote it as a simple guide to help people make sense of their own behaviour and give them some hope that life can get better. These responses from readers explain why the graphic book format has worked for them.

‘When I saw this book it was like seeing my life illustrated on its pages. It’s like the book was made about me and for me. There were thoughts in there that I had never dared to share with anyone – and there they were, facing me on the page. I had never told anyone about my abuse and had resigned myself to the fact that this “secret” of mine would die with me. I felt so ashamed and alone. In the book it says about shining a light on things. That’s how it felt. The book helped me understand my shame. And I could see I wasn’t alone. It helped me do the one thing I never thought I would do. I phoned a helpline and now I have an appointment for counselling. It’s true what the book says about hope being scary – but I’m grateful for it.’

‘I am a very visual person and so this book just made so much sense to me. Books that are too wordy or clinical get into my logical brain and I try and analyse the things I feel and think… This book gets to a part of your brain that you cannot easily reach. Because all the elements of you can understand, they can ‘see’ and ‘hear’ the words and the pictures. Many would have been much younger when they were abused and the way the book is made, it felt like it was talking directly to those younger damaged elements of myself.’

‘Particularly useful to me was the “I’m Not Mad?” chapter – the scientific explanation of the stress reactions and crossed wires that I was experiencing. As a scientist-type, this wholly resonated and I only wish I’d understood it sooner as I’d have been kinder to myself. Having revisited the book several times, I actually found myself giving myself broader permission to be forgiven – essentially to “indulge” in some of the more emotional stuff I am far less comfortable with.’

‘After being raped in January I can honestly say that The Courage To Be Me has got me through the last few months, giving me the courage to remain in the judicial system...To know I am not going mad and that I am not alone has given me so much strength… There are no words to describe the power of this book. I am just so glad I found it.’

‘I’m dyslexic and had actually given up on trying to find a book about sexual abuse that I’d be able to get through. This is the first book I’ve been able to read all of the way through. The pictures helped me understand information without triggering me. I was able to “see” this side of myself for the first time. It helped make this part of me not invisible anymore. I struggle to find the words to say how I feel, but my counsellor and I now use the images in the book. I’ve even started drawing myself. I think the best thing about this book is that I don’t feel alone and I don’t feel so weird anymore. Thank you.’ The Courage To Be Me costs £12 from Amazon. Bulk orders can be made from the author at www.ninaburrowes.com +++ News feature

Bringing death back into our lives

Why do we find it so hard to talk about death? Catherine Jackson previews Kicking the Bucket, a festival of living and dying that aims to get people talking about death

Stephen Jenkinson was once director of a children’s grief and palliative care programme and assistant professor at a prominent Canadian medical school, responsible for running a home-based palliative care programme. He gave up working in what he calls ‘the death trade’ when he felt he could no longer continue with what he came to consider a deception, ‘a shell game’ – malpractice even. ‘I thought I was there to help people die well. What I discovered was that nobody wanted help to die well because no one wanted to die. I was trying to help people who had no intention of dying at all.’

Jenkinson is among the line-up of speakers, celebrants, performers and workshop leaders taking part in the Kicking the Bucket festival of living and dying, which takes place 22 October to 13 November in and around Oxford. These days he farms, teaches and seeks to spread the word worldwide, not just about dying well but about what he sees as its necessary corollary, living well. ‘Life has to continue, but you don’t. Every culture worth a damn knows that,’ he says. ‘It’s the end of life that gives life a chance.’ But in Western cultures we’re no longer taught that. The frogs we dissect in biology class are dead but not us. Instead, he argues, we’re taught ‘death phobia’ – to be terrified of death.

‘I thought the context for working with dying people was the individual and the family. Period,’ Jenkinson says. ‘Then I realised that all of these people I was working with were on the receiving end of this dominant cultural understanding about what dying is. That was when my willingness to work at an individual level very quickly waned. I found it was actually malpractice to work with death phobia in dying people who had never in their lives had any training in how to die.’

Jenkinson will be speaking at a showing of Griefwalker, a documentary film about his work with dying people, his teaching sessions with doctors and nurses and his counselling sessions with families. His message is, ultimately, very simple; it comprises just two questions that he asks the dying people with whom he works, and we can all ask ourselves: ‘Can we agree that you are dying now? And if we can, what is this time for?’

It’s a message that runs through the festival programme, which is explicitly about living as well as dying, as its title makes explicit. The programme is kaleidoscopic: a New Orleans Jazz Band; death cafés; art, writing and song workshops and exhibitions; discussions on how to plan and prepare for death, from home funerals to living wills; films and performances about death, loss and grieving; activities for children and young people, and opportunities for meditative silence and simply sharing experience.

This is the second Kicking the Bucket festival; the first was in 2012. ‘We are doing it again because we still see a huge need for open, creative conversations about death and dying,’ says Festival Director Liz Rothschild. ‘There is definitely a gradual shift in our attitudes towards death but it is still hard to access useful, honest and inspiring material on the subject and opportunities to share the experience with strangers, friends and family members are still very rare.’ Rothschild, a director, actor, writer and celebrant, also manages the Westmill Woodland Burial Ground in Oxfordshire. Too often people, and their families and friends, are not prepared for death, she says. ‘My work as a celebrant and burial ground manager has made me realise that, by the time I meet people, it’s too late. It’s made me passionate about the idea of death education. There’s a silence around death. People are concerned about confronting it but when they do they tell me they feel relief, less alone, less frightened, and empowered to make decisions. Sometimes these conversations are had more easily with strangers, and that is something that the festival can facilitate.

‘The other aspect is that we are not very good as a society at responding to people who are grieving. We expect grief to be got over quickly. The person who has died is cloaked in silence and that is almost like a second death for the bereaved person because you feel you can no longer allow that person to live in your memory. It’s like cutting off the relationship. Talking about the person who has died, telling their story, is maintaining that relationship.’

Isolation of grief

These conversations, the telling of stories about life and death, are what the festival hopes to inspire. Jane Harris, an accredited counsellor and supervisor, also makes films with her husband Jimmy Edmonds, a TV documentary film maker. When their son Josh died in a road traffic accident in Vietnam, aged just 22, her two professional worlds merged. ‘It’s not that strange – film and therapy are both about relationship with people,’ she says. She and Jimmy made Beyond Goodbye, a film about Josh’s funeral that, by capturing the preparations and the event itself, created a record and celebration of his life too. Since then they have completed Say Their Name for the charity The Compassionate Friends – a series of interviews with parents whose child has died and siblings – that they will be presenting during the festival.

‘Bereaved people and bereaved parents in particular can be very isolated in their grief and the silence around that aloneness is deafening,’ says Harris. ‘You walk into a room and there is almost a hush. You are like the bad fairy at the wedding. People project their fears onto you; they think your being there will somehow mean their child will die. Beyond Goodbye was our way of saying goodbye to Josh. But it was also about bringing death into the open and challenging the silence and fear that his death seemed to bring up in us and in others. By making films and writing about it, we are making the statement that this silence is not OK. We wanted to do something creative and constructive that would move things forward by opening up conversations.

‘People who have seen our films tell us they now feel more comfortable about simply saying they don’t know what to say to someone who is bereaved, which is so much better than avoidance, or silence, or platitudes. Bereaved people aren’t different; they are people who have been bereaved and they need to continue to be part of their community, their networks, however difficult that might be.’

GP Gillian Rice hopes that the emerging trend in the NHS towards supporting people to die at home will heal the huge rift that has emerged between the living and the dead in the past century, as death and funerals have become increasingly hospitalised and professionalised. Rice, with poet Clare Williamson and artist Eleanor Glover, will be leading a festival workshop on the art and writing group, Shadow into Light, that they ran for bereaved people from her Bedminster surgery in Bristol. ‘I sense that death is coming back into the community,’ Rice says. ‘There has been an increasing awareness among doctors that we need to be much more open to talking about death and dying, probably coming out of the hospice movement. We are nowhere near the point where people are relaxed around death, but more people are having the experience of being around someone who is dying and being present at the death and more people are opting to spend the terminal phase at home. I think that’s bringing death back into the community and hopefully, ultimately, that will produce a generation of people for whom death is less frightening and who won’t feel the only safe place to die is in hospital.’

Talking about death

The festival includes a series of death cafés, hosted by OxBel – Oxfordshire Befriending for Life – part of Age UK Oxfordshire. The death café movement (it is now a worldwide phenomenon, with nearly 1,000 events in 23 countries) was launched three years ago by Jon Underwood. A Buddhist, he wanted to provide spaces for people to meet and talk about death, unstructured and in any way they wished. Death cafés are essentially pop-up events, although Underwood hopes shortly to open a permanent venue in London, which will host cultural events alongside serving the more usual conventional skinny lattés, cakes and teas. ‘People come to the death cafés for their own reasons,’ he says. ‘Personally I come to it through Buddhism, from a wisdom tradition that believes that looking at death can be helpful in life, and that’s how I experience it. It’s an important opportunity to regulate my mental health and have a happy life. It combats complacency. It reminds me that the next minute in my life is not promised and that I need to make the most of it.’

Joan Gardner, OxBel Coordinator, was inspired to start hosting death cafés in Oxford by hearing Jon Underwood speak at the 2012 Kicking the Bucket festival. OxBel’s core work is supporting seriously ill people and their families in the last 12 to 18 months of life. ‘The subject of death generates all sorts of emotions – curiosity, intrigue, fear, vivid recollections. I think we are all, at some level, eager to hear and share and maybe learn from other people’s stories and experiences,’ she believes. ‘When I attended the death café at the first Kicking the Bucket festival, I was struck by the quality of the conversations – the way they immediately went beyond the superficial and how complete strangers in the room seemed to connect in a way that felt authentic. That is what convinced me that OxBel was in a perfect position to offer similar opportunities for people with an appetite for this kind of exploration. ‘We hope too to encourage others going about their everyday lives to spend a little time thinking and talking about living well and aiming to die with as few regrets as possible. And the publicity is fantastic for starting lots of impromptu chats about why talking about death might make it just a little less scary, a little more normal and natural.’

Alongside conversations about death, medical advances have created another conversation that is becoming increasingly urgent – about decisions to prolong or end life. Chris Larner will be performing his one-man play, An Instinct for Kindness, at the festival. It’s about his ex-wife Allyson’s decision to end her own life at Dignitas in Switzerland. By then very severely disabled by multiple sclerosis, Allyson asked Chris and her sister to accompany her.

‘When we came back on the plane together we felt like we had been to the gates of Hades and back. Allyson was an actress and I am an actor and director. I decided I had to tell the story properly, and in a formal setting. The experience was burning a hole in my heart,’ Larner says. ‘Interestingly, as I wrote the play I got more and more angry on Allyson’s behalf at the hassle of getting to Dignitas – the exhaustion, the cost, the secrecy. Allyson would have done anything to have had her friends and family around her bedside. I don’t see why, if we have such control over every other aspect of our lives, this last taboo should hold such terror.

‘My first draft was full of polemic but as I started to rehearse it that all faded away and it became what it is: a story of a woman and how her manner of dying affected her and all of us; I let the politics speak for itself. In rehearsal my director Hannah Eidinow kept stopping me and asking, “What are we doing? This is heart-breaking stuff. Why are we putting ourselves through this?” I think it was my way of grieving, although it didn’t feel like it at the time.’

Theatre is, he believes, an ideal medium for prompting people to think about death. ‘There is something about theatre that is empathic to the human condition, much more than other art forms. At its best it encourages a hall full of people to partake in the same emotional journey as the protagonists.’

He first performed the play at the Edinburgh Festival in 2011, less than a year after Allyson died. The audiences then and since have tended to be people who either support assisted death or are facing the same issues themselves. ‘It’s not surprising when you think that the Terry Pratchett BBC documentary on assisted death got about 1,200 complaints and 70 per cent arrived before it was even aired. There’s no off button in the theatre and there are a lot of people out there who simply don’t want to discuss it,’ Larner says.

Not talking about death

Health professionals are, it seems, no different from lay people when it comes to avoiding the topic of death. Liz Rothschild says few came to the 2012 festival – or few who identified themselves as such – and she was advised that few would turn up if they included a death café pitched specifically for them: ‘That to me suggests that they feel they should know about these things and not need support themselves.’

Sue Brayne agrees. A psychotherapist, trainer and author of The D-Word: talking about dying, and a member of the festival planning team, her particular interest is in what happens ‘at the bedside’ of the dying person (the topic of one of the festival panel debates). She also runs workshops on loss and bereavement for therapists and counsellors.

‘Psychotherapists and counsellors are not well trained in death and dying,’ she says. ‘For many, listening to clients’ stories brings up a lot of their own experience. If you are not trained, how do you work with that and where do you talk about it? As a profession, we tend not to. But therapists are just as vulnerable as anybody else. In my workshops I offer a space for people to come together and talk about their own experiences and how to integrate them with their professional work. My experience is that they very much enjoy that. You can see the relief in the room.’

Jane Harris recalls well-meaning friends and colleagues telling her they couldn’t imagine how she, or anyone bereaved of a child, would ever be able to work as a therapist again. She disagrees. ‘Bereavement and loss are transformative experiences. They inform who you are and they inform my practice. For the bereaved parent, things are never the same again. You have to learn to live with a different reality, to present in the world in a way that is acceptable to others, but that child will always be part of you; that child is still my child. Josh’s death has led me to a much deeper level of connectedness and insight with my clients. I chose to go back to work and I hope I am a better practitioner because of these lived events.’

It hasn’t been easy: ‘I trained psychodynamically and have always been very boundaried. Making these films and sharing this information about myself has meant I have had to adapt my approach. I don’t talk about myself ever in my sessions but there is a lot of information about me out there now. I struggled a lot with that in supervision and therapy but I now think it’s not a bad thing. I feel much more comfortable in myself than I did even a year ago because for me there’s an integration of life and death in all this.’

Dying wisely

Stephen Jenkinson argues that health professionals cannot cope with death because death for them is failure: ‘Success in healthcare terms is about keeping people alive.’ The word therapy derives from the Greek for cure, he points out. He has a book coming out next March in the UK – Die Wise: a manifesto for sanity and soul. ‘My worry is that what I am saying will be turned into an intervention to facilitate people going to their demise appropriately accepting or sedated and antidepressed. That would be terrible.’ Dying people are, he says, among the heaviest users of antidepressants in North America. There is a similar urge to ‘cure’ grief, particularly among therapists: ‘There is the belief that grief is something that intrudes into the natural order of things and must be contained and ameliorated. The recipe for sanity is to be impervious.’

He says fear of death is understandable in a culture dominated by death phobia: ‘Life is a loveable thing, most of the time. But that makes death more heart-breaking than fearful.’ He wants ‘to tear down the fence between living and dying so they are in the same place for us. If we are going to change how things are, we have to be willing to include dying in our understanding of health.’

It is that separation of life from death and the living from the dead that Liz Rothschild too tries to bridge when she conducts a funeral. ‘People weep, laugh, comfort each other. These things are all part of the funeral. I always make a point of touching the coffin at some point. There is a distance that grows up between the living and the dead. Touching the coffin includes them.’

Kicking the Bucket takes place in and around Oxford from 22 October to 13 November. For details, see www.kickingthebucket.co.uk or please call 01367 240508 or email [email protected] +++ The changing role of the university counselling service

Clare Pointon describes the changes in her role in a university counselling service in an increasingly market-oriented, cash-strapped arena and faced with rising student demand

When I first joined a university counselling service eight years ago, the work was generally shaped around a neat seven-session contract. Using an almost exclusively one-to-one relational model, I regularly worked through a beginning, a middle and an end with my clients and could usually review their needs and offer more sessions, should they need it. I always had a few students of particular concern, including those who self-harmed, and I would sometimes refer someone on for specialist or GP support.

My clients were negotiating, as young people aged 18 to 25 usually are, transitions into adulthood of varying complexity. But most were able to benefit from short-term counselling for support, heightened awareness and a greater understanding about their life to date and their choices in the moment. The work had a certain rhythm to it – it was usually manageable but busy at the usual peaks of the academic year, around spring term dissertation hand-ins and final projects.

Not so today. The question at assessment now is no longer primarily how many sessions we offer but whether it would be ethical for our service to engage with the person before us and, if so, how. Not having mental health advisers on our team, as some university counselling services do, we regularly refer out immediately. In this scenario, our role becomes one of ongoing case management and therapeutic holding as we support the student to access – and wait for – the NHS, long-term or specialist help they need.

When we do take someone on, it may well not be classic counselling that we suggest. Nowadays my colleague on campus and I use our rare quiet days – for us, in late summer and early autumn – to plan a schedule of other offerings, such as wellbeing initiatives, self-help ideas, relaxation sessions, groups/workshops, staff trainings, management briefings and meetings with NHS and other service providers. We know that a giant wave of demand for one-to-one work will hit us by mid- November and, from then on, the challenge for our service will just be to stay afloat.

Case study: Jake’s story (academic year 2013-14)

‘I found myself in really unfamiliar territory. I was losing sleep, feeling more depressed than usual and, after a particularly turbulent night where I woke up with cuts on my arms, I swallowed my pride and sought help. I went to my GP and to my course leader, both of whom said they thought I should seek counselling. I was very much against the idea initially, but I did a rough self-evaluation and asked myself if I really wanted to listen to my own opinion because I was hurting myself and depressed.

‘When I started counselling it was really a date in a calendar; it was something I had to go and do. I hadn’t imagined that having a personal crisis mixed with an existential crisis could be so chaotic. By throwing appointments at me over the past year – the doctors, my course leader and the counsellor – whether or not they were aware of it, they were building a structure that I had to follow. That’s what I got out of it at first because at first I wasn’t interested in opening up or in a vivisection of my own psyche. I just liked the fact that the days weren’t running together. I had to have a calendar and I relearned order.

‘At that lowest point in my mental state, I was just relying on other people telling me what to do. So it was really important to have counselling because I needed to return to a sense of autonomy. And that’s exactly what counselling gave me back. It was crucial for me to have counselling exactly when I had it, because of the risk factor for me and because of the fact that I felt a level of autonomy had slipped away. I was craving being ordered around because either I felt like I’d lost control of my life or I simply didn’t want responsibility for it.’

Rising tide of demand

These are changing times. In a climate of financial upheaval and spending cuts at UK universities and HE institutions, BACP cites a 2013 survey by the Heads of University Counselling Services (HUCS) which says the number of HE students seeking counselling from their educational establishment rose 16 per cent between 2010 and 2013. In the same period, there was an 85 per cent increase in those seeking online counselling, as services began diversifying what they offered. Average waiting times for first appointments went up to between five days and three weeks, while the number of sessions offered by the majority of HE counselling services remained on average four to five.

Ruth Caleb, Head of Counselling at Brunel University and Chair of the Mental Health and Wellbeing in HE Working Group, says the CORE outcome measures used by many counselling services show that students are presenting with a higher incidence of complex mental and emotional issues, as well as self-harm and risk. ‘Jake’ (above) – whom I saw for seven months in his final year to support him to complete his degree – is typical of these students presenting at high-risk of or with severe mental health difficulties. BACP has not collated robust statistics on severity or suicide risk, but Patti Wallace, its Lead Advisor for University and College Counselling, says it’s clear that more students are now coming to university with pre-existing mental health issues: ‘There is more complexity of need, greater risk and counsellors are having to handle more difficult situations across the board. They are doing this with fewer resources and that puts pressure on the counselling service. Ultimately my concern is that there are services where students aren’t being seen as quickly as they have been in the past. If that happens, it would be a real loss because the timeliness of a service is really important for students.’

She argues that speed of response is particularly important with this client group. Students, because of their age, are less likely than older adults to have faced similar problems in their lives and to have evolved the necessary coping strategies. They are also negotiating the stresses of what she calls a ‘time-sensitive environment’, in which missing deadlines or failing exams can have a significant impact on their life at university and, potentially, their future.

So how, when and why did university counselling services get so stretched and demand from students increase?

Clearly there has been a rise in the number of young people with mental health issues in the general population in recent years. But there is also increasing realisation of the psychological vulnerability of HE students, voiced by the Royal College of Psychiatrists in its 2011 report, The Mental Health of Students in Higher Education. Developmentally, the report pointed out, HE students are already coping with transition – leaving home for the first time, looking after themselves, joining new peer groups and taking on academic demands. They are living in an environment where there is often pressure to misuse drugs and alcohol, at an age (mostly 18 to 25) that is also statistically the peak period of onset for severe and enduring mental health issues like schizophrenia or bipolar disorder. Added to this, it said, is a harsh national economic climate, with increasingly uncertain job prospects and where students often have to earn money while they study, sometimes leaving them less time than they need to meet their deadlines. Also the more democratic policy of widening access to university for students from different backgrounds and profiles means that, while a greater percentage of the population now undertakes HE, the newly expanding student groups – for example, the financially lucrative and growing cohort of international students – bring specific needs for which institutions may not previously have made significant provision.

Then, in September 2012, the Government introduced significant cuts to HE funding. In a radical shake-up of the fee structure, instead of a block grant from government to cover their costs, universities and colleges were now required to generate funds to cover half their budgets themselves, from fees charged to the students they recruited. The drive for some HE institutions to recruit became intense. Many staff across the sector felt less secure as, in an attempt to cope in the new climate, jobs were cut and departments reviewed, reorganised and merged. For students, it was a whole new era – they now had to pay £9,000 a year for their studies and faced the prospect of graduating with an average personal debt of £27,000.

‘The £9,000 is a huge debt on their shoulders,’ says Ruth Caleb. ‘On top of this they have to pay for their food, their rent, their books and their lives so, in order to cope, many students are now working a number of hours that are impinging on their course. They’re finding that they’re getting behind or they haven’t got the time to do their assignments properly. It’s a major problem for many of them.’

A shared responsibility

Charlotte Halvorsen, Head of Student Counselling and Mental Health at City University, agrees. Students are not only taking out loans and working more to make ends meet during their studies; as a result, she says, they feel under greater pressure to get a good degree in order to find a well enough paid job at the end of it. They may even at some level assume they are entitled to a degree, whatever their academic outcome, because they’ve paid so much for it. And, when pressures and problems do hit during their studies, they feel less able to take the time out that they might need or even to consider leaving if their course or the HE path is not right for them. In a 2012 survey, BACP found that 81 per cent of students who responded felt counselling had helped them stay at university or college.1 However, alongside the general push to recruit and retain students, Charlotte Halvorsen says there needs to be a level of understanding in institutional leadership that ‘sometimes we encounter a student who is failing in the system and the best outcome may be to support their exit sooner rather than later’.

As institutions recruit more students who are themselves under greater pressure and of whom more declare extra needs, she calls for more ‘joined-up thinking’ between different departments. Academic departments have a duty to support the students they recruit – not just to hand them over to the counselling service. ‘There should be more consideration given to and consultation with the students recruited,’ she says. ‘Students who declare any special needs prior to arrival should be assured that their academic department is aware and appropriate support has been put in place.’ In the current climate she believes some institutions are compromising on investment in the necessary support structures in order to survive. ‘It’s almost turning into a customer- driven service, a private sector business,’ she says. ‘The business need is to maximise student fees and that’s done by collating numbers rather than by appreciating individuals’ needs for support.’

Ruth Caleb shares her concerns: ‘Counselling services are not the owners of responsibility for mental health in an institution,’ she says. ‘That has to be owned by everybody, from the vice chancellor down, including academic schools and departments. It is up to the university to offer the appropriate form of support for its students, so if you expand the number of overseas students, for example, you need to be aware that those students will have particular stresses… they may be doing their study in their second, third or fourth language, they may be leaving family behind, they may be struggling financially, they may know no one in this country and they may experience culture shock.’ Likewise, she argues, students recruited into HE from, for example, BTEC courses that offer more course work assessments, one-to- one support and less exam-based work, may need more practical help with the transition.

So are institutions letting down students in their drive to recruit large numbers? Sir Bob Burgess, Vice Chancellor of the University of Leicester, acknowledges the financial pressure across the sector. ‘I think this year has been the most challenging I can remember,’ he says. ‘And it’s inevitable that, when the Government announces cuts, that’s going to trickle down to staff and to students.’ He accepts that, for some students, the pressures of the new fee structure will contribute to their difficulties but argues that, as greater numbers – some 50 per cent – of young people now enter HE, it’s natural that the level of demand for support will increase. He believes there is a need for more personal tutors offering pastoral care, more funding for counselling and for staff training in mental health.

‘It would be good if we could increase funds for these forms of support,’ he says, ‘but in the current climate that is challenging to deliver.’ Another useful support for students who are assessed as having a mental health problem has been the Disabled Student Allowance (DSA), although this is currently ‘under review’ by the Government. This allowance enables students who are assessed as eligible to have a mentor to help them with a range of supports, including stress management and confidence building.

Outsourcing threat

Meanwhile the pressure on counselling services, usually working to frozen budgets, continues to build. In terms of practice, Ruth Caleb says this means that, in many cases, counsellors are often unable to see a student for as long as they might need. Time is taken up by the sheer numbers of requests, including supporting those whose complex needs may require regular check-ins for the whole of their course. Waiting lists are long – both in university counselling services and in the NHS. In many services, she says, particularly those with lone counsellors for whom there is little or no extra cover at busy periods, practitioners become overwhelmed and burned out. They have little time for CPD or peer support or time to plan the crucial input they can offer an institution to academic practice and student wellbeing: ‘The more pressure we are under from the people coming to see us, the less we are able to do preventative work – staff training, student groups and other strategic activities. Counselling services tend to be the boats in the water with the fishing nets fishing people out. We need to see why they are jumping in.’

In such a climate, the spectre of outsourcing university counselling lurks in the shadows. It’s already happened in Northern Ireland where all HE and further education (FE) counselling is now contracted out. Patti Wallace argues that outsourcing is not the answer in an age of growing psychological demand, as properly funded, embedded counsellors can offer much more. Located within the educational environment and with relationships across departments, staff counsellors not only see students one-to-one but can run groups and workshops, support and train staff and input to management in a crisis. Nowadays, she says, the remit of on- site counsellors has widened so much that BACP is currently developing a new competency framework for the kinds of skills required to work in both FE and HE: ‘Today we look for people who have knowledge across mental health issues; experienced people who have worked in a range of settings, who are good at assessing and deciding what’s going to be the most useful intervention for this client in this context; people who are able to see someone bringing three or four different issues and work out how they can help them get to the point where they can function again adequately within this context rather than trying to help them resolve every issue in their lives.’

Creating dependency?

For Alan Percy, Head of Counselling at the University of Oxford, this new era challenges HE counsellors to reflect on what we do and why. ‘The key thing for all counselling services is not to be pulled away from the key performance indicators,’ he says. ‘The measure of the effectiveness of the service is the effectiveness of the clinical interventions. It is important to evidence the real changes – in terms of feeling, symptoms and functioning – the service has made to the students who use it.’

He agrees with Patti Wallace that speed of access to counselling is very important, but argues that the perceived need for an immediate response – by the student seeking help and perhaps by the institution – must be tempered by this understanding about effectiveness. Our priority, he says, is to select the most appropriate intervention for each student from a repertoire of self-help, groups, workshops and one-to-one counselling. As for how many sessions are offered, he argues it’s better to give most people one or two and protect the possibility of a limited amount of medium and long-term work for some than to make a more average offering to all. ‘I think that puts a lot of emphasis and responsibility onto the individual doing the assessment,’ he says. ‘But if you’ve got highly skilled qualified counsellors, that’s where they should be deploying their skills.’

The key, he argues, is to resist the pull to offer one-to-one work: to balance demand and expectation against the reality of what a service is able to do. In his service, much of the longer-term work is done by (trainee) associate counsellors, who may need long-term experience as part of their course learning; higher risk work is managed by core counsellors linked into other support services.

Like Charlotte Halvorsen, Ruth Caleb and Patti Wallace, Alan Percy believes a staff counselling service can be a proactive holistic force within an institution, contributing widely to student wellbeing and increased understanding among staff about mental health and the difference they can make to this. However, he argues that greater general understanding about mental health also has a downside. For him it’s one of the drivers for the rising demand for counselling that, in his view, are independent of the new financial realities of higher education. They include an over-medicalisation of student distress: ‘If every difficulty or upset is symptomised as a mental health illness,’ he says, ‘it makes it a lot harder to deal with both for the student and for those trying to help, rather than understanding it as a difficulty which is very distressing but is a normal consequence of the person’s developmental process. If that is seen as an illness, it becomes a way of objectifying the person, making them feel passive, undermining their self agency and expecting someone – a doctor or a counsellor – to sort it all out.’

‘Consumerised’ climate

Instead of creating a new form of dependency, Alan Percy argues, counselling is more helpful if it allows a young person to individuate, so developing their own internal resilience. He theorises that a general societal shift to more ‘child-centred parenting’ has been partly responsible for raising some young people who, while apparently more mature and confident, are in fact more emotionally dependent on their parents and come to university with a greater expectation of being looked after. ‘The risk is that institutions parallel over-protective parenting by trying to satisfy impossible demands and expectations,’ he says.

Setting this alongside a point made by many academics that the new fee structure has spawned a climate of ‘consumerisation’, that increasing numbers of complaints are made by today’s HE students who see their £9,000 a year ‘buying’ them the right to a whole range of services, including counselling, the potential dangers become evident. Our responsibility as HE clinicians, argues Alan Percy, is to be clear in the face of others’ expectations and to spell it out that change involves hard work and engagement on the part of the person seeking help: ‘If you’re not honest right at the beginning, giving a coherent message about what you can and can’t do, you are inevitably going to be setting up disappointment and dissatisfaction,’ he says.

So have our students – and sometimes as importantly their parents – morphed from clients to customers since I started my work in HE? To some extent I would say yes. Then how does that play out in the power dynamic of the therapeutic relationship? I believe, with Alan Percy, that it is crucial for us to be assertive about what we can and can’t offer. For, unlike those in most other university departments, our job may not always be to offer the customer what s/he wants. At the same time I am probably – consciously and unconsciously – more aware of potential comeback when I make a clinical decision not to take someone on for counselling. I certainly make sure my reasons are logged in my client notes. Knowing the importance of standing my ground – with students and with managers – is crucial. But in a climate of high institutional anxiety and uncertain job security, the challenge as in-house student counsellors is sometimes to be brave enough to do it.

Clare Pointon is a psychotherapist, writer and former BBC journalist who has worked as a university counsellor for the past eight years. She runs psychological training courses for staff and students, as well as relaxation classes.

Reference

1. Wallace P. The impact of counselling on academic outcomes: the student perspective. AUCC Journal 2012; November: 6–11. +++ Student–tutor conflict in counsellor training

As counselling tutors/trainers embark on a new academic year, Jayne Godward reports on her research into experiences of managing student–tutor conflict

Training people to become counsellors is rather like trekking through a jungle. It is extremely interesting and, at times, exciting; you encounter so much that is new and unexpected and there is so much to see, hear and experience. But it is also personally challenging, and you need to be prepared for and alert to the potential hazards. Difficult relational dynamics and conflicts will arise between tutors and students and these can easily lead to you ending up in the swamp, being bogged down and under attack.

Conflict is a common occurrence in groups1 and perhaps inevitable on counselling training courses as students become aware of themselves and their own needs. This can be a particularly vulnerable period as they develop personally, attend therapy and work closely in groups with peers and tutors.

The key factors leading to conflict identified by Connor2 and Nelson and Barnes3 are the personal issues and vulnerability of both the student and the trainer, the need for trust and safety in trainees, interpersonal dynamics, power relationships, role conflict and ambiguity. Other causes of conflict not to be ignored are transferences, countertransferences and projections on both sides.2

Having waded through this jungle swamp with my colleagues on several occasions, I decided to carry out a qualitative research study to look at the methods experienced counselling tutors use for dealing with conflict between themselves and their students.

Nine humanistic tutors with eight to 20 years of counsellor training experience took part in the study. Six were working in colleges and three in universities. They wrote at length about their experiences and ways of managing conflict, and gave specific examples. Four of the tutors also took part in a focus group.

My analysis of their responses highlighted two factors in particular that could hinder conflict resolution: the role conflict experienced by tutors between their roles as therapist and tutor, and the organisational context in which they worked. I will look at these factors first before moving on to discuss the strategies that were suggested for dealing with the actual conflict.

Role conflict of the counsellor trainer

It became apparent during the study that these counselling trainers often experienced a tension between their roles of therapist and tutor. There was a tendency to want to act in a therapeutic and supportive way towards students, whereas being a tutor necessitates carrying out assessments and making judgments about a student’s work and progress and ultimately deciding on their fitness to practise.

These dimensions of the professional self could be complementary at times, and counselling skills could be useful in conflict situations; however sometimes the tutor dimension had to have priority, as this was the main aspect of the trainer’s job and the students were not on the course to receive therapy from their tutors. Trainers, particularly those from a person-centred background, talked of using their counselling skills when dealing with conflict (the therapist dimension of the role). One tutor described a difficulty he and a co-tutor had with a student who was questioning the way the personal development group was being run and wanted the tutors to disclose and be more involved. The student felt that he was being observed, assessed and judged in the group but, instead of meeting the tutors to discuss what was going on, he attacked them in the next personal development group meeting. The tutor wrote: ‘What we hoped he witnessed was our ability to stay grounded in the person-centred approach. In doing so we allowed him to share his experience with his peers, without judgment.’

To an extent modelling your counselling approach and getting alongside a student could be helpful and could resolve a conflict situation. However difficulties arose when students were unable to reflect on their part in the conflict or were lacking in self-awareness. The question discussed by tutors in this study was how far do you continue to work in a therapeutic way with students and when does it become unhelpful to the student’s development?

One tutor described how she switched to the ‘tutor dimension’ of her role: ‘So in a conflict, when I’ve done what I can to reach out to that student to see what it is, to understand, to get support for them, then the thing I’m wanting to do with that student is to say, “And now I’d like you to reflect on your part in this and I’d also like you to think about how that might be enacted possibly with your clients or with other people out there.”’

Some tutors argued that the key aspect of their role was to keep focused on the training so that students could succeed on the course; others recognised that it might not always be possible: ‘It’s become impossible for them to look at their part in it and then, in terms of training and where we want them, where I want them to be at the end of the course, they’re not going to get there anyway because they can’t look at themselves.’

This would be an example of a situation where, no matter how much empathy and support the tutor gives the student, they still might not be ready to become counsellors at this point and to pass the course.

In terms of students’ expectations of their tutors, sometimes they were seen first and foremost as therapists and second as tutors. Focus group members spoke of how students could react if tutors did not live up to their expectations of what a therapist should be like. ‘They have us on this pedestal and see us in a certain way and when we don’t act in that way they can take it quite personally and be hurt and angry,’ one participant said. Another said simply: ‘I can’t always be the therapist they might want me to be.’

Trainers also discussed the responsibility that goes with their role, including the assessment aspect and the power imbalance in the tutor–student relationship. They spoke of the importance of being assertive, following policies and procedures, and being factual rather than blaming.

What was clear from the responses to my study was that it did not come naturally to therapists to maintain the firm professional trainer role and it wasn’t easy to bear the personal effects of dealing with conflict. There is a clear need for a considerable amount of resilience and experience in the role. As one participant wrote: ‘There is a part of me that doesn’t want to be in the more powerful position.’ Organisational context

Doing the research, I began to have an image of a trainer on a unicycle on a high wire, pedalling furiously to keep up there and whizzing from the therapist side to the professional tutor/assessor/maintainer of standards side. What became apparent from this study is the need for a robust supporting framework so that the tutor does not topple off.

Counselling tutors are not working in isolation – the success of conflict resolution depends on the environment in which the tutor works and on the structure of the course itself. Counsellor training involves supervisors, placement providers and, often, personal therapists. It became clear that all of these need to be pulling together in the same direction as the trainer. As one of the tutors said: ‘To have a sense that everybody involved with their [the students] training is moving in the same direction and singing from the same song sheet, I think is enormously helpful.’ Another participant described a situation where concerns about a student’s performance were not raised by their supervisor until near the end of their course, although the placement providers thought the student was doing well: ‘The placement providers became angry, siding as it were with the student and adding to the conflict that might otherwise have been more amicably resolved.’

This ‘pulling together’ was one of the main factors that determined whether conflicts were resolved smoothly and successfully. Sometimes decisions about students were determined by what the educational establishment decided, even if they went against counselling ethics and the standards of a course. One tutor found her college did not support her with a difficult student who was not following course guidelines: ‘The student set up her own counselling practice... instead of finding a placement. When I challenged her about this she complained to the college and accused me of harassment. The college could not see the problem as she was gaining the required hours to pass the course,’ she wrote.

Often the student’s point of view would be given more weight than that of the tutors or the training on the programme: ‘They [the college authorities] bend over backwards to see the student’s point of view, sometimes in a way that feels unsupportive actually to the person’s development.’

Sometimes tutors were not allowed to encourage unsuitable students to leave the course, because that would have resulted in loss of income to the college: ‘We’re in a recession and we’ve got to keep bums on seats and all the rest and that’s just got worse and worse over the years.’

I have been in a course team where we were told that students could not be failed on grounds of being unfit to practise; the only way that the person could fail and not become a counsellor was if their academic work did not pass. One focus group member echoed this frustration: ‘If a student is not willing to reflect on self and is impervious to feedback from others, that’s not a good therapist, and something’s gone wrong if I am able to pass a student like that… I think we have problems with that when it comes to our manager ’cos she’s not got that background.’

Occasionally organisational policies and procedures were helpful to the course team. Exceptionally, one tutor had been supported by her manager: ‘I’ve always been supported (fairly and without collusion) by my line manager(s) so am lucky in this respect.’ Whatever the context, the individual tutor’s approach to the conflict was important in its successful management. Many of the participants talked about wanting to empathise and understand their students’ point of view and actively find out what was going on for the person. To do this participants tried hard to be fair and non- judgmental, to show genuine interest in the student and be willing to apologise if found to be at fault: ‘When people feel aggrieved, what they want even more than a head on a plate is to feel heard in their distress. So, “I’m sorry I did that. I can see so clearly how you felt belittled” can be very powerful.’ Feeling listened to might be all that is required and, as another tutor said: ‘I believe that if they are heard maybe I will be heard too.’

Dealing with conflict

The participants in this study were enthusiastic about using the course group for conflict management. There was some wish to avoid tackling individual students directly, although to bring up some issues in a course group when they do not concern all members may be irksome to the rest.

Some of my research participants suggested that group activities and group time could be used to promote reflection on behaviour and attitudes, with the trainer encouraging students to reflect on what is going on for them and their own part in the conflict. However this strategy can sometimes backfire: ‘I attempted to deal with the conflict within the group setting. This resulted in further conflict involving most other members of the group. My co-tutor stepped in – in support of me to help manage the situation – which resulted in the anger and distress being projected onto him. Eventually, the need to move on rather than dwell on the conflict became apparent, although this was difficult in terms of relationships between trainers and students.’

Using the conflict situation in group exercises as part of the course appeared to be a good way to promote learning. Some tutors were also keen on students challenging each other and being involved in assessment.

The value of having a co-tutor during conflicts was particularly highlighted. As one participant wrote: ‘Having a co-tutor is very helpful as they can “hold” the group whilst something is being unpicked between a student and the other tutor. Also, if one of us is triggered by a student, the other tutor can act as a “reality check” – and also take on the main contact with that student, whilst the trigger itself gets sorted out in supervision etc.’

Conclusions

This article has highlighted some of the key aspects of managing conflicts between tutors and students that emerged in my research: in particular the tension between the therapist and tutor dimensions of the trainer’s role and the significance of the course structure and organisational context. An important finding from the study is that there needs to be an integrated approach to conflict management, rather than a knee-jerk response.

Although not suggested by the tutors, my view is that training providers may need educating about the requirements of counselling courses and the need to give the course team adequate support in managing their dual role. Students also need to understand what is expected of them from their participation in the course, and perhaps what to expect of their tutors.

Returning to my jungle metaphor, I offer here a checklist for the tutor or course leaders about to embark on their latest educational expedition with a new cohort of students. Are the following elements in place?

Does everyone have the same route map, including the students? Do you all know where you are going and the aims of the expedition?

Is the back-up support there – eg co-tutors, team, supervisors, placement providers, therapists, training supervisor, own therapist?

Are you confident that the funders/ supporters will not scupper the expedition or change the route at short notice?

Has the expedition been thoroughly planned and potential difficulties and risks pre- empted? Are you prepared for encounters with wild animals and other likely hazards?

Being involved in counsellor training is exciting and rewarding, but it can be an exhausting and emotionally hazardous process too. I hope the findings from my study will be helpful for those planning and running practitioner courses.

Jayne Godward is a person-centred counsellor and supervisor, Senior Lecturer at Leeds Metropolitan University, and Manager and trainer at Yorkshire Counselling Training, Hull and Bradford.

References

1. Corey G. Theory and practice of group counseling (8th edition). Belmont, CA: Brooks/Cole; 2008. 2. Connor M. Training the counsellor; an integrative model. London: Routledge; 1994. 3. Nelson ML, Barnes KL, Evans AL, Triggiano PJ. Working with conflict in clinical supervision: wise supervisors’ perspectives. Journal of Counselling Psychology 2008; 55(2): 172–184. +++ A story of falling

A life-threatening accident and the resulting awareness of his own vulnerability have transformed the way Alistair Ross works with clients

As counsellors and therapists, we become used to dealing with the trauma of other people’s lives. We go to the darkest places with them and accompany them back into the light. So you would think that we would be prepared for our own traumas, not imagining they could happen so unexpectedly. This is my account of surviving one such trauma earlier this year and how I now reflect on its impact on my ongoing work as a therapist and supervisor.

Nobody teaches you how to fall, unless you are taking up judo or want to jump out of an aeroplane. Even then the emphasis is on how you land, rather than fall. Falling is an alien activity for the human species. This is a story of how I fell. My worst nightmare was happening before my very open eyes.

As a child I had a recurring and disturbing dream in which I was falling endlessly into darkness. It would only stop when I jolted awake, sitting bolt upright, bathed in sweat, breathing deeply. This time I was falling 160 feet down a rock gulley, until I crashed to an abrupt halt on a water-filled ledge. This was no nightmare from which I could wake and escape. Each stage of my fall, as I tumbled over and over, resulted in my head, arms, back, ribs, knees, shins and ankles crashing against unrelenting rock. I can recall as if in slow motion the exact moment my forehead smacked against a sharp rock and my vision became obscured by blood dripping from my head. Once I stopped falling down the mountain, I knew immediately I was alive but badly injured. I could not move my right wrist; my legs and ankles couldn’t bear any weight, as I discovered when I tried to stand up; my back issued warnings of excruciating pain every time I moved.

I had been walking on my own on Tryfan, an iconic and rather beautiful mountain in Snowdonia, which I had climbed before with friends. The snow was becoming unstable because of an unexpected rise in the temperature. After slipping several times, I decided to return the way I had come but took a wrong turn and found myself in unfamiliar terrain. I came across a gulley and was looking over to see if it offered a navigable way down; my foot slipped and I fell forward, my momentum carrying me down head first.

Despite the effort and pain I dragged myself to one side of the ledge and balanced on a rock, out of the water. The shock and cold hit as I began to shiver uncontrollably. I had lost my hat and gloves and, despite my lined trousers, now torn, and my warm jacket, the cold began to creep in like some stealthy, deadly enemy. I can recall very clearly thinking, ‘I wonder if this is it?’ I knew I was in a remote part of Tryfan (somewhere above Milestone Buttress) where it was unlikely that any walkers would come across me. I knew hypothermia was setting in. I also knew my son would not be alarmed as I was not expected home for another five hours. Your life does indeed flash through your mind when faced with the possibility of death.

My personal faith in God allowed me to say, ‘Well, God, if this is it, this is it.’ The words of the Old Testament book of Ecclesiastes came to mind: ‘To every thing there is a season, and a time to every purpose under the heaven: a time to be born, and a time to die.’ Yet, paradoxically, I also felt a burning desire for this not to be so; there was so much more of my life to be lived, even if how I lived might be irrevocably changed. I did not have the energy to bargain with God. Actually, that is not the kind of God I believe in.

Miraculously, my mobile phone was undamaged and located a signal strong enough to get a message through to my son, who contacted the Ogwen mountain rescue team. Those who know me think it was miraculous that I had even charged it up, although I had consciously done this the day before. When I got through, apparently I told my son somewhat nonchalantly that I had had ‘a bit of a fall, hit my head and hurt my hand’. He imagined I had simply fallen over.

Within an hour Ogwen mountain rescue rang and informed me they had sent a team out to find me. The team happened to be practising on Tryfan that day and so were able to get to me more quickly. I became aware of the noise of a helicopter that drowned out the chatter of my teeth but watched with a sickening feeling as they flew past several times. I never felt so abandoned or bereft in my entire life. It transpired that the air crew had seen me but were having some difficulty with turbulence and finding a safe location to drop down a paramedic. I sobbed tears of relief when the paramedic appeared over the side of the gulley. Sadly, I can’t recall his name but his friendly, matter of fact approach was an immense comfort. He wrapped me in an emergency foil blanket and placed heating pads on whatever part of my body he could reach and stabilised my head in a neck collar.

The mountain rescue team then arrived with an ingenious two-piece stretcher and loaded me onto it while the helicopter hovered low enough to be able to winch me on board. The line reached my stretcher, just. I had never felt so helpless, my broken body needing the firm but gentle care of others, just like a baby. As I was winched hundreds of feet through the air I could see very little and registered with regret that I had missed the view of a lifetime. Once cocooned in the helicopter I expressed my faith through a prayer, thanking God for my continuing life, however it would unfold.

As my stretcher was wheeled into the emergency department at Bangor Hospital a team of doctors and nurses were standing in a semi-circle poised for action. My clothes were cut off so I could be properly assessed. Various needles and drips were stuck in. In the midst of this medical care there were two acts of kindness that deeply touched me. The first was the doctor who used warm water and cotton wool balls (or equivalent) to gently clean my head wounds and remove the dried blood from my face and scalp, saying, ‘So you might look a bit better and it will be less of a shock for your wife when she arrives.’ Even more touching was the nurse who gently massaged my toes to help provide some warmth while my body temperature recovered. That skin-to-skin human contact meant so much.

After the fall

It transpired I had two fractures to my left fibula, three fractures to my right fibula and ankle and three fractures to my right wrist, including a spiral fracture that required an operation to insert a Y-plate and various pins to hold the wrist together. My head wound was a deep dent in my forehead as well as multiple lacerations (which they glued together).

I had fallen, but not into some dark abyss, as in my childhood nightmares or as chronicled by Kierkegaard.1 I was not in despair; nor was I experiencing the ‘nameless dread’ about which Bion writes.2 I had fallen physically, but spiritually I experienced being held. This takes me to why I love being on mountains, which is captured in the title of one of my favourite books, The Solace of Fierce Landscapes.3 This is a theological and academic text that explores how we develop our spirituality in barren, inhospitable and remote places. For me it is to do with a wild freedom and the aliveness of being ‘on the edge’, but the mountains are not all about triumph and conquest: there is also present the dark side of a granite-like God. Yet my experience was not a descent into an abyss; paradoxically I felt ‘held’ by the presence of God, as if this God of mine would not let me go. When the British psychoanalyst DW Winnicott talked about dreadful childhood experience, he identified a sense of ‘falling forever’, as if falling into infinite and endless space, and the disintegration of being.4 I felt that, fearful as I was of Winnicott’s ‘falling forever’ and a return of my childhood trauma, I was instead falling into an infinite and eternal God where being remains being in connection to the Other.

Nobody told me that becoming a patient is so like becoming a baby. My week in Bangor Hospital was spent in constant pain, alleviated by oxygen and morphine. With only one working limb, I needed four people to turn me, wash me and move me. I slept during the day but was woken every three hours throughout the night for ‘observations’. Most of the staff and patients spoke Welsh, which was an experience I enjoyed. I was unable to communicate (my Welsh is very limited), unable to walk or move, and needed help to go to the toilet; refuge came in sleep. Adulthood babyhood connects unconsciously with original babyhood that is beyond our conscious recall. My distress at no one answering my buzzer at night and my overwhelming anxiety that this pain would never go away have echoes of a pre-time existence as a baby. Some staff had the capacity to be ‘good enough’ mothers; others I experienced as ‘abandoning’, with little capacity for empathy. Having experienced being a helpless and vulnerable patient, it dawned on me that being treated as human and with respect in even the simplest acts was so important.

All this took place on a ward with beautiful views of the very mountains on which I had so perilously fallen.

Discharged from hospital, I needed to learn to become ‘at home’ in a broken but recovering body. At six weeks my legs were out of plaster; I no longer needed to rely on a walking frame or wheelchair to help me move from room to room, although I needed to re-learn how to balance and walk again. But there was also the realisation that major injuries masked more minor ones, such as torn ligaments in my knees and a shoulder that didn’t work quite as it should. There was a long road ahead to recovery, but many people sustained me through their visits, thoughts, prayers, kindness and generosity. Wisdom drawn from Ecclesiastes 3:7 states there is ‘a time to tear and a time to mend’. I had experienced my tearing and so I was now (and still am) living for my mending.

Returning to practice

How has the knowledge of this event and my unplanned absence affected my clients, if at all? Is it just ‘business as usual’, as if I have been on some grand prolonged holiday? I returned to my therapeutic practice five months ago. Due to the demands of my primary role as Director of Psychodynamic Studies at Oxford University, I only maintain a small private practice from my home, consisting of two clients and three supervisees. One client I have been seeing for 10 years and he is able to contain his own childhood anxieties, identify his current issues and hold his ego identity. My second client is a 16-year-old student whom I had been seeing for nine months before we agreed to take a break. The issues we had been working on therapeutically were her depression and conviction that she will die young, following the sudden death of her very close friend a year earlier. She had not received the texts I had sent saying we could not meet on our pre-arranged date. When she turned up on my doorstep, expecting to resume our sessions, she was visibly shaken and upset to find me sitting in a chair with my ankle encased in a large plastic boot and a walking frame beside me. ‘OMG, are you OK?’ she asked. ‘You could have died!’

We have started work again and we have both changed. I bring to my work an increased vulnerability that I cannot hide behind theory or the intellectual defences in which I am practised. Hiding vulnerability is difficult to do when you are still using a crutch and wearing a large, grey, plastic boot. My client had seen me in a physically vulnerable state and her first concern now was to know if I was up to seeing her again. The fact of my vulnerability meant that she turned her anger on God for allowing this to happen to me, adding ‘even though I am not sure I even believe in God’. I suggested that she might be angry with me and also trying to protect me at the same time. She smiled in a knowing way.

In the therapeutic space what has happened is that I have brought my physical vulnerability, which matches her psychological vulnerability, and both of us have had to admit that this is in the room. In our own differing ways we both find this difficult to do, so in many ways we are a good match for one another. My external wounds match her internal wounds. I am not using her to meet my emotional needs, but the quality of my being has changed and this is present consciously and unconsciously, to be used in any therapeutic work I do. There is a quality of attunement that has been enhanced through this process. A time will come when she can express her anger to me in a more direct way but that, of course, will be a step in the right direction of her wholeness and healing. My physical steps in the right direction are still happening, so it is an ongoing journey we both need to maintain, stepping out into an unknown future.

I do not see myself as some kind of ‘wounded healer’, despite my wounds. For me that would be to claim too much, or it may simply be that I am not yet ready, but I do think I may become a better therapist. What I do claim is to have been swamped by an overwhelming experience of warmth, love, affection, care and prayer from the widest range of people imaginable. Long-lost people from my past have been in touch. People have cared who I didn’t know cared. And, sadly, some people who I thought would have been in touch have remained stubbornly silent. My wife started a daily blog, using her typical Scouse humour, mainly at my expense. She once posted a picture of me lying in bed looking ill, a post-it note attached to my forehead with a ‘Best before’ sell-by date on it, which went viral. So I bring a ‘me’ into the therapeutic space who has experienced the humbling yet profound gift of being loved and valued as a human being just as I am. This is a part of me I hope I can continue to make available to others, in and out of therapy.

Alistair Ross is Associate Professor of Psychotherapy, Director of Psychodynamic Studies and Dean of Kellogg College, Oxford. He is Chair of BACP’s Professional Ethics and Quality Standards Committee. His latest books are Research Ethics for Counsellors, Nurses and Social Workers (with Dee Danchev; Sage, 2013) and Counselling: a practical guide (Icon, 2013). References

1. Podmore SD. Kierkegaard and the self before god: anatomy of the abyss. Bloomington, IN: Indiana University Press; 2011. 2. Bion WR. Attention and interpretation. London: a scientific approach to insight in psycho-analysis and groups. London: Tavistock Publications; 1970. 3. Lane B. The solace of fierce landscapes: exploring desert and mountain spirituality. New York: Oxford University Press; 1998. 4. Winnicott DW. Ego integration in child development (1962). In: Winnicott DW. The maturational process and the facilitating environment. London: Hogarth Press; 1965. +++ Feedback in supervision

Why is feedback rarely sought by supervisors? Emma Redfern explores the possible blocks and fears and why systematic relational feedback is essential to a healthy supervisory relationship

I have been a therapist for 11 years and a supervisor for four. During that time I have been in relationship with and given feedback (systematic or otherwise) to six different counselling supervisors and two EMDR (eye movement desensitisation and reprocessing) supervisors. Or have I? To supervisees reading this article, I ask: when was the last time you gave feedback to your supervisor (whether verbal or written as a lead in to dialogue, either ad hoc or systematic)? when was the last time your supervisor asked for feedback? is the feedback you give restricted to a particular area of the work? do you schedule regular reviews of your work and relationship? are you able to dialogue with your supervisor about your relationship?

To all supervisors reading this article, I ask: when was the last time you requested feedback from your supervisee(s) about how you are doing? have you asked how well supervision is meeting your supervisees’ needs? how much do you rely on observation of your supervisees’ behaviour (they smile, pay and come back) to assess the health of your supervisory relationships?

What is good supervision?

According to Gilbert and Evans,1 research into supervisor effectiveness suggests that the ‘best’ supervisors both receive feedback about how they relate to their supervisees and also provide clear and direct feedback of their own to those same supervisees. The BACP information sheet S2 ‘What is supervision?’ similarly states that ‘good supervision provides a space in which reactions, comments, challenges, feelings and two-way feedback can all be shared’ (my emphasis).2

I believe there is a place for relational systematic feedback from supervisee to supervisor. Sadly, my experience has been otherwise: feedback has been rarely invited by my supervisors and, if attempted, has often not been welcomed or understood. Talking with peers, therapists and supervisors and reflecting on my own practice as a supervisor, this absence of relational systematic feedback, particularly in the direction of supervisee to supervisor, appears to be fairly widespread. Here I want to explore some of the unconscious and sometimes conscious phenomena that I think contribute to this. In my experience there is often disquiet/distaste in parts of the psychotherapy world about ‘being judgmental’. I believe one of my early supervisors may have experienced this disquiet. Their report, when I was in counsellor training, offered four words on my counselling abilities (I imagine it was a stock phrase). They were positive words, thankfully, but the giving of them, without examples, dialogue and personalising, contributed to my own disquiet about ‘being judgmental’ and provided me with an unhelpful model. Such inner fears and shame do not contribute to building a relationship in which mutual feedback is possible.

The drama triangle

Many of us in the helping professions would identify as ‘wounded healers’. As such, we may have been victims in childhood and later find ourselves as adults acting out Karpman’s drama triangle of victim, persecutor and rescuer in our relationships with others.3 Aspects of this include insecure attachment styles; limited authentic expression; increased feelings of fear, shame, blame and increased dissociation, and activation of the fight/flight/freeze responses. It hardly needs spelling out that any such responses run counter to the giving and receiving of appropriate and constructive feedback.

I am sure we can all remember or can imagine how difficult it can be for a supervisee to give feedback to a more experienced, more powerful supervisor. This can be exacerbated when a trainee has no means of choosing their supervisor or when some sort of formal appraisal is required from the supervisor (a report for a training organisation perhaps, or an accrediting body).

Also, drama triangle dynamics can affect both parties. As Gilbert and Evans point out: ‘Realistically, we cannot assume that all supervisors have a secure attachment base; the co-creation of the supervisory relationship will be influenced by the “working models” that both supervisor and supervisee bring to the relationship.’1

Supervisees have told me about past supervisors who regularly wept or behaved in a punitive and fear-driven way towards them when they refused to accept that their supervisor’s views were necessarily the ‘right way’.

Oppression in relationship

Other barriers to mutual feedback/review of the supervisory relationship include common unconscious models of mental health such as the medical model and the deficit model. In the medical model the supervisor is perceived (by one or both parties) as the mental health professional dispensing expertise, knowledge and prescribing certain courses of action to a dependent supervisee/patient. In the deficit model the supervisee may be viewed (by one or both parties) as flawed and as someone who must be prevented from harming their patient/client who is even more in need of the non-flawed/fixed supervisor’s expertise (via the supervisee). According to such power dynamics, giving feedback becomes the province of the supervisor; the supervisee may not even realise that feedback can go both ways and that he or she has needs that may not be addressed.

In my experience (which includes being a traumatically-birthed incubator baby, white, educated, middle-class, professional, raised by parents who grew up in World War II, the ‘younger’ twin, now living and working in a relatively non-multicultural area), the medical and deficit models sketched out above have been influential in three of my past supervisory relationships. In all three cases I ended the relationship because I felt that my needs came last (after those of the supervisor and/or organisation, followed by those of the client) or were squeezed out completely. Only in the most recent relationship was I able to state that my needs were not being met, and I still ended the relationship (I felt that the supervisor had no desire to change to accommodate my preferences and needs).

Now, as a supervisor, I can see that at times I have been seduced by a similar dynamic in some supervisory relationships. The supervisee fills the hour with talk of the clients and I/we make no room for talk about ‘us’ and whether the supervision is meeting the supervisee’s needs. Time and money are too limited. Gilbert and Evans quote Heath: ‘One of the typical symptoms of oppression is that there are no resources available to address the oppressed groups’ concerns and dilemmas. Only selected and dominant “truths” can be met. No time. No resources… means no inclination and no commitment.’1

Narcissist–co-narcissist relationships

Early in my life as a counsellor I experienced what I call ‘vertical supervision’ in which it seemed that my supervisor tried to counsel my clients via me. It was as if I was meant to be a receptacle that carried away what I had been given to pass it on to my clients when next we met. I felt unseen, unvalued and silenced (none of which I could voice). In the supervisor’s presence I was compliant, hiding from both of us my inner discomfort. Afterwards I might rebel by rejecting what had taken place as inappropriate or untimely. I would also feel angry.

Thankfully, as part of my professional growth, I have learned to reflect and make meaning of experience. The meaning I have made of this early relationship is that we created a narcissist–co-narcissist relationship (particularly as defined by Alan Rappoport4). My early experiences have provided me with a tendency to default into a co-narcissistic role, especially when encountering a person with narcissistic tendencies. Thus, I struggled hard to please my supervisor, deferring to their opinions. In their presence I struggled even to know my own view or hold onto my own experience. Out of their presence, I took the blame for the interpersonal problems I sensed existed between us. (At the time I was also dependent on my supervisor for a supervisor’s report.)

In the circumstances Rappoport describes and I experienced, feedback from the co- narcissistic position to the narcissistic position is virtually impossible. Similarly, if the polarities are reversed, with the supervisee taking the narcissistic role and the supervisor the co-narcissistic role, then the supervisory relationship and processes will also be badly compromised. As Rappoport writes: ‘In a narcissistic encounter, there is, psychologically, only one person present. The co-narcissist disappears for both people, and only the narcissistic person’s experience is important’.4

Rappoport goes on to explain that there are three common types of responses by children to their parents: identification, compliance and rebellion. In this early supervisory relationship I achieved three out of three. My rebellion came in the form of ending the relationship by letter, without saying why or goodbye. The catalyst for my leaving was when I realised that perhaps the responsibility for my discomfort wasn’t all mine, and that maybe we didn’t even have a ‘relationship’ as such.

The unspoken relationship I have since come to recognise that this supervisor may have been using the CLEAR model5 (the R stands for ‘review’ of the supervision session) in some of our sessions. Asked ‘How was today’s session?’ I regularly said how helpful it had been and thanked my supervisor very much. Was this sufficient feedback? To my mind, no; it was a verbal expression of deference; it was certainly not fully authentic and there was much left unsaid.

In an article in the December 2013 issue of Therapy Today, Mick Cooper argues in favour of relational systematic feedback from client to therapist.6 The article refers to David Rennie’s work on deference in the client–therapist relationship. I consider Rennie’s work applicable also to the supervisee–supervisor relationship and suggest that it should be part of the role of the supervisor to initiate enquiry into any ‘inner discomfort’ that the supervisee may be experiencing and that may be being co- created in and getting in the way of the supervisory relationship. (Similarly I would expect a supervisor to take the initiative to voice their own inner disquiet, if any exists.) Adapting Rennie’s work, I suggest that, for supervisees, withholding comment is often a ‘preferred deferential strategy’.7

Dave Mearns likens the supervisory relationship to an iceberg in which only a small percentage of the relationship is open to mutual awareness and the bulk is open to the awareness of only one or neither party and constitutes what he terms ‘the unspoken relationship’.8 The latter includes ‘unclarified differences of opinions… counsellor’s unvoiced reactions to the supervisor… supervisor’s unexpressed assumptions about the counsellor’.

Addressing the lack of feedback

So how can this absence of supervisee feedback be addressed? I suggest there are a number of ways in which systematic relational feedback can be enabled.

Education and training

It is important that supervisors receive supervision training and that their training and/or CPD pays attention to the importance of giving and receiving feedback in forming a sound and effective supervisory alliance.

The Centre for Supervision and Team Development training in supervision teaches CORBS, a structured way of giving and receiving balanced feedback,9 as well appreciative enquiry.10

As I mentioned earlier, the CLEAR supervision model developed by Peter Hawkins includes the R for ‘review’,5 in which the supervisor encourages feedback from the supervisee about what in the supervision session may have been helpful or a hindrance and what they would like to be different in future supervision sessions.

Hawkins and Shohet cite Batts’ ‘five barriers to supervision’.9 These barriers include avoidance of contact, denial of difference and denial of the significance of difference. Training on these issues would also seem relevant to reducing fear of feedback.

Contracting Explicit and mutual contracting with a supervisee is important, including explicit reference to feedback. I was delighted to agree a contract with a supervisor for my EMDR practice in which one of the rights of the supervisee was to receive feedback. I would now add to this my own right as a supervisee to give feedback.

Developing an internal supervisor

I suggest that development of an internal supervisor11 (rather than being dependent on an external supervisor or the internalised supervisor) may assist in enabling supervisee feedback.

Personal development/therapy

Ideally a supervisor has undertaken a substantial amount of personal therapy and is a reflexive practitioner who is able, for example, to accept the interactional nature of any ruptures/blocks to the supervisory alliance and is ‘open and willing to explore his own contribution to the process’.1 Such a supervisor models and promotes a supervisory relationship and way of being characterised by qualities of the ‘healthy triangle’ of vulnerability, potency and responsiveness.

Speaking the unspeakable

Mearns speaks for many when he suggests that the supervisory alliance includes provision for regular ‘time-outs’ in which both parties can attend to the unspoken relationship.8 He also writes about the importance of creating a relationship of freedom, non-defensiveness and lack of fear so that a supervisee can feel safe enough to express the inexpressible.

Hawkins and Shohet refer to Borders and Leddick’s checklist of 41 points for supervisees evaluating their supervisors.5 They suggest that evaluation and review should be a two-way process that is regularly scheduled into supervision arrangements so that mutual feedback around ‘how I am doing’ can be given and any renegotiation of the supervision contract attended to.

The Leeds Alliance in Supervision Scale (LASS)12 is a useful tool in this process. As a starting point to dialogue, the supervisee places a mark on a scale to indicate how they feel about the supervision session in three areas: ‘approach’, ‘relationship’ and ‘meeting my needs’. The scale can be downloaded free from www.scottdmiller.com

Advocating discrimination

Because ‘relationship is at the heart of effective supervision’,2 I think that we can easily become complacent. After all, we know about being in relationship, don’t we? We’re effective psychotherapists.

I suggest that supervisors and supervisees would benefit from thinking about the supervisory relationship: from a participant-observer position and third person perspective2 when assessing and choosing between one supervisory relationship and another in determining, individually and together (and informed by research), what an effective supervisory relationship looks like in the light of regular, quality feedback.

Finally, I want to end by referring to Farhad Dalal and his thoughts on judgment. He argues that, as a society, our capacity for judgment has become frozen, rendering us unable to think. He suggests that ‘there is an important distinction to be made between judgement and judgementalism’ and that there is a need to ‘[hold] on to our capacity for judgement’.13 He continues: ‘We can say, adapting Descartes, I discriminate, therefore I am. If I give up discriminating (that is, thinking), then I cease to be human. In fact, I would go so far as to argue that what the world needs is not less discrimination, but more.’13

Emma Redfern works in private practice in Devon as a trauma-informed senior accredited psychotherapist and supervisor. She uses Hawkins and Shohet’s process model of supervision and an integrative relational approach. Email [email protected]; visit www.emmaredfern.co.uk

References

1. Gilbert M, Evans K. Psychotherapy supervision: an integrative relational approach to psychotherapy supervision. Milton Keynes: Open University Press; 2000 (p91). 2. Despenser S. What is supervision? Information sheet S2. Lutterworth: BACP; 2011. 3. Karpman S. Fairy tales and script drama analysis. Transactional Analysis Bulletin 1968; 7(26): 39–43. 4. Rappoport A. Co-narcissism: how we accommodate to narcissistic parents. Free to download from www.alanrappoport.com/pdf/Co-Narcissism%20Article.pdf; 2005 (accessed September 2014). 5. Hawkins P, Shohet R. Supervision in the helping professions (4th edition). Maidenhead: McGraw Hill; 2012 (pp66–68). 6. Cooper M, Wilson J. Systematic feedback: a relational perspective. Therapy Today 2013; 24(10): 30–32. 7. Rennie DL. Clients’ deference in psychotherapy. Journal of Counselling Psychology 1994; 41(4): 427–437. 8. Mearns D. On being a supervisor. In: Dryden M, Thorne B (eds). Training and supervision for counselling in action. London: Sage Publications; 1991 (pp116–128). 9. Hawkins P, Shohet R. Supervision in the helping professions (3rd edition). Maidenhead: Open University Press; 2006. 10. Shohet R. Love and fear in supervision. Masterclass. British Psychological Society, London; 1 March 2013. 11. Casement PJ. Learning from the patient. New York: Guilford Press; 1991. 12. Wainwright NA. The development of the Leeds Alliance in Supervision Scale (LASS): a brief sessional measure of the supervisory alliance. Unpublished doctoral thesis. Leeds: University of Leeds; 2010. 13. Dalal F. Thought paralysis: the virtues of discrimination. London: Karnac Books; 2012 (p9). +++ Making meaning in a third language

Awareness of difference through language can lead to a deeper level of communication between client and counsellor, writes Gala Connell

Practitioners in Europe have worked in a second language since the inception of psychoanalysis, although this aspect of their practice is rarely documented in the literature. Recent years, however, have seen a growing interest in the issues that may arise in therapy when the practitioner is using a second language to communicate with clients.

Research shows that practitioners can successfully conduct psychotherapy in their second language, especially if they are sufficiently fluent in the language and if they manage to achieve a good therapeutic alliance.1, 2 Difficulties highlighted in the literature include the challenges presented by dialects/accents, emotional vocabulary, splitting between languages in different roles and the use of a second language to disconnect or distance oneself emotionally.3

I grew up in Russia and moved to England 16 years ago. Now I am one of the many practitioners who use their second language to communicate with clients. I was curious to know what I was bringing to therapy as a practitioner with a difference, and I wanted to explore the challenges and opportunities it offered. This article draws on my own research for my master’s dissertation into the experiences of therapists who use their second language to work with clients.4 I asked four practitioners from different European countries to share their experiences with me. I also chose to be interviewed myself: I wanted to have a similar experience to that of my participants and I was also hoping to surprise my unconscious: that I would find out something new about myself.

The research was mainly focused on the existential and metaphorical meaning of the lived experience of migrant practitioners working in the UK. But the issues discussed here are, I argue, relevant beyond the migrant practitioner or client and their struggles to communicate, and beyond the challenges posed by interpretation/translation too. What I am writing about is, essentially, the fundamental psychotherapeutic process of finding a common language with clients.

All participant and client details, except my own, have been anonymised.

Language and self

Emma, one of my interviewees, described vividly the impossibility of ever fully integrating the English language into her sense of self: ‘It’s much more than just words that come out of your mouth. You embody your language. It’s part of my fabric. English is still like a foreign body... There are still certain bits of the language that my face hasn’t grown around.’

Her words encapsulate the separation that having to use a second language can open up in a process that is essentially all about presence, congruence and communication.

One of the central ideas used in Gestalt therapy is change of perception through the switch between figure and ground. Figure is something at the forefront of our mind; the ground comprises those things that are outside our immediate awareness. The foreignness of a therapist brings the difference into conscious awareness, making it figural:

Emma: ‘As soon as I open my mouth people know that I am different.’

Gala: ‘I am asking myself to what extent is my speaking a foreign language different from any other difference that a counsellor may have and that would be obvious, that you wouldn’t have to disclose; it would be there in the room.’

The illusion of understanding that comes simply from sharing the same language is gone, stripped away. Two people are trying to make meaning of experience: ‘There are no expectations, just a desire to understand.’5

Interestingly, from my interviews came a strong sense that, if they trained in English or another second language, these therapists struggled to work with clients who share their mother tongue:

Nefeli: ‘In Greek I would struggle to communicate, because the experience is not there, I am not really used to be a counsellor in Greek.’

They described how, if they worked in their mother tongue with a client of the same nationality, it could lead to a kind of collusion.

Emma: ‘… there could be a real pull in some sort of… collusion or whatever the word is for it… You know, where you suddenly felt, “God, yes, we are the same here! We’re both whatever, Russian, Dutch,” and so you suddenly find it more difficult to keep separate… especially when you are separate from all the rest of the world.’

George: ‘… it helps in the beginning. Therapy goes, wow, great even... Good joining, good contacting and later what? You come to the point… when your identity… joins… subconsciously really.’

There is a creeping loss of role clarity and a blurring of identities; the therapist struggles to maintain objectivity. This phenomenon is what Akhtar6 calls ‘nostalgic collusion’.

Third language

In the face of these difficulties, I would argue that what emerges for these ‘second language therapists’ and their clients is a new ‘third language’ of therapy, in which the practitioner’s professional identity and language identity are integrated. The therapist has to start from scratch, to abandon all preconceptions and engage with the client in developing a language that works for both of them.

This ‘third language’ is a dynamic, ever-changing language that emerges through dialogical interaction between practitioner and client.

The concept complements the other ‘thirds’ used in psychoanalytic theory. Akhtar7 writes about ‘a third individuation’ as a process whereby immigrants form a new bilingual identity that is not just a combination of two separate identities but something new and distinct. Lacan8 introduced the idea of thirdness in relation to the intersubjective encounter: the third element acts as a mediator between two subjectivities and makes it possible to see the other’s point of view without losing one’s own perspective. Then there is ‘the analytic third’: the unconscious third subject co-created in intersubjective therapeutic encounter,9 and Jung’s ‘the third thing’ that unites the opposites.10

The difference is that the third language is real, conscious (or easier to bring into consciousness) and tangible, and can therefore act as a working metaphor for the analytic third and potentially transcend the context of therapy in a second language.

It is interesting to ask how the ‘third language’ may relate to the intersubjectivity of a therapy session and whether it changes with each client. I am aware that every one of my clients has an impact on me and I change accordingly. Yet there must be a core element that helps me to maintain my identity. I would argue that the concept of thirdness, the third language, helps me to stay in touch with my core, and allows me to feel safe so I can be creative and flexible in my work with clients. Indeed, I may use many different third languages that emerge, one for each client, in each intersubjective encounter.

The new language identity is not a fixed structure; it grows and changes and this process is unique for each individual. The boundary between the separate identities gradually becomes less prominent as the foreign language gets more internalised, resulting in spontaneous use of humour, dreams etc.7 One of my interviewees, Nefeli, for example, told me excitedly about her newly found ability to write poems in the English language. A lot of my dreams are now in English and I sometimes speak English in my sleep.

Back to basics

Another interviewee, Paula, was particularly self-conscious and worried that she might not be able to help her clients because of her lack of language proficiency. But this example from her work I think very strongly illustrates what I am arguing here. Paula was talking about a client whose speech had been affected by a brain injury. This client had been in therapy before but never stayed beyond the first couple of sessions:

Paula: ‘I struggled. I don’t even know what we were talking about most of the time, and I struggled a lot, but things changed… and it was amazing… we reached the point that we speak very slow… I can send back to him the feelings, I think… the language is not that important… we were just being together and it didn’t matter much… Now he start talking about, you know… important things… he tries… he says, you know, like…. if I have to guess the words because he can’t have these basic words… so he says the other way… “It’s not a school, it’s not the university”… and I say “college?” and he says “Yeah, that’s the word!”… so it’s slow you know… Or he’s describing things with hands, he moves a lot … I think that’s the most beautiful thing that I’ve experienced.’

There are several important elements in this extract: struggle, feeling lost, lack of words and then slowing down, using hands, helping each other to find a word and language becoming ‘not important’. There’s also excitement and joy: ‘It was amazing… the most beautiful thing.’ The struggle with language brings the therapist– client interaction back to an almost preverbal state of basic connection, basic emotion.

Jiménez, a Spanish speaking psychotherapist working in Germany, has written similarly about his own experience. At the time his command of the German language was limited, but the linguistic difficulties were overcome by a higher degree of attunement and by sharing the emotional state at a non-verbal level. These also allowed Jiménez to connect directly to the patient’s unconscious:11 ‘I believe that… the central and supporting kernel of the analytic relation is basically non-verbal. In this sense, a command of a foreign language that would not be sufficient to carry out tasks such as text translation may suffice to establish and maintain an analytic relation, as long as analyst and patient develop an emotional relation… Experience showed me now and again that a continuous exchange process would occur between my patients and me, a process whose most outstanding product was a progressive sharpening of verbal communication. While I played mainly the role of “translator of the unconscious”, my patients would put into a more differentiated language what I sometimes said in an imperfect, babbling fashion.’

Essential to this creative process is an honesty and transparency about the struggle itself, as these exchanges illustrate. Paula says: ‘I just spontaneously say like I am talking to a friend. I say “I am not making sense today” or something… and we laugh… I don’t see it as a struggle now.’

Similarly, Nefeli tells me: ‘I think it’s important to have a joke and a laugh. Sometimes I might have said “Oh, that’s my accent.” And in the interview process itself, we find we have achieved this shared joke.’

Gala: ‘So it does come up?’

Nefeli: ‘Yeah… it comes up s---ly [indistinct] and…’

Gala: ‘Sadly?’

Nefeli: ‘Subtly, not sadly (laughs).’

Gala: ‘Ah (laughs).’

Nefeli: ‘You see? And then I say, “It’s probably my accent.”’

The moment of misunderstanding because of the accent is resolved by simply being open about it. When this happened between us, I felt excited and energised. It was mutual, as shown in the lightness of the interaction and in the laugh that we shared. It was a moment of meeting12 marked by relief of resolving misunderstanding and by noticing that the misunderstanding was a gift to both of us, a spontaneous illustration of what we were talking about.

The struggle to find words becomes a metaphor for the existential struggle to connect, to understand and to be understood. I remember my own struggle in the early stages of learning English: there was so much to say, but I could barely put enough words together to form a simple sentence. How could my client ever understand what I was about? Even now, writing this article, I struggle: so much to say yet my means feel so limited. Struggling with the language now or the memory of feeling silenced in the first stages of acquiring a new language helps me understand the client’s distress, her struggle to communicate something about herself that is beyond words, even in her own language.

This personal experience has ‘given us glimpses of different dimensions of ourself… which we can enter to put us into a feeling state that is closer to our client’s present experiencing and thus act as a “bridge” for us into a fuller meeting with our client’.13 The act of disentangling meaning together – first at the preverbal level, jumping straight to feelings, and then pulling back and trying to put it in words – with all the imperfections, failed attempts and misunderstandings – becomes a metaphor for existential meaning making in a wider context of therapy and beyond.

Gala Connell is an integrative counsellor and psychotherapist. She is one of a team of IAPT counsellors for depression working with NHS patients at Leeds Counselling, a registered charity in the centre of Leeds. Email [email protected]

References

1. Skulic T. Languages of psychotherapy: the therapist’s bilingualism in the psychotherapeutic process. A dissertation submitted in partial fulfilment of the requirements of the degree of Master of Health Science. Auckland: Auckland University of Technology; 2007. http://aut.researchgateway.ac.nz/bitstream/10292/514/3/SkulicT.pdf [accessed September 2011]. 2. Georgiadou L. ‘It is difficult... it is a huge challenge, but...’: trainees’ experiences of counselling practice in a second language and culture. Unpublished paper presented at the BACP Research Conference 2012. 3. Christodoulidi F. The therapist’s experience in a ‘foreign country’: a qualitative inquiry into the effect of mobility for counsellors and psychotherapists. PhD thesis. Manchester: University of Manchester; 2010. 4. Connell G. Through the looking glass: making meaning in a second language. Unpublished MA dissertation. Leeds: University of Leeds; 2012. 5. Ayora Talavera DA, Faraone M. Language barrier or porthole to discovery? Dialogical experience within a therapeutic relationship: revisiting the process of dialogue. International Journal of Collaborative Practices 2012; 3(1): 53–63. 6. Akhtar S. Technical challenges faced by the immigrant psychoanalyst. The Psychoanalytic Quarterly 2006; 75(1): 21–43. 7. Akhtar S. A third individuation: immigration, identity and the psychoanalytic process. Journal of the American Psychoanalytic Association 1995; 43: 1051–1084. 8. Lacan J. The seminar of Jacques Lacan (1975). Book I. New York: Norton; 1991. 9. Ogden T. The analytic third: working with intersubjective clinical facts. International Journal of Psychoanalysis 1994; 75: 3–20. 10. Jung CG. Mysterium coniunctionis: an inquiry into the separation and synthesis of psychic opposites in alchemy. London: Routledge; 1963. 11. Jiménez JP. Between the confusion of tongues and the gift of tongues or working as a psychoanalyst in a foreign language. International Journal of Psychoanalysis 2004; 85: 1365–1377. 12. Stern D, Bruschweiler-Stern N, Harrison A, Lyons-Ruth K, Morgan A, Nahum J et al. The process of therapeutic change involving implicit knowledge: some implications of developmental observations for adult psychotherapy. Infant Mental Health Journal 1998; 19(3): 300–308. 13. Mearns D, Thorne B. Person-centered counselling in action. London: Sage; 2007. +++ Talking point

We need courageous conversations

Jackee Holder urges coaches and counsellors to face up to the reality of racism

My first real experience of coaching was in 1987. I was fresh out of university and working as a youth and community worker in the London borough of Hackney.

As part of our professional development all full-time youth and community workers in the borough were allocated a non-managerial supervisor. My supervisor, Rose, was a manager in another organisation and was African-Caribbean, just like me. We met monthly and from the start our shared racial identities meant that I felt able to talk openly about my personal experiences of race and diversity, which were key issues in our multi-cultural team.

I found my voice in those sessions: a voice I rarely vocalised in our team meetings and in the borough-wide monthly youth worker forums. I allowed myself to be vulnerable and in that space my potential was realised; within 18 months I confidently moved into a new role and began a part-time postgraduate course so I could gain my professional qualification in youth and community work. Rose may well have been the catalyst for my journey into the world of coaching.

That was some 27 years ago and the coaching profession has gone through a rapid acceleration process in that time. There has been an increase in the number of professional coaches from black and minority ethnic (BME) backgrounds, yet we are still hugely under-represented among leadership and executive coaches in the corporate and private sectors, both here in the UK and worldwide.

In a recent tele-class on diversity presented by a global coaching professional association, I sat through the call wanting to share and name specifically some of my experiences in the coaching profession that I felt were racially and culturally motivated. However the general ethos of the event appeared to homogenise experiences of difference under the diversity umbrella; the message was, ‘We are all diverse.’

I marvel at how often, when meeting coaches for the first time in these kinds of professional contexts, I feel I have to justify my presence in the room. I am sensitive to and aware of the fact that thoughts and feelings triggered in these moments can be located in my own personal wounding and past experiences. I have worked on much of this over the years, both in personal therapy and coaching supervision, and this work continues. Yet not all of it is mine. Outside, in the wide world, I face racism and discrimination, just like any other black person. I cannot fully erase that possibility, and we need to remember and connect with the fact that, for many people, discrimination is a regular occurrence in the very organisations with which we coaches work.

If we fail to embrace ethnic diversity in our training, CPD and peer events, how can we be sure we are noticing and highlighting it when it appears in the culture of the organisations and leaders with whom we working?

These moments, when the reality hits home of how different our experiences, connections and understanding can be around race, diversity and inclusion, are what motivated me to write about the invisibility and lack of real conversation in the coaching industry around these issues.

Consultant and diversity and inclusion specialist Paul Anderson-Walsh writes: ‘Inclusion helps you to make a difference with your difference.’1 I believe that the coaching profession cannot afford to be silent on these issues. We do the profession a disservice when we believe that we are so beyond the everyday experiences of different groups that we can see and treat everyone as the same. People are not the same and nor are their experiences. The clients and organisations we serve, the people at all levels within them, are having different experiences that require a safe space where they can be brought out into the open and made sense of.

Executive coaches Carol Campayne, Caroline Harper Jantuah and Lori Shook (see http://diversitypractice.co.uk/authentic-leadership-coaching/) say one first step is to engage in ‘courageous conversations’. They write: ‘We stunt our client’s growth by failing to put fierce courage into action, challenging the messy stuff of race, culture, religion, sexual orientation that gets in the way.’ We need to take the blinkers off and recognise that colour and race are real and current issues of diversity that deserve to be at the forefront of our professional conversations and training. I look forward to exploring ways to take this important issue forward, individually, collectively and as a profession.

Jackee Holder is a trainer, facilitator and an executive and business coach. Her full article is published in the October issue of Coaching Today. Visit www.bacpcoaching.co.uk/coachingtoday.php

Reference

1. Anderson-Walsh P, Spencer L. Introducing: the business of inclusion. London: Bookboon; 2014. http://bookboon.com/en/introducing-the-business-of-inclusion- ebook +++ Dilemmas

The dangers of dual relationships

This month’s dilemma

Jim has a mixture of paid work roles and enjoys the variety this brings. He has a private counselling practice two days a week and works for a local school on a third day. The school has recently offered Jim another day’s work each week, as an assistant on a new project. Jim is very excited at the prospect, not least because the extra money will make a big difference to him. However Jim has a client, Indy, whom he has been seeing for a couple of months. Jim is aware that Indy has been job- hunting as this has been discussed in sessions. In their next session, it transpires that Indy has been offered the job as manager of the project that Jim has been appointed to. What should Jim do?

Opinions expressed in these responses are those of the writers alone and not necessarily those of the column editor or of BACP.

Brian T Jones (psychoanalytic psychotherapist)

In this case, it is Jim’s responsibility to decline the job offer. By accepting it, Jim and Indy will enter into a dual relationship. The dual relationship, according to the BACP Ethical Framework, involves two or more concurrent relationships with the same person. Dual relationship behaviours occur when the therapist engages in a relationship external to the client/therapist field. In the case of Jim and Indy, even a time-limited interaction such as the job constitutes a violation of the framework.

The question then becomes why are dual relationships problematic for therapists? Many professions maintain dual relationships. While others may have varying opinions about whether dual relationships are ethical, therapists ought to be vigilant in avoiding them. The therapist/client dyad involves a developed relationship that permits the discussion of personal feelings, thoughts and the revelation of one’s private and internal world. Given Jim’s professional demeanour, he may not be likely to expose Indy’s thoughts and experiences. However, Indy’s continued thoughts and interactions may produce an undue influence on their professional or therapeutic life. The undue influence involves an undeserved or unwarranted pressure to behave in a certain manner. Jim’s presence may place such a pressure on Indy vis-à-vis preferential treatment or discomfort in the workplace.

Second, Jim is at risk of jeopardising the therapeutic transference. The work relationship may constitute a form of reciprocity that differs from the therapeutic relationship. In the work relationship, Indy maintains a position of power over Jim that does not transfer to the therapeutic situation. Such a power dynamic has the potential to disrupt or intrude on the current therapeutic work. For example, what if Jim disagrees with a decision made by Indy that was not addressed at work? Jim’s repressed feelings concerning the disagreement may reveal themselves as a negative countertransference reaction. Therefore Jim begins to lose his objectivity within the relationship.

The case is complex and difficult. However, I would suggest that the potential problems outweigh the monetary benefits. As stated above, the risk to the therapeutic relationship and the undue pressure placed on Indy pose significant risks to Indy’s wellbeing and treatment process.

William Johnston (person-centred counsellor in private practice)

Dual relationships in therapy are always problematic. What this throws into stark relief for me is that the core issue is one of authority. I think that Jim has only two choices: he either accepts the job and ends his therapeutic relationship with this client, or he keeps his client and declines the job.

I noticed the strength of reactive fear that I experienced at the thought of finding myself in a similar situation. I like to think that I do not behave in an authoritarian way towards my clients; that there is even a level of equality between us. I had to acknowledge that, however much I might strive for that sort of equality, it is a fantasy. Even if the only power that I operate is to manage the space in terms of time boundaries and making sure that we are not interrupted, I remain the authority in that respect, just as Indy will be the authority in cases of dispute at Jim’s workplace.

How could either party operate within that hierarchy with so many confidences held between them? Given also that so much that arises in therapy has to do with child energies that the counsellor often has to hold as though playing the role of parent, how might any parent feel if they suddenly found themselves being managed by some precocious offspring?

When questions of authority arise between counsellor and client, they can be held within the safety of the sessions and Jim can allow the tension of their relationship as a means to explore what it means to be one up or one down. If Indy has an alternative space where he can explore that balance – where he can, if we take matters to extremes, take revenge on Jim without Jim being in any position to challenge or hold that desire – Jim’s position must become increasingly perilous.

In fact, there would be similar problems if Jim were to find himself managing Indy outside of their counselling relationship. The nature of this particular set-up just makes it more obvious that power is the issue here.

I do hold authority over my client, and I would hope that I have the experience and awareness to use that authority creatively and to understand its limits and potential dangers, as well as its creative possibilities. My client is not bound by those structures, and I should be in no position to bring what happens at work into the sessions without my client’s permission.

Most important of all, without the boundary of my authority within sessions I should become incapable of serving my client. If I put myself in a position where my client can abuse me then, in effect, through the loss of boundaries, I abuse my client.

Rachael Wright (school therapist)

It would not be fair to Indy or Jim to be both manager and client or counsellor and colleague. Jim has a number of obligations to himself and others: to work in the best interests of his clients, to earn money to sustain himself (and possibly others) and to work towards a fulfilling career. But he has to decide which to prioritise as, in this case, there is a potential conflict of interests. Jim cannot work in the best interests of his client while also fulfilling his own needs. So whose needs are greatest? And should there be a discussion about it?

To raise it with the client for discussion puts Indy in a very difficult position and is likely to sabotage the therapeutic relationship, so I would suggest Jim needs to take independent action. Jim’s priorities should be with his existing commitments and, unfortunately, this new offer of work would directly threaten his commitment to Indy and could, at worst, damage his reputation.

I felt for Jim and imagined his deep disappointment in having to turn down the job. It made me reflect on the nature of our roles – particularly when we work in the community (I work in schools), and how often our roles may be pulled in all sorts of other directions and how hard we have to work to protect our role as counsellor, with its necessary boundaries.

I have just had to turn down a free trip to a theme park with my kids on the basis that it was with families with whom I have worked and will potentially work. Unfortunately I could not be both counsellor and helper/mother/colleague. Sad but necessary.

Judy Stafford (Registered Member MBACP)

Jim’s dilemma is the result of his enjoyment of diversity in his professional practice. While this makes his life exciting and dynamic, it can also produce difficulties, as this dilemma indicates. He clearly needs to now make an ethical decision, which primarily safeguards his client. This is complex since not only does Jim have two roles but Indy, his client, does too, and their dual roles both overlap with each other.

As I see it, Jim needs to be transparent with Indy, since the counselling relationship cannot exist or continue without that. He then needs to decide what’s best for Indy and, if he turns down the extra day’s work and continues as Indy’s therapist, he will need to be careful that his other, existing work at the school doesn’t involve any interaction with Indy.

If Jim decides he really does need the extra day’s work, then he will need to end the counselling contract with Indy. This must be done sensitively, with a satisfactory ending, and Indy will need to be referred on to another counsellor.

The decision is Jim’s but he needs to act in a way that doesn’t undermine Indy’s autonomy. It sounds as if Indy is finding his feet, and receiving this job offer will certainly increase his self-confidence and his sense of his own value. We are not told what issues have brought him to counselling, nor what stage the counselling has reached and it may be that after two months the relationship is nearing a conclusion anyway.

Jim certainly needs to give all these aspects careful consideration and discuss them in supervision, bearing in mind that hard decisions often have to be made. To avoid complexity in future, he may decide it might be easier to simplify his own way of life.

November’s dilemma

Sherifa completed her counselling qualifications three years ago. However she has been unable to find paid employment as a counsellor. Although she has continued to work in a voluntary capacity in order to maintain her practice, she has become increasingly frustrated and has decided to set herself up in private practice. As a first step, she enrolled on and completed a business start-up course, where she was advised to set up a website and to include testimonials from her current clients at her placement. However, Sherifa has just seen a conversation on a social networking site where some members have suggested that this is not wise. What are the ethical issues involved and what should Sherifa do?

Email your responses (500 words maximum) to Heather Dale at [email protected] by 27 October 2014. Readers are welcome to send in suggestions for dilemmas to be considered for publication, but these will not be answered personally. +++ The interview

The quality of connection

Mick Cooper talks to Colin Feltham about his kaleidoscopic interests and fundamental belief in the healing power of the therapeutic relationship

You’re significant in the counselling and psychotherapy world for many reasons, and I’m wondering where to begin. Can you first fill us in on your path from childhood to academic psychology?

As a child I loved maths. After that it was physics and chemistry. But when I thought about university, I wanted to do something more about people. I considered philosophy, but psychology seemed more concrete.

In my late teens I also started getting interested in hypnosis. I was on a summer camp when someone did a guided relaxation with some hypnotic suggestion. I tried it out myself and was both awed and scared by the power that it seemed to have. I learned a guided visualisation where you ask someone to imagine a journey through a forest, and then you ‘analyse’ their personality by the kind of things they describe. It seemed to go down very well at parties!

More than anything though, I wanted to do something that would make the world a ‘better place’, and studying psychology seemed a way into that. I’ve done a lot of different things, but the desire to help create a fairer, happier world is still the ‘red thread’ that runs throughout all my work.

At what stage did your interest in existentialism emerge, and was it a natural progression for you into existential therapy?

I read Jean-Paul Sartre’s Roads to Freedom trilogy in my early 20s, and loved the pathos and realism of his writing. I remember one summer on a Greek island, sleeping in a cave by night and swimming in the sea and reading Sartre by day. I got so absorbed in that phenomenological, detailed way of seeing the world that I wrote a short ‘Sartre-esque’ story about meeting my girlfriend at Athens airport, and her telling me she had met someone else. The story was lousy but, as it turned out, prophetic: she had been seeing someone while I was away.

Just as I was starting my PhD in my mid-20s, I saw an advert in the local paper for a counselling certificate course. I wanted to do something practical along with my academic work. The course, at City University, was a 60-student-strong unstructured group encounter based on person-centred principles: exhilarating and bruising in equal measures. I learnt an enormous amount about myself, but found the interminable negotiations over when to have a coffee break too much.

After that, I was keen to train as a Gestalt therapist as I liked the dynamism of the approach. However the course I applied for wouldn’t let me join in the second year. Around the same time I’d also been interviewed for a place on the existential counselling diploma at Regents College and in the end decided to take it. I wasn’t particularly drawn towards existential therapy: I just wanted to do something humanistic-ish. Can you clarify your position on the relationship between this and the person-centred approach, both of which you’ve written on extensively? Not everyone agrees on their compatibility.

Both existential and person-centred approaches are very broad spectra, so there’s no really right answer on whether they are compatible or not; it depends on which versions you are looking at. In general, though, both tend to emphasise the development of a caring, empathic therapeutic relationship, and both explore clients’ experiences in a phenomenological way. After that, the existential approaches bring in more assumptions about freedom, death, meaning etc, and the person-centred approaches bring in more assumptions around growth, actualisation and emotional processing. I tend to find both sets of assumptions fairly helpful in developing a deeper understanding – and acceptance – of clients’ experiences.

You’ve also had a long involvement with counselling in schools and I believe your current role as National Advisor for Counselling for the Children and Young People’s IAPT Programme extends this involvement?

Yes, and for the past two years I’ve been working on Counselling MindEd, where we’ve been developing free e-learning sessions for counsellors working with children, young people and young adults (www.minded.org.uk). The counselling in schools work is incredibly important to me because it’s a way of extending therapeutic practices and values out into the wider community. It means that tens of thousands of kids can access emotional support in their own school. It’s also really important, though, that young people can access counselling outside of schools, and I’m currently working with Youth Access to develop the evidence base for counselling in the voluntary and community sector. Through the counselling in schools research, I’ve had an opportunity to work alongside some great people at BACP, like Nancy Rowland, Karen Cromarty and Jo Pybis. I’m sure that’s been a large part of why I’ve stayed so involved for so many years.

Another theme for which you’re well known is the development of research, including (often unpopular among counsellors) randomised control trials (RCTs). Are you still actively trying to get this message across?

For me, the most important thing is that relational therapies are freely available to large numbers of people, and if that means compromising some of my methodological principles, I think it is worth it. Having conducted a few small scale RCTs, I’m also much more positive about them. For the participants, it’s a chance to get therapy that they wouldn’t otherwise have, and I’ve yet to hear a participant say that they felt de-humanised or manipulated. Katie McArthur wrote an excellent article about this in Therapy Today (‘RCTs: a personal experience’, Therapy Today, September 2011).

I believe you’ve also trained in emotion-focused therapy (EFT). Can you tell us what attracts you to this?

I’ve done a couple of introductory courses in EFT and love the way that it helps to develop the person-centred approach. I think the person-centred field owes a great debt of gratitude to EFT practitioners and researchers like Les Greenberg, Robert Elliott and Jeanne Watson. They’ve been enormously important in establishing the evidence base for person-centred and experiential practices and giving this approach a foothold in the NHS.

You’ve led doctoral programmes in counselling psychology. What divisions do you see between counselling psychology (BPS/HCPC) and counselling and psychotherapy without the psychology affiliation (BACP)?

Both approaches are rooted in a relational model of practice: engaging with clients in deeply valuing and respectful ways. If I had to identify some divisions, I’d say that counselling psychologists tend to draw on a wider range of methods, particularly from CBT and third wave CBT, while counsellors tend to be a bit more single orientation. Counselling psychologists also tend to draw more from the psychological. Having said that, for me, the commonalities are much more important than the differences. I just wish there was more collaboration between the two professions: for instance, on developing the evidence base for relational practices.

Relational depth is another of the themes with which you’re associated. What new research and clinical threads are emerging within this theme?

We published a new edited book in 2013 entitled Relational depth: new perspectives and developments (Palgrave). It’s got some really interesting new research in there. Sue Wiggins, for instance, developed a measure of relational depth, and went on to show that it was correlated with positive therapeutic outcomes. And Rosanne Knox looked at clients’ experiences of relational depth, and what they think helps to bring it about. A major theme that comes out is the importance for clients of feeling genuinely cared for by the therapist. This is more than just non-judgmental acceptance; it’s about clients feeling that they really matter to their therapists.

And pluralism and pluralistic therapy, which you and John McLeod have pioneered – where is that development heading now?

I’d like to think there was something really important in what John and I were trying to say, even if our first attempts to express it were clunky at times. It’s not about working in an integrative way, per se, or the structure of ‘goals’, ‘tasks’ and ‘methods’. The really critical point for me was about developing shared decision making with clients and, more than that, creating a framework that helps us to think openly, non-defensively and creatively about what’s most helpful in therapy.

In the last few years, we’ve had some great new people come on board with this pluralistic project. We’ve just finished a multi-site study of pluralistic therapy for depression with Tony Ward (University of the West of England) and Biljana van Rijn (Metanoia Institute), and Windy Dryden and I are editing a handbook of pluralistic therapy for Sage. I’ve also really valued it when people challenge the way John and I formulated things and suggest new and better ways of articulating a pluralistic approach.

I believe you’ve had an interest in the political aspects of therapy but perhaps you’re not so well known for this?

Yes, I grew up in a communist household and was interested in anarchist politics in my late teens. So issues of social justice and change were with me from the very start. One thing I feel particularly passionate about is extending our learning about human wellbeing and relating into the wider political field. As therapists, we’ve learnt about what people need to thrive and to relate to each other in empathic and cooperative ways, and that knowledge could be so helpful in creating a better and fairer society. For instance, I think we could make a massive difference to society if there was more emotional literacy training in schools. I’ve tried to write about this, and really hope I can do more in the near future.

You recently moved from Strathclyde to Roehampton University. What was behind your move, and where will it take you?

I’m a born-and-bred north Londoner, and always had a yearning to go back down south. Our older kids also often talked about going back to Brighton where they were born, though when it came to it they were distraught at leaving friends. I was also really excited about going to the University of Roehampton, where there’s so much going on in the counselling and psychotherapy field. We have courses, for instance, on play therapy, art therapy and integrative therapy, as well as the doctorate in counselling psychology, and there are some great new colleagues. A lot of my role will be to lead on research, and we’ve recently set up CREST: the Centre for Research in Social and psychological Transformation. So I’m hoping we can conduct studies that will help to establish and extend relational practices, as well as developing the interface between social and psychological models of change.

I understand you have a large family – how well do your busy professional life and family commitments co-exist?

My wife, Helen, and I have four kids: Zac (7), Shula (9), Ruby (12) and Maya (14). Helen is fantastic – not just at multi-tasking but at omni-tasking – and without her there would be no way of doing this much. But I am away or working quite a lot of the time, and the irony of being apart from my kids because I’m presenting a paper on child mental wellbeing isn’t lost on me! I guess one thing I do is try and find something specific to connect with each of our kids on. With my daughter Shula, for instance, who has been diagnosed with Asperger’s (which she asked me to say), we have chats at bedtime about things like disabilities and what it would be like to be a conjoined twin (her favourite topic). So I guess I try and make up for quantity with as much quality of connection as possible. +++ How I became a therapist

Jeremy Christey

Jeremy Christey is the new Chair of BACP Universities & Colleges

I come from a Manchester background. My father is down on my birth certificate as a ribbon and tape weaver, having worked in the mills of Lancashire. My mother was a cleaner. They came to London to give me a different start to life. There’s a wonderful black and white photograph of my mother, pregnant, at a mainline London station, starting a new life.

Undiagnosed dyslexia in childhood meant that when I left school at 16 I was only really any good at woodwork. I had another bash getting into a traditional education, but both the college and I failed at that too.

I ended up on the dole at my parents’ house, now out of town, with sinking mood and sinking prospects. With no qualifications I had approximately zero chance of finding work in the recession of the early 1980s. So I blagged my way into some voluntary work and moved back to central London.

Someone suggested that I was a good listener and pointed out social work to me, and I developed a portfolio of experience so I could apply to university as a mature student. I volunteered at a hospital for the elderly, used that as an opportunity to move into residential social work and live-in posts in an adolescent therapeutic community, a unit for homeless men and a (unique and somewhat chaotic) drug rehab centre for people still using opiates.

Keyworker interactions with individual residents, the more intimate and influential conversations, were the areas of the work that I most enjoyed and I started accumulating as much training as I could.

Over the years I accumulated thousands of hours of topic-based short courses, hung around more substantive counselling trainings, starting with personal construct psychology in 1986, then an integrative (principally humanistic) postgraduate diploma in the early 1990s and a counselling psychology masters as a mature student, focusing on the psychodynamic traditions. I was stunned that there was theory behind these therapeutic conversations and soaked up as much of it as I could.

With HIV taking a foothold in the drug-using community, I started that as a specialism and worked at an HIV service launched by the first wave of gay men affected by the disease in Brighton. I then specialised as an HIV counsellor working in the NHS, and started private practice in the early 1990s in primary care.

Primary care was where I cut my teeth on pragmatic methods in shorter-term, focused work. Despite being a good student, I experienced a limit to what I could bring to the humanistic approaches. I changed to a psychodynamic gear, did the three-times-a-week analysis, applied a good blank screen to the work and tried my best to work with the emerging relational issues – to begin with at least.

This proved too much of a withholding approach, and obviously more activity was required for shorter-term work. The theories of the shorter dynamic ways of working opened up a less evangelistic approach – a strategic pragmatism of acknowledging early experience but working more with the effect of that in current relationships.

I have settled with this approach now, toggling between the past and present, but mostly with a present, change-focused approach. Discovering the relational and dynamic foundations of CBT drew me into training in that approach, and I use that as well as the psychodynamic traditions, very much as Beck had in mind.

I have trained with Tim and Judith Beck in recent years as a CBT therapist and have passed on some of this in training cohorts of UK CBT therapists, with that balance of sensitivity to the relational but within the well-evidenced world of CBT formulation and interventions.

I am now balancing my clinical and directing work. I am a counsellor/psychotherapist with the University of Sussex Counselling Service and Project Director for Students Against Depression, a very well used website of resources and interventions for depression in young people. Harnessing the talents of the pool of motivated young people who shape the website has taken me back to my HIV campaigning work nearly 30 years ago. I have thrived on the challenge and versatility of working with differing modalities and I hope I can apply some of this in my new role as Chair of BACP Universities & Counsellors. +++ Letters

If not us, who will help them?

The letter from Carol Jones in the September issue of Therapy Today resonated totally with my own experiences and perspective. I too have funded my own training and expended years of blood, sweat and more than a few tears to become the practitioner I am today, with a holistic approach to each unique and individual client who appears before me in the counselling room.

I too hoped for better things when GPs were charged with heading up and being responsible for the Clinical Commissioning Groups (CCGs), but this has once again ended in disappointment. I see those prepared to jump on the Government’s CBT bandwagon being regarded as the ‘right stuff’, while much more experienced counsellors are sidelined or, as Carol states, deemed ‘unsafe’ by NICE. Why? Well one reason is that, as ethical practitioners, we are unable to blow our own trumpets to any great degree when it comes to positive outcomes, and this really doesn’t fit in with the tick box culture of evidence criteria and the practice of recording positive clinical outcomes. How indeed do you capture someone’s life changing on a spreadsheet? Which box do you tick? If we could shout about our success stories from the rooftops, maybe we might gain some recognition for the valuable but largely unsung work we do, week in week out, away from the limelight (and the funding).

My hopes were raised dramatically recently when I received an answerphone message from a man claiming to represent the CCG for GP surgeries in my area, asking if I would be interested in taking referrals from surgeries in the city. Would I call him back, please? Would I?? My spirits soared, but after several unsuccessful attempts to call him back (and an excited call to my supervisor), I contacted the CCG and was informed that they had never heard of this individual. I had to conclude that this had been a prank call. An odd thing to make a joke of something so important – I failed to see the funny side. In my mind, I had imagined the scenario: a grateful client returning to their GP who, astonished at the improved wellbeing of the client, contacts the CCG etc, etc. Maybe I should have been less naive, but I live in the hope that one day the powers that be will wake up and see the incredible resource for mental health that is just going to waste in this country.

Like Carol, I feel being deemed ‘unsafe’ by NICE is insulting to those of us who work tirelessly and largely unrewarded in the voluntary sector, as very few opportunities exist for us to obtain paid work. I have a small private practice as a lone practitioner, and I mean small (typically two to three clients at any one time) and work with survivors of rape and child sexual abuse at a rape centre one to two days a week in a predominantly unpaid capacity. My only other income comes from casual waitressing to make ends meet!

In what other profession would you be expected to work unpaid after a long and arduous training, having gained years of valuable experience in trauma and alleviating distress? You only have to look in the Therapy Today recruitment section to see how few paid posts are available for experienced counsellors, but there are chances aplenty to work for nothing. Some might say that I am foolish in the extreme to continue, but it’s hard to walk away from clients like ours. If not me, then who will help? And Ora Dresner from the Camden Psychotherapy Unit is right (‘A slice of the cake’, July Therapy Today): eight sessions of CBT is not the answer for those with more complex issues, and it never was. We are badly letting down people in need in this country, and why, when people like Carol and I just want the opportunity to practise without having to abandon our effectiveness, professional ethics and principles to ‘fit in’ to a failing system?

For me and many others working in a similar way, counselling is not just a nice little hobby meriting a pat on the head (which was all my patronising MP had to offer). Counsellors like me all over the country are offering professional, effective and credible long-term solutions for those in great distress, and there are many such people out there without access to any sort of appropriate service at all. It’s high time this wasted valuable resource was recognised and used. Time indeed to wake up to reality.

Jill Davies Member MBACP

Suicide and mental disorder

I’m writing this letter to share more widely a presentation I gave at the BACP Making Connections conference in Bristol, 5 September 2014, based on my PhD thesis, in which I asked, could mental disorders be defence mechanisms that the human mind has evolved to counter the risk of suicide?

Statistics show that people who are depressed, addicted, psychotic and so on are more likely to take their own lives. The correlation holds across a range of common mental disorders. The question arises, why? What is the causal relationship? The usual assumption is that causality goes one way: it’s the mental illness that creates the risk of suicide. But if that were true, as evolutionary psychologists argue, mental illness would have been bred out of the human species a long time ago. Traits such as depression and addiction are so widespread and occur across so many cultures that they must be evolutionary adaptations.

Causality is more likely to go the other way – it is the threat of suicide that triggers mental ‘illness’. Perhaps mental ‘illness’ has a life-or-death survival function, to incapacitate or distract the person sufficiently so that it prevents suicide.

Psychotherapists see this function operating day to day. So many clients ask, ‘What is the point?’ They speak of emptiness and loneliness and futility. They struggle to find meaning and purpose in life, to find a good enough reason for living. Spoken or not, to some extent the danger of suicide is there. In diverse ways, the reptilian brain has responded to that danger. It has taken over. Some people find themselves compelled to use drink or drugs. As addicts often say, addiction is the solution, not the problem. Once an addict finds new purpose in life, his or her addiction goes away by itself – that is how 12-step programmes work.

Some people find themselves emotionally shut down, sometimes to the point that they can hardly get out of bed. If someone has suicidal thoughts, then depression could be the safest place to be. One survey has found that traumatised people were less likely to attempt to take their own lives if they also showed signs of depression.1

An ‘anti-suicide’ hypothesis would explain the co-morbidity seen in mental health – for example, that addiction and depression routinely occur together. The same survival response may underlie many other mental ‘disorders’: self-harming, eating disorders and even psychosis have been described by their sufferers as various means to the same end, to prevent suicide. Could this hypothesis be true, and if so, what would it imply for the practice of counselling?

CA Soper Doctoral research student at University of Gloucestershire; counsellor with Listening Post. Email [email protected]

Reference:

1. Ferrada-Noli M, Asberg M, Ormstad K, Lundin T, Sundbom E. Suicidal behavior after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity, and assessments of suicidal behavior. Journal of Traumatic Stress 1998; 11(1): 103–112.

Hit by reality of an unviable career

Following several articles in Therapy Today concerning the lack of paid opportunities for newly qualified counsellors, I am writing to give my experiences as a trainee who has considered giving up the idea of counselling as a career, due to financial constraints. It is well documented that there is a dearth of paid work for the newly qualified. The reality of the situation hit me when, a year into the course, I attended a placement open day at a low-cost service and learned that most of their counsellors had continued to work on a voluntary basis after qualifying. When I asked one of the counsellors what the situation was regarding pay, she said dismissively, ‘Oh you don’t go into counselling to get rich.’ Students on placement were required to pay £32 every four weeks for supervision. Another agency I approached charges students £12 per week for placements and a one-off fee of £50.

Clearly it would take me years to accrue the minimum of 450 client hours required for most jobs (including those in the NHS) and I would have to commit to working unpaid while doing so. My household income is low and this would make life very difficult. The main cost of training for me would be lost earnings rather than course fees or therapy. I would be in my early 50s when qualified and feel that I am unlikely to recoup this financial outlay through paid counselling work (either in private practice or agency work). Let’s face it, the idea that counselling is a profession of middle-class helpers is entirely accurate. I believe it is akin to the situation with internships in the arts and media; certain career paths are now open only to the affluent.

The training I have received has been wonderful and I cannot fault the guidance I have received from my tutors. But I have become entirely disillusioned with the idea of counselling as a viable means of making a living (even a very modest one).

Name withheld

Same old anti-CBT arguments

Reading Catherine Jackson’s review of Thrive, Layard and Clarke’s book about CBT (Reviews, Therapy Today, September 2014), I was surprised that she said it was mainly about CBT. Similar things could be said about the person-centred and Gestalt books reviewed in the same issue of the journal.

I would assume a book review would contain both elements of good and bad in equal parts, finding the middle ground for others to make their mind up on purchasing the book. However, what I found was that it became an opportunity for Catherine to vent her feelings on the two authors, politics, NICE and CBT in IAPT services.

After two paragraphs it was almost like Catherine couldn’t wait to get the book review out of the way and get on her soap box about the ‘same old, same old’ arguments that have been raised since IAPT was implemented in England.

Her first sentence sets the tone with the word ‘self-congratulatory’. Leaving orientation out of this for one moment, Layard and Clarke do deserve to congratulate themselves because, thanks to them, £173 million was invested in the mental health of England. Let’s acknowledge that 15 per cent of the population are receiving more therapy now than ever before. In time we will get it right and we will be able to offer people the right therapy at the right time. Let’s at least become a little optimistic in achieving this. I do agree with Catherine that services still have not got this quite right.

I would invite Catherine to find a way to move forward with these same arguments. Those arguments, like IAPT services, have moved on. Government, commissioners and services are willing to move on, learn some lessons and embrace other modalities. Isn’t this one of the reasons why Counselling for Depression is now a commonly accepted treatment in IAPT services? We are also moving forward in research to find ways of evidencing other modalities.

What really interests me is that this reviewer is Deputy Editor of Therapy Today, a journal from an organisation that embraces all modalities. I wonder what some of the members are thinking and feeling when they continually read, or have to listen to, the slating of IAPT services or CBT? How many training courses accredited by BACP use CBT as part of their integration model? How many of the readers reading that book review are in IAPT services themselves, or trainers of CBT or integrative counsellors using CBT in their practice? So what is Catherine saying about her fellow colleagues? The review reads as judgmental, cynical, condescending and rude. Her last sentence captures this when it says that only advocates of CBT will enjoy this book and others of a critical stance will be further enraged. There is a separation and divide here of the different orientations and I am definitely not comfortable with that.

This is how I’d describe the book if I were to review it.

‘Thrive is a decent, easy to read, jargon-free book giving an understanding of mental health. It would suit student, seasoned practitioner, commissioner and service manager with its two parts discussing the problem with mental health and what can be done. Within those parts there are useful chapters on how many people suffer with mental illness, how it affects people’s lives and what is the economic and social cost. There are also good chapters on what works for whom where modalities like EMDR, short-term psychodynamic therapy and interpersonal therapy are offered. There is also a great chapter on young people and a further chapter on how we could all work together to create a better culture on mental health. This book of course is part of the CBT family and might not suit everyone but nevertheless, with simple short chapters and plenty of graphs and illustrations, it is a book to keep on the shelf to remind ourselves why we do the work we do for those who suffer from distress.’

In order to thrive in life we have to continually move forward. In the talking therapies what is going to help is a united front, supporting one another and the modalities we choose to practise from. Let’s in future keep the reviews (as the journal’s guidelines suggest) as an overview of the book, its strengths and weaknesses, usefulness and to which audience it is best suited.

Elaine Davies

Out-dated mode of education

In response to the letters in the September issue entitled ‘Positive experiences of boarding’ (Caroline Elliott) and ‘School is only one influence on children’ (David Gladwell), I would suggest reading Nick Duffell’s first book The Making of Them, where he does not discount other influences on children’s lives, and nor does he discount the possibility of boarding school for children at 16 when they can make an informed choice. His concerns are for younger children and the many children who have been sexually, physically and emotionally abused at boarding schools, and his assertions are evidence-based from his therapy practice. Currently 130 private schools in this country have recently been or are currently under investigation after allegations of abuse.1 I am extremely glad that someone like Nick Duffell is focusing on these less publicised child protection issues.

As Caroline Elliott points out in her letter, there may be children who benefit from boarding who come from homes where there is serious disruption or parents unable to provide a loving environment. However, this makes boarding schools seem rather more like social service children’s homes than establishments of excellence in education, their success depending on parents who, for whatever reason, feel unable to provide a suitable home environment.

As a parent of two children, now adults, I cannot imagine ever having wanted to send them to boarding school. Both my children thrived well at inner-city comprehensives. I loved picking them up from school or being at home for them when they arrived back from school, helping them with their homework, hearing about their day, meeting their friends, cooking their dinner and everything else. If they, or I, were away for a weekend, I missed them and looked forward to seeing them. Being unnecessarily separated from my children for two-thirds of the year was unimaginable. In fact I would have been heart-broken.

Most boarding schools today recommend a complete severance of contact with home for the first three weeks of boarding. What is it like to endure that as a parent of an eight-, nine- or 10-year-old? And how does that make a child feel? It is generally accepted that children suffer from homesickness when they first go to boarding school and I am surprised that David Gladwell did not feel a ‘wrench’ at first, even if he went on later to find positive experiences. He does, however, mention the ‘considerable emotional (and financial) cost’ for his parents.

For the past 10 years I have worked in Sure Start Children’s Centres, working with postnatal depression and facilitating Solihull attachment-based parenting groups. I hope I have not misunderstood attachment theory, but to my mind there are very few circumstances, if any, that justify the existence of boarding schools. Even if you think there may be positives, I would say there are certainly better ways than this to bring up your children and help them become responsible, sociable and emotionally intelligent adults, and better ways as well to cope with difficult home circumstances. Boarding schools were set up in the days when Britain was a colonial power, to provide education ‘back home’ for children of colonial administrators. Surely it is time that this out-dated mode of education was abandoned?

Val Harding Dip Couns; MSc intercultural therapy

Reference: 1. See http://boardingconcern.org.uk

David Smail (1938–2014): an appreciation

It was David Smail’s singular achievement to have set out an understanding of emotional suffering based firmly in reality. In a series of books, starting with The Treatment of Mental Illness (1969), co-written with TM Caine, to his last, Power, Interest and Psychology (2005), he argued that people’s problems were invariably and inevitably to do with our vulnerabilities as embodied beings or with our exposure to ‘noxious social influences’ that have their origins, most often, ‘far beyond the orbit of our personal lives’.

Reflecting on his first encounters, as a young clinical psychologist, with those diagnosed ‘mentally ill’ in the large asylums, David said: ‘Even the most severely disturbed didn’t appear ill so much as confused and despairing, beside themselves sometimes with frustration, grief or rage; the less disturbed... were at least profoundly unhappy.’

There was, he went on, ‘if you bothered to talk to them, not one whose life story did not abound with good reasons for their distress’.

He was being in no way ironic when he said it was Margaret Thatcher who taught him to see in all its awfulness what the social environment did in producing human unhappiness and misery. The ‘utter soulless, callous indifference’ of those years towards ordinary people made it obvious to him that what matters in psychological wellbeing is not ‘responsibility’ or ‘self reliance’ or ‘initiative’, however these are presented, but ‘the provision within society of material resources’. Denied them, what is the result? The damaged and derived seek help ‘in droves, mostly bemused and blaming themselves for what they saw as their own inadequacies’.

A courageous writer, taking on many deeply held assumptions, David was also an original one. He was well read, far beyond the confines of psychology, but re-reading him is to be struck by how much thinking he was doing for himself. It’s like he kept asking the simple questions: why are people suffering and in these ways? What causes this? Why do we believe what we believe?

It is because we feel things to be inside us that we look inside, as it were, for the solution to our difficulties, and we are too easily encouraged to do this by many professionals. But this way of thinking is itself a product of culture; culture defines the meaning of experience and all the evaluations we make of ourselves and each other are shaped by culture.

We have come, he said, to regard emotional pain and suffering as not just abnormal but unnatural. We believe we have a right to have it removed, and so we turn to supposed experts. We never think that what we feel is normal – almost by definition it’s not – and the result is anxiety and shame. For instance, post-traumatic stress, he said, has become a disorder rather than a completely understandable response to a traumatic situation.

In this context psychotherapy is, at best, a form of solidarity, of comfort and encouragement and demystification; at worst, it is itself a form of mystification, blaming people for their own difficulties.

David could be excoriating in his criticism of therapy: psychoanalysis, ‘a quite extraordinary moralistic approach’ to ‘neurotics suffering’; humanistic approaches that could ‘drip with uplifting precepts and blueprints’. Psychotherapy, especially as it became more respectable, literally could not afford to see that people may well be willing to change but simply lack the power and resources to do so.

It was part of David’s project to re-empower individuals who were suffering; ‘how to survive without psychotherapy’ is, after all, the understandably provocative title he chose for one of his books. But he also challenged what he called, ‘the tyranny of normality’. He wanted people to trust their own experience: ‘Nobody has been where you have been at the same time you’ve been there and with the same people,’ he wrote. ‘Only you know what your life has been like.’

David wrote lucidly, with not one word of what he called ‘mumbo-jumbo’, and everything he said was underpinned by a lifetime working as a clinical psychologist in the health service and, after retirement, as a student counsellor. Who can argue with this statement, which could be seen to summarise a great deal of what he was arguing: ‘As things are, the hugely unequal distribution of power works against the vast majority of people being able to live a life in which insecurity, anxiety, confusion, ignorance and pain are kept to a minimum. For things to improve for the majority, power would have to be redistributed.’

These are some of David’s key writings: Illusion and Reality: the meaning of anxiety (1984); Taking Care: an alternative to therapy (1986); How to Survive Without Psychotherapy (1996), and Power, Interest and Psychology: elements of a social materialist understanding of distress, published in 2005.

Paul Gordon

Contact us

We welcome your letters. Letters that are not published in the journal may be published online on the Therapy Today website – TherapyToday.net – subject to editorial discretion. Please email the editor at [email protected] +++ Reviews

From fixity to fluidity

Person-centred communication: theory, skills and practice Renate Motschnig and Ladislav Nykl Open University Press, 2014 256pp, £28.99 ISBN 978-0335247288

Reviewed by Mike Gallant

This inspiring work is not primarily about counselling practice; it is a book that encapsulates the nature of the person-centred approach (PCA) as a ‘way of being’ rather than a school of therapy. Rogers’ later writings and practice were very much to do with the application of a solidly grounded theory of human personality development to diplomacy and international relations, so it is not too surprising to see a book that applies his philosophy to personal, systemic and organisational settings, as well as to counselling psychology.

Emanating from Vienna, the book has a contemporary continental flavour, both in its relational post-humanistic approach and in the writing itself. Having said this, the book constantly refers back to basic tenets of the original Rogerian approach, freely quoting him alongside succinct case studies and useful text box invitations to the reader to reflect on potential learning points.

The first half of the book sets out the theory and the skills required in applying the PCA across a wide range of settings. This is not a book dominated by psychotherapeutic practice, although I found myself disappointed that the majority of examples are taken from this area of application. In the second half the authors examine the approach in practice, including useful observations about online and other written communication, its use in learning and teaching and the nature of dialogue and encounter.

So, apart from person-centred course tutors, who is this book aimed at? The authors make a credible case for the global applicability of the PCA, despite its mid-20th century, Western, privileged, male origins. In my opinion this book should be read by every potential power-wielding human being likely to make any impact on the world! It certainly gave me a warm sense of validation, and I would especially recommend it to practitioners of other modalities who wish to gain a broad understanding of what is sometimes, unreasonably, viewed as a simplistic and possibly utopian vision of how individuals, groups, organisations and societies can grow from fixity to a fluidity that embraces difference and equality.

Mike Gallant is Senior Teaching Fellow (Counselling & Psychotherapy) at Warwick University

For further information about the book, please visit http://www.mheducation.co.uk/html/0335247288.html

The mind–body split Touching the relational edge: body psychotherapy Asaf Rolef Ben-Shahar Karnac, 2014 416pp, £39.99 ISBN 978-1782200949

Reviewed by Diane Parker

This beautifully presented and immensely readable volume is a worthy addition to the current literature on body psychotherapy. Rolef Ben-Shahar is a widely acclaimed clinician and writer in the emerging field of relational body psychotherapy, both in his native Israel and the UK. His book presents a compelling case for addressing the mind-body split in traditional psychotherapy, which he eloquently describes and explains, placing body psychotherapy firmly and clearly in its historical, cultural, philosophical and theoretical context. As Silke Ziehl notes in her foreword, the main aim of the book is a call to bring to an end some old divisions that remain powerful: those between traditional and body psychotherapy; between conscious and unconscious processes, and between the individual and ‘other’.

The book is presented in three parts – Historical, Theoretical and Clinical. Part I traces the historical development of body psychotherapy from seminal theorists Ferenczi and Reich to contemporary developments from the relational psychotherapy perspective – the body in relationship – embracing various related modalities such as Gestalt therapy, dance therapy and embodied relational therapy (ERT), originated by Totton here in the UK.

Part II outlines some of the main concepts in body psychotherapy, including the author’s own theory of bodymind – the self as an embodied entity, one that is ultimately experienced and understood both in and through the body.

Finally, Part III offers the reader a window into the clinical work of a relational body psychotherapist through fascinating case vignettes, illuminating some of the conflicts and challenges psychotherapists face when working with the body.

Clinicians and psychotherapists of all modalities will find Touching the Relational Edge a rich source of material. The book will also appeal to ‘curious non- professionals’ – clients or people with a general interest in psychology and psychotherapy.

As a dance movement psychotherapist, I wondered if concepts such as somatic countertransference (or resonance) may feel alien to some of the book’s audience. However I found the sections on history and theory enlightening, and it was helpful for me to see where my own developing practice is situated within the context of the relationship between body psychotherapy and contemporary psychoanalysis.

Diane Parker is a coach, dance movement psychotherapist and editor of Coaching Today

Forensic group therapy

Forensic group psychotherapy: the Portman Clinic approach John Woods and Andrews Williams (eds) Karnac, 2014 240pp, £23.99 ISBN 978-1780490496

Reviewed by Christopher Davies

This short book explores the important work of the Portman Clinic, a unique NHS service offering outpatient psychotherapy to offenders, ex-offenders and those whose intellectual disabilities put them at risk. Group members will typically be people who have breached normal social boundaries, having in common a tendency to action and a compulsion – conscious or unconscious – to repeat risky or transgressive behaviours without thought for the effect on others or consequences for themselves. As the editors put it, ‘Please help me stop myself’ is the underlying plea.

Group rather than individual psychotherapy is often more helpful for these clients. It ‘dilutes’ the transference relationship with the therapist, provides reassurance and support for change where others are struggling with equally shameful issues, and enables self-deception to be effectively confronted. The book’s contributors vary slightly in theoretical orientation but all draw on the work of key clinicians, such as Estela Welldon and Mervin Glasser, who have worked in this field. A regular ‘group workshop’, a sort of supervision forum, is attended by all group psychotherapists practising at the Portman – just one part of a very containing environment in which patients are held by therapists who feel themselves to be contained as they work with the difficult material presented in their groups.

In Part 1 the book introduces the principles and approach adopted by the Portman. Part 2 describes a range of themes and applications, and here therapists reflect on their work with individuals who present with histories of sex offending, paedophilia, child abuse and perverse or violent behaviour. Interesting additional chapters explore the use of Anthony Bateman’s ‘mentalization’ approach with those presenting with anti-social personality disorder, as well as an adapted form of group analysis with men with intellectual disabilities. This second part is rich with clinical vignettes, illustrating the significant therapeutic work done with groups that society views as untreatable and unspeakable.

Well-edited and of a manageable length, this volume offers an insight into the therapeutic work of a remarkable team of therapists. I recommend it not just to those working in this area but also to any therapist who wishes to understand better the power of group psychotherapy to work with some of the most damaging and damaged individuals in our society.

Christopher Davies is a group analyst and NHS adult psychotherapist

The plastic brain

Neuroscience for counsellors Rachal Zara Wilson Jessica Kingsley Publishers, 2014 288pp, £24.99 ISBN 978-1849054881

Reviewed by Angela Cooper

Did you know that autism spectrum disorder is often accompanied by dyspraxia, and that knowing the difference between procedural and declarative memory is vital in working with cases of dissociative identity disorder? Were you aware that a proposal has been made to replace the Diagnostic and Statistical Manual of Mental Disorders (DSM) with a diagnostic classification based on brain plasticity or that sleep is governed by the ‘circadian clock’, partly regulated by planetary dark–light cycles?

These are just some of the many fascinating subjects Wilson explores as she reviews the latest neuroscience discoveries and their implications for counselling. The key learning in neuroscience relevant to counsellors concerns the plasticity of the functional brain. As Wilson says, psychology and neuroscience are moving closer together, and it is important that counselling is not left behind.

The book explains the neurological processes in a number of conditions, ranging from post-traumatic stress disorder to psychosis, and how the counsellor can use this knowledge when working with a client with that diagnosis. The focus throughout is on encouraging the client to practise different ways of thinking, acting and responding so they establish new neural pathways.

This is an accessible work on a complex subject that is constantly producing new findings. Even as she finished the book, Wilson was aware of the wealth of new material coming through. I hope she brings out an updated version.

I have a few minor reservations. I was unsure about the use of the word ‘forgiveness’ as a necessary goal when working through anger, and would have welcomed further exploration of the concept of plasticity. Overall, however, this excellent book is essential reading for trainees, experienced counsellors and trainers.

Angela Cooper is a counsellor and supervisor

Overcoming avoidance

Beyond the frustrated self: overcoming avoidant patterns and opening to life Barbara Dowds Karnac, 2014 304pp, £26.99 ISBN 978-1782200529

Reviewed by Jane Cooper

This book is a fascinating study of the consequences of avoidant attachment. We follow ‘Brenda’, who is caught in a self-frustrating pattern, stressed by closeness, her need for connection denied, and trapped in a left brain, analytical place. We see how she dips in and out of various therapeutic processes and eventually finds transformation in play and spiritual practice.

Barbara Dowds does not hide the fact that ‘Brenda’ is based on her own experience. A humanistic and integrative psychotherapist, her first career was in molecular genetics and what is special about this book is its integration of the scientific and the poetic. I finished it wanting to read Proust and fascinated by the neuroscience of repression.

The book follows Brenda through her four main difficulties – with energy regulation, boundaries, power in the social world and lack of narrative memory. It is succinctly written yet draws widely on attachment theory, neuroscience, body therapies, psychodynamics and psychodrama, and is studded with memorable examples from literature. Dowds is particularly good at summarising the key points of others’ work and making delightful and surprising connections between them.

This is a book for all of us – clients and practitioners – but also for all citizens of the 21st century. The insights are many and diverse. They range, for example, from how meritocracy sustains competitive individualism to why play is of evolutionary benefit.

Towards the end of the book, Dowds focuses on her own psychotherapeutic practice, sharing with us an innovative way of working with avoidant attachment that focuses on feeling tone rather than strict chronology. In the penultimate chapter she draws on the work of Dan Siegel to promote her thesis of integration (ideally a right brain, left brain, right brain dance) as the desirable outcome of the therapeutic process.

I found this book profound, refreshing and accessible. It brings new meaning to the phrase ‘being in your right mind’. Once or twice I wondered if it would work with a male protagonist but maybe that will be the focus of Dowds’ next book?

Jane Cooper is a counsellor and supervisor

Critiquing psychology

The therapeutic turn: how psychology altered western culture Ole Jacob Madsen Routledge, 2014 194pp, £24.99 ISBN 978-1138018693

Reviewed by Colin Feltham

Part of the Concepts for Critical Psychology series edited by Ian Parker, Madsen’s book looks at how psychology has made itself so influential in the last century, and how therapy has become so central within psychology.

Its nine chapters look at consumerism, religion, the self-help industry, neoliberalism and the psychology profession itself. A short chapter on psychology and sport initially seems out of place but Madsen stresses the role that the ‘mental part’ has come to play in top level sports coaching, and is quick to show the serious limitations of psychology in this arena. Among his other targets are the ‘ADHD epidemic’ and how this relates to prevailing socio-economic conditions that are rarely understood by psychologists.

Madsen is a Norwegian academic psychologist and draws on many well-known continental philosophers, such as Adorno, Foucault and Zizek, critical psychologists like Parker and Prilleltensky, as well as sociologists like Furedi, Sampson and Illouz. Curiously, far less in evidence for such a topic are names such as Epstein (US) and Smail (UK). He does refer to Rose’s magisterial Governing the Soul, a sociologist’s analysis of the psychologisation of the 20th century that I think is unlikely to be bettered.

Its Scandinavian references may appear to limit its applicability to the UK reader but its exposure of psychology to political scrutiny makes it significant reading for trainee and practising counselling and clinical psychologists, and for counsellors and psychotherapists interested in considering the limitations and distortions of the profession.

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

To read the introduction to this book, please visit http://www.ewidgetsonline.net/dxreader/Reader.aspx? token=6e324be65d944d5c87966b72759a6258&rand=1121222236&buyNowLink=&p age=&chapter=

Film reviews

Dog eats dog in scramble for survival

Julian Edge reviews Two Days, One Night (Deux Jours, Une Nuit), a powerful exploration of morality among people struggling to survive on the margins of western neo-liberal society

Sandra (Marion Cotillard) has been off work due to ‘depression’. Now deemed recovered, but still fragile, she discovers that her employer has made her 16 co- workers an offer: a €1,000 bonus so long as they agree to Sandra’s job being cut. They vote on Monday. Sandra has Saturday and Sunday to visit them at home and ask them to forego their bonus.

In other words, the Dardenne brothers bring us a film that works as both a narrative of a harrowing personal struggle and a scathing social commentary. Here we see a society reduced to a dog-eat-dog morality in the scramble to survive on the scraps left over by the brutalities of neo-liberal economics.

As Sandra proceeds from colleague to colleague, we feel the tension and share her revulsion at what she is being asked to do. We also sense a distance between them as they meet. While she sometimes encounters warmth and generosity, there is also a palpable sense of anger, guilt and fear. In her wake she may leave acrimony, marital abuse or inter-generational violence.

Sandra sinks back to declaring her own worthlessness, returning repeatedly to the antidepressant tablets that she has been told to stop taking. They give her the boost that she needs for each interaction, and we know, as therapists, that she risks facing the need for ever-increasing doses, possible side effects, addiction and withdrawal. I found myself wondering, ‘What is it that I wish for Sandra?’ The courage to win this squalid dog fight? The strength to contest the terms of battle? The serenity to walk away from it all?

As a counsellor, I can say that I want to help Sandra reach her own decision. As I watch her make every effort to change these other people, I recall the aphorism, ‘You can only change yourself.’

However, I cannot avoid struggling with the idea that it is therefore also my task sometimes to help people accept injustice. The strength of the film from this perspective is the way it reminds me of the complex interacting tensions that come together in my therapeutic practice. I work to be there in the moment of interpersonal relationship with the client. I work to foster the locus of evaluation in the client. I also work to be aware of the client in her social contexts and I monitor the influence of my own socio-political positions. But the issue of justice does not go away.

I found all these tensions powerfully brought home in this narrative, and was deeply affected by Marion Cotillard’s portrayal of resilient vulnerability.

Julian Edge is a counsellor in private practice and with Age UK Manchester.

Two Days, One Night (Deux Jours, Une Nuit) is directed by Jean-Pierre Dardenne and Luc Dardenne. Les Filmes du Fleuve, 2014 (15; 95 minutes). In French with English subtitles.

Have you seen a new film or been to a concert, exhibition or event that you think has special resonance for counsellors/psychotherapists? If you’d like to write a short, lively review for this page, please contact Chris Rose, Reviews Editor, at [email protected] +++ TherapyToday.net reviews

Lilting Written and directed by Hong Khaou Film London/BBC Films/Skillset, 2014 (15, 86 minutes)

Reviewed by Rachael Peacock

Lilting offers an intimate portrayal of love, grief and cultural difference in contemporary London.

Kai (Andrew Leung) has unexpectedly died in a road traffic accident. Those closest to him, his male lover and his mother, are mourning his sudden loss and remember him through flashbacks. These say much how about Kai lived two cultural lives: the life with his British lover, Richard (Ben Whishaw), and his intense relationship with his mother, Junn (Pei-pei Chung), a Chinese-Cambodian woman living in a retirement home. Junn does not speak English and Kai acted as interpreter for his mother while never disclosing his own sexual identity to her.

Throughout, Lilting delicately balances the cultural loneliness of Junn, a woman stubbornly lost in the privacy of her grief, with Richard’s dogged attempts to connect with her emotionally and linguistically through the services of a Mandarin interpreter, Vann (Naomi Christie).

The complexity of cross-cultural communication is handled sensitively and perceptively, emphasised by the key area that Vann chooses to leave out of her interpretation – the nature of Kai’s relationship with Richard. The power of withholding is painfully evident in the scene where Richard attempts to tell the truth about his love for Kai. Vann’s decision to omit this from her interpretation of his words is carried through to devastating effect, and Ben Whishaw superbly conveys the pain and frustration of failing to bridge the cultural gap with Junn.

Grief is quietly depicted through the multilingual dialogue, illuminated by the ochre half-light that shrouds the film. It is explored in depth as an experience evoking vulnerability, longing and denial in unique ways for both characters, paying attention to the cultural conventions that inform their grief.

Overall, the film attempts to find a balance in how it explores both characters and the complexity of their situations. Flashbacks convey the fragility of memory, allowing the audience to feel empathy for both characters while experiencing Kai’s ambiguous feelings about coming out to his mother. Despite Junn’s rejection of Richard’s offer of connection, we are encouraged to empathise and understand how difficult it must be for her to have lost her son and only connection to life in Britain. Equally, the scenes spoken in Mandarin that do not have English subtitles provide insight into Richard’s experience of being unable to communicate with the woman he considers to be the key connection to Kai.

Bereavement is not depicted as a neat process of ‘stages’; the film patiently sits with the pain of loss in an authentic way, and ‘coming out’ is similarly presented as a continual, life-long process rather than a single event. This sensitive depiction of cultural differences and their associated impact on sexuality and grief makes Lilting an invaluable film for trainee and experienced counsellors alike. Rachael Peacock is a trainee person-centred counsellor

August: Osage County [DVD] Directed by John Wells Smokehouse Pictures, 2013 (15, 120 minutes)

Reviewed by Jude Fowler

I’m fascinated by what it is that binds families together and the psychological wounds they pass from generation to generation. Working with children and adolescents, I see their yearning for fulfilling relationships with parental figures again and again. And I see adults who repetitively configure their relationships in the same destructive patterns from childhood, hoping for a different outcome.

The Westons, the fictional family central to the film August: Osage County, are a powerful example of these destructive and seductive processes. The film exposes the ways in which the matriarch, Violet (Meryl Streep), can reel her adult children back in – even the ones who thought they’d got away. Addicted to prescription drugs, she holds court like a black widow spider at the centre of her web. She hated her own mother, doesn’t like herself and rages at her daughters, all of whom have developed their own coping mechanisms to protect themselves.

The action takes place in the stifling heat of August on the plains of Oklahoma, flat as far as the eye can see. The writer, Tracy Letts, grew up here and uses the relentless space to reinforce the aching emptiness of the characters. Barbara (Julia Roberts) states, ‘This is the plains – a state of mind, a spiritual affliction, like the blues.’

Originally written as a stage play, the film retains a heightened realism that in some scenes feels too theatrical. The men are, on the whole, portrayed as sensitive and loving but weak in the face of such overbearing women. However the emotional intensity of the relationships in this film conveys a truth that resonated with me.

Despite the brutal onslaught of ‘honesty’ from a number of the characters, it is the secrets that are the most toxic. Secrets are stored for future use when their disclosure will cause the maximum harm. The film is bleak and as Barbara says, ‘Thank God we can’t tell the future. We’d never get out of bed.’

Here is a family caught in destructive patterns of relating, with little or no insight into the dynamics. It made me appreciate even more the need to understand our family dynamics, to shed light on our current ways of relating and offer hope for more effective and fulfilling relationships in the future.

Jude Fowler is a counsellor working with children and young people

The Lunchbox [DVD] Directed by Ritesh Batra DAR Motion Pictures, 2013 (PG, 105 minutes)

Reviewed by Chris Rose

This engaging and gentle film is set in Mumbai, where the bustling street scenes and packed trains provide the backdrop for a story of isolation and loneliness. Ila (Nimrat Kaur) prepares the daily lunchbox for her unfaithful husband in the hope that her cooking will make him notice her. When the lunchbox is mistakenly delivered to Saajan (Irrfan Khan), a sour widower about to retire from 35 years as an accounts clerk, her culinary talents are finally appreciated. From this a relationship develops that is conducted through food and brief, handwritten notes. The camera never lingers on the food, but the aromas seem to waft from the screen, connecting the characters and the viewers. The written notes are equally powerful, speaking volumes in two or three lines.

This eccentric relationship brings both Ila and Saajan a vision of other possibilities, symbolised in the shared fantasy of life in Bhutan, where happiness is more important than GDP. But it is hope, rather than actual romance, that in the end changes their lives.

‘The wrong train may take you to the right station,’ is a saying repeated in the film. Saajan and Ila might want the destination to be a ‘real life’ relationship with each other, but the train doesn’t seem to stop at that station. Instead it takes them to the ‘right station’: a new appreciation of self and others, the emergence of hope, and a motivation to change what needs to be changed.

I was reminded of the stage that often occurs in long-term therapy, where the client longs for a personal and intimate relationship with the therapist. We know that fulfilling this fantasy will not bring the changes that the client desires. The therapeutic relationship offers another route, through creating a different experience of relating and a new understanding – and, like the relationship in the film, by bringing hope.

Saajan softens and opens himself to others: he befriends a young colleague, an orphan who in many ways is equally isolated. Ila finds the strength to plan her escape from her loveless marriage – a courageous step in a society where, as the film demonstrates, women’s roles are so often limited to caring for men.

Beautifully acted throughout, the film pulses with a quiet and contained expression of emotion, drawn from body language and restraint rather than drama and declaration. We can make of the ending what we will. It resists the temptation to deliver the stereotypical romance, playing with it but never fully succumbing to the clichés. Instead it offers a more subtle and thought provoking take upon our ever-present need for genuine connection.

Chris Rose is a group psychotherapist, author, blogger and Reviews Editor for Therapy Today +++ From the Chair

Thank you to everyone

BACP Chair Amanda Hawkins writes her final column in the role

So here I am, writing my very last Chair’s column. Stepping down is an interesting space, often reflective and quite confusing at times. I find myself unable to remember what I have done in my time as Chair, or feeling alternately proud of what I have achieved, that I have not done enough, and that I could have done more. But I did what I did and now it’s time to hand over the baton to someone else and move forward.

Before I go I want to shine a light on some of the unsung heroes who I feel contribute a huge amount to BACP and the profession but very rarely get acknowledged – our families. My husband David Exall, who is also a counsellor and a member, has supported me unflinchingly through these past three years, without a murmur of complaint. He has looked after our children, mopped me up when things have been tough and put his own career aside to support my work with BACP. Without him, I don’t think I could have coped. My children have also donated their time, patience and understanding, watching their mother unpack an overnight bag only to pack it again, but very rarely moaning and protesting. A huge big thank you to you all.

Many partners, children and families have donated this level of support to the role and to past Chairs over the years. The Chair’s role has changed dramatically as the organisation and the profession have grown. It is a voluntary position, with just a small amount of recompense for loss of income. Time spent away from family is not compensated, unlike in a paid position. I entered into the role fired with passion for the profession of counselling. In this reflective space I find myself aware that it has taken more from me and my family than we probably realised, and this feels important to acknowledge. Perhaps passion is not enough; looking forward, perhaps we need to think more about how we support the Chair in this critical role? It is important to enable a wide mix of people to take it on and not be restricted to those who are financially secure and have no family responsibilities.

I don’t have the answers but it feels important to raise the question.

I am very much looking forward to the BACP summit on social justice in November. This area of work has become ever more important to me during my time as Chair, so it feels fitting that I hand over at this event, which coincides with our Annual General Meeting. You’ll have seen the publicity for the summit and the interview with the keynote speaker Jeffrey Kottler in the September issue of Therapy Today. I have seen Jeffrey speak on a number of occasions and he is fantastic. His work on using counselling skills outside the therapy room for social justice and change is truly inspirational.

Alongside Jeffrey, there will be four themed workshops to encourage deeper debate, all looking at areas of social justice that currently concern BACP: the links between a counselling perspective and a social justice/social change perspective; the role of counselling in community-based alternatives to custody for female offenders; parity of esteem between physical and mental health, and counselling as a vehicle for increasing social inclusion among marginalised groups. I’m going to find it hard to choose which workshop to attend. I hope that you will join us at The Lowry in Salford on 21 November. You can find out more and book your place on the BACP website at www.bacp.co.uk/events/. Jeffrey is also running a half-day workshop the next day, which is an equally tempting prospect.

So it’s time to say goodbye to everyone who reads this column. Thank you so much for your letters of support and the kind words that you have shared when I have met you personally. I was especially touched by those of you who wrote to me after my mother’s diagnosis with Alzheimer’s and dementia.

Writing the column was a daunting prospect when I became Chair; all I could do both in this space and in the Chair’s role was offer myself… warts and all. I have found writing the column hugely helpful at times in processing my month-by-month experiences as Chair and trying to work out their relevance to you, the members. It has been a bit like clinical supervision in that respect – the place that has brought me back to why this work is so important and, conversely, what of it is not. +++ BACP Public Affairs

BACP urges review of Welsh policy

BACP has called on the Welsh Government to review its current policy preventing counsellors and psychotherapists from conducting mental health assessments.

The Mental Health Measure was introduced in 2010 to improve the uptake and regulate therapy provision in Wales. But, says BACP, the Measure has had an unintended effect and highly qualified and experienced counsellors and therapists are being prevented from conducting mental health assessments.

Currently professions including specialist mental health nurses, registered occupational therapists and social workers, but not counsellors and psychotherapists, are considered eligible to conduct assessments.

BACP’s response to the Welsh Government’s consultation on the Measure notes that it has done much to improve referrals to therapy. But the ban on counsellors doing mental health assessments is reducing employment opportunities and the employability of counsellors and psychotherapists and so damaging therapy services. Well-qualified and experienced therapists are leaving their posts and being replaced by other professions who may not have their mental health experience and specialist training, BACP says.

BACP at the Labour Party Conference

BACP co-hosted a fringe meeting with the British Psychological Society (BPS) at the Labour Party’s Annual Conference. The event, on 23 September, heard from an expert panel, followed by a lively question-and-answer session from the audience.

The panel included Labour MPs Chris Ruane and Kevan Jones, BACP Vice- President Professor Dame Sue Bailey, BPS President-Elect Professor Jamie Hacker Hughes, Chair of the Board of Science at the British Medical Association Professor Baroness Hollins, and Ian Hulatt, Mental Health Adviser at the Royal College of Nursing.

Kevan Jones offered a simple message to the audience: ‘Talk about mental illness and keep talking about it as if it was any other condition.’ Professor Hollins recommended that we ask party campaigners in next year’s general election about their party’s policies on mental health, and Professor Hacker Hughes called for access to psychological therapies within 28 days of referral.

Chris Ruane spoke about the benefits of mindfulness in the workplace, health, education and the criminal justice system. Ian Hulatt argued that nurses should be more psychologically attuned to the people they were caring for, but that they need more training. Professor Sue Bailey spoke about children and young people and her vision of an NHS where ‘parity is a word that doesn’t need to be used again’.

BACP at the Conservative Party Conference BACP was represented at the Conservative Party Conference in Birmingham at the end of September.

BACP representatives attended the Health and Social Care Alliance fringe event where Secretary of State for Health Jeremy Hunt cited his commitment to mental health services and hinted at an impending Government announcement on parity of esteem between mental and physical health.

Mind’s event on ‘Mental Health: everything you wanted to know’ heard from Nicky Morgan, Secretary of State for Education, and James Morris, Chair of the All Party Parliamentary Group on Mental Health. They both articulated the Conservative Party’s commitment to mental health services.

Nicky Morgan also praised school-based counselling as a mental health service for children and young people.

The growing problem of loneliness among older people was explored in Age UK’s fringe meeting on ‘Ideas and Opportunities for an Ageing Britain’.

The British Psychological Society’s event focused on ‘Reducing Crime: how do we know what really works?’. Speakers highlighted the need for research into effective psychological interventions in the criminal justice system.

Guidance on Parkinson’s

BACP has urged NICE to recognise that people with Parkinson’s disease and depression need specialist psychological therapy.

NICE is currently consulting on an update to its clinical practice guideline on Parkinson’s disease. BACP has welcomed NICE’s recognition that depression can be a symptom of Parkinson’s disease but is concerned that the guidance will not make recommendations on interventions and management of comorbid conditions unless the treatment differs from that offered to people without Parkinson’s.

BACP says the guidance should include information on effective psychological therapies for people with Parkinson’s and depression. It says there is good research evidence that they benefit from a specialist approach because therapies may need to be modified to accommodate the possible effects of the disease on cognition. +++ BACP News

Shared commitments to ethical practice

Tim Bond outlines the key changes in the draft revised BACP Ethical Framework, which will shortly be sent to all members for their views

BACP members will have each received by email a consultation copy of the first full draft of the revised Ethical Framework.

In this article I want to tell you about how your contributions to the three webinars held earlier this year have influenced the revision of our Ethical Framework.

Be prepared for some surprises. I hope they are welcome ones as I have attempted to reflect your responses to the webinars. We have never had so many people (1,868 in total) taking part in a consultation on our professional ethics. Even more importantly, the quality and thoughtfulness of the responses has been particularly helpful.

As in previous versions of the Ethical Framework, I have followed two principles in writing this draft. First, I have taken into account the range of views and the reasons you offered for your views to try to find common ground between them, rather than choose one view over another. I have been greatly helped by the BACP Policy team, who produced several analyses of all the webinar responses.

Second, I have tried to respect examples of practice that significant groups of practitioners of counselling, coaching or psychotherapy considered to be good and ethical. Like any profession, we have legitimate differences of view, often related to our different therapeutic approaches or the needs of different clients and settings. We find it easier to agree on core ethical principles than on the detail of specific ways of delivering our services. I have tried to reflect this in how I have written the draft revisions.

Why make changes?

The current version of our Ethical Framework has lasted over 12 years. During that time there have been many changes that have implications for our practice. The governance and regulatory basis of all health and social care provision have changed substantially, often in response to serious scandals. Even though we have not been directly implicated in these scandals, we need to adapt to this new professional environment if we are to play our part in ensuring the highest standards of practice in the health and social care arena. We also have to recognise that we, as a profession, are not immune from difficulties and poor practice and that we can benefit from the learning of other professions. The 2010 and 2013 Francis Inquiry reports on Stafford Hospital1,2 are the most recent and influential in a long series of investigations and recommendations on preventing poor standards of health and social care. These too I have taken into account.

BACP is also among the early adopters of a new type of professional registration: the Accredited Voluntary Register run by the Professional Standards Authority. The Authority is also responsible for overseeing the UK’s nine health and care professional regulatory bodies, which include the General Medical Council (GMC), the Health and Care Professions Council (HCPC) and the Nursing and Midwifery Council (NMC). I have therefore also taken account of the latest developments in their ethical frameworks, which guide our most closely related professions, such as psychologists, social workers, doctors and nurses.

The draft Ethical Framework sent to you for consultation has key passages highlighted to draw them to your attention to make it easier to complete the accompanying online questionnaire seeking your views. I am going to cover here the most significant changes.

Finding our ethical voice

One of the consequences of so many scandals in health and social care is that regulatory voices have become increasingly strident and authoritative in how they express ethical standards. Both the GMC and the HCPC include a summary of core duties in their respective standards and ethics guidance. These are expressed in terms of strict obligation: ‘You must …’ The idea of adopting a similar list produced a very mixed response among respondents to our first webinar. Very few people wanted to return to a rules-based system but they could see the potential benefits of expressing our ethics as simply and directly as possible. After trying several different approaches I decided to adopt one of the suggestions made at the webinar. Our ethics grow out of our collective sense of commitment and responsibility; they are not something imposed upon us; expressing our core ethics as ‘commitments’ would be consistent with our values.

To capture this spirit, which ran through most of the responses, I have used ‘We will …’ where other codes use ‘You must …’ and ‘We will normally…’ where others state ‘You should …’ This has made a significant difference to the ethical voice. For example, the HCPC Standards of Conduct, Ethics and Performance3 requires, ‘You must keep accurate records’ (Duties section 10). Our proposed Ethical Framework sets out a similar responsibility but in a different voice: we will work to professional standards by ‘keeping accurate and appropriate records’ (Commitment 3d).

The draft uses only one ‘must’ – ‘We must be competent to deliver the services being offered’ (Good Practice 8). Everywhere else our responsibilities and obligations are written as commitments that, as members of our professional association, we share and that we each take responsibility for implementing.

Title and structure

The proposed title is the Ethical Framework for the Counselling Professions. I decided against listing counselling, coaching and psychotherapy separately. Other roles may be recognised within BACP over the likely lifespan of this revised framework. It seems better to have a title that can encompass a number of possibilities so we don’t need to keep changing it. What we have in common are the therapeutic theories underpinning counselling that we apply in our different professional roles.

The revised framework is structured in three parts. It starts with ‘Commitment’, which provides an overview of our core ethics and is written in a style that clients could read and understand, should they find this helpful. The next section is ‘Good Practice’, which sets out in more detail what the commitments mean for us as practitioners. Part 3, ‘Ethics’, sets out the values, principles and professional, moral qualities that underpin our ethical standards. This is the section that BACP members often find useful when considering how to respond to ethical dilemmas.

I am going to explore here the key features of each of these sections that have been influenced by the discussions arising from the webinars.

Commitment – candour

Most of the content of ‘Commitment’ is consistent with the current Ethical Framework but expressed more directly and simply. Even the explicit commitment to ‘Put our clients first’ by making them ‘our most important concern during our work together’ is an expression of the values and principles that underpin current practice. The duty of candour recommended by the 2013 Francis report2 is also substantially present in the current framework but is made more explicit in the revised draft as a commitment to promptly inform a client if anything ‘occurs that may cause you harm and quickly limiting or repairing that harm as far as possible’ (section 6b).

Good practice – supervision

In the second webinar I provoked the biggest range of responses by arguing that supervision should make a bigger contribution to professional accountability by being more closely co-ordinated with line management (where relevant). I also proposed that clients might be able to contact their practitioner’s supervisor if they had any difficulties with them. Both these suggestions are possible under the current Ethical Framework, but are not explicitly required.

The feedback to the webinar included some very persuasive arguments for some aspects of supervision being independent of line management but not necessarily wholly detached from the employing agency’s strategy and operational issues. I have attempted to capture this in the draft by committing us to finding a balance between our obligations to our employing agency’s strategy and the independence of supervision (section 46), supported by an annual review of agreed divisions of managerial and supervisory responsibilities.

The draft Ethical Framework does not require that clients know the identity of their practitioner’s supervisor or that clients can approach a supervisor directly in specified circumstances. Views on these were too divided to find common ground. Instead it reads: ‘We will clarify who holds specific responsibilities for our clients between practitioner, supervisor and any line managers and review how well these responsibilities are working in practice’ (section 49). It also commits us to review our application of the Ethical Framework at least annually in supervision (section 48). All supervisors are also expected to know their legal responsibilities to their supervisees’ clients (section 52). (Further guidance will be provided on these legal responsibilities in due course.)

My aim here is to encourage supervisors to carefully consider how they relate to their supervisees’ employing agencies and their responsibilities to their supervisees’ clients, without restricting us to particular ways of fulfilling these principles and responsibilities.

There is a growing recognition of the additional risks to standards where practitioners work in isolation, without access to any constructive and informed scrutiny of colleagues and managers. Private practitioners working alone are likely to practise in considerable professional isolation; so too are practitioners who are the sole person providing their particular type of service within an agency. The draft framework therefore makes provision for supervision to include ‘addressing the issues around the effectiveness and safety of services provided that would normally be available in a well-functioning team’ (section 47).

Ethics – diversity and problem-solving

The feedback from the webinars suggests that the ethics section of the current framework is valued by many members and used as a point of reference in supervision or to consider ethical problems or dilemmas. I have therefore kept much of it but have updated it to reflect the challenges of social diversity. In the values section I have extended ‘facilitating a sense of self’ to include ‘sense of self in relationship’, to encompass relational and communitarian views of self. This might seem a technical change but it opens up the interpretation of our principles – especially autonomy – to those cultures and races that have a relational or collective understanding of self. ‘Promoting social justice’ has also been added to the values. ‘Care’ has been added to the section on ‘Professional moral qualities’ and is defined as being ‘actively and compassionately supportive of the wellbeing and capabilities of other people’. An awareness of the significance of ‘self in relationship’ and ‘care’ are well-established features of feminist ethics that apply equally well across the genders.

Next steps

A full copy of the draft Ethical Framework, with a weblink to the online questionnaire for your comments, has been emailed to every member. Please do respond. We want your feedback in order to write the final draft, which will be completed during spring 2015. The final, agreed version will come into effect for all BACP members and registrants from January 2016.

Feedback received to date has been significant in many more ways than there is space to mention here. The more feedback we receive, the more confident we can be that what we adopt in 2016 will be truly a joint commitment. The draft Ethical Framework will also be available online at www.bacp.co.uk/efc. For queries about the consultation and questionnaire, please contact [email protected], putting Ethical Framework in the subject line, or call 01455 883300.

Professor Tim Bond is consultant to the BACP Ethical Framework.

References

1. The Mid Staffordshire NHS Foundation Trust Inquiry. Robert Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust. London: Department of Health; 2010 2. The Mid Staffordshire NHS Foundation Trust Inquiry. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: the Stationery Office; 2013. 3. HCPC. Standards of conduct, performance and ethics. London: HCPC; 2012. New commissioning guidance

BACP has published new guidance on Preparing your Service for Commissioning, as part of its series of NHS commissioning resources.

The guidance is written by Louise Robinson, BACP Healthcare Development Manager, and builds on the 2009 BACP guidance on NHS Commissioning: a toolkit for psychological therapy providers.

The aim is to provide members with a simple, comprehensive and accessible guide to the key issues they need to know about if they are to successfully tender for contracts to provide psychological therapies through the NHS.

The contents of the new guidance cover the national policy context for local commissioning of psychological therapy services, service provision and commissioning, business planning, and securing contracts long term.

The national policy context section includes information on the main mental health policy papers and frameworks that set out the Government’s overarching goals and standards for psychological therapy services, including summaries of relevant NICE guidelines and government white papers.

The service provision and commissioning section looks in detail at the different service models for providing psychological therapies and the different tendering processes being adopted by Clinical Commissioning Groups (CCGs), with practical advice on how to present your service to meet your commissioner’s needs, and information on legal issues and contracts. ‘Business Planning’ offers practical information on establishing and growing your psychological therapy business, with explanations of key elements such as Payment by Results, costing your service, governance and management, outcome measures and technology.

In her foreword, Zubeida Ali, Chair of BACP Healthcare, says: ‘This comprehensive resource will help us, as therapists and service providers, to understand and engage with the changing policy and commissioning context, and inform and support the business planning required to improve quality and influence local commissioning.’

A suite of training resources and other information on NHS commissioning are available free to BACP members at www.bacp.co.uk/commissioning

BACP registrants pass half-way mark

Some 683 BACP members joined the BACP Register in August, taking the total to over 20,000 – more than half the membership.

A booklet with information on becoming registered is being posted this month to every eligible MBACP and Individual Member who has not yet completed the registration process. The booklet is intended to help members achieve registration and continue their BACP membership, and gives details of Certificate of Proficiency (CoP) assessments up until August 2015.

The CoP is the route for MBACP and Individual Members to join the register. Many members have given feedback on the assessment, which is computer-based and uses case studies and multiple choice questions to assess counselling knowledge, skills and abilities. The current pass rate is very high, at 93 per cent. Members who have taken it say the process is much less terrifying than they feared. BACP registered member Lindsey Mason wrote: ‘I just wanted to feed back to you that you were correct and the CoP computer system was easy to use, the two invigilators were very helpful and I found out today that I passed.’ Hannah Bridge fed back: ‘All the preparatory information and sample case study were really helpful. Telephone/email support has been terrific… the two people managing the day were just the ticket and it was lovely to meet other therapists. I particularly appreciated the lack of frills; I feel that is a good way to spend my membership fees.’

If you are an MBACP or Individual Member and have not yet registered, visit www.bacpregister.co.uk for dates of available CoP assessments and for more information on becoming registered, or call Customer Services on 01455 883300.

BACP Summit workshops

Details have been confirmed of the workshop topics for the BACP Summit on social justice on 21 November. The Summit takes place at The Lowry in Salford, followed by the BACP 2014 Annual General Meeting.

Professor Jeffrey Kottler will open the event with his presentation on ‘Changing people’s lives while changing your own’. Delegates will then choose between two workshops: Mick Cooper, Professor of Counselling Psychology at Roehampton University, on developing the links between a counselling perspective and a social justice/social change perspective, and Sarah Swindley, Chief Executive Officer at Lancashire Women’s Centres and Chair of Women’s Breakout, on ‘Wrap-around community care as an alternative to custody for female offenders’.

After lunch, there will be a workshop on ‘Counselling as a vehicle for increasing social inclusion among marginalised groups’ led by Dr Keon West, Lecturer in Social Psychology at Goldsmith’s University.

Jeffrey Kottler will also be leading a half-day workshop on 22 November on ‘The Power of Storytelling in Psychotherapy – and Everyday Life’. This workshop is open only to delegates attending the Summit.

Tickets for the Summit are £120 for BACP members, £190 for non-members and £60 for student and reduced fee members. The morning workshop costs another £15. To book, please visit www.bacp.co.uk/events/conferences.php

2014 Annual General Meeting

BACP’s 38th Annual General Meeting will be held on Friday 21 November 2014, at The Lowry Centre, Salford Quay, Greater Manchester M50 3AZ, commencing at 4.30pm.

The AGM will follow on immediately after the close of the BACP Summit, and we hope that members attending the Summit will stay on to join in. It will also be available this year as a webinar and we hope that this will enable many more members to participate.

We will be sending all members more information on how to access and participate in the AGM webinar in a separate AGM update email. The meeting Agenda, Financial Statements 2013–14, postal/proxy voting form and Minutes of the 2013 AGM will be sent to all members in a dedicated mailing towards the end of October.

In the meantime, if you have any queries at all about the AGM, please contact Jan Watson, Assistant to the Chief Executive, at [email protected] or call her on 01455 883383.

BACP seeks professional conduct adjudicators

BACP is looking for members willing to serve as adjudicators with the BACP Professional Conduct department.

The department is responsible for processing complaints made against members/registrants. To do this, it relies on a bank of adjudicators who are ready and available to serve on the panels of lay people and professionals who consider conduct matters.

Adjudicators need to be passionately committed to the issues of fairness and equality and be able to make what are often difficult decisions. The role requires analytical skills and the ability to identify what information may be required to reach a decision. As making a judgment may seem counter-intuitive for a practitioner trained to be non-judgmental, it is important that potential applicants give some thought as to whether this would pose any difficulty before applying.

The Professional Conduct department will be recruiting up to 10 adjudicators. Panel members are likely to be needed for no more than a few days a year.

For more information about the role, what is required, the application process, details of remuneration and the contracting process, please go to www.bacp.co.uk/vacancies

Good practice resources

BACP is looking for writers to help produce a new, web-based bank of good practice resources linked to the revised Ethical Framework.

BACP is gradually archiving and replacing the existing information sheets.

Members interested in helping write the new resources should contact Susan Dale, BACP Good Practice Guidance Manager, at [email protected]

2015 Student Event confirmed

Bookings are now open for the sixth BACP Student Event, on 28 March 2015 at Imperial College London.

The aim of the event is to bridge the gap between student and practitioner. Counselling and psychotherapy students say they would welcome more help post- qualification in progressing their career. The event includes a comprehensive programme of workshops on topics such as developing a career path, what it’s like to work in the various specialist sectors, how to do well in job interviews, and the practicalities of setting up in private practice. Delegates can also book one-to-one sessions with some of the exhibitors and attend taster talks in the main exhibition area.

You can view a short promotional video at http://youtu.be/91ZjizryZ4A

For more information, visit www.bacp.co.uk/studentevent/ or call the BACP Customer Services team on 01455 883300.

New Private Practice lead

BACP has created a new post of Lead Advisor, Private Practice, reflecting increased activity in the sector.

BACP has over 11,000 members working at least part time in private practice. At over 2,900 members, BACP Private Practice is the second largest and fastest growing of the seven BACP divisions.

Patti Wallace has taken on the part-time post initially for a year, alongside her existing role as BACP Lead Advisor for University & College Counselling. Her priority tasks will be raising the profile of private practice counselling and working with the BACP Private Practice Executive to develop online resources to support BACP members in private practice.

BACP Private Practice Chair James Rye said: ‘The new post demonstrates BACP’s commitment to and recognition of the sector’s growing importance within the profession as a whole.’

New Coaching website

BACP Coaching’s new website is now live at www.bacpcoaching.co.uk. The Executive is inviting members to write about their work as a counsellor/therapist who coaches for the website’s ‘Who Are Our Members?’ page. It would also welcome feedback on the website – is it more intuitive and user friendly?

If you have any comments or suggestions, please email [email protected]

Why I joined... BACP CYP

Rebecca Cupples is a school counsellor employed by Familyworks, based in Newtownards in Northern Ireland. She currently works part time in two different schools. She joined BACP in 2008 when she enrolled to train as a counsellor but didn’t join BACP Children & Young People (BACP CYP) until several years later.

‘I have always enjoyed working alongside children and young people. Growing up in Northern Ireland, I was often away helping on summer camps or drop-ins for young people. Following my degree at Queen’s University I worked for six years full time with young people in two different charities, and it was a real privilege to share in these young people’s lives. However, I felt I wanted to be better equipped to support children and young people struggling with difficult circumstances and so I went back to university in 2008 to take a certificate in person-centred counselling. That was when I first joined BACP.’

She joined BACP CYP in November 2013 when she was studying for a post- qualifying diploma in counselling children and young people. ‘Becoming a member was encouraged within the course. I’d heard about the division through BACP but to be honest I wondered if I really needed another subscription. But when I read some of the free articles from the journal that were online, I couldn’t believe I hadn’t signed up a long time ago,’ she says.

‘Every time a journal appears through my letterbox I can’t wait to rip off the plastic and get stuck into reading it – although as a mum of two little boys I don’t usually have time to do that straight away. The journal is a great resource for me to update my toolkit, learn from the experiences of others and discover new resources that could help me in my work. The articles can range from reflections on working with particular issues such as anxiety or self-esteem to practical skills such as using clay or sand. The book reviews are a favourite of mine as they help me find books that I might read or use in my work.

‘I’m very thankful to have a supportive agency and supervisor but the role of a school counsellor can be isolating at times. I see the journal a bit like a colleague who shares their experiences and difficulties and I find that very supportive.’

She would urge any CYP counsellor to join. ‘The more members we have, the more experiences we can share and the more we can learn from each other and hopefully that will allow us to offer an even better service to children and young people.’

To join BACP Children & Young People, or any of the BACP divisions, please email [email protected] or visit www.bacp.co.uk/expert_areas/ +++ BACP Professional Standards

Newly accredited counsellors/psychotherapists

Sarah Aldridge Christine Barrell Susanna Borner Sue Crown Carol Dalton Jane Dixey Jeraline George William Hanmer-Lloyd Samantha Horrocks Linda Hug Martin Johnstone Denise Kilgannon Penny Marr Colin McKee Paul Mollitt Wayne O’Sullivan Corinna Tebbutt Debera Torpey Jonathan Trubshaw Alison Walker June Whitehead Kelly Williams

Organisations with renewed service accreditation terms

Drug & Alcohol Project Ltd (DAPL) Insight Healthcare Ltd

Members not renewing accreditation

Angela Bell Kimberly Fitzgerald Dana Lockhart Sarah Osborne Joanna Satula-McGirr Martha Stigler

Members whose accreditation has been reinstated

Jeraline George Indu Khurana Denise Kilgannon Jane Matheson Alison Turner All details listed are correct at the time of going to print. +++ BACP Professional Conduct

Withdrawal of membership Milton Keynes City Counselling Centre (MKCCC) Reference No: 112660 Milton Keynes MK9 2ES

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

The Panel made a number of findings and the Panel was unanimous in its decision that these findings amounted to Serious Professional Malpractice in that the service for which MKCCC was responsible fell below the standard that would reasonably be expected of an organisation exercising reasonable care and skill. The Panel agreed that, in view of the findings, MKCCC was incompetent, negligent, reckless and provided inadequate professional services. The Panel did not find any evidence of mitigation.

In view of the serious nature of the findings, BACP’s remit of public protection and the impact of MKCCC’s actions on both clients and counsellors within the centre, the Panel was unanimous in its decision to withdraw membership from MKCCC. The Panel also had regard to the fact that MKCCC as an organisation was now dissolved and therefore no longer existed as a legal entity.

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

Withdrawal of membership Joanne Louise Blackledge Reference No: 679904 Wigan WN3 5JA

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

The Panel made a number of findings and the Panel was unanimous in its decision that these findings amounted to Bringing the Profession into Disrepute in that Ms Blackledge had behaved in such an infamous and disgraceful way that the public’s trust in the profession might reasonably be undermined if they were accurately informed about all the circumstances of this case. The Panel did not find any mitigation.

Having regard to the serious nature of the Panel’s finding and BACP’s remit of public protection, the Panel was unanimous that Ms Blackledge’s membership should be withdrawn.

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

Mental health research call

The Chief Medical Officer (CMO) Professor Dame Sally Davies has called for more research into mental health in her latest Annual Report. The report takes public mental health as its focus, and emphasises throughout the need for more and better data and more funding for mental health research.

The report points out that just 5.5 per cent of the total UK health research spending in 2009/10 went into mental health, significantly less than the proportion spent on cancer, infections or cardiovascular disease. This is disproportionate to the burden of mental health on the UK economy and its known toll on the national economy, the CMO argues.

The report acknowledges that mental illness is the leading cause of sickness absence in the UK, accounting for 70 million days off work in 2013 and costing the UK economy £70–£100 billion per year. Despite this high burden of mental ill health in the UK, there is a significant treatment gap in access to mental health services. In England approximately 75 per cent of people with mental health problems receive no treatment.

The CMO says it is essential to gather more research data to make a strong economic case for more investment in mental health, although much more data are available now than 10 years ago to inform strategic decision makers and commissioners on the economic impact of the decisions they make.

Professor Davies specifically highlights the lack of robust evidence on ‘wellbeing’, largely due to the lack of clarity about what is meant by the term. The report recognises that wellbeing in mental health could be a very useful issue to explore but says there is currently insufficient evidence of their effectiveness to justify commissioners investing in interventions aimed at ‘improving wellbeing’.

The full report can be downloaded from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/35162 9/Annual_report_2013_1.pdf

Research volunteers

Have you ever thought about getting involved in research as a volunteer research participant? Each week, new opportunities to get involved in research are posted on our online Research Noticeboard.

The topics are varied and participation usually requires either the completion of an online survey or an interview.

Being a research participant is very rewarding as it gives you the opportunity to contribute towards the evidence base for counselling/psychotherapy, which in turn may lead to increased funding for and further recognition of the services you provide.

You can find out more at www.bacp.co.uk/research/Research_Notice_Board/ First PhD scholarship awarded

BACP has awarded its first PhD studentship, in partnership with the University of Sheffield, for a feasibility trial of the effectiveness and impact of counselling in universities and/or colleges of further education.

There is evidence that the demand for counselling services has increased among students in the last two decades. There is currently a lack of research evidence on the impact of counselling on academic outcomes. The studentship presents the opportunity to design and implement a feasibility trial of counselling in this context, exploring the impact of different kinds of counselling intervention.

Final call for conference papers

If you would like to submit a paper to present at the 2015 BACP Research Conference, the deadline for submissions is 7 November 2014.

The theme of this year’s conference is ‘Understanding professional practice: the role of research’. The conference is co-hosted by the University of Nottingham and will take place on 15–16 May 2015 at the East Midlands Conference Centre, Nottingham. Find out more at www.bacp.co.uk/research/events/index.php

Enquiry of the month

This month’s research enquiry asked: ‘What research has looked at counselling for the trauma caused by infidelity?’ To answer this question we searched our internal abstract database and Google scholar (http://scholar.google.co.uk), using the search terms ‘counselling’, ‘trauma’ and ‘infidelity’.

Much of the literature has focused on couples therapy. Snyder and colleagues1 describe a three-stage model based on cognitive behavioural and insight-oriented approaches. The stages are: 1) dealing with the initial impact of the infidelity; 2) exploring contributory factors and finding meaning, and 3) reaching an informed decision about how to move on. Preliminary work using this model suggests it is an effective affair-specific intervention.

Hall and Fincham2 explore attribution and forgiveness in relation to infidelity. They conclude that forgiveness fully mediates the association between attribution and termination of relationship. In terms of implications for practice, the authors recommend addressing attributions in therapy before attempting to facilitate forgiveness or reconciliation.

If you would like help with a research query, please email [email protected]

References

1. Snyder DK et al. An integrative approach to treating infidelity. The Family Journal 2008; 16(4): 300–307. 2 Hall JH, Fincham FD. Relationship dissolution following infidelity: The roles of attributions and forgiveness. Journal of Social and Clinical Psychology 2006; 25(5): 508–522. +++ Behind the pictures

Eva Bee describes the inspirations behind her illustrations for the October issue

Do you consider yourself to have a trademark style? If so, how would you describe it?

I’d like to think that my style is distinctive. I would say it’s defined by blocks of colour and line work detail, with strong use of texture to create a ‘retro’ feel. I would like to be known as much for strong ideas as the illustrative style – I like to give each image a twist, changing the familiar by one notch to make it something that catches the eye.

How would you describe the creative process you go through when working on your illustrations? Does it vary?

I always start with the article, reading a piece several times and often referring to other reference material to get a firm grasp of the subject. I then jot down ideas and either produce a series of sketches in pencil on paper or work straight onto the computer using a pen and graphics tablet to produce roughs, which I then send to the client. When the client and I are happy with the concepts, I then work over the original sketch in more detail before using a variety of ink pens to create the final line work. This is scanned into the computer and forms the detail, around which I place blocks of colour. I also use hand-drawn and found textures to bring warmth to the image.

Generally speaking, how do you come up with your ideas? What inspires you?

The copy is always my first source of inspiration, unless the client has an idea of what they would like me to produce already, in which case I will work around those suggestions. Otherwise, the ideas are informed by the key themes in the article. From there, I often research the subject further to get a feel for the kind of imagery associated with the subject I’m illustrating and note down anything that comes to mind. I like to spend a while either writing or doing quick thumbnail sketches of all the thoughts that occur to me and then I whittle these down, keeping the strongest to develop further.

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?

For some of the articles the ideas developed over a period of time after thinking around the subject. The cover image and the Ross article ideas both came to me fairly quickly but I still spent some time coming up with a number of ideas to be sure that I’d got the strongest solution.

Can you describe what informed/influenced/inspired your Therapy Today illustrations? Very much the articles themselves and research around the subjects in the copy. As these articles contained quite emotive ideas I also tried to empathise with the thoughts and feelings of the authors to try to ensure that these feelings came across in my solutions.

Did illustrating these particular subjects throw up any challenges? If so, what were they?

Yes, any discussion around therapy and counselling is bound to throw up sensitive issues and I was aware of the need to tread carefully when coming up with ideas.

Can you describe in a nutshell what you were trying to convey with each image?

With the cover image I wanted to convey the sense of distress Jake feels in his personal account in the article about university counselling. The inside illustration for the same article was more about getting across the general themes from the whole piece, the pressure and stress felt by both students and their counsellors in a Higher Education environment. The ‘A story of falling’ illustration was about conveying the brokenness of the author and his client but how this vulnerability was also positive, a source of strength that helped each ‘mend’ the other. The student–tutor conflict illustration was a twist on the jungle analogy given in the copy.

How do you feel about your finished work? What do you like most about your images? Do you have a favourite image?

I’m pleased with how the illustrations have turned out. I loved the freedom the brief gave me to really push the ideas in interesting directions. I’m particularly happy with the cover image – I think the directness of the concept and simplicity of the final image work well for a cover.

Apart from Therapy Today, where else might we see your work?

I’m just about to start illustrating a regular comment piece in the pages of the Guardian, so you’ll be able to pick up the paper on a weekday and find me in there. I’ve also worked with other newspapers and magazines, including Nature, Reader’s Digest, Director and Nursing Standard.

Eva Bee lives and works from a home studio in the beautiful peak district of Derbyshire. Clients she has worked with include Nature, Reader’s Digest, The Guardian and The Royal College of Nursing. You can see Eva’s portfolio of work at www.evabee.co.uk. Contact Eva by email at [email protected] or call +44 (0)7761 607151. Follow her latest work and news on Twitter @evabee_draws +++ TherapyToday.net Noticeboard

Supervision

Bosham/Fareham/Skype Member MBACP (Accred) counsellor and qualified supervisor. Experienced and trained to work with adults, couples and children. Humanistic/integrative approach, but can work with different models; also offer support with accreditation. Face-to-face work; also via Skype. Contact 07716 124328

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

London Supervision offered by a qualified counsellor/psychotherapist about to start the second part of a supervision training at Re-Vision leading to a diploma (currently hold a certificate in supervision). Free supervision from an integrative perspective offered from November 2014–June 2015 (inclusive) while completing supervision training. Experience working with adults and young people on a range of issues, including sexual minority clients – completed Pink Therapy’s ‘Essentials Certificate’ in working with sexual and gender minorities. Contact [email protected]; visit www.rashahammami.org

London, EC2/Skype/phone Experienced, integrative counsellor offers supervision in the City as well as by phone and Skype. Contact 07948 353125; nick@counselling- and-hypnotherapy.net; www.counselling-and-hypnotherapy.net

London, N Qualified and experienced, integrative/psychodynamic supervisor and counsellor. Student rates negotiable. Contact Lindy Medway 020 8361 5111; [email protected]; www.counsellingtime.com

London, NW Experienced, Member MABCP (Accred) counsellor/psychotherapist offers psychodynamic supervision. Reduced fees while on supervision training course. Contact Reitzy Rosalinda Diamant 07977 451131; [email protected]

London, NW10/NW6 Supervision/network group – open to all modalities – seeks new members. Group meets on Sunday once a month from 10.30am–12.30pm. Contact Vanessa 07985 387021; Sorcha 07595 292129

London, Pinner/Northwood/Hertfordshire Experienced supervisor and counsellor with 18 years’ post-qualification counselling experience. Integrative/person- centred/CBT/EMDR counsellor of adults, couples and young people, EAPs, companies, FE, HE, voluntary organisations and private practice. Individual and group supervision. Trainee rates. Contact Teresa Townsend 07958 303487; [email protected]

London, SE/Kent Member MBACP (Snr Accred) supervisor and counsellor with established private practice offers supervision to practitioners and students. Experience with private clients, agencies, EAP providers and within GP settings. Contact David Smith 020 8857 6018; www.smithpractice.com

London, SW6/Fulham/Skype Experienced supervisor; UKCP registered, Registered Member MBACP. Humanistic/integrative supervision; work with TA/systemic/attachment/family constellation approaches. Contact Alexandra Piotrowska 07957 586656; [email protected]

Rutland/Leicestershire/Lincolnshire/Northamptonshire Supervision with psychodynamic/integrative, Registered Member MBACP with 15 years’ experience working with adults, children and young people, including work with SEN, EAP and CSE (special educational needs, employee assistance programmes, and childhood sexual exploitation). Contact 07817 183031; [email protected]

Placements

Birkbeck, University of London Associate counsellor sought. Voluntary position would be suitable for a qualified counsellor working towards accreditation. Requirement: minimum 150 clinical hours. Minimum one-year (up to two years) contract. Supervision provided. January 2015 start. Send a CV to Hanneke Kosterink at [email protected]

Crawley/Horsham/Mid Sussex Volunteer placements for counsellors and psychotherapists in a service that provides counselling for patients with disordered eating and obesity. Gain experience of working within an NHS framework. Training workshops/CPD and regular clinical supervision provided. Contact 01322 220294; send your CV to Manjit Bungar (HR Officer) at [email protected]

Leicester Placement for diploma-level and qualified therapists. Contact 0116 416 1626; www.rhcp.org.uk

London Psychodynamic supervisor on supervision training course seeks a placement. Experienced, Member MBACP (Accred) counsellor/psychotherapist. Contact Reitzy Rosalinda Diamant 07977 451131; [email protected]

London, Lewisham/Greenwich Placements offered by a BACP accredited service that provides up to 24 person-centred sessions with adults in a children’s centre setting. Several placements available due to the service expanding. Applicants either to be in training on a BACP accredited course or qualified and working towards accreditation. Requirements: applicants should be in at least their second year of training with 30 hours’ supervised clinical practice. Fortnightly supervision provided on Tuesday evenings. For an application pack, contact Catherine Taylor (QCCS Administrator) at [email protected]

West Sussex Your Space Therapies provides counselling, psychotherapy and play therapy in schools and offers counselling, psychotherapy and play therapy placements in all areas of West Sussex. Training and supervision are provided and trainees are supported on a path to find paid work with the service once qualified. For more information, contact Laura Creasey at [email protected]

Research

Call for participants A qualitative exploration of how person-centred therapists work with embodiment with children and young people following child sexual abuse. For further information, or to express an interest in taking part in the study, contact Julie Jakeman at [email protected] Call for participants Are you the child of a bipolar mother? Seeking therapists of any modality to participate in research exploring the above experience. Contact Lisa Tilling at [email protected]

Call for participants Have you worked within the prison system as a counsellor and, if so, what are your views on its therapeutic value? Contact Janet Hardy at [email protected]

Call for participants Research participants required for a qualitative study: ‘An interpretative phenomenological analysis of the experience of therapeutic rupture in relation to attachment style in therapists.’ Therapists with five or more years’ post- qualification experience sought from CBT/person-centred/psychodynamic modalities for hour-long, semi-structured interview as part of MSc in Integrative Counselling and Psychotherapy with the University of Derby. Contact [email protected]

How do clients experience loyalty to an abusive parent? Research opportunity for female integrative psychotherapists or trainee psychotherapists (year three or above) who were raised within a Western culture and have a history of abusive parent/s to volunteer in a research study exploring loyalty to abusive parents. If you would like to volunteer and be part of this research study, contact [email protected]

Participants wanted How does a therapist with an ambivalent attachment style manage their ambivalence effectively in relational therapy? Research participants required for a heuristic study, including a semi-structured interview. Contact 07866 406266; [email protected]

Participants wanted MA student seeks humanistic counsellors to interview who are willing to talk about their experience of crying in front of clients. Contact Llinos Parry 07970 904468; [email protected]

Participants wanted Participants who live in London sought for six to 12 hours’ coaching sessions, including one video session of 20–30 minutes, to complete a coaching module. I am a trainee counsellor with some interests in coaching. For further information, contact Myriam 07963 441455; [email protected]

Networking groups

London, NW10/NW6 Supervision/network group – open to all modalities – seeks new members. Group meets on Sunday once a month from 10.30am–12.30pm. Contact Vanessa 07985 387021; Sorcha 07595 292129

Milton Keynes MKARC is a Milton Keynes-based networking group of accredited counsellors/psychotherapists. BACP accredited, UKCP and other equivalently registered counsellors/psychotherapists interested in joining the group are invited to get in touch for further information. Contact [email protected]

Wimbledon NFP Peer support group for students, trainees and qualified counsellors on Tuesdays in Wimbledon. Seeking new members. Contact [email protected]; visit www.counsellingwimbledon.co.uk/#!peer- support/cr2d

If you are a BACP member, you can place a free entry on the TherapyToday.net noticeboard under one of four headings: supervision, placements, research or networking groups. Please email your wording (approximately 30 words) and BACP membership number to [email protected]

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