Page 31 Page Those tears tears Those

shouldn’t they shouldn’t should be mine, mine, should be The corrosive effects of coercive control of coercive effects The corrosive THEIR STRINGS? WHO’S PULLING PULLING WHO’S The voice of the counselling and psychotherapy profession and psychotherapy the counselling of The voice // Therapist and journalist – confronting the ethical challenges – confronting and journalist Therapist depth // relational at Working Emotional burnout – the cost of counselling help people with dementia? compassion // Can NOVEMBER 2017 | VOLUME 28 | ISSUE 9 28 | ISSUE VOLUME 2017 | NOVEMBER

THERAPY TODAY NOVEMBER 2017, VOLUME 28, ISSUE 9 Welcome

I first heard the term Editor’s note ‘compassion fatigue’ The United Nations has designated 25 November when used to explain International Day for the Elimination of Violence a dramatic drop in against Women. It also marks the start of a 16-day period of activism against all gender- charitable giving just based violence. We are all invited to ‘orange the after Live Aid. world’, using the colour of the UN campaign to Apparently, the public couldn’t symbolise a brighter future without violence. bear to look at any more footage of This campaign influenced our decision to the human fallout of famine, war and commission an article on coercive control for disease. Maybe they were self-caring? this month’s issue. Coercive control is a relatively Emotional burnout is particularly new crime, in terms of UK law, but an age-old difficult for therapists and still widely misunderstood, pernicious form because working with of violence, inflicted, largely, by men on women, feelings and caring for within intimate relationships. But it is also found in other arenas, and used others is why we chose by women too – in cults, for example, and in modern-day slavery, and, this profession in the indeed, in parent–child relationships, work situations and others where first place. As Dr Linda one person exerts power over others through emotional manipulation Dubrow-Marshall points and threat. As the authors of the article point out, such clients are very out in our cover feature, likely to come to counselling for some quite other reason, and it’s vital that ‘There can be shame in counsellors are alert to the potential for this to be an underlying issue. admitting that we are We have some very interesting letters this month in response to the experiencing compassion fatigue, articles in last month’s issue on the closure of the counselling courses but we are human, and we are not at the University of East Anglia and prescribed drug dependency. The protected from stress just because letters pages are your forum for engaging with issues that concern you we have therapeutic skills.’ and adding to the debates. I know a lot of discussion goes on outside the I too have felt this way. Now, if I look magazine, on Twitter and in Facebook groups, but do please write to us at my diary and have to steel myself as well. for the week ahead, I know I need to Catherine Jackson decrease my client hours when I can, Editor increase my self-care and take a break asap. And breathe... Rachel Shattock Dawson Consultant Editor ‘... an engaging read... thoughtful and well

CHARLIE BEST written... presented in a lively and attractive way’

Editor Catherine Jackson Disclaimer Views expressed in the journal Copyright Apart from fair dealing for the purposes e: [email protected] Therapy Today is published on behalf of the British Association and signed by a writer are the views of the of research or private study, or criticism or review, Consultant Editor Rachel Shattock Dawson for Counselling and Psychotherapy by Think, Capital House, writer, not necessarily those of Think, BACP or as permitted under the UK Copyright, Designs Reviews Editor John Daniel 25 Chapel Street, London NW1 5DH the contributor’s employer, unless specifically and Patents Act 1998, no part of this publication e: [email protected] t: 020 3771 7200 w: www.thinkpublishing.co.uk stated. Publication in this journal does not may be reproduced, stored or transmitted in any form by any means without the prior permission Printed by: Wyndeham Southernprint, Units 15-21, imply endorsement of the writer’s views Media Editor Bina Convey in writing of the publisher, or in accordance with e: [email protected] Factory Road, Upton Industrial Estate, Poole BH16 5SN by Think or BACP. Similarly, publication of advertisements and advertising material does the terms of licences issued by the Copyright Dilemmas Editor John Daniel ISSN: 1748-7846 not constitute endorsement by Think or BACP. Clearance Centre (CCC), the Copyright Licensing e: [email protected] Subscriptions Reasonable care has been taken to avoid errors, Agency (CLA), and other organisations authorised Group Art Director Jes Stanfield Annual UK subscription £76; overseas subscription £95 but no liability will be accepted for any errors by the publisher to administer reprographic Art Director George Walker (for 10 issues). Single issues £8.50 (UK) or £13.50 (overseas). that may occur. If you visit a website from a link reproduction rights. Individual and organisational in the journal, the BACP privacy policy does members of BACP may make photocopies for Sub-editor Justine Conway All BACP members receive a hard copy free of charge as part of their membership. not apply. We recommend that you examine teaching purposes free of charge, provided these Production Director Justin Masters t: 01455 883300 e: [email protected] privacy statements of any third-party websites copies are not for resale. Group Account Director Rachel Walder to understand their privacy procedures. © British Association for Counselling BACP and Psychotherapy Managing Director Polly Arnold BACP House, 15 St John’s Business Park, Lutterworth, Case studies All case studies in this Group Advertising Manager Adam Lloyds Leicestershire LE17 4HB journal, unless otherwise stated, are ABC total average net d: 020 3771 7203 m: 07725 485376 t: 01455 883300 e: [email protected] permissioned, disguised, adapted or circulation: 44,386

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THERAPY TODAY 3 NOVEMBER 2017 Contents November 2017

Here and now News 6 News feature 8 The month 12 Letters 16

The big issues What can I possibly achieve? 20 Sonia Khan describes the challenges and rewards of working with people with dementia When your life is not your own 24 Linda Dubrow-Marshall and Rod Dubrow-Marshall outline the corrosive effects of coercive control Meeting at relational depth 28 Mick Cooper asks if we are any closer to understanding relational depth On the sporting couch 34 20 Gary Bloom combines his roles of therapist NICK LOWNDES/IKON IMAGES LOWNDES/IKON NICK and journalist in his radio show ‘Here was a dignified woman in her early 80s, desperately Regulars Turning point 33 holding on to herself, camouflaging Wisdom from experience deficits of memory, bewildered and Research into practice 38 Liddy Carver highlights research on the challenges frustrated, struggling to understand facing university counselling services what was happening to her. In time, Dilemmas 40 The police want to see Ruth’s client records I answered my own question about Talking point 42 what I could achieve.’ What qualities do you seek in a supervisor? Self-care 44 Sonia Khan meets her first client with dementia, at the start of a journey of profound learning Lynne Barnett turns to photography for stress release Analyse me 74 Graham Music answers our questionnaire NOVEMBER 2017 | VOLUME 28 | ISSUE 9 THERAPY TODAY THERAPY

Those tears should be mine, shouldn’t they

e 31 The voice of the counselling and psychotherapy profession Your association From the Chair 45 BACP round-up 46 On the cover.. Classified, mini ads, recruitment, CPD 51 Unloving bonds What are the signs that WHO’S PULLING THEIR  RINGS?

a client may be subject to SSE VOLME 2 2017 NOVEMBER The corrosive eff ects of coercive control the corrosive effects of

coercive control? Working at relational depth // Therapist and journalist – confronting the ethical challenges Emotional burnout – the cost of compassion // Can counselling help people with dementia? Company limited by guarantee 2175320 Page 24 Registered in England & Wales. Registered Charity 298361 01 COVER-NOVv7-cj SM V1-cjf.indd 1 30/10/2017 10:27

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

THERAPY TODAY 5 NOVEMBER 2017 In the news

Our monthly digest of news, updates and events Gender identity concern Attempts to change people’s gender are indicators of a mental disorder’. It identity through psychological also commits the signatories to work interventions are unethical, potentially together to address the wider issues harmful and not supported by evidence, of raising public and professional leading psy-organisations and LGBTQI awareness of the risks of conversion groups have said. therapy, ensuring all new and existing The groups, including BACP, UKCP, therapists have training in these issues, Pink Therapy, the Association of Christian and ensuring that the research evidence Counsellors, the British Psychoanalytic relating to reparative therapy is regularly Council and the British Psychological monitored and reviewed. Society, have amended their original Andrew Reeves, Chair of BACP, said: Memorandum of Understanding (MoU) ‘BACP in no way supports or condones on conversion or reparative therapy the practice of conversion therapy and (November 2015), which referred only knows that the new memorandum will to sexual orientation. The revised MoU ensure individuals are protected from specifically includes gender identity. judgmental and uninformed therapy.’ It states that ‘neither sexual orientation The revised MoU can be downloaded nor gender identity in themselves from bit.ly/2zkSjL2

51% 49% 54% 87,000 of men would go of people who have of primary people used Scotland’s down the pub if they had cosmetic surgery schoolteachers don’t NHS 24 mental health wanted to talk to a say their decision feel adequately trained first-response telephone friend about a mental was influenced by to help a child with a and online support health problem social media mental health problem services last year bit.ly/2yze6kF bit.ly/2zA3Gzo bit.ly/2gN4Tff bit.ly/2yulYng

Mental health first aid campaign The Government has announced a new, £15 million programme to train one million people in England in ‘mental health first aid’ skills. The campaign will be designed and delivered by Public Health England, working with Mental Health First Aid England and other mental health organisations. The aim is to improve people’s personal resilience and give them the skills and confidence to recognise and respond to others when they have mental health problems. It will include an online learning module designed to improve the public’s knowledge, skills and confidence about mental health so they can assess their own mental wellbeing and learn techniques to reduce stress, as well as feel better equipped to support others. The campaign will launch next year and run for three years. bit.ly/2yu7vHT

THERAPY TODAY 6 NOVEMBER 2017 How do we know counselling works? NICE should be drawing on a wider range of evidence, in addition to randomised Doubts controlled trials (RCTs), to inform its guidelines, a paper about couple published in the BACP journal counselling Counselling and Psychotherapy Most couples don’t Bullying Research (CPR) says. think couple therapy Written by BACP researchers works, a new survey by and resilience Jo Pybis and Naomi Moller and the charity Tavistock Professor Michael Barkham Relationships has found. A new study has found that the harmful effects of bullying of the University of Sheffield, The YouGov survey of on children lessen over time, thanks to their own resilience. the paper criticises both the evidence and the methods over 2000 adults found The study used data on 11,108 children from the Twins Early that 64% of people in used by NICE to review its Development Study (TEDS), based at King’s College London, long-term, committed guideline for depression in relationships would which allowed researchers to separate out genetic and adults, which is currently out not seek help from a environmental influences. Children and their parents filled for consultation. couple counsellor if out questionnaires about peer bullying at ages 11 and 14, There is, they say, a lack their relationship was and about mental health difficulties at ages 11 and 16. of high-quality RCTs directly in difficulty. The researchers found that exposure to bullying causes comparing counselling with The most common anxiety, depression, hyperactivity and impulsivity, inattention and other treatments. They also reason, given by 43%, conduct problems at the time, and that anxiety can persist for at argue that NICE should draw was that they didn’t least two years. But, by five years, all these effects have stopped, more widely on evidence such as the wealth of data think that couple although 16-year-olds who have been bullied at age 11 remain therapy would work. on patient outcomes and more vulnerable to paranoia or cognitive disorganisation. However, 36% said experience collected by IAPT they would try it if they ‘While our findings show that being bullied leads to services, and on qualitative were provided with detrimental mental health outcomes, they also offer a message data from service users. evidence that it had the of hope. In addition to interventions aimed at stopping bullying The paper reviews the potential to improve from happening, we should also support children who have evidence for counselling for their relationship. been bullied by supporting resilience processes on their path to depression, using these wider ‘The idea that couple recovery,’ the study’s lead author, Dr Jean-Baptiste Pingault, said. data sources, and finds that it therapy doesn’t work bit.ly/2ybPQ60 is equally as effective as CBT. is simply not true – and bit.ly/2yvwXx7 the evidence is clear on this,’ Tavistock Relationships Chief Executive Andrew Depression in childhood Balfour said. Parents can have a very different perception of their Anna Feuchtwang, Chief Executive of the National ‘We need to start a children’s mental wellbeing to that of their children, Children’s Bureau, which jointly published the national conversation new research reveals. report, said: ‘Worryingly, there is evidence that about the importance Researchers from the UCL Institute of Education parents may be underestimating their daughters’ of getting help for our and the University of Liverpool analysed data from mental health needs. Conversely, parents may be couple relationships. the Millennium Cohort Study of 10,000 children picking up on symptoms in their sons that boys Many who need such born in 2000/01. Parents’ reports of their children’s don’t report themselves.’ help are not seeking it. emotional problems were roughly the same for boys The data also revealed clear links between family ‘The consequences and girls throughout childhood, increasing from income and depression, and differences between of this are far-reaching seven per cent of all children at age seven to 12% at ethnic groups. Children from better-off families were for the adult partners age 11. By age 14, 18% of girls were reported to have less likely to have depression at age 14. Girls from involved as well as emotional problems, compared with 12% of boys. At mixed and White ethnic backgrounds and boys from for their children and this age, the children were invited to self-report their mixed and other ethnic groups were more at risk of future generations.’ mental wellbeing, and 24% of girls reported symptoms depression; Black African girls and Bangladeshi and

SHUTTERSTOCK bit.ly/2yw1DP4 of depression, but only nine per cent of boys. Indian boys were least at risk. bit.ly/2hifDVJ

THERAPY TODAY 7 NOVEMBER 2017 Self-care

Burnout ...the high cost of caring? Burnout is an ever-present risk in the caring professions. Sally Brown talks to counsellors about their experiences, and how to avoid it

mma,* a London-based that the number of clients I take on can’t be tipped over into unbearable by just counsellor in private practice, be determined by finances,’ she says. one client presenting with particularly realised all was not well when she We may be mental health acute or distressing needs. Efound herself unable to make decisions. professionals, but counsellors don’t Jenner herself didn’t realise that ‘Even small, inconsequential decisions, always ‘walk the talk’, and it’s all too what she dismissed as ‘tiredness’ and like what to do at the weekend, began to easy to focus on improving our clients’ the effects of juggling full-time work feel overwhelming,’ she says. Qualified self-care and neglect our own. Even and family life were the warning signs for just six months, she decided to ‘dip with an awareness of compassion of burnout. ‘People started to bring her toe’ into private practice. ‘People fatigue and the impact of vicarious my attention to my memory and said it would take time for my caseload trauma, we can think ‘it won’t happen concentration problems. I was still to grow, which suited me,’ she says. to me’. ‘Counsellors find it hard to admit able to be very present for my clients, But, within weeks she had 16 clients when they are struggling. It’s similar but, outside the counselling room, and was feeling overwhelmed. to what I see in first responders and I couldn’t follow a conversation. It was ‘People would say, “You’re doing medical staff – there can be a shared disorientating, and I got very irritable great!” But it didn’t feel great. It felt too culture of being strong, here to help with my family and people close to much. I wish I’d been told to approach others,’ says Fiona Dunkley, BACP me. Then, when I was driving, I would it like running a marathon – you need to senior accredited counsellor and suddenly forget which pedal did build up to a large caseload, rather than trauma specialist. ‘We sacrifice our what. I saw my GP and ended up in aiming to get a full caseload straight self-care for the greater cause.’ an MRI scanner and being tested for away, because it is totally different to We can also fall into the trap of Alzheimer’s. Then, when everything any other job in terms of the emotional thinking that, because the lives of our was ruled out, it became clear I was and physical demands.’ clients are so awful, our needs pale by suffering from stress and burnout.’ Emma had what she calls a ‘mini- comparison, says Lisa Jenner, a BACP breakdown’, where she withdrew from accredited counsellor and supervisor, What is burnout? her social life and felt increasingly who also delivers training on preventing Burnout is a ‘syndrome of emotional anxious and fearful. She came close to vicarious trauma. ‘We can be blind to exhaustion, depersonalisation and giving up, but, after a planned holiday, the impact on ourselves until it’s almost reduced personal accomplishment put some changes in place, including too late. It’s often friends and family that can occur among individuals who reducing her client load and changing members who recognise that we are do “people-work”,’ explains Professor her working hours, which made it struggling before we do.’ Christina Maslach, the US psychologist possible to carry on. ‘It’s not easy, as it’s Nor is it necessarily about size of widely known for her pioneering my sole source of income, but I realised caseload; a manageable caseload can research in this field and co-creator of the Maslach Burnout Inventory.1 She first came across it in the late ‘People started to bring my attention to my memory 1970s, when she was an assistant and concentration problems. I was still able to be very professor at the University of California, Berkeley, and researching how people present for my clients, but, outside the counselling in the emergency services, hospitals room, I couldn’t follow a conversation. It was and psychiatric units responded to challenges at work. ‘I stumbled across disorientating, and I got very irritable with my it in the interviews I was doing. A family and people close to me’ pattern emerged – people talked about

THERAPY TODAY 8 NOVEMBER 2017 ‘If everyone else seems outwardly confident and competent, we look around and think, “I have to put on my happy face and not let anyone know I’m not doing as well”’

vicariously, you can find that you no longer have the capacity to absorb it in entertainment,’ says Dunkley. ‘I am very mindful of what I expose myself to in social media and TV. I am exposed to enough trauma in my work, so I have to watch what I absorb in my personal life. Trauma is very related to adrenaline, so you can become overloaded.’ For others, burnout shows up in the body – we find ourselves more prone to bugs and viruses, or physical symptoms. ‘We need to listen to our body as it holds a wealth of information,’ says Dunkley. ‘We might be telling ourselves to keep going, but our body will be telling feeling overwhelmed, emotionally that we are experiencing compassion us to slow down by creating physical and physically exhausted, and losing fatigue, but we are humans, and we are symptoms, aches and pains or illness.’ their sense of compassion. But when not protected from stress just because I first wrote an article about it, it was we have therapeutic skills,’ says Dr Linda The toxic environment for a magazine, not a journal, because Dubrow-Marshall, BACP-accredited But there is a danger in being too no journal was interested in it. They counsellor and lecturer in psychology prescriptive about ‘typical’ symptoms dismissed it as “pop psychology”. But at the University of Salford. ‘Admitting of burnout, and therefore medicalising that article got sacks of mail from people this means we can address these issues.’ the condition, believes Maslach. ‘That saying, “this is happening to me.” A lot Another insidious and undermining was never the aim of my research. of people had been struggling on, symptom is a sense of hopelessness What worries me about making it into thinking it was just them, and they about the efficacy of our work, says a “mental illness” is that it is essentially couldn’t let anyone know. If everyone Professor Thomas Skovholt, educational saying something about the individual else seems outwardly confident and psychologist at the University of – that they have a disease, they have a competent, we look around and think, Minnesota and author of The Resilient problem, so we have to fix the person. “I have to put on my happy face and Practitioner.2 ‘We can feel less intensity We should also be thinking about what not let anyone know I’m not doing as in offering hope for the demoralised is going on in the work environment. well.” But once we become more open client, and a loss of a sense of the Burnout is a regular, chronic, everyday to talking to each other, we realise we work being meaningful.’ experience at work that wears you away, aren’t the only one feeling this way.’ Other symptoms vary from individual so that you can’t deal with stressors as What differentiates burnout from to individual. I know I am becoming you would normally.’ exhaustion, depression or anxiety, is emotionally ‘knocked off balance’ by a Maslach’s research has identified often the most devastating symptom client’s material when I lose tolerance six factors that make burnout more for therapists – compassion fatigue: the for any other ‘drama’ outside the likely: work overload, lack of control, loss of a sense of caring about clients, counselling room, including plot lines insufficient rewards, breakdown of or feeling irritated by their problems. in TV programmes and films.‘ When you workplace community, absence of 1 GETTY IMAGES/ GARY WATERS GARY IMAGES/ GETTY ‘There can be shame in admitting have absorbed an amount of trauma fairness, and value conflict.

THERAPY TODAY 9 NOVEMBER 2017 Organisational conflict is another ‘Internal conflict, issues, says Dubrow-Marshall. ‘When risk factor, says Skovholt. ‘Internal my father died, I did not want to take on conflict, especially among senior especially among senior new clients who were coming to work on management, increases the risk of management, increases grief issues. Some family members were burnout. I have come across this even also demanding of me during that time, in senior therapists – we are supposed the risk of burnout. I have so I took a short break from working with to be experts on human development, come across this even in very demanding clients, which allowed and these people are fighting and me to recover and heal. I also undertook hating each other. That can be really senior therapists – we are personal therapy, and got outside input distressing for the counsellors they are supposed to be experts on when I was ready to return to a more managing and supervising. It’s also hard demanding and challenging practice.’ when your values don’t match those of human development, and the organisation you are working for. these people are fighting Protection and prevention Anything that takes away the meaning and hating each other... Babette Rothschild, in Help for the of the work or the sense of fairness or Helper,4 suggests varying the intensity justness increases the risk of burnout.’ It’s also hard when your of empathy in sessions as a protective For Helen,* it was a sense of not values don’t match those measure. Skovholt says counsellors being valued that undermined her should aim simply to be a ‘good- wellbeing when she was working as of the organisation you enough counsellor’, and know when a a counsellor for a national charity. ‘It are working for’ B+ effort is enough for a client, rather seems crazy now I look back on it, than A+. He says that experienced given that the charity was national and counsellors often operate with high profile, but I didn’t feel supported Grief and uncertainty ‘boundaried generosity’. ‘Being an or that the work I was doing was Aspects of the work itself can effective therapist requires boundaries, valued. As an organisation, there was also put the counsellor at risk – but also generosity and willingness an awareness of vicarious trauma, but notably, according to Skovholt, the to give only so much,’ he says. ‘It’s like nothing was put in place to prevent it. ‘accumulation of unresolved grief’. the advice about oxygen masks on an I didn’t have enough supervision and, ‘A therapist–client relationship is a airplane – you have to put on your own as I worked out in the field, I felt isolated human relationship. As therapists, we before you can help anyone else.’ from my colleagues. I also wasn’t paid are always being left by our clients,’ Maslach talks about the ‘detached very much, and that made me feel he says. ‘We have to let go of them, concern’ used by medical professionals unappreciated. But it was my first job but what do we do then? Do we think as a burnout defence. Of course, after qualifying, and I felt lucky to get it, about them? And we also have to detachment is more difficult for so I didn’t question the conditions. By keep up the capacity for new clients. therapists, for whom ‘putting ourselves the time I felt confident enough to think We have to keep making attachments into our clients’ shoes’ is core to our it wasn’t right, the environment had but we are always losing them.’ work. ‘You can work with “one foot in, undermined my resilience and I was Another key factor is feeling you one foot out”, rather than both feet in,’ finding it increasingly hard to deal with are not making a difference with says Dunkley. ‘With both feet in, you are clients’ material. I had nightmares about clients. ‘Burnout is related to unclear, too meshed with the client, and may not my clients, became exhausted, and disappointing outcomes. It’s hard to be the most effective in helping them.’ stopped eating and sleeping properly. sustain work where the results aren’t But it’s not easy. ‘I have experimented All I wanted to do outside of work was concrete,’ he says. Dr Els van Ooijen, with Rothschild’s “varying the intensity” zone out in front of the TV. In the end, supervisor, trauma specialist, and with clients and it just isn’t possible for I felt I had no choice but to leave.’ writer, agrees that it’s important to me,’ says Jenner. ‘I can’t focus on the Skovholt has also explored this, monitor your sense of ‘doing a good client and also hold something back with his colleague, Michael Helge job’. She says: ‘Working outside of your for my own self-care. In the past, I have Ronnestad, in their book, The experience and capability is extremely got over-involved; I’ve followed clients’ Developing Practitioner.3 They describe undermining. But, in organisations, court cases to the point where I felt how newly qualified practitioners counsellors can be in a situation where like I was also going through it with in relationship-intense professions this feels unavoidable.’ the client. I no longer do that. But can easily become overwhelmed by There is also the ever-present element I’ve realised I can’t control my level the emotional demands of the work, of anxious uncertainty from not knowing of empathy, so my self-care needs to especially in the early weeks and what work with a new client will involve. focus on what I do after sessions.’ months, and can be driven to take It can be particularly difficult if we have ‘Care for self’ is one of six core an ‘early exit’, although most adjust personal issues that are causing us principles that underpin our work and continue in their career. distress when clients present with similar as counsellors; ‘resilience’ is one of

THERAPY TODAY 10 NOVEMBER 2017 Self-care

the ‘personal moral qualities’ we are Skovholt similarly sees value in rituals. advised to aspire to, defined as ‘the Sally Brown He says he sometimes gets home from About the author capacity to work with the client’s seeing several clients in a row in a state concerns without being personally Sally Brown is a of what he calls ‘emotional depletion’, diminished’ in the BACP Ethical counsellor and coach unable to think, listen or talk. ‘It’s a Framework. As Professor Tim Bond, in private practice danger for the counsellor’s personal (therapythatworks.co.uk), author of the framework points and family life. Rituals can help with a freelance journalist, out: ‘Taking care of ourselves as and Executive Specialist the transition from counselling work practitioners matters to our clients. for Communication to personal life.’ They need to know that we are for BACP Coaching. For Jenner, a key change was sufficiently resilient to be able to work scheduling longer gaps between with them and to be able to withstand client sessions. ‘I make sure I do the challenges of that work.’ risk of burnout in the future, including something physical in the break, such Effective supervision plays a key part, reducing her counselling days. ‘My as stretching, or walking outside. It’s says van Ooijen. ‘Supervisors need to get sabbatical reaffirmed that I loved being such a simple change but it makes to know their supervisee well enough a counsellor, and I wanted to remain a significant difference.’ Dubrow-Marshall so that they can tell when they are not counsellor, but doing it full-time wasn’t also suggests paying attention to the themselves. I spend some time with sustainable for me in the long term,’ scheduling of clients: ‘I used to keep supervisees at the start of the session she says. ‘I now see clients on two Monday mornings free for my most checking that they are OK. You need to days a week, and focus on training demanding clients – usually the least develop a working relationship so they and writing on the others, which affect personally motivated to change or the feel they can discuss honestly with you me in a different way.’ most disturbed or narcissistic ones – as what is going on.’ Multiple roles can give a sense of I had more energy after the weekend. Independent supervision can be perspective, agrees Skovholt. ‘Over the I sometimes saw these clients one particularly important for those working years I have thrived on doing teaching, after the other, because I got into the in an organisation, she believes. ‘An supervision, therapy, research, and therapeutic space I needed to be in independent supervisor is there as a writing. But it doesn’t work for everyone in order to work effectively with them.’ check that your supervisee is not put – for some, it just adds to their sense The most protective factor of all, into a position where they are working of being overwhelmed.’ says Maslach, from her four decades outside their level of experience and We also need to give some thought of research, is something that competence. That is where the Ethical to what we do in our leisure time, he counsellors tend to be good at: human Framework is helpful. I would advise believes. ‘In my research, one of the relationships. ‘Research about work and counsellors to keep a copy with them things that has helped protect people psychology for decades has shown that at work and draw their employer’s from burnout is an element of “vitality” we are better able as human beings attention to it when necessary. We in their lives – having something in to live life, do well and cope, and be also need to encourage counsellors their personal life that really gives generally healthy if we have good to do appropriate CPD, particularly in them a sense of pleasure, energy and relationships with other people. The areas where they feel under-confident. high satisfaction. We are dealing with more people we have who are fun to It helps them have confidence in distressing, difficult things a lot of the be with, teach us, and support us, the themselves by developing their own time, so we need a contrast to that in better off we are. It’s about keeping reflective and critical thinking skills.’ our life, and for that to be ongoing. yourself grounded in the everyday and After taking a four-month sabbatical, For one practitioner I talked to, it was knowing you have people around who Jenner made changes to reduce the absorbing herself in weaving.’ have your back.’ Dunkley recommends using a ‘ritual’ to ground yourself after a difficult ‘You need to find a way to session. ‘You need to find a way to REFERENCES symbolically shake off the symbolically shake off the energy 1. Maslach C. The cost of caring. Los Altos: that you have taken into your body. Major Books; 2015. energy that you have taken Sometimes I mindfully wash my hands, 2. Skovholt TM. The resilient practitioner: burnout prevention and self-care strategies into your body. Sometimes or do a simple breathing exercise, or for counselors, therapists, teachers, and health some yoga moves. Another therapist professionals (3rd ed). New York/London: I mindfully wash my I know uses juggling balls. If you don’t Routledge; 2016. 3. Ronnestad MH, Skovholt TM. The Developing hands, or do a simple get rid of the energy, you risk bringing Practitioner. New York/London: Routledge; 2012. it into the next session, and then taking 4. Rothschild B. Help for the helper: the breathing exercise, or psychophysiology of compassion fatigue it home with you at the end of the day, and vicarious trauma. New York: WW Norton some yoga moves’ which can spill into your personal life.’ & Co; 2006. *SOMEANONYMOUS. BE TO PREFERRED CONTRIBUTORS

THERAPY TODAY 11 NOVEMBER 2017 The month

nominees have been shortlisted for this year’s Mind Media Awards – the winners are announced this 53 month tinyurl.com/y9cceda9

Tune in Radio A dose of nature Depression narrows and internalises our view of the world around us. When we are outside, in a natural environment, we immediately widen our peripheral vision, and the awakening of other senses in response to sounds and temperature broadens our horizons still further. Spending time in a natural environment is becoming widely recognised as an essential aspect of recovery from mental ill health. Isabel Hardman, Assistant Editor of The Spectator, talks to psychiatrist Dr Alan Kellas about her experience of Theatre trauma-based anxiety and depression, and how important Barber Shop a dose of nature can be. Isabel Hardman on Nature and Chronicles Depression aired on BBC Radio 4 in September and is A scheme to tackle high still available on BBC iPlayer. tinyurl.com/ybxwzl2r suicide rates among black Film men by training barbers in basic counselling skills Film WONDER failed to secure funding. August Pullman is a But it did spark playwright The Work 10-year-old boy with facial Inua Ellams to capture the disfigurement who is starting role that the barber shop Rarely has group therapy mainstream school for the has played for generations been documented as first time. In an uplifting tale in the lives of African men. powerfully as it is in of difference and diversity, He spoke with men in The Work, which follows ‘Auggie’, played by Jacob barbershops in six cities a group of prisoners Tremblay, meets bullies and across the world – London serving time in northern makes friends in a film that (Peckham), Johannesburg, California’s maximum- makes a plea for acceptance, Harare, Kampala, Lagos security Folsom Prison. compassion and recognition and Accra – and found Taking part in a four-day of inner beauty. Based on common threads in all therapy programme, the bestselling novel by their tales: men working alongside three RJ Palacio, and co-starring away from their homes; volunteer civilians, Julia Roberts and Owen men cut off from their the men endure the Wilson, the film depicts how fathers; men in search of raw and revealing process of confronting their pain. The difficult it is for anyone who companionship. Barber documentary film explores how hatred is both externalised is in any way different to fit in Shop Chronicles returns and internalised in men who have spent a lifetime avoiding with the standard norm, and to the National Theatre in and repressing their emotions. Intense and moving, it gives challenges us to question London on 20 November a glimpse of what rehabilitation looks like when therapy how we support and make following a successful is given a chance. The Work had a limited screening room for physical difference. UK tour. in cinemas in September and is currently available to Wonder is on general release tinyurl.com/ycgx9f4n download from several online stores. from 1 December.

THERAPY TODAY 12 NOVEMBER 2017 Know of an event that would interest Therapy Today readers? Email media@ thinkpublishing.co.uk

Theatre A Christmas Carol Dickens’ festive tale of

BBC Don’t redemption and compassion miss rings many bells with Television the therapeutic process: Podcast confronting the truth, How to get angry Overshadowed encouraging transparency, The workplace is a Friendships can be intense during teenage years, but what if motivating change, and hotbed of simmering your new ‘bestie’ also happens to be your eating disorder? maybe a spiritual awakening anger and frustration, Vlogger Imogene posts videos of her life that chart how a to boot. You could say but expressing these sparky, outgoing teenager gets caught up in an escalating, miserly Ebenezer Scrooge emotions can lose you destructive, internal battle with her eating disorder, manages to complete the your job. What to do? personified in Caol, who becomes ever-more present and equivalent of a 12-step Surviving Work is a influential in this innovative and compelling drama. Irish recovery programme in website offering ‘helpful writer and performer Eva O’Connor (who plays the eating the space of one night. stuff for human beings’ – disorder) based the series on her own experience and her This new adaptation of A for healthcare and other award-winning play of the same title. Overshadowed is Christmas Carol, written by workers trying, literally, to available on BBC iPlayer. tinyurl.com/y8xm9eh9 David Edgar for the Royal survive work. This three- Shakespeare Company, stars minute podcast, How to Phil Davis and runs at The Get Very Angry, offers a Royal Shakespeare Theatre, humorous and healthy Stratford-Upon-Avon, until take on handling anger Exhibition 4 February 2018. at work by showing it as tinyurl.com/y77apejt a powerful motivator, BRUCE NAUMAN rather than something to The darker side of human nature is always centre be quashed. There are stage in Bruce Nauman’s art, where deep-seated useful tips on how to let fears, compulsions and our potential for violence it all out in a safe place. are recurring themes. Tate Modern is showcasing a tinyurl.com/yahmsze2 collection of some of the influential American artist’s best-known work, in which he explores the power and nuance of language and communications through video, performance and neon pieces. Amusing and unnerving, the video works include Raw Material Washing Hands (1996) and Violent Incident (1986), where a disastrous and disturbing dinner party scene is played across 12 monitors. Bruce Nauman’s work can be seen in the Artist Rooms space at Tate Modern, London until July 2018. tinyurl.com/yc79nevf

THERAPY TODAY 13 NOVEMBER 2017 The month

Read a new book worth reviewing? Email [email protected]

Reviews

Supervision in Psychoanalysis and The Political Self: understanding the Mindfulness-Informed Relational Psychotherapy: a case study and social context for mental illness Psychotherapy and Psychoanalysis: clinical guide Rod Tweedy (ed) (Karnac Books, £28.99) inquiring deeply Diana Shmukler (Routledge, £30.99) This fascinating collection of essays Marjorie Schuman (Routledge, £30.99) The subtitle accurately has been compiled at just the right Here, Marjorie Schuman attempts describes what is on time, as more clients (consciously or to integrate the lessons of eastern offer here: a single case unconsciously) bring to therapy their mindfulness practice with western study through which anxieties, fears and stresses about how relational psychotherapy under the Shmukler explores the external world is affecting their banner of ‘inquiring deeply’. the role of supervision personal lives and internal worlds. The book is strong as an introduction while working with Contributors, including David Smail, to mindfulness. Schuman offers some one client, Jane, also Sue Gerhardt, Nick Duffell and Nick useful techniques for transforming a psychotherapist. The Totton, cover far-reaching topics, such difficulties and a number of ways book chronicles the as the social context of individual of re-approaching traditional process and how the work finished, distress, the ‘selfish society’, boarding psychotherapeutic practice. However, and ends by considering the theory school survivors, pornography and I found myself feeling restless. The that supported the therapy. sexual addiction. Each chapter has the book is light on psychoanalytical theory Patrick Casement, who supervised same message at its core: that both our and doesn’t do justice to previous some of the more difficult aspects of own and our clients’ mental health and crossovers between approaches. I the work, provides the foreword, and wellbeing are constantly being informed began to feel that, in seeking to apply Andrew Samuels’ afterword offers and shaped by the external (social, ‘inquiring deeply’ as an integrative a sensitive reflection on the work, political and economic) world. solution, I’m already practising the including the important point that it is For me, the book’s only weakness attitudes Schuman identifies, while possible to be ‘warm and related – and is its tone, which can remaining in traditional also boundaried, reflective and kind’. be heavy-going. It is an western modes. At this Shmukler’s approach allows the important text, but it is point, the case studies reader to experience moment by not an accessible read. lacked the depth of moment what was occurring from It is also on the expensive insight that I needed inside, and sometimes outside, the side for a paperback. to convince me that therapeutic relationship – one which Claire Kelly, integrative integration was necessary. was often under threat of disintegrating psychotherapist and Christopher Kidd, altogether. Both experienced and counsellor in private counsellor in novice practitioners have much to practice in Manchester private practice gain from this fascinating, insightful account, particularly as it explores the struggles of the therapeutic endeavour Coffee with Freud and the challenges in finding the most Brett Kahr (Karnac Books, £14.99) appropriate supervisory support. Kahr has written widely on the history of psychoanalysis and its modern-day practice The theory is brought to life here and has an encyclopaedic knowledge of Freud, for whom he has great respect in a way that is both challenging and and admiration. What makes this book so riveting, as well as satisfying. Shmukler bravely and openly entertaining, is the very human portrait it presents of Freud at explores the nooks and crannies of what ease, discussing his achievements in the cosy setting of the Café seems to have been a challenging and Landtmann, but quickly becoming much less comfortable and co- troubling therapeutic relationship, and operative when he suspects his own unconscious is under scrutiny. provides wider insights and learning Kahr leaves the reader in no doubt about the huge contribution for other practitioners about the tension psychoanalysis made to the understanding and treatment of held between difficulties and potential people who would previously have been shut away in asylums, in our day-to-day (and, in this case, or subjected to misguided and often cruel procedures by medical year-to-year) work. physicians keen to demonstrate their patent cures. But how does Steven Wells, psychotherapist, simply having a conversation about one’s symptoms alleviate supervisor and trainer in private them? The answer is that, in therapy, the conversations are of a practice in south London, and a kind that isn’t possible elsewhere. doctoral candidate Jonathan Sunley, psychodynamic psychotherapist/counsellor

THERAPY TODAY 14 NOVEMBER 2017 First lines ‘I didn’t know about the loaded gun hidden under his shirt, but the instant Captain Jason Fuller walked into my El Paso office on a summer day in 1980, my gut tightened and the back of my neck stung. War had taught me to sense danger even before I could explain why I was afraid.’ From The Choice by Edith Eger (Rider, £14,99)

Previews A book that shaped me Anxiously Attached: understanding and How to Understand Your Gender: The Hobbit working with preoccupied attachment a practical guide for exploring Linda Cundy (ed) (Karnac Books, £14.99) who you are JRR Tolkein (Houghton Mifflin) Cundy’s contributors address the Alex Iantaffi and Meg-John Barker Although my mum and I are chalk origins of anxious attachment in parent- (Jessica Kingsley Publishers, £14.99) and cheese, we share a love of infant relationships; research about This down-to-earth guide explores reading. This is the only novel developmental aspects; typical features gender from its biology to its role in she ever insisted on reading to and defences in adults, and our relationships and me, and I remember lying on the how these may present in interactions with family, psychotherapy. Enmeshed friends, partners and lounge carpet, night after night, dynamics in adult strangers. It includes being pulled into Tolkein’s world. relationships, including the activities and reflection I remember the contrast between therapeutic relationship, points designed to help the safety of Bilbo’s cosy home, are also highlighted – ones people of all genders and how one painful exploit leads where threat of separation engage with gender to another for him. and loss activate intense diversity in relation to their attachment-seeking. own lived experiences. I see parallels in my own life and in my work with clients, and often refer to the choices Bilbo Pluralistic Therapy: distinctive features The Guide to Interpersonal has to make – returning to safe John McLeod Psychotherapy familiarity, or taking a more risky (Routledge, £14,99) Myrna M Weissman, John C Markowitz, path for the greater good. Pluralistic therapy is a flexible, Gerald L Klerman (Oxford University integrative approach to counselling Press, £28.99) Jo Bisseker Barr, counsellor and psychotherapy that has also found This updated and expanded edition in private practice in the applications in fields such as mental provides a definitive, practical guide New Forest and writing for health, life coaching and careers to interpersonal psychotherapy (IPT). wellbeing practitioner at guidance. McLeod is one Written by the originators www.writeyourmind.co.uk of its co-founders. In of the approach, it features this book, he offers an clinical examples and introduction to what is sample therapist scripts distinctive about this to explain how to use increasingly popular IPT to treat depression, What book contributed method and describes 15 bipolar disorder, anxiety to making you into the theoretical features and disorders, eating disorders, person you are? 15 practical techniques post-traumatic stress, Email a few sentences to for practitioners. and other disorders. [email protected]

THERAPY TODAY 15 NOVEMBER 2017 We very much welcome your views, but please try to Letters keep your letters shorter than 500 words – and we Send your letters to the Editor may need to cut them at [email protected] sometimes, to fit in as many as we can

Integrative or integration? week, but we need to be aware that we can, ‘Weak moral relativism’ and often do, become very important to our I am disappointed by the increase in the clients. It is not patronising or rescuing to I read Nick Davis’ letter, ‘Shared despair’, in number of therapists describing themselves be mindful of how our clients perceive our your letters page (September 2017) with a as ‘integrative’, without having an integrative breaks (the subject of Talking Point in visceral sense of shock, especially after having framework with which to practise from. July’s Therapy Today). On the contrary, it is read the personal account by a counsellor As an integrative therapist myself, sensitive, thoughtful and empathic, and a of losing her beloved son in the Manchester I often encounter fellow therapists who bedrock of safe therapeutic practice. Arena bombing in the same issue (‘Picking up describe themselves in this way, having Frances Bernstein MBACP (Accred), the pieces’). trained perhaps in person-centred UKCP (Reg), Cert Sup Nick Davis refers to the editorial by counselling, and then gone on to develop an Rachel Shattock Dawson in the June issue, interest in, say, CBT. Without any integrative where she writes about ‘senseless acts’ of framework to base their approach on, it is Strangled by protocols terrorism. He appears to imply that they do not a true integrative approach; it is ‘technical make sense if we view them ‘systemically’ and eclecticism’ or ‘assimilative integration’. I would like wholeheartedly to endorse ‘see that it is the bombers who are in deepest Integrative therapy has its own framework, the sentiments expressed by Mark Emery despair and enraged beyond endurance at such as Clarkson’s 5 Relationship Model, or in these pages (‘Bureaucratic exercise’, the injustice and structural violence that is the Faris and van Ooijen Relational-Integrative Letters, September 2017). perpetrated daily’ by our foreign policy. This, Model (RIM). If we are to practise safely I acknowledge that finding a way to of course, may be so, but it is hard to see how and ethically within the modalities we have regulate our work and ensure a good-quality acknowledging this despair through ‘holding adopted, the term ‘integrative’ should be service is challenging, but the lack of trust both sides of the relationship’ would help reserved for this description only, rather and apparent expectation that we are doing bombing innocent people make sense to us than to describe ‘cherry-picking’ from other wrong and need bringing to heel are in the west, even though it makes sense to theories and models. increasingly dispiriting. those who do it. Rather, I would argue, it just Linda Harris MSc, Reg MBACP This seems to be a universal shift in human leaves us embracing a weak moral relativism. Counsellor and psychotherapist relations. I have been working for the NHS Of course, we can (and must) condemn the for over 20 years, and have witnessed the slaughter of innocent people in Manchester increase in bureaucracy and reliance on and place a very large full stop after it. We Fostering dependency protocols and procedures to the point where might then talk about the rights and wrongs they are now strangling almost all endeavours, of UK foreign policy in the Middle East. I read Stephen Harley-Sloman’s letter creativity and compassion. Although this Responding in this way does not (‘Patronising to clients’, September 2017) is usually attributed to financial issues, mean that some deaths matter more than with concern. It seems to me that his letter I experience it as mostly fear-based, and others – although I would argue that some exemplifies a blind spot that I have come see its echo in BACP. deaths do matter more to us when they across before in some counsellors, who Kim Pearl, Reg MBACP (Snr Accred) involve those we love. Rather, it suggests believe that if they promote their clients’ Middlesex that, in the immediate moment, the shock autonomy and do not foster dependency, and horror of the Manchester bomb then dependency will not happen. demands an emotional reaction and not a The reality is very different for many of We may be present for just political analysis, which Nick Davis offers our clients. Dependency develops because 50 minutes of a client’s by suggesting reading matter to help us of early life experiences and inner-world week, but... we can, and understand the ‘deeper context’. configurations. It may be more likely to often do, become very Finally, I would like to point out that develop in a relationship-based therapy, important to our clients. It is our ‘drones’ are not ‘threatening death but may be present in any therapeutic not patronising or rescuing continuously above’ many of these bombers’ relationship, within which there is always to be mindful of how our homes, as many of these bombers are born a potential for a power imbalance. We may clients perceive our breaks and bred in the places they bomb. be present for just 50 minutes of a client’s Stella Williams MBACP

THERAPY TODAY 16 NOVEMBER 2017 To the Editor

Dangers of prescribed meds It is the final insult to be told by your GP that the symptoms... The important role that counsellors and therapists are playing in treating are nothing to do with the drug people whose lives and health have been damaged by long-term use of at all antidepressants and benzos is becoming more and more apparent. You, as a profession, are the impartial, unbiased voice that can speak up and out on our behalf. As Sally Brown stated in the first paragraph of her excellent article (‘What the doctor ordered’, September 2017): ‘The unmedicated client is becoming a rarity.’ I imagine that there is another cohort of clients that you either already on meds or having been can also identify, who are, like me, some years away from long-term use of an offered them, and now it is the exception antidepressant but whose health has been damaged, first by the trauma of when they have either said no or their GP drug withdrawal, and second by the ongoing, constant hyper-arousal due to has recommended talking therapy. The unbalanced nervous and digestive systems. article was not only extremely useful, but The reason that your voices are so important to ring out on our behalf is that also very timely indeed. the NHS – the GPs, psychiatrists and specialist/consultants, to whom we turn to tell our stories – constantly deny our truth and reality. They are often the Ben Amponsah MBACP (Accred) original prescribers and do not want to know that we have been harmed by Psychotherapist/consultant/ the drugs. It is the final insult to be told by your GP that the symptoms that you coach/trainer are suffering, which bear no resemblance to anything you presented with when first prescribed the drug, are nothing to do with the drug at all but ‘remission’, ‘the return of your original problem’, ‘your anxiety’ or ‘medically unexplained Drop the disorder symptoms’ (MUS). We desperately need your support, particularly as the new focus on mental Responding to Sally Brown’s feature (‘What health will inevitably lead to the greater prescribing of antidepressants, unless the doctor ordered’, September 2017), I just something fundamental changes in the current system. We need you to speak want to update readers on our campaign, out about your experiences of working with clients like us. Sally Brown’s article asks specifically ‘What can therapists do?’ She mentions ‘A Disorder for Everyone!’ (AD4E), which the work being done by the All Party Parliamentary Group on Prescribed featured in the April issue of Therapy Today Drug Dependence, with the BMA, to have the problem of dependence (‘Just listen to their stories’). Since the first recognised and appropriately supported and funded. In tandem with those event, in Birmingham a year ago, we have initiatives, Marion Brown and the Recovery and Renewal independent held others in Bristol, Edinburgh and London, self-help patient group in Scotland have raised a petition with the Scottish with attendances of 70 to over 100 people Government (now closed). I have also raised a similar petition calling on each time. the Welsh Assembly Government to take action to recognise and support The events provide a space to critique individuals affected and harmed by prescribed drug dependence and the biomedical model and the narrative withdrawal. The petition is at http://tinyurl.com/y8qyrqtq and open until of ‘diagnosis and disorder’, and explore 28 November, so please take a moment to sign your name. Your support is a simple thing but would help us enormously. James Moore’s campaign alternatives that can help people make sense for tapering kits is mentioned in the article, with a link to his webpage of their experiences, however extreme. A (www.jfmoore.co.uk). participant at the Birmingham event told Help us get our voices heard by raising yours and making a difference. us, ‘Now I feel empowered to offer the Stevie Lewis (Mrs) people I work with the option at least to Monmouthshire explore alternative ways of understanding their pain.’ Contributors have included poets, academics, artists, researchers, activists, filmmakers, experts by experience, Pernicious over-prescribing in helping them through their own mental therapeutic professionals and more. health issues. There has even been talk of We have more events booked for Liverpool I felt compelled to respond to your cover ‘pill shaming’. (7 December), Manchester (8 December) and news feature (‘What the doctor ordered’, I fundamentally disagree with this stance. Brighton (16 February). You can find out more September 2017) about the over-prescription I am a counselling psychologist and we, at www.adisorder4everyone.com, follow us of drugs to clients, many of whom would as a professional body, have long been on Twitter @dropthedisorder and join in the have been better served by being directed to worried about the pernicious effect that discussions on our Facebook group, talking therapies. This seems to have elicited over-prescribing is having both on clients’ ‘Drop the disorder!’. some rather angry push-back on social media ability to work through the issues and also Jo Watson UKCP (Reg) from therapists who feel that meds are very on the therapy itself. Over the past 15 years, www.adisorder4everyone.com useful and have been instrumental, for them, more and more of my new clients arrive www.jowatsonpsychotherapy.co.uk

THERAPY TODAY 17 NOVEMBER 2017 As individual practitioners, we can express our dismay and anger at the erosion of relationship-based therapies and the associated ethical values that form the basis of our work, but we need a strong collective voice

Coming off meds It seems clear that current policy makers courses across the professional education have little understanding of, or interest in, landscape. I invite students, tutors, I read ‘What the doctor ordered’ (September non-instrumental approaches to human researchers and practitioners to reflect on 2017) and want to highlight to readers the distress. As individual practitioners, we can Desmond Tutu’s words: ‘If you see an elephant comingoff.com website, which contains useful express our dismay and anger at the erosion sitting on a mouse and you say you’re neutral, information for people interested in learning of relationship-based therapies and the you have taken the side of the elephant.’ more about coming off psychiatric medication associated ethical values that form the basis How can we hold open a dialogical space in a careful, planned way. of our work, but we need a strong collective for critical thinking, and how can we help The site includes topics such as alternatives voice. The Psychotherapy & Counselling promote Rogerian qualities of difference to medication, a harm reduction guide and Union calls on BACP and the other and core conditions in our society? Can we real people’s stories. Professor Phil Thomas of professional bodies to take a more outspoken come together to lobby for more optimistic the University of Central Lancashire, a former and active stance in defending counselling approaches to health and wellbeing? consultant psychiatrist, is among the website’s and psychotherapy, in academia, in training Dr Salma Siddique UKCP (Reg) advisers, and it was recommended in a 2008 institutions and in the wider areas of social Psychotherapist and supervisor Department of Health publication, Medicines policy. This is both an ethical responsibility Management: Everybody’s Business. and a practical necessity for the future of Zoe Gilbert MBACP (Accred) our profession. Interpreters’ role Richard Bagnall-Oakeley UKCP (Reg), MBACP Prossy Kakooza’s account (‘Treat us like Erosion of relationship-based Integrative adult and people’, October 2017) of her experiences therapies child psychotherapist, of counselling, mental health services and Chair, Psychotherapy and Counselling interpreters did not shock me. I know from Andy Rogers’ reflections (‘Standing on the Union (http://pandcunion.ning.com/) our clients that these experiences are sadly edge’, September 2017) on the University of too common. East Anglia’s (UEA) short-sighted closures of It is not always the case. I have also its internationally renowned person-centred REFERENCES heard about much better experiences for training courses highlight the threat to our 1. Wampold BE, Imel ZE. The great psychotherapy clients. I have seen how our interpreters at profession posed by neoliberal ideology and debate (2nd ed). New York/Hove: Routledge; 2015 Mothertongue can make a critical difference policies. We are told that the ‘manualised, 2. Shehzad A, Rhodes L, Moreea O et al. How to clients’ lives by the way they receive and durable is the effect of low intensity CBT for technocratic and instrumental’ approaches depression and anxiety? Remission and relapse relay distressing stories. Yet they have few that pertain at UEA are ‘evidence-based in a longitudinal cohort study. Behaviour Research outlets for the emotional impact this can practice’, yet research consistently fails to and Therapy 2017; 94 (July): 1–8. have on them. Supervision groups provide show the superiority of one therapeutic a much-needed and appreciated space for modality over others.1 We need dialogue interpreters to share their dilemmas and Recent research shows very poor long-term solutions, and be supported and challenged outcomes for clients of IAPT services,2 yet the I appreciated Andy Rogers’ article (‘Standing so that they can help their clients in the best expansion of short-term, manualised models on the edge’, September 2017) expressing way possible. continues, seemingly driven by ideology his thoughts about the closure of UEA’s We have recently published a second rather than by ‘evidence’. I, and many others, person-centred counselling programme. volume of stories by interpreters from feel horrified at the ongoing, unjustified It seems even more important to promote across the world, In More Words, and have attrition of relationship-based therapies, the humanistic talking therapies at this time made a six-minute film about interpreters’ both in the workplace and in training. when so many are feeling anxiety and distress, experiences of supervision, which can be The Psychotherapy & Counselling Union rather than the perceived ‘quick fix’ of CBT viewed at www.mothertongue.org.uk played a central and recognised role in and/or medication. Dr Beverley Costa DPsych, UKCP (Reg) mobilising opposition to the closures at I am concerned about the lack of dialogue Psychotherapist, Chief Executive UEA, as we did previously (and more within the counselling community on the Officer and Clinical Director, successfully) at Strathclyde University. range and reconfiguration of counselling Mothertongue

THERAPY TODAY 18 NOVEMBER 2017 To the Editor

Suicidal effects of drugs Men and suicide What happens to the client who has been taken on by the agency or private practitioner I am writing to comment on the news feature Following on from the June article on muscle and is then discovered to have a serious on prescribed drug side effects (‘What the and masculinity, ‘Muscle-bound man’, it was mental health issue? Is he or she to be ‘cast doctor ordered’, September 2017), and good to see Phil Mitchell’s article ‘Boys can off’ or ‘abandoned’? The reason given for this how research has shown that 60% of those be victims too’ in the October issue. Phil action is often that it is unethical to work with prescribed antidepressants report side effects, highlights the male fear of his masculinity anyone beyond one’s level of competence. such as impact on sex life, work and social life. being questioned, and therefore keeping quiet This raises many other questions. Those I have always been sceptical of such about sexual abuse. This article is set in the seeking therapy often cannot afford to go to research, because these are the very effects of context of a changing western world where a highly qualified practitioner in the private depression that the medication is attempting male and female roles are much less clearly sector, but they may be greatly helped by an to alleviate, and we know that this medication defined, and yet the ancient, traditional role agency volunteer working in a humanistic is hit-and-miss in terms of benefit. I have of man as provider and protector is still deep way, backed up with effective supervision. not been able to examine the methodology in the psyche of many men. If a man admits How would it feel to be told one is ‘too of this research to understand how they to any kind of weakness, he fears ridicule. difficult’ to be a client? The suicidal person have controlled for the underlying effects of It was sobering to see the national statistics is likely already to believe that they are depression in their study, but I wanted to share on male suicide highlighted in the October a burden to others and that it would be a more sinister and significant side effect of news pages – ‘Of the 6,188 suicides registered better for everyone if they were dead. antidepressants that I believe affects a much in the UK in 2015, three quarters were male’, One of the EAPs for whom I work seems smaller percentage, but has a far higher impact. and shocking to read Phil’s closing comment to me to adopt a refreshingly clear position I experienced this close up when a friend that, for some men, ‘death can be preferable on this issue. On a sheet given to every took just one tablet during a period of to being seen as less of a man’. client, they state that they would not break postnatal depression. They said it was like Thanks for highlighting male needs in confidentiality in the event of self-harm, and ‘the wheels were coming off’ and they felt a journal supporting a disproportionate would ‘not act on a client’s behalf or intervene completely out of control. Needless to say, number of female to male counsellors, Phil. when there is a threat of suicide’. The person they didn’t take any more, and recovered back Jennie Cummings-Knight is given responsibility for him or herself, to their previous state in about 24 hours, but MBACP (Reg) but within the context of at least short-term it was a profoundly destabilising experience, Writer/lecturer/counsellor therapy. I do not wish to convey that I think where they felt suicidal and without the www.goldenleafcounselling.com all would-be clients can be suitably held normal ‘brakes’ that usually kick in with such within the framework of one session a week. thoughts. Following this, I did a bit of internet However, I do think that there is too much research. There are several well-publicised Duty of care fear of recrimination and that the therapist or cases of suicide in similar circumstances, agency may have swung too far in the attempt and commentary from other professionals. Therapy today takes place within the context to keep themselves safe. Is this risk-averse The worrying part is that, in some cases, GPs of the perceived need to safeguard against attitude really in the interest of the client? will just prescribe a higher dose, rather than undesirable outcomes. Many agencies and Elizabeth Garsten MBACP recognise the situation, which I can only practitioners have become risk averse. (Snr Accred) imagine could have dire consequences. ‘Difficult’ clients are increasingly excluded. Private practitioner Although I believe this adverse reaction Is this compatible with the ethical ‘duty of only affects a small proportion of those taking care’? What happens to such clients? this medication, the impact is enormous A person with suicidal ideation, for Many agencies and and one that seems to be not well known. example, may well be weeded out at the practitioners have become It took a personal experience to jolt me out assessment stage. Good reasons can always be risk averse. ‘Difficult’ clients of my complacency. found for such a course of action. The canny are increasingly excluded. Justin Havens FdA BA BEng MSc would-be client may be aware of the risk of Is this compatible with the MBACP (Accred) stating his or her true level of distress, and ethical ‘duty of care’? Psychological therapist then the whole issue goes underground.

THERAPY TODAY 19 NOVEMBER 2017 Dementia

What can I possibly achieve? Sonia Khan describes the unique challenges and huge rewards of working with people who have dementia

ou walk into the reception to welcome What is dementia? reasonably intact and occasional forgetfulness your client and are met with a blank Dementia may be viewed as a group of is experienced, clients may be struggling to Y stare. Despite having had numerous symptoms, including memory impairment, come to terms with the diagnosis. Therapy sessions, your client has no recollection of who reasoning and communication problems, may help affirm a sense of identity, provide you are or what you have previously discussed. and fluctuations in mood. Alzheimer’s disease emotional support and an opportunity to I was an eager trainee therapist when I is the most prevalent and well-known form communicate emotions, revive order and was first allocated a client with dementia. of dementia, although other conditions may meaning, and restore a sense of mastery.5 As I knew nothing about the condition, other than cause dementia.2 Diagnosis of dementia is the condition progresses, the psychotherapist its associations with memory impairment, imprecise and certainty can only be achieved may serve as an auxiliary memory, as and had neither personal nor professional by dissection of the brain post-mortem. It is a Sinason6 describes: ‘One of the functions of experience of it. I shared my sense of progressive condition and currently there is working with a deteriorating patient was to hopelessness and futility with my supervisor, no known cause or cure for it.3 According to hold their memory, their knowledge, their asking, ‘What can I possibly achieve?’ He the Alzheimer’s Society,4 currently there are choice of words.’ Reflecting on her personal encouraged me to at least meet the client. approximately 850,000 people with dementia experience of Alzheimer’s disease, Dartington, My initial session with Helen affected me a psychotherapist, writes:7 ‘I also spend time profoundly. Here was a dignified woman in her feeling sad, and sometimes I think about early 80s, desperately holding on to herself, ‘As long as I see in death. I work with a psychoanalyst to reflect camouflaging deficits of memory, bewildered the eyes there is on the feelings I have and the changes and frustrated, struggling to understand what I am experiencing.’ was happening to her. In time, I answered my something there, According to Bonder,8 as words are own question about what I could achieve. As they’ve got an gradually lost, verbal psychotherapy may psychotherapists, we do not aim to ‘fix’ our become unsuitable and expressive therapies, clients’ problems but to create a space where awareness, that’s it for such as art and music therapies, may be more they can safely explore their world view me, and even if it’s beneficial. In addition, psychotherapeutic and express themselves; this also applies to interventions such as reality orientation, working with clients with dementia. I learnt for split seconds that validation therapy, reminiscence not to see people with dementia as dementia something is taken disorientation therapy and resolution sufferers, but as people who have dementia; therapy have been developed, particularly to see the person and not just the condition. on, who are we to say for this client group. Research into outcomes I developed an interest in the subject, of these methods is limited and comprises researched it and continued to work with that’s not of value?’ mainly anecdotal evidence. clients with dementia. Inspired, I wrote my MA To those who question the point of offering dissertation on psychotherapists’ experience therapy to people with dementia, Cheston’s5 of working with clients with dementia,1 and in the UK. These figures are predicted to rise comment offers a sharp riposte: ‘Dementia this article draws on this research. It is based to one million by 2025 and to double to two must be understood as a personal tragedy... it is on the experiences of Edward, a Gestalt million by 2051. Psychotherapy for people with unacceptable that its most immediate victims therapist; James, an integrative therapist who dementia is becoming much more common should so often have to struggle unheard and draws on humanistic approaches; Anna, an than it was. unheeded against personal disintegration existential therapist, and Emma, a counselling Since dementia brings loss of memory, and social isolation.’ This very much reflects psychologist. I too am an integrative therapist. which creates loss of continuity and process, my research participants’ views. Edward told None of us, at the time of the research, had the efficacy of psychotherapy for people with me: ‘I’ve not worked with a client where it received any specialised training in working dementia has historically been questioned. was so difficult that we couldn’t communicate with clients with dementia. All names have The progressive nature of dementia dictates with each other... Never at any point did I been changed, as have any identifying details the way a therapist may work. In the early think, “What am I doing here and what is the of the clients mentioned in this article. stages of dementia, when memory is client doing here?”’ For James, psychotherapy

THERAPY TODAY 20 NOVEMBER 2017 What can I possibly achieve?

provided his client with: ‘… just this kind of it just for a few seconds... I think there’s a value Psychotherapeutic literature abounds glow of, I suppose, comfort in his own skin. already in that, even if I can’t make something with phrases to define and describe the And I think, if I can introduce that into the happen long term.’ therapeutic relationship. room for 50 minutes once a week, then I She continued: ‘As long as I see in their Working with this client group means think that’s a pretty good justification for eyes there is something there, they’ve got an engaging with clients who may forget to my presence really.’ awareness, that’s it for me, and even if it’s for attend sessions, get lost en route, or rely on For Anna, there was value in the brief split seconds that something is taken on, who someone to accompany them. They may containment and validation she could offer: are we to say that’s not of value?’ carry no recollection of content (thus negating ‘I can’t necessarily take that strong emotion process), lose track of what is being said mid- of isolation away but I feel, if I just can give From ‘you and me’ to ‘we’ sentence, and even forget who their therapist them, for some moments, just a feeling that Bond, interaction, collaboration, alliance; is. How then can a therapeutic relationship

LESLIE MURRAY / ALAMY STOCK PHOTO STOCK ALAMY / LESLIE MURRAY things are OK, or contained, [if I can] contain fellow travellers, analyst/analysand. be established, deepened and maintained?

THERAPY TODAY 21 NOVEMBER 2017 Dementia

For Clarkson, the therapeutic relationship is I used to see Helen at the provider According to James: ‘My interpretation is that a central feature, the factor ‘that determines organisation’s rooms but, due to her health I’m someone with whom he can relax enough the effectiveness of psychotherapy’.9 Norcross issues and difficulties with the journey, she just to be himself in his home environment.’ writes: ‘... the most common of common increasingly missed sessions. Finally, after factors, the most convergence amongst consulting with my supervisor, I decided that Attunement the professional divergence, is the the only way to continue the work was to offer As the therapeutic relationship evolves, therapeutic relationship.’10 home visits. Every time I visited Helen for therapists meet their clients’ changing needs Research on the therapeutic relationship these sessions, thanks to a timely reminder and clients learn to trust that their therapist with clients with dementia is scarce, but, from her daughter, she would open the door will meet them where they are. The following drawing on their research with nursing immaculately dressed, usher me in to her vignettes from my research illustrate how that home staff and residents in the later stages of pristine living room and graciously offer me a could still happen with a client with dementia. Alzheimer’s disease, Williams and colleagues11 cup of tea. Most days she did not remember my • Time: Traditionally psychotherapists adhere acknowledge the impact of the characteristics name but ‘recognised’ me and vaguely recalled to 50-minute sessions and the responsibility of dementia but conclude: ‘... most participants the purpose of my visit. Over time she spoke for punctuality lies with the client. Edward’s spontaneously shared their feelings and of her past and the loss of her husband, and client struggled to come for sessions: ‘He concerns and... many remembered their shared photographs and memorabilia with me. would get lost or he would be late.’ To nurse, looked forward to her visits, and were Gradually I felt she grew to trust and accept accommodate his client, Edward extended the saddened by termination [of the relationship].’ me. One day when she opened the door she session time when possible, not something In the early stages of dementia, the was in her dressing gown, having missed her he would normally do. Yet, by doing so, he therapeutic relationship may follow a daughter’s reminder. The mask of the gracious created opportunities for the therapeutic traditional course. As memory evaporates, hostess dissolved and her frustrations with relationship to mature and deepen: ‘When [the the therapist too fades away, and specifics client] was late, he would think of me sitting of content and words disappear. However, on his shoulder and he would remember even when explicit memory diminishes, ‘Dementia may my words.’ Edward’s flexibility provided an implicit memory may enable clients to retain lead to the creation of opportunity for their relationship to flourish, a ‘felt’ sense of the therapist. I found that, as whereas a rigid attitude may have stifled it. cognition failed and content and process a false self, to disguise • Place: The therapy room serves as a dissipated, the therapeutic relationship in fact container that holds both therapist and became the cornerstone of the work. Clarkson failings of memory client, and when the frame changes shape, writes: ‘The person-to-person relationship is and to protect against it impacts on the therapy in unexpected the dialogic relationship or core relationship. ways. As described above, several of us at It concerns the authentic humanness shared feelings of shame and some point had agreed to visit our clients by client and therapist. It has also been embarrassment’ for sessions in their own home. referred to as the “real” dimension of the • Approach: To facilitate communication and therapeutic relationship.’9 connection as his client’s words disintegrated, Daniel was 80 when we first met. James, although not an art therapist, used his Accompanied by his wife, he came regularly her memory and anger at herself emerged. innate artistic abilities to integrate facets of art and punctually for sessions. Dapperly dressed Dementia may lead to the creation of a false therapy into his work. ‘I would bring things in... and always smiling, he would wait for me self,12 to disguise failings of memory and chalks and pastels and things like that. And we in the reception and ‘recognise’ me when I to protect against feelings of shame and would sit down together and get creative. I’d walked in, although he rarely remembered embarrassment. In that moment, we met as write on bits of card, just words, very simple my name. When he did, he used it repeatedly, two human beings: one with something to say, words that would give off an image, and then almost as if to prove that he ‘knew’ me, just and the other someone she could trust to hear we’d both draw, or paint something abstract, like any other client. As our relationship her without fear of judgment or derision. which reflected that.’ developed, he told me he would wake up James described a similar process as his Edward described his client ‘realising that in the night, frightened and anxious, and client’s cognitive abilities declined. He too he may have said things to me that he’d said imagine my face; this reassured him. In a would go to his client’s home, and, although his maybe minutes before’. Emma had found world that was rapidly disintegrating, I client did not recognise him: ‘He knows that a very simple way to deal with this: ‘Where offered a measure of stability and security. I’m a friendly face. He knows, he has that facial people have struggled with words, I’ve For Emma, the therapeutic relationship recognition.’ As the therapeutic relationship said, “Do you want me to just wait for you offered a ‘relationship where they know I’m evolved, James inferred that his client saw it as to remember it, do you want me to try and interested. Because I think the client group a supportive relationship in which his authentic prompt you?”’ often has been marginalised by other people, self could be revealed, where he didn’t have When words evaporated, Emma too depending on the extent of the dementia.’ to hide his frailty and impaired memory. used other means to communicate. ‘One

THERAPY TODAY 22 NOVEMBER 2017 ‘I had to let go of my Much has been written about the power imbalance in the therapeutic relationship, Sonia Khan About the author assumptions and meet even with cognitively sound clients. This issue my clients where they becomes even more complex when working Sonia Khan with clients with dementia. What happens has an MA in were. I also had to let if the client does not recall giving consent counselling and for therapy or what was agreed about areas psychotherapy go of aims, objectives to explore? And who decides when therapy and an ADIP in integrative ends? In my own work, I regularly ask clients and goals’ psychotherapy if they would like to continue seeing me and from Regent’s University, London. if they are comfortable to talk about the topics She works in private practice in we are touching on. St. John’s Wood, London. She also client wanted to show me all the pictures in Anna finally decided she could not continue volunteers at St. Joseph’s Hospice, her house and show me her garden... It felt the therapeutic relationship with one client Hackney, a large, inner-city hospice. appropriate for her to show me things rather who repeatedly forgot sessions and who was than struggle with speaking them sometimes... unable to recall who she was or why she was In more advanced stages, like… a woman who there. She initially switched the sessions to particularly liked knitting, I took in some… the client’s home, but the client continued REFERENCES knitting wool and we sorted it out together to forget she was coming or who she was. ‘I 1. Khan S. Dementia: exploring therapists’ while we were talking.’ had to ring in the morning before I arrived experiences. Unpublished MA thesis. • Process: I learned that I had to let go of my there... and I rang 10 minutes before I rang the London: Regent’s University; 2016 2. Alzheimer’s Society. Factsheet 400. assumptions and meet my clients where they doorbell. When I rang the doorbell, she didn’t What is dementia? London: Alzheimer’s were. I also had to let go of aims, objectives and know anyway that I was coming.’ Finally, she Society; 2012. 3. Alzheimer’s Society. Factsheet 458. The goals, and any sense of achievement I might decided not to continue: ‘I have actually got progression of Alzheimer’s Disease and experience. My original question, ‘What can now feelings of guilt... I could have gone [on] other dementias. London: Alzheimer’s I possibly achieve?’ became irrelevant and but yet I felt I couldn’t contain it anymore. I felt Society; 2011. 4. Alzheimer’s Society. Facts for the media. meaningless. The focus became the encounter. so many boundaries were broken I couldn’t London: Alzheimer’s Society; 2016. Our relationship had to transcend words, contain it.’ Therapists working with these 5. Cheston R. Psychotherapeutic work content and process. clients sometimes have to make some very with people with dementia: a review of the literature. British Journal of Medical Buber writes about the rarity and meaning hard, ethical decisions. Good self-care and Psychology 1998; 71: 211–231. of moments of connection: ‘These moments supervision are vital. 6. Sinason V. Mental handicap and the human condition: new approaches from are immortal, and most transitory of all; no Not least, working with dementia forces us the Tavistock. London: Free Association content may be secured from them, but their to confront our own fears of cognitive decline, Books; 1992. power invades creation and the knowledge as Emma explained: ‘Maybe the fear that we’ll 7. Dartington A, Pratt R. My unfaithful brain: a journey into Alzheimer’s disease. In of man, beams of their power stream into get it, you know… that that’s a mirror, and just Davenhill R (ed). Looking into Later Life: a the ordered world and dissolve it again because we’re therapists doesn’t mean we psychoanalytic approach to depression and and again.’13 His words seem remarkably wouldn’t get it.’ dementia in old age. London: Karnac; 2007. 8. Bonder BR. Psychotherapy for individuals appropriate in the context of dementia. Yet, the relationships I have forged with with Alzheimer disease. Alzheimer Disease clients with dementia stand out for me. The and Associated Disorders 1994; 8(3): 75–81. 9. Clarkson P. The therapeutic relationship. Challenges and rewards depth, candour and authenticity I encountered London: Whurr Publishers; 2003. Working with these clients presents huge enabled us to meet without masks. I always 10. Norcross JC. The therapeutic professional and personal challenges. Forming felt that my clients held on to a ‘sense’ of me relationship. In: Duncan BL, Miller SD, Wampold BE, Hubble MA (eds). The heart an alliance with a client with dementia means and our time together, even though they lost and soul of change: delivering what works eventually being forgotten. James succinctly the specifics. At times, it was difficult to enter best in therapy. Washington: American describes the impact of this: ‘We’re all human a relationship, knowing what lay ahead, but I Psychological Association; 2010. 11. Williams CL, Tappen RM, Lynn CE. Can and therapists are more human in many ways knew too that, for it to be helpful, I had to drop we create a therapeutic relationship with – more feeling, than the average person… and my defences and allow my clients to matter to nursing home residents in the later stages of Alzheimer’s Disease? Journal of Psychosocial so there’s a little bit of upset.’ me, so long as, at every step, I looked for ways Nursing and Mental Health Services 1999; Because memories of the therapist fade to care for myself. 37(3): 28–35. away, it becomes necessary to re-establish the Ultimately, I was the one left remembering the 12. Winnicott DW. Ego distortion in terms of true and false self. In Winnicott DW (ed). alliance at every session. I gently remind the moments we had shared: the laughter, the quiet The maturational process and the facilitating client what has happened in past sessions and words and the averted gazes. ‘Our’ history was environment. London: Karnac; 1960 attempt to convey a sense of intimacy and left with me to hold and cherish; the moments (pp140–152). 13. Buber M (Trans. RG Smith). I and Thou ease non-verbally. of connectedness remained with me. (2nd edition). London: Continuum; 1958.

THERAPY TODAY 23 NOVEMBER 2017 Presenting issues WHEN YOUR LIFE IS NOT YOUR OWN Linda Dubrow-Marshall and Rod Dubrow-Marshall urge counsellors to be alert to signs that a client may be subject to coercive control

ina appeared to be a little depressed and anxious and was frequently on the verge of tears. She had been persuaded by her course tutor to make an appointment with the college counsellor as she had been missing her Gadult education classes for several weeks; her tutors were concerned – it wasn’t like her. Friends at college had also noticed that Gina wasn’t going out so much and didn’t hang out with them at weekends. She was always rushing home to be with her husband, and they didn’t see her for weeks on end. Gina, a mature student with a professional career behind her, had re-entered higher education to retrain to work alongside her husband in his business. Why was she acting in this way? At the first counselling session, Gina was not very forthcoming. ‘I’m OK, I’m just struggling a bit with everything right now… but I’m OK, really, I’m OK.’ Everything was OK with her husband and family too. ‘Yes, yes, it’s all really, really great – my husband is so supportive. I don’t know where I would be without him. I worry sometimes that I don’t measure up to his standards, but I do my best and I will get better. I don’t know what he would think about me snivelling in your office like this and I’m not sure whether I really need your help – I’m really well supported at home and I’ll be fine.’ Gina, it turned out, was a victim of coercive control in a psychologically abusive relationship. This article highlights how such clients may present in the counselling room and the signs counsellors and psychotherapists need to be alert to if they are to identify and support people who are affected by, or have survived, this hidden form of abuse. Very often a client may present with anxiety and depression or a problem that is seemingly unrelated to their ‘perfect’ relationship; it can take time and trust for the real picture to emerge. An estimated one in four women and one in six men will experience 1 domestic abuse at some point in their lives. The Office for National IMAGES GETTY

THERAPY TODAY 24 NOVEMBER 2017 when they can sleep’. ‘Gaslighting’ is another form of manipulative behaviour, where one person tries to exert power over another by making them doubt their own judgment to the point that they question their sanity (the name comes from the 1940 film with that title).6

Warning signs One of the difficulties in identifying coercive control is that relationships extend along a continuum of healthiness, and can be seen from a range of viewpoints (the individuals concerned, family, friends, counsellor, Statistics reports a 10% increase in domestic abuse-related offences for psychotherapist, GP). This can make it difficult to assess whether an the year ending March 2017 (a total of 464,886 offences), with the increase unhealthy relationship has become actively abusive. An unhealthy attributed in part to improved recording of these crimes.2 There are relationship can, for example, involve a lack of trust, respect or ongoing challenges in recognising domestic abuse and coercive control communication, without necessarily being abusive, but these factors for what they are, and this is partly because the perpetrators do their best can also tip into abuse, and counsellors and psychotherapists need to convince their victims that they are actually the recipient of benign to be aware of the warning signs, so that they can offer their clients protection and loving care; hence the abuse is not reported and is often appropriate support. not spotted by loved ones and friends. This is similar to the ‘Stockholm The signs can include missed counselling appointments within Syndrome’,3 where a hostage/captive is psychologically manipulated an overlying pattern of increased isolation, emotional withdrawal or into identifying with and loving their captor, at the expense of their own numbing, dissociation, increased anxiety and nervousness, depression, identity and wellbeing. This difficulty in identifying when coercive control and a change in personality or behaviour patterns. A number of is a factor makes it vital that counsellors understand its psychological organisations that work with survivors of domestic abuse and violence features and dynamics across different contexts, and are equipped have produced taxonomies that describe the continuum of healthy with appropriate strategies for helping this particularly vulnerable and through to abusive relationships.7 The Duluth healthy/unhealthy sometimes misunderstood client group. relationship wheel8 is a useful illustration of how an apparently healthy relationship can develop unhealthy and abusive aspects over time. Psychological subjugation The main psychological features of controlling and coercive Stark broke new ground when he drew a clear distinction between behaviour also exist in other contexts where people are subjected to coercive control as a form of ‘subjugation’ within relationships and coercive or undue influence. These include human trafficking and well-recognised models of domestic violence.4 The concept is now, after modern slavery (including sex trafficking), gangs, and extremist groups long campaigning, enshrined in UK law, under the 2015 Serious Crime or cults, of which an increasing prevalence has been reported recently Act (see box).5 Significantly, the Serious Crime Act explicitly recognises (there were 3,805 recorded victims of modern slavery in 2016, a 17% psychological abuse, or ‘controlling and coercive behaviour in an increase on the previous year9). Importantly, there can also be an intimate or family relationship’, as a criminal offence when there is no overlap between trafficking, domestic abuse and cultic practice, as in physical abuse (this was traditionally the evidence standard used for the case of Maoist cult leader Aravindan Balakrishnan, who was jailed taking action against perpetrators of domestic abuse). While physical abuse sometimes accompanies, and often follows, a long period of coercive control, the Serious Crime Act, by establishing clear definitions of controlling and coercive behaviour, allows professionals to identify it The Serious Crime Act (2015) defines and intervene as appropriate before it manifests in physical violence. In 2017, 4,246 offences of controlling and coercive behaviour were controlling and coercive behaviour reported across the 38 police forces for which data were available.2 The as follows:10 types of behaviour cited include ‘isolating a person from their friends ‘Controlling behaviour is: a range of acts and family’, ‘monitoring their time’ and ‘taking control over aspects of their everyday life, such as where they can go, who they can see and designed to make a person subordinate and/ or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour ‘Controlling behaviour is: a continuing act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim’

THERAPY TODAY 25 NOVEMBER 2017 for 23 years in 2016 for keeping prisoner two women and his own by the wayside. In addition, when Julie and Keith saw Natalie for her daughter in a flat in Brixton, and subjecting the women to rape and birthday, she looked gaunt and tired and was only really interested in sexual abuse over a period of more than 40 years. talking about Ben and their ‘vital work’ to save humanity through yoga Research has identified the common psychological processes and mindfulness. What concerned them most of all was when Natalie involved when people become controlled and psychologically announced that she and Ben would be going to South Korea for the dependent on an abusive partner or lead figure in a business, gang or summer, abandoning their earlier plans for a family holiday together. cult. These are outlined in Lifton’s11 model of ‘thought reform’, which describes eight themes processes whereby an abusive and ‘high- Supportive dialogue demand’ relationship takes over the mind of the victim, resulting in We have worked with many families like Natalie’s, through the a ‘totalistic identity’.12 They include ‘milieu control’ (control over the organisation RETIRN/UK (the Re-Entry Information and Referral person’s environment), ‘doctrine over person’ (whether from a partner Network), and have developed the Strategic and Personal-Oriented or by a group leader) and ‘dispensing of existence’, where the influence Dialogue (SaPOD) approach to help families and concerned others over the person becomes bound up in a powerful, totalistic form of get through to people who they think are subject to coercive control identification with the abuser or abusive group. It is the coercive control and undue influence. Rather than using a confrontational approach, and the resulting totalistic identity that effectively trap the person in an which may push the person further away, SaPOD uses a motivational abusive relationship and environment where it can be hard for anyone, interviewing approach,13 which supports and extends dialogue, is including the victim themselves, to recognise the problem and that empathetic toward the person’s perspective, and gently challenges they need to seek help. them to resolve their own ambivalence when openings (such as doubt) present. It also allows for an emphasis on harm reduction, which Disconnection and isolation might mean that, while the person may not leave the relationship It is often family members who first report concerns about a loved or group, they may adapt their involvement in a way that reduces one. A family member will notice that their loved one is becoming the risk of harm. disconnected from them and is changing in subtle – sometimes less Psychotherapists and counsellors can use these same types of subtle – ways. It is common for the loved one themselves to report strategic interventions when working with people who are currently that they are blissfully happy in their relationship or group, and it is experiencing coercive control. They need to balance the ethical therefore vital that counsellors and psychotherapists are able to spot principles of autonomy – ‘respect for the client’s right to be self- when a healthy obsession or devotion has tipped over into coercive governing’ – and beneficence – the ‘commitment to promoting the control and abuse. The signs can include a change in personality, a client’s wellbeing’.14 This can be very challenging when the practitioner change in appearance, isolation from family and friends, lack of access recognises dangerous signs of coercive control that threaten the client’s to financial resources, being driven everywhere by their partner wellbeing but the client does not understand that she is subject to and not going anywhere by themselves, a change in emotional state, coercive control, or is too frightened to question the relationship or such as increased anxiety and depression, and apparent increasing consider leaving. Gina, the university student, was unable to recognise dependence on a partner, group or relationship. Of course, these can that she was having any problems when she first came for university also signify other difficulties; a holistic assessment is required, which counselling, but she returned when she failed an assessment, and, in will take time, and can be augmented with feedback from other people, further counselling sessions, began to acknowledge the effect of her whether reported indirectly by the client or directly to the therapist. relationship on her studies. This illustrates how laying the foundation A particularly strong indicator of coercive control is when the person’s for a trusting and respectful therapeutic relationship can have future mobile phone is being tracked by a partner or group so that their pay-offs that are not immediately realised. Patience and understanding whereabouts are always known. are often required with clients who have been subjected to coercive When Julie and Keith first began to be concerned about their daughter control and need time to build up trust before they can express their Natalie, they were, like many parents, afraid that they were being overly hidden doubts and fears.15 anxious, or even a little judgmental about their daughter’s new partner, Another warning for practitioners is to be sensitive to issues of whom they liked but felt they did not know really well. Natalie had power in the therapeutic relationship. They should avoid temptations graduated with a first-class degree a few years before and had surprised her parents when she announced she was going to get engaged to Ben, her boyfriend from university, and stay on in the town (some 100 miles from her parents’ home) where they had been studying. Her happiness ‘Vulnerability to coercive control and excitement initially consoled Julie and Keith, but their feeling of is not restricted to any particular disconnection from their daughter grew, as did their concerns about socioeconomic status, age, religion, some of Natalie’s decisions, which seemed ‘a little out of character’. For example, Natalie had decided to invest her savings in Ben’s culture, level of education etc, or business, which was a small but apparently growing consultancy offering gender or sexual orientation (although mindfulness and yoga training. Both Natalie and Ben were increasingly women, as with domestic abuse, are devoting all their time to the business and to an expanding but close- knit group of friends. Natalie’s plans to start a family, take a postgraduate more often the victims, and men degree and pursue other hobbies (she was a talented cellist) had gone more often the perpetrator)’

THERAPY TODAY 26 NOVEMBER 2017 Presenting issues

to provide answers for clients, or otherwise impose standards of behaviour, and instead aim to help them to identify their motivations Linda Dubrow-Marshall and Rod Dubrow-Marshall and needs, and make appropriate changes that they feel ownership About the authors for. It is helpful for practitioners to be aware of their own emotional reactions to working with clients who have been subjected to coercive Linda Dubrow-Marshall, PhD, MBACP control, and to practise good self-care, particularly with regard to their Reg (Accred), HCPC Registered emotional reactions to the painful material presented by their clients. Counselling and Clinical Psychologist, Vulnerability to coercive control is not restricted to any particular and Rod Dubrow-Marshall, PhD, MBPsS are the Programme Leaders for the new socioeconomic status, age, religion, culture, level of education etc, or MSc Psychology of Coercive Control gender or sexual orientation (although women, as with domestic abuse, programme at the University of Salford. are more often the victims, and men more often the perpetrator). They are the co-founders of RETIRN (the Power in relationships is negotiated over time, and anyone is vulnerable Re-Entry Information and Referral Network) to an imbalanced relationship that can fall somewhere toward the UK, a private practice that provides coercive end of the continuum. There are many cases where men are services to individuals and families who affected (with a woman as perpetrator), and it also features in same-sex have been affected by coercive influence in groups and abusive relationships. relationships. It is important that counsellors keep an open mind to the range of controlling and coercive behaviour that sadly exists. Linda is also the Programme Leader for There is also more work being done to identify and support victims the MSc Applied Psychology (Therapies) programme at the University of Salford. Rod is a social psychologist who has and survivors of elder abuse. As with other forms of coercive control, been researching the psychology and aetiology of coercion elder abuse can be physical but often includes psychological abuse, and undue influence in cults and extremist groups and where the elderly person is drawn into becoming dependent on a relationships for over 20 years. He is a member of the Board particular person (relative or acquaintance), loses their sense of self of Directors of the International Cultic Studies Association and autonomy, and is coerced into becoming acquiescent, gives over and is Co-editor of the International Journal of Cultic Studies. their money, moves house, and gives up or restricts their activities and The authors welcome comments to l.dubrow-marshall@ contact with others. Elder abuse sometimes overlaps with financial salford.ac.uk and [email protected] abuse, where the perpetrator takes over the person’s finances so they have no control over their own income. Financial abuse can be hard for practitioners to detect and may only be revealed in counselling as an adjunct to other matters. REFERENCES

Recovery 1. www.lwa.org.uk/ Recovery work with people who have left coercive relationships and 2. Office for National Statistics. Statistical bulletin: crime in England groups can include helping them to understand the principles of coercive and Wales: year ending Mar 2017. Newport: ONS; 2017. 3. Stein A. Terror, love and brainwashing. Abingdon: Routledge; 2016. control, which can help reduce their feelings of personal shame and 4. Stark E. Coercive control. Oxford: Oxford University Press; 2009. guilt. However, they must also understand the personal dynamics that 5. HM Government. Serious Crime Act 2015. London: the Stationery have played a contributing role, so they can avoid becoming involved in Office; 2015. www.legislation.gov.uk/ukpga/2015/9/contents/enacted 6. Sarkis SA. 11 signs of gaslighting in a relationship. [Blog.] Psychology subsequent relationships that may be overly controlling. People who have Today 2017; 22 January. bit.ly/2xOt7Nt escaped a controlling group or relationship may need help with practical 7. Hassan S. Combating cult mind control. Boston: Freedom of Mind issues, such as housing and employment, and may have safety needs if Press; 2015. 8. Domestic Abuse Intervention Programs. Wheels: understanding the former partner or group is threatening them. They may experience the power and control wheel. [Online.] Domestic Abuse Intervention an existential void and struggle to establish their sense of identity outside Programs (undated). www.theduluthmodel.org/wheels/ 9. Anti-Slavery Commissioner. Modern slavery in the UK. [Online.] the relationship and the control that has dominated their life for so long. London: Anti-Slavery Commissioner; 2017. These issues may present quite obviously in clients who have recently 10. HM Government. Statutory guidance framework: controlling or left a coercive relationship or environment, but they may be camouflaged coercive behaviour in an intimate or family relationship. London: Home Office; 2015. bit.ly/1PqviuX by presenting symptoms of depression and anxiety, which a client may 11. Lifton R. Thought reform and the psychology of totalism. London: not associate with their earlier abuse. Practitioners can integrate this WW Norton; 1963. specialist approach with standard work to help clients develop self- 12. Dubrow-Marshall R. The influence continuum – the good, the dubious and the harmful – evidence and implications for policy and awareness and self-esteem. Supervision with someone experienced in practice in the 21st century. International Journal of Cultic Studies working with coercive control may be very useful, as well as self-care (see 2010, 1: 1–13. 13. Miller R, Rollnick S. Motivational interviewing. New York: Guilford above). It can be very painful to enter the phenomenological world of a Press; 2012. person who has experienced coercive control and to relate empathically 14. BACP. Ethical framework for the counselling professions. to their ‘powerlessness’. So counsellors and psychotherapists have Lutterworth: BACP; 2016. 15. Dubrow-Marshall L, Dubrow-Marshall R. The psychological a vital role in supporting clients to grow in their confidence to form development and consequences of involvement with new religious authentic relationships and overcome longer-term effects of coercive movements: counselling issues for members, former members and control and abuse. The value of training and continuing and professional families. In: Harvey S, Steidinger S, Beckford J (eds). New religious movements and counselling: faith beliefs and counselling beliefs. development cannot be underestimated. London: Routledge (2018, in press).

THERAPY TODAY 27 NOVEMBER 2017 Mick Cooper asks if we are any closer to identifying what happens, and how and why, when therapist meets client at relational depth

MEETING AT RELATIONAL DEPTH

THERAPY TODAY 28 NOVEMBER 2017 Counselling practice

hat do you remember about your string cheese. What, I think, Dave also really published by Sage this month), this seems first-ever session with a client? I wanted to say is that, in the counselling world, a good time to review what we’ve learned remember the shabby, homely we have become so concerned about getting since its first publication in 2005. Wfurnishings of the youth counselling centre ‘over-involved’ with our clients that we have in which it took place. I remember being forgotten about the dangers of being under- The experience of relational depth really anxious about whether or not the client involved: of providing them with a relationship One of the first things that a lot of the research would show: my first two hadn’t turned up, that is so cold, impersonal and detached that it looked at is what is it like to relate deeply and I was beginning to take it personally. And can end up doing more harm than good. to another person, either in therapy or I absolutely remember the shy, thoughtful The result was Working at Relational Depth outside it. Most of this research found that young woman who turned up, well ahead of in Counselling and Psychotherapy, which the experience of relational depth could be time, and told me about the problems she we first published in 2005. I was, I confess, described in terms of four main areas: what was having with her schoolmates and her surprised by how warmly it was received. It people felt inside, how they experienced the over-intrusive father. Most of all, though, I became one of the highest-ranked texts on other, what the relationship was like, and remember coming out of the session feeling the Amazon.co.uk counselling bestsellers list how the atmosphere around them was.3 that I had experienced some really powerful, a few months before publication, and has In terms of internal feelings, people deep, profound connection with this young pretty much stayed there ever since. The book, described feeling energised and focused at woman. More than that, I sensed that there of course, has its critics. For instance, some these times of relational depth, yet also safe was something about this in-depth connection members of the person-centred community and calm. They often talked about relational that was right at the heart of what was healing felt that our perspective was too directive and depth being a very physical experience in the therapeutic work. confrontational. But we held conferences on (for instance, electrifying or tingly feelings), From 2003 to 2005, I had the privilege to be relational depth; it was the focus of a special and also a level of emotional intensity. They able to explore these experiences and ideas issue of the journal, Person-Centered and also said that, at these times, the ‘other’ was in more depth with Dave Mearns, co-author Experiential Psychotherapies, and the book experienced as very genuine: real, human and of the much-loved classic, Person-Centred served as a key text in the emergence of a present – coming from the ‘core’ of their being. Counselling in Action. Dave had been writing ‘relational’, ‘dialogical’ approach to person- In terms of the relationship between about ‘relational depth’ since the mid-1990s. centred therapy. them, people described powerful feelings of When his publishers, Sage, asked counselling For me, one of the most gratifying outcomes connection, closeness and intimacy at these trainers what books they would like to of the book was the number of research studies moments of relational depth, and talked about see, several had suggested a more detailed that followed, mostly conducted by doctoral this in very evocative terms: for instance, a exploration of this topic. For Dave, ‘relational or master’s level students. Of course, in trying ‘heart to heart’ meeting, or ‘like electricity depth’ was a way of pulling the Rogerian1 to research relational depth, there is always flowing one from the other’. Feelings of ‘core conditions’ (empathy, congruence and the danger of destroying it: like catching a mutuality and equality in the relationship unconditional positive regard) back together butterfly and inadvertently crushing it in the were also very common, and people often again. As a counselling trainer himself, Dave process.2 But I also think that research has said that relational depth happened without had seen how trainees and trainers could end a very important function here, because, words. In terms of the atmosphere, they often up seeing each of these conditions as separate like relational depth, it is about learning and described feeling in some kind of altered state,

IKON / OTTO DETTMER / OTTO IKON techniques that got ‘implemented’ at separate growing and being open to change. So, as the or that there were changes in their perception times (‘Now I’m doing empathy’; second edition reaches the bookshelves (it’s of time: for instance, long periods of time ‘Here’s a bit of congruence’; ‘This one’s unconditional positive regard’). Dave wanted to say that it is really all one thing: when you are there for a client, ‘... people described feeling energised and you are relating focused... yet also safe and calm. They often in a way that is ‘empathically- talked about relational depth being a very congruently- physical experience... and also a level of accepting’, and emotional intensity. They also said that, at you cannot pull these core conditions these times, the “other” was experienced apart like strips of as very genuine: real, human and present’

THERAPY TODAY 29 NOVEMBER 2017 Counselling practice

seemed to go by in a flash. Some people also something similar.6 Nevertheless, in some others, the therapists and clients seemed to described these experiences as spiritual. studies clients have not reported experiences be experiencing quite different ‘journeys’. The striking commonalities in how of relational depth, and, overall, they seem Although the design of this study was these experiences of relational depth were significantly less likely than therapists to report somewhat artificial, other studies in described – both across participants within it. In addition, one study found that young which participants have rated their depth the same study and across studies – suggest people really struggled to describe any such of relating after the session have found that the phenomenon of relational depth is a moments of connection with their therapists.7 something similar. real and distinctive occurrence. Initial research They could identify important moments in Interestingly, the more experienced suggests it also extends beyond western therapy, and were certainly able to talk about therapists did not seem to be any better cultures, but more cross-cultural studies are therapists’ relational characteristics, such at matching their clients than the trainee needed. However, we have also found some as their warmth or supportiveness. But the therapists. However, female therapists did differences in the experiences of relational notion of experiencing moments of closeness achieve a better match than male therapists. depth, particularly between therapists and or relational intimacy with their therapist clients. For instance, consistent with their appeared alien to the way these young people The impact of relational depth roles, therapists are more likely to experience thought about the counselling process. Does achieving this connection have any feelings of respect and empathy for the other Across studies, there are some indications actual impact on the therapeutic work and at these times, while clients are more likely to that clients may experience less relational the client’s outcomes? The best evidence describe feelings of being known, understood, depth with psychodynamic therapists than here comes from a study using the Relational cared for and accepted. with humanistic therapists. Clients also Depth Inventory. This asks clients to identify report more depth of connection with female a particular helpful moment or event in For therapists therapists. Interestingly, this seems to be therapy, and to rate how accurately 24 items All the studies conducted so far suggest that particularly true for male clients: the deepest associated with relational depth fit with this the vast majority of therapists experience levels of connection are between a female experience (for instance, ‘I felt a profound moments of in-depth connection with their therapist and a male client; the shallowest connection between my therapist and me’).9 clients. For instance, one survey found that between a male therapist and a male client. This demonstrated that experiencing a around 98% of therapists could identify at least depth of connection was associated with one experience of relational depth.4 Interview Shared relational depth a striking 10–30% of the overall positive studies with therapists have found similar One question that has always fascinated me is outcomes: that is, the more that clients prevalence across orientations and client whether the client and therapist experience experienced relational depth in a partcular groups. In terms of frequency, one survey relational depth at the same time. I tested this moment of therapy, the more they improved. found that therapists experience relational myself, in a study in which pairs of practising In support of these findings, interview depth somewhere between ‘sometimes’ and and trainee counsellors were asked to conduct studies also indicate that a majority of clients ‘often’ in their therapeutic work.5 20-minute ‘counselling’ sessions with each feel that moments of relational depth have a Surprisingly, perhaps, there is no difference other, and, at every minute, to rate their significant positive impact: both immediately in the degree to which therapists of different own sense of depth of connection in their and in the longer term.6 In terms of immediate orientations report experiences of relational respective roles.8 effects, clients describe these moments of depth. There are also no differences across I didn’t expect to find much match, given meeting as facilitative, healing and changing, age, ethnicity or gender. However, more the body of research showing that therapists’ and also describe a positive impact on the experienced therapists seem to report and clients’ perspectives are typically very therapeutic process itself. In the longer term, more experiences of relational depth. Also, different. However, there was an overlap the most commonly reported impact is an perhaps not surprisingly, while therapists of around 45%. This varied a lot across the increased connection with their own selves. have reported experience of relational depth pairs: in some cases, the therapists and Clients also report feeling more powerful, in short-term therapies, long-term therapy clients were really closely matched in their feeling better, and developing improved relationships appear more conducive to a assessments of the degree of connection; in relationships with others. greater depth of connection.

For clients But is relational depth something that ‘In terms of immediate effects, clients describe therapists just imagine happening; does these moments of meeting as facilitative, it have any bearing on what clients really experience in the therapeutic work? The healing and changing, and also describe a research suggests that clients do, also, have positive impact on the therapeutic process this experience. In one study, around 80% itself. In the longer term, the most commonly of clients reported experiences of relating in depth with their therapists, and clients in most reported impact is an increased connection qualitative interview studies have reported with their own selves’

THERAPY TODAY 30 NOVEMBER 2017 What blocks it Clearly, a meeting at relational depth is not SOMETHING WONDROUS HAD JUST TAKEN PLACE something that can be made to happen. By definition, it’s a spontaneous encounter, ‘Grace’ was a 39-year- continued to look at me an eternity. The contrast and it’s also a deeply human and respectful old woman who worked and the enormity of her between her fragile touch with counsellor Anne pain was tangible. Then her and her racking sobs meeting – so not something that a client can Deacon for over two years. tears came, at first slowly, seemed a chasm apart. be manipulated into. Nevertheless, there Throughout her childhood, as she blinked hard as if to ‘I didn’t feel any sense may still be things that therapists can do Grace was regularly beaten force them out of her eyes. of a need to comfort her to make its occurrence more likely. by her parents and mentally Then she was sobbing, in any way. I felt a deep When therapists are asked how this tormented in the most her body shaking with the empathy for her, and, in connection occurred, they most often mention sadistic of ways. force. She looked at me that moment, I was willing ‘taking risks’: in particular, taking the risk of Anne writes: ‘Grace now with panic in her eyes to just sit alongside her in saying to a client how they are experiencing the learned early in her life to as she experienced for the that dreadfully painful and therapeutic work. They might say, for instance: keep her feelings under first time what it felt like terrifying place she now ‘I sense that you are feeling a bit disconnected control and never show to cry for her self. I leaned found herself in. (In the past any emotion. Every waking closer, her tears now were to cry would have resulted today’, and then follow that through to a more moment was fearful for her falling on to her arms and in a beating.) She was not honest and authentic dialogue. as she never knew what clothes, and the noises she only crying for the first However, clients say that moments of might provoke another made came from deep time, but she was touching relational depth are most likely to happen attack.’ Grace did not within her very soul. another human being. To when their therapists are offering something know what her feelings ‘I asked softly if she me, in that moment, she ‘over and above’ what they would expect from felt like because she wanted me to sit next to was saying, “I trust you a professional relationship: a genuine, very real had not been allowed to her. She nodded. I moved with my tears and with commitment and care.6 Closely related to that, experience them. ‘Even fear slowly across to the settee my touch.” they talk about their therapists being really had been replaced by a and sat down, half-facing ‘My chest cavity was full real and human: genuine, themselves, and void of nothingness.’ her (touch was something to the brim with emotion For the first few months she was afraid of, so I and it felt difficult to breathe. not faking things or putting themselves of counselling, Grace and needed to be extremely I no longer felt any desire on a professional pedestal. So, for instance, Anne worked together to sensitive), and then made to cry for her pain. But the one client said: ‘I think I had only expected help Grace recognise what my hand available to her. effort of just staying close to receive from her professional self… her feelings were and put It seemed a while before was intense. [I]t felt like she was giving from her core.’ labels to them. ‘Then came she very slowly moved ‘Eventually her crying Clients talk about the therapist’s ability to the day when she was her hand towards mine. subsided. Just as gently create a welcoming and safe atmosphere; telling me of yet another I made no movement and and slowly as she had first their patience; their ability to act in a way beating and, as my eyes gradually she touched held my finger, she now that is trustworthy, reliable and professional. filled with tears as I listened, my finger with hers. All began to release it, and, as Interestingly, too, the clients emphasise how she suddenly stopped the while her sobbing if in slow motion, we took mid-sentence and said to continued. Suddenly I was up our original positions the therapist feels really on their side: not me: “Those tears should aware she was carefully facing each other. She just a neutral, non-judgmental presence, but be mine, shouldn’t they.” I and gently starting to looked into my eyes nodded. Grace continued hold my finger. again, and in that moment, READER to look at me and then I ‘When I felt her finger we knew that something SPECIAL saw her eyes beginning touching mine I was truly wondrous had just to fill with tears as well. careful not to make much taken place.’ OFFER (This was the first time in 18 movement. I was aware of Anne continued to SAGE is delighted months that she had shown the courage it was taking work with Grace for a emotion). She continued for her to touch me. The further eight months. At to offer Therapy to look at me as if she way she was touching the end of her counselling, Today readers needed to be connected me was so tentative and Grace decided that she a 25% discount to my tears to allow hers uncertain and instinctively would pursue her love on this second to flow. Time seemed I didn’t respond straight of art and enrolled on edition, with to stand still, quietness away; I waited until she was a course at the local new content on seemed to descend on the holding my finger more university. Her first year recent research, room, there was nothing securely. I then very slowly was a success and she developments happening, yet there was held her back and we sat went on to take the and debates around relational depth, so much happening. Grace like that for what seemed degree course. and new case studies. To receive your discount, add the code UKCOUN25 (Adapted from: Knox R, Murphy D, Wiggins S, Cooper M (eds). Relational depth: at the checkout on the Sage website: new perspectives and developments. Basingstoke: Palgrave; 2013 (Chapter 1). tinyurl.com/relationaldepth

THERAPY TODAY 31 NOVEMBER 2017 Counselling practice

in arguments with our they both look under the street lamp together. ‘If therapists want to deepen partner, even though we After a while, the policeman checks with the their levels of relating with know it makes things worse. drunk whether he has definitely lost them So, as therapists, we need there and the drunk says, ‘No, I lost them in clients, then it would seem to ask ourselves: ‘What are the park, but this is where the light is.’ So it is important that they allow my chronic strategies of with research into relational depth: we can themselves to express a genuine disconnection? Are there look under the street lamp, at easily definable ways in which these might and measurable phenomena like therapists’ care and concern for the people leak into my therapeutic techniques, but we may be focusing on only they are working with’ work? What might I do the most visible and surface-level agents of about this?’ (A recent study change. We need to take a torch into the park found that around 50% of to see more of what’s out there. someone who actively values them, and sees therapists’ chronic strategies of disconnection Of course, we will never ‘catch’ relational things in their way. Mostly, however, clients say leaked into their therapeutic work, at least to depth, hidden behind a bush like some that the emergence of a meeting at relational some degree.10) scurrying mouse, but at least we can learn depth is less about their therapist and more more about its habitat, its terrain. And maybe, about them. For instance, they talk about their Beyond the visible in some fleeting moments, we will catch a own readiness and desire to engage at depth; This is just some of the new evidence glimpse of it, and stand in awe of its power, how relational depth is something that they informing an understanding of the role of profundity and beauty. However evasive, very proactively entered into: a deliberate relational depth in therapy. There are also however hard to find, those experiences of choice to take the risk and open up. One client, new findings in the social neuroscience field, deep relational connection may be the most for instance, said: ‘[I]t was a very definite thing showing how in-depth relating can have a meaningful in life, and the most significant within myself that happened, that I allowed positive effect on the brain, and health in the therapeutic healing process. myself to be so open, and let my defences studies research showing that the quality down enough… it was almost as if I’d got to and quantity of interpersonal relationships the point… of no return and I thought, “I’m are among the strongest predictors of REFERENCES going to go for it”.’6 mortality. But the research reviewed here If therapists want to deepen their levels comes specifically from our own field of 1. Rogers CR. The necessary and sufficient conditions of therapeutic personality change. of relating with clients, then it would seem counselling and psychotherapy, and tries Journal of Consulting Psychology 1957; 21(2): important that they allow themselves to to put relational depth right into the centre 95–103. express a genuine care and concern for the of an understanding of therapy processes 2. Connelly AE. Trainee therapists and relational depth. Nottingham: Sherwood Psychotherapy people they are working with. This is not and outcomes. Training Institute; 2009. about pretending that we care; it’s about There is an old adage about a policeman 3. Cooper M. Experiencing relational depth in therapy: what we know so far. In: Knox R, Murphy expressing our natural warmth, compassion who sees a drunk looking for something under D, Wiggins S, Cooper M (eds). Relational depth: and humanness. Of course, boundaries are a street lamp, and asks him what he has lost. new perspectives and developments. Basingstoke: critically important for therapy. But what the The drunk says he has lost his keys, and so Palgrave; 2013 (pp62–76). 4. Leung J. A quantitative online study exploring research on relational depth suggests, as Dave the factors associated with the experience and Mearns originally argued, is that, if therapists perception of relational depth. Glasgow: University implement boundaries in an impersonal, Mick Cooper of Strathclyde; 2008. 5. Di Malta GS. The development and validation detached, uncaring way, then it has the About the author of the Relational Depth Frequency Scale. London: potential to act against the helpfulness University of Roehampton; 2016. Mick Cooper 6. Knox R. Clients’ experiences of relational depth. of the therapeutic work. is Professor of Glasgow: University of Strathclyde; 2011. So, rather than looking at how we can make Counselling 7. Gurvitz S. Young people’s experience relational depth happen, it might be more Psychology at of important moments of change in the therapeutic relationship. London: University of useful to look at what stops us, as therapists, the University of Roehampton; 2017. from relating more deeply with our clients. Roehampton, where 8. Cooper M. Clients’ and therapists’ perceptions A concept that may be useful for this is he is Director of the of intrasessional connection: an analogue study of Centre for Research change over time, predictor variables, and level of that of chronic strategies of disconnection, in Social and Psychological Transformation consensus. Psychotherapy Research 2012; 22(3): 274–287. developed by relational-cultural therapist (CREST). He is a chartered psychologist, 9 9. Wiggins S, Elliott R, Cooper M. The prevalence Judith Jordan. This describes strategies we a UKCP-registered psychotherapist, and and characteristics of relational depth events in may have developed as children to protect a Fellow of the British Association for psychotherapy. Psychotherapy Research 2012; ourselves from interpersonal hurt, but which Counselling and Psychotherapy. He is 22(2): 139–158. 10. Cooper M, Knox R. Therapists’ self-reported have now become self-defeating. For instance, author and editor of a range of texts on person-centred, existential and relational chronic strategies of disconnection in everyday as children, we may have gone quiet and life and in counselling and psychotherapy: an approaches to therapy. passive when we feared others were going exploratory study. British Journal of Guidance & For resources and training on relational Counselling 2017: dx.doi.org/10.1080/03069885.2 to hurt or reject us, and we may still do this depth, visit mick-cooper.co.uk. 017.1343457

THERAPY TODAY 32 NOVEMBER 2017 Turning point

‘Better to talk about it in the session with the client than for it to come back into their minds in the middle of the night, when there is nobody to listen’

had been working as a counsellor come into my mind, and I have taken a for a few years, and had been to a seminar deep breath and managed to speak these I where a colleague had described working thoughts, although hesitantly, and as a with a boy who had cancer. The boy spoke question. In every case, the atmosphere has about buying a motorbike when he came changed, there has been a palpable sense of out of hospital, and driving it really fast. I relief, and the work with the client has taken was surprised the therapist hadn’t asked a huge step forward. It has been clear that I him whether he wanted to kill himself; the have understood something that has worried therapist had said the boy wasn’t ready, that them for a long time, but they have felt unable he ‘couldn’t take it’. I would have asked him to share it with anyone. The thoughts have immediately, but I now worried that perhaps in themselves been frightening, but they I would have done some harm. have become less terrifying to the client after I told Hanna Segal, an older, more we have talked them through. Defences are experienced psychoanalyst, that I still indeed raised against fantasies or ideas that worried about saying the wrong thing to are worse than reality, not against realistic clients – what if I put an idea into their heads ones. The client and I have sometimes that they hadn’t had before? She said two been left needing to grieve for real losses, things that stayed with me. First, ‘if it has but there has also been a huge relief at the occurred to you in the session, it will already disappearance of the exaggerations. have occurred to them’. She said that pupils of Melanie Klein (like herself ) were taught to I now see this as part and parcel be more concerned about ‘leaving patients of counter-transference or projective About Julia alone with a worry’. Better to talk about it identification. Normally, when we share ideas Julia Segal has worked in the session with the client than for it to with a client, there is a natural to and fro of for 35 years as a come back into their minds in the middle unconscious communication that recognises psychoanalytically of the night, when there is nobody to listen. and acknowledges shared understanding. But informed counsellor, lecturer and trainer, ‘Defences are raised against frightening these particularly powerful ideas are blocked and is an author of ideas that are always worse than reality; by the client because they have some kind of numerous books. She you can help reduce them to a realistic terror attached to them. As a result, I think, we currently works in level,’ she advised. attribute them to ourselves alone, as if they north-west London as Putting this into practice was a revelation. had nothing to do with the client. It is this that a counsellor for people affected by neurological Time and again with clients, a clear idea has makes them hard to say. That is where the and other physical come into my mind that to me seems literally input of a more senior therapist is helpful; first health conditions. unspeakable – thoughts about a client being in supervision, but later, in our own minds, we Her latest book is The crazy; a client dying because nobody loved need to hear their voices casting doubt on our Trouble with Illness: How illness and disability him enough; a mother not loving her daughter. most disturbing assumptions and giving us affect relationships Time and again, Hanna Segal’s words have confidence in our role and capacities. (Jessica Kingsley, 2017).

THERAPY TODAY 33 NOVEMBER 2017 Media ON THE SPORTING COUCH Gary Bloom describes how his roles of therapist and journalist combine and collide in his radio show, On the Sporting Couch

he guest radio studio at Swansea recorded outside the cosy confines of the evening. I approached talkSPORT with the Sound is small and far from talkSPORT studio on London’s South Bank. idea of the programme, and they said, ‘Find glamorous or show-biz. However, the I had mixed feelings as the recording a guest and we’ll commission a pilot.’ sound engineer beamed with pride. progressed. First, I realised I was party to I approached a former Premier League T‘The equipment might be dated, but it works an emotional outpouring with which many player with whom I had done some just as good as the new-fangled stuff. You’ll listeners would connect. I hoped the ancient broadcasting work in the past. He’d had his have a decent show.’ He was right. equipment was working. I also felt the pressure fair share of ups and downs and I thought Rugby referee Nigel Owens was running to deliver a memorable piece of radio. There he’d support my idea for the radio show. He late. He couldn’t get his car out of his rural would be no session two next week, as there was polite, but said he didn’t know of any driveway as a tractor had blocked him in. normally is in therapy, and these are not players who’d be prepared to go public. After Nigel is probably the most famous rugby union therapy sessions in the usual sense, as they are putting the phone down to me, he called referee in the world these days, after officiating self-evidently not confidential. Nor are they another commentary colleague of mine and in the last World Cup Final. He’s only about really interviews. Think In the Psychiatrist’s reportedly said: ‘If Gary Bloom thinks he can 5ft 7in tall, but his witty put-downs of rugby Chair – the popular BBC Radio 4 programme find a sportsman or woman to go on the radio players who tower above him on the pitch hosted by Anthony Clare – but more relational, and admit they have mental health issues, he’s have become a YouTube phenomenon. and my subjects are all sporting celebrities. ******g mad.’ When he arrived, I noticed he was wearing In truth, there was very little about sport in I was not deterred. Boxing legend Sugar Ray an anti-bullying wristband. As the recording the show with Nigel Owens. His shame about Leonard once said, ‘Nothing could satisfy me of our conversation progressed, he became not ‘coming out’ dominated the programme, outside the ring… there is nothing in life that tearful as he described his early life when he and by the time we had finished, I felt close can compare to becoming a world champion.’ was bullied at school and how he struggled to tears myself. It was a strange goodbye. He Leonard would later suffer from depression to come to terms with his sexuality while was whisked away into the Swansea Sound after retirement from boxing, and he made growing up in rural south Wales. It was an newsroom to record an item on Welsh rugby. numerous attempts to reignite his career. extraordinary recording, during which he I was left struggling for words after such an Could I find my Sugar Rays? finally broke down as he explained how he intimate disclosure. There is some research to suggest that bitterly regretted the attempt he had made sportsmen and women who identify more on his life because he couldn’t deal with the Talking feelings strongly with their athlete persona are more shame of telling his parents he was gay. I first had the idea for the programme after likely to experience emotional adjustment I’m a sports journalist and practising spending a lot of my training hours in a men’s difficulties when they retire from sport.1 psychotherapist. I was in Swansea to record therapy centre in Oxford. A recurring theme Maybe, for these people, ‘going public’ is a programme I’ve developed with talkSPORT with my clients was: ‘As a bloke I find it difficult their way of dealing with these changes? radio called On the Sporting Couch, which to talk about my emotions’, yet many men talk So why not ask them? I did, of course, and aims to replicate as far as possible a 50-minute freely and with great emotion about sport. Just every one of my guests turned out to have a therapy session. Nigel was the first guest I’d listen to any football phone-in on a Saturday different motive for appearing on the show.

THERAPY TODAY 34 NOVEMBER 2017 ‘There is some research to suggest that sportsmen and women who identify more strongly with their athlete persona are more likely to experience emotional adjustment difficulties when they retire from sport. Maybe, for these people, ‘going public’ is their way of dealing with these changes?’ VCL/CHRIS RYAN VCL/CHRIS

THERAPY TODAY 35 NOVEMBER 2017 Most of the guests said they just wanted to The pilot show was aired in December pass on the message, ‘Don’t suffer in silence.’ 2016, and had such a good response that ‘It’s been a recurring Some wanted to give this message without talkSPORT asked for six more shows. Now the tension in these having to be too open about their personal radio station took over booking the guests and struggles with their mental health. used the show with Duncan Bell as a ‘calling interviews: the card’ to give an idea of what would happen broadcaster and New territory to prospective guests. We hoped some would My first guest was former England and Bath open up on air, but I never demanded that. therapist in me were rugby prop forward Duncan Bell. I got in touch I prepared by reading a guest’s sometimes at war; with him through Cognacity, the London clinic autobiography (if there was one), and then what makes good where I work. This was to be the pilot show. If it visiting them to make sure they knew what went well, and talkSPORT liked it, there might they were letting themselves in for. As with a radio versus what is be others. I was nervous, but not as nervous therapy session, I didn’t plan any set questions, good therapy practice’ as Duncan. and this allowed the radio shows to meander My fears were many and varied. I was in the same way a therapy session would, so it worried about what my supervisor might sounded less like a formal interview. If a guest drifting, I wondered if he simply didn’t want to say about me conducting an on-air therapy started talking about his or her schooldays, know. What came next was, for me the core of session; what my tutors at my training college I’d go with that. I always carry in my memory the whole session. I told Marcus that I felt like would have said, and also what might happen something my supervisor once said to me a bowler, and that each time I bowled a ball, if my regular clients heard the show. Should I back in my early days of training: ‘Gary, you he simply held up his bat in a block stroke. tell them about it, even? I took these concerns must wait with your clients at the bus stop. ‘I just don’t want to know what’s wrong with to supervision and was told, ‘This has never Don’t pick them up in a taxi!’ me – what good would it do me knowing?’ been done before with sports people. Create So I waited. he said. I said it might help him reduce his the rules, based on your training.’ So I did. Former England cricketer Marcus anxiety and depression. He dismissed me Trescothick was my next guest. He, like other with an ‘OK’. sports people who came on the show, each I had the overwhelming feeling that I was ‘I always carry in my for their particular sport, has become an threatening to disturb a carefully constructed ambassador for mental health in cricket, mechanism that had helped him keep his memory something working with the Professional Cricketers game together, and allowed him to continue my supervisor once Association. Our pre-interview chat took place to play competitive sport. I was instantly at the Oval in London. Marcus, immaculately reminded of our basic ethical principle as said to me back in my turned out, struck me as someone who therapists: ‘First, do no harm.’ I felt I was in early days of training: presented a good public image for the work danger of breaking down something that was he was doing to promote mental health. very necessary and important. I let it go. “Gary, you must wait At the peak of his cricketing career, Marcus Later, as I began to deconstruct the with your clients at had been hit for six by debilitating anxiety interview with Marcus in my head, I wondered the bus stop. Don’t about travelling abroad, which culminated why he’d agreed to do it. He’s an ambassador in an incident at Heathrow airport, when for mental health for cricket and maybe he pick them up in a he couldn’t bring himself to board a flight was willing to do as much as he could. Many taxi!” So I waited’ to Dubai with the rest of his Somerset team would shy away from that role, and Marcus colleagues. He’d had an idyllic childhood in has my respect and admiration. At the start of the recorded interview, Somerset, with Mum, Dad and sister, regularly The post-interview response was once again I told Duncan he could stop the session at travelling to local cricket games. Dad was a hugely positive, but I was left feeling that I had any time, and if he was uncomfortable with handy cricketer himself, and Mum made failed listeners by not pursuing my questions the recording, he could say so. Five minutes the teas. about his mental health. It’s been a recurring in, I asked him about his family. ‘Can we During the recording, I tried to discover why tension in these interviews: the broadcaster move on?’ he said. I capitulated. A therapist Marcus had these anxieties. He was evasive. and therapist in me were sometimes at war; colleague later told me she wished I hadn’t. I had previously re-acquainted myself with what makes good radio versus what is good Duncan went on to talk about what it’s Bowlby’s attachment theory, in readiness for therapy practice. like to live with anxiety and depression as a our meeting, but Marcus was ready for me. He professional sports person, and how, when answered all my questions politely, but without Revealing he eventually told his club and country, they opening even a chink in the well-developed In a later show, one of the world’s leading supported him unequivocally. His message armour he had constructed. Nor did he display darts players, James Wade, talked openly about was clear – without that support and the right any real curiosity about his condition. I might his social exclusion as a child and his fury at people to talk to, he probably wouldn’t still have been asking him why he had dark hair. the failure to diagnose his bipolar disorder be around to tell his story. With time running out and the recording and ADHD. He talked with extreme frankness

THERAPY TODAY 36 NOVEMBER 2017 Media

about his less than perfect childhood and understand why, and nor did he want to how his excellence at his sport had made a understand. I was left with the sense that, if huge difference to his life. However, as with I could have worked with him for longer, in all the sportsmen and women I interviewed, a more private setting, maybe it could have being at the height of his sport brought intense changed things for him. mental pressure that was hard to bear. He Another guest was former Olympic clearly felt misunderstood by the Professional swimmer Rebecca Adlington, who talked Darts Corporation, and that many of his about the online trolling to which she was brushes with them over his conduct could subjected about her physical appearance. have been handled better had there been a Rebecca is now running learn-to-swim Gary Bloom greater understanding about his diagnoses. clubs, as well as forging a new career as a About the author As a therapist, I wondered if his anti-social TV presenter. I was intrigued to understand Gary Bloom is an integrative outbursts were more of a message that no why she chose such a very public career, given psychotherapist working in one was listening to him. the online abuse she had already received. Oxford and at his Harley Street The recording with James was arguably Contrary to my male guests, ‘Becky’, as clinic in London. He also works the most powerful of the series, and probably she insisted I call her, didn’t strike me as in in schools in the south-east the closest I managed to get to the essence any great need of therapy. She’s bright and using a sport-based therapy to challenge behavioural and of what an on-air therapy session would be confident about who she is, has good insight academic underachievement like. I had visited James in Cardiff a fortnight into her feelings and motivations, and only in adolescents. before the recording, to give myself a chance wanted to be involved in the show to help www.abc-education.org.uk to get to know him better without the pressure other young women who were facing online of the recording light being on. There was trolling about their appearance. a real connection between us, and this was The recording took place in her home, in On the Sporting Couch has just won bronze at the replicated when we met again in the recording her upstairs lounge. ‘This is my private space,’ Arias national radio awards studio two weeks later. The response on social she said, before we began. I wondered if being in the Best Sports Programme media was hugely positive. James has a huge in her home would alter the dynamic between of 2017 category, and following and there were several messages us, and listening back to the broadcast, I felt I has been nominated in the Radio category for the of support from Twitter users who also have was slightly more friendly and chatty, rather Mind Media Awards 2017. ADHD and bipolar disorder. than therapist-like. Or perhaps I didn’t feel the Past programmes can be I wondered whether the radio show was need to challenge her thinking, given she does heard at talkSPORT.com/ therapeutic for James. He had been constantly that already, and is open to understanding sporting-couch told to ‘shut up’ by his teachers and his darts more about herself. organisation. The disclosure seemed to be Nearly all the people I interviewed had a REFERENCES part of coming to terms with something message to impart: ‘Don’t suffer in silence.’ 1. Lavallee D, Gordon S, Grove JR. unresolved. From my perspective, this That is exactly why I undertook the project. Retirement from sport and the loss of recording was by far the easiest. Eighty per cent of talkSPORT’s audience are athletic identity. Journal of Personal One of the hardest interviews was with men, the majority of them aged 35-44 – the and Interpersonal Loss 1997; 2: 129–147. former footballer Keith Gillespie, whose demographic most at risk of suicide. My motivation for doing the show was to warn hope is that a few of them might listen to young players of the temptation of gambling the show and think, ‘You know what, addiction. Keith managed to fritter away therapy isn’t so daunting.’ £7 million on gambling during his time as an elite player. He put it down to being both ‘bored and lonely’. But every time I tried to open up an emotional landscape for him, he quickly closed it down. It reminded ‘Former Olympic swimmer Rebecca Adlington, me of a first session with a client who is ambivalent about being in therapy, and who talked about the online trolling to which she isn’t particularly curious to look at their was subjected about her physical appearance. own material. Keith didn’t display any real curiosity, and I left the studio feeling a bit flat She is now running learn-to-swim clubs, as well and wondering if the recording had been as forging a new career as a TV presenter. I was worthwhile. My producer was positive: ‘His intrigued to understand why she chose such a reluctance to open up is the story,’ she said. She was right. So many things had very public career, given the online abuse she happened to him and he didn’t really had already received’

THERAPY TODAY 37 NOVEMBER 2017 STUDENT COUNSELLING – WHAT IS ITS FUTURE? Liddy Carver reviews current research on the Liddy Carver complex challenges facing student counselling About the author

services today Liddy Carver is a BACP-accredited counsellor. She works urther and higher education is in supporting these goals. With ever- as a counselling driven by ‘marketisation’ principles increasing numbers of students coming educator at Wrexham F– primarily, the need to maximise to them with more complex emotional Glyndwr University, volunteers at a student student numbers and minimise costs. and mental health support needs, how counselling service, This month’s Research into Practice do counselling services fulfil this role, and is Managing Editor examines the role of counselling services and should they even be trying to? of Counselling and Psychotherapy Research.

Current challenges for mental health support, as more collected data to be best used’. They describe a programme students from more disadvantaged Looking to alternative ways to instituted at a large, midwestern A very recent paper from a backgrounds, with poorer mental meet student need, the survey US university, and the paper offers research team at Sheffield health, are attending university. found a growing interest in online some good examples of ‘clinician- University helpfully sets the scene These students all bring higher peer support communities and friendly’ QI strategies suitable for with its comprehensive survey of needs, necessitating high-intensity mobile phone apps, but warns the further/higher education the challenges facing embedded therapies, and are now likely to there is currently no national sector. The university embarked higher and further education have much higher prevalence of system of quality assurance for the on a 20-year programme, led by a counselling services across the mental ill health than the general latter: ‘Users could benefit from QI co-ordinator who spent some UK, and how they are responding.1 population. More preventive having professional guidance on 6–8 hours a week introducing Broglia and colleagues programmes are needed to help the appropriate use of apps.’ QI strategies into routine clinical conducted an online survey vulnerable students manage their counselling practice and to of heads of UK counselling emotional health, Broglia and Quality improvement overcoming clinicians’ suspicions, services (113 out of a potential colleagues report. But there is an anxieties and resistance. 160 responded), to obtain optimistic assumption here that As in the UK, US universities and The service now has an ongoing comparative data on staffing, universities are a natural place colleges have also been trying programme of user satisfaction attendance at counselling to locate student mental health to find cost-effective ways to surveys, outcome studies, chart sessions, uptake of different kinds support. Many students with tackle escalating demand from reviews, evaluation surveys, and of support, and the use of new complex and risky presentations students for their counselling special intern research projects. technology as an alternative to need secondary care level services services. Maffini and Toth2 are The satisfaction questionnaires face-to-face therapy. but, with thresholds so high in enthusiastic proponents of quality have resulted in a reduction in A wealth of information the NHS, they don’t get access improvement (QI), frequently wait times to two days maximum, emerged from the responses (the until they are seriously unwell. mistrusted by practitioners and provide evidence to support article is Open Access, so readily University counselling services (ironically) as management requests for additional funding available). A finding of immediate can’t be expected to plug the gap bean-counting that sacrifices to meet unmet need. Outcome interest was that the current spike in the NHS by default. quality for quantity. Certainly, as measures provide clinicians in student demand appears to The authors say all services their article points out, QI is rooted with important feedback about coincide precisely with the need to be using validated clinical in the corporate sector (notably, effectiveness. Chart reviews introduction of student fees and outcomes measures in order to the Ford Motor Company). examine how well counsellors consequent increase in student inform service development debt. The survey also produced (not all were). There was, they ‘...the current spike in student demand data to support the hypothesis that say, ‘an absence of a culture of widening student participation has evaluation and a lack of strategic appears to coincide precisely with the in itself led to increased demand implementation that would enable introduction of student fees...’

THERAPY TODAY 38 NOVEMBER 2017 Research into practice document diagnosis, treatment ‘A primary issue rates. The overall conclusion, intimate relationships, compared and planning, and are now Bishop says, is that students at with 16.9% of online clients. Under completed by the majority of that college high-risk of drop-out may be the ‘intrapersonal goals directly clinicians. The requirement for counseling centers less likely to seek help and that related to others category’, 16% of all pre-doctorate students to face is that their university counselling services online goals related to the ‘fitting complete a QI project as part of have a clear duty to reach out and in’ subcategory, but none in the their studies has produced some principal goal is not, actively promote counselling to face-to-face counselling. very useful data, such as how and should not be, those likely to be most vulnerable. The study concludes that online international students view the counselling can avoid the stigma service and its cultural sensitivity, the retention Online options often associated with seeking which led to successful efforts to of students’ therapeutic support, meaning that reach out to these groups. If counselling services are to it can reach young people who Overall, Maffini and Toth meet escalating need within might otherwise struggle to talk conclude, clinician resistance to services and those who do not, reduced resources, inevitably about their problems face-to-face QI measures may be inevitable, but and whether students without the most cost-effective methods with a counsellor. But as to the it can be overcome through open diagnosed mental health problems for delivering counselling will direct comparison of the two and non-judgmental dialogue. QI benefit equally from counselling. be needed. Most university approaches: ‘Young people utilise is ‘about curiosity and exploration,’ From previous research, Bishop counselling services have online and face-to-face counselling they write. Start small, with a defines high-risk students as those introduced online alternatives to address different types of ‘doable’ project that addresses who are the first in their family of varied kinds, from instant therapy goals [and as] a way to a particular interest or concern to attend college, are from lower messaging to online video and access other types of support.’ for the service, and let the data socio-economic backgrounds, computerised, self-help CBT What matters then, is surely gathered lead its subsequent and with poorer academic packages. Terry Hanley and that they have that choice. growth and direction. performance in school. colleagues joined forces with the The study recruited 429 youth counselling service, Kooth, Ethics of student students. Low-risk students to compare what young people retention who received counselling aged 11-25 gain from online and were significantly more likely face-to-face counselling.4 Get in touch In another US study, Kyle Bishop3 to complete their studies than The researchers used an If you’re interested in continuing this debate explored the ethical tension facing high-risk students who received exploratory mixed-methods or suggesting papers for university and college counselling counselling. However, high-risk design to examine the therapeutic these pages, please email services who may feel under an students who had counselling goals identified by the young Liddy Carver at research@ obligation to support their college’s were no more likely to complete people using the Kooth counselling thinkpublishing.co.uk primary aim to retain students their studies than other high-risk services, whether online or face when it might be a better personal students who did not. Nor did to face. Data were taken from the choice for a student to leave: having more counselling sessions organisation’s Counselling Goal REFERENCES ‘A primary issue that college reduce risk of drop-out among System (CoGS), which encourages 1. Broglia E, Millings A, Barkham counseling centers face is that their high-risk students. Interestingly, clients to set goals for counselling M. Challenges to addressing principal goal is not, and should there were no changes – no clear and enables their progress to be student mental health in embedded counselling services: a survey of not be, the retention of students. It spikes – in risk throughout the assessed quantitatively. UK higher and further education would be unethical for counselors students’ college careers where More personal growth goals institutions. British Journal of Guidance & Counselling 2017; to attempt to retain students who intervention might be most helpful. (46.05%) were identified online http://dx.doi.org/10.1080/0306988 were disrupting the college Several messages emerge. One than in face-to-face counselling 5.2017.1370695 community or emotionally is that, even with counselling, (28.85%). Emotional wellbeing 2. Bishop K. The relationship between retention and college unable to succeed in the high-risk students are more likely goals were more frequent in counseling for high-risk students. college environment.’ to drop out than low-risk students. face-to-face counselling (35.58%) Journal of College Counseling Bishop’s study goes to the The reasons may be several, than online (16.32%). Most online 2016; 19(3): 205–217. 3. Maffini CS, Toth PL. Quality heart of this ethical dilemma Bishops says: ‘... high-risk students issues related to improving improvement in university by exploring four questions: the may have lower resiliency, may relationships with friends (61.80% counseling centers. Journal of College Student Psychotherapy impact of counselling services be less responsive to counseling versus 24% face-to face), while the 2017; 31(1): 43–58. on retention; at what points might intervention, may be facing more most common goal in face-to-face 4. Hanley T, Ersahin Z, Sefi A, Hebron high-risk students benefit most severe issues, or may be less counselling was improving J. Comparing online and face-to- face student counselling: What from extra, targeted counselling proactive about seeking counseling relationships with family (76% therapeutic goals are identified support; the differences in intervention than their peers.’ versus 21.35% online). None of and what are the implications for retention rates for high-risk Ethnic and cultural variables have the young people in face-to-face educational providers? Journal of Psychologists and Counsellors in students who use counselling also been shown to affect retention counselling set goals related to Schools 2017; 27(1): 37–54.

THERAPY TODAY 39 NOVEMBER 2017 any choice in the matter. Hence, we can never guarantee strict THIS MONTH’S confidentiality. In doing so, Ruth failed to achieve appropriate and fully informed consent. Therefore, DILEMMA: a rupture in their therapeutic The police have requested access to my case notes alliance may be inevitable.

Seek legal advice oug comes from an him if he doesn’t change. He into the pregnancy, after Dabusive family and thinks things will settle down a particularly violent Vernon Cutler presents in therapy with once they have the baby. argument, Doug’s wife MBACP (Accred) difficulties in his marriage. Doug’s therapist, Ruth, leaves him and reports Counsellor and He repeatedly gets angry who is in private practice, the incident to the police. psychotherapist in with his wife, and has hit has been keeping thorough Subsequently, Ruth receives private practice her on several occasions. He records, including details of a request from the police to My first advice to Ruth is to believes she provokes the the abusive behaviour, and see her case notes. contact her insurer with a view attacks by belittling him and has filed these in his case Ruth thinks her primary talking back. However, he notes. She explained this duty of care is towards to seeking legal advice, and ask admits that he has a ‘short when she contracted with Doug. She also fears that, that they recommend a solicitor fuse’, and he feels remorseful him, and told him the records if she releases his case and meet their fees. after each incident. Doug’s were strictly confidential notes without his consent, Beyond that, however, is the wife is now pregnant. She Eighteen months into this will rupture their issue of Ruth’s initial contract has told him she will leave the therapy, and six months therapeutic alliance. with clients. When I contract with clients, I make it clear that, while I will respect their confidentiality, WHAT SHOULD RUTH DO? which includes any notes that Please note that opinions expressed in these responses are those of the I keep, ultimately, I will not writers alone and not necessarily those of the column editor or of BACP. disobey a court order. My advice to Ruth would be to seek legal representation and to resist the police request to access her Missed opportunities Neither supervision nor CPD brief factual session notes to records until her legal position is provided Ruth with a better avoid the risk of inaccuracies. clarified or she receives a court Jill Swindells MBACP understanding of the issues While we have a duty of care order demanding the release of Person-centred counsellor and inherent risks for Doug, his to our clients and no legal duty to her case notes. in the criminal justice system wife or herself. For example, report, we need to balance these Hopefully, if Doug is able (victims and offenders) and SafeLives’ Quick Start Guidance against protecting others from to recognise that Ruth has pre-trial therapy trainer suggests physical violence often harm. Ruth’s client contract should defended his confidentiality to In my experience, from my worsens during pregnancy. have included the possibility the best of her ability, then the training workshops, therapists There is no specific guidance that she might need to break therapeutic relationship need and supervisors are often from the Crown Prosecution confidentiality, both to protect not be ruptured. But, ultimately, involved in forensic practice Service (CPS) for working others and if required by a court of Ruth cannot disobey a clear legal without realising it. We need to therapeutically with clients who law. Ultimately, refusing an access requirement. Moreover, to do recognise that clients (victims, disclose their own or others’ request from either the police or so would not only compromise witnesses or offenders) who crime(s). However, I believe it the CPS is likely to result in all notes her professional position, but, disclose criminal behaviour is advisable to follow the CPS and records being subpoenaed, so by implication, her relationship might become involved with guidance on pre-trial therapy neither Ruth nor Doug would have with her other clients. the criminal justice system and for vulnerable or intimidated subsequently appear in court. adult witnesses. How we subsequently work In particular, as it is not our ‘We can never guarantee strict needs to be carefully considered, role to investigate, we should reassessed and possibly avoid both extensive discussion confidentiality. In doing so, Ruth failed re-contracted around, with of events and making detailed to achieve appropriate and fully informed a potential trial in mind. records. Ideally, we should Unfortunately, opportunities document first disclosures consent. Therefore, a rupture in their were missed over the 18 months. verbatim, and thereafter make therapeutic alliance may be inevitable’

THERAPY TODAY 40 NOVEMBER 2017 Dilemmas

Working beyond could be argued that she will be ‘By not explaining advise her whether she must her competency colluding with Doug’s behaviour accede to the request, as normally by protecting him and potentially to Doug, from the only court orders must by law be Anne Embury MBACP normalising it. Her reluctance beginning, that his honoured. Ruth needs to know the (Snr Accred) could also be the result of her wife’s safety is more law relating to cases of abuse. This Counsellor and Suicide own fear that Doug may divert his is even more vital where the client Liaison Service Lead, aggression towards her, projecting important than is both the abuser and abused Outlook South West blame on her for his actions, (historically, in Doug’s case). My concern is that Ruth is instead of taking responsibility. his confidentiality, The request is the legal working outside of her skills and Doug may feel the confidentiality Ruth has provided a manifestation that private competence levels. In seeking to agreement should shield him, space, not of safety, violence needs public exposure. build a therapeutic alliance by irrespective of his violent This is an opportunity for Doug demonstrating the core condition behaviour, which is not the case. but of the very to deal with the rage he carries of unconditional positive regard I understand the need secrecy in which from his abusive birth family. Now for her client, Ruth may have to maintain a therapeutic is the time for Ruth to use the unintentionally colluded with relationship and that this engages abuse flourishes’ therapeutic alliance to help him Doug’s belief that his wife’s clients and nurtures change. to break his cycle of violence. She behaviour is the cause of his However, the initial boundaries of Regarding the police request could engage seriously with him violence towards her. confidentiality can be referred to for her case notes, Ruth should to help him to find ways to control I am also fearful for Ruth’s here: safeguarding is the priority. phone her professional indemnity his violence and explore a future personal safety. As Doug’s belief insurer’s legal helpline. They will with his pregnant wife. has been that Ruth’s notes were Strictly confidential? strictly confidential, he could be justifiably angry with her. He has Jonathan Harris a known history of violence and UKCP (Reg) March’s dilemma: admits to having a ‘short fuse’. Psychotherapist, Ruth works in private practice. Combe Martin, Devon Elsa has been a counsellor uncovered memories of She needs urgently to seek advice We can praise Doug for coming in private practice in severe childhood sexual from her supervisor to support to therapy and sticking with it Sheffield for 15 years. abuse. As a result, they are her and provide guidance, and for 18 months. Sadly, however, She is conscientious in now working intensely, she should also review her it hasn’t stopped him hitting his her support of vulnerable in twice-weekly therapy. clients in their slow journey In addition, the foster personal security. wife, although the phrase ‘violent to a fully functioning life. parents of a child she has argument’ might not mean physical Elsa restores her been working with have Safeguarding priority violence. Has Ruth been afraid of equanimity by walking in the suddenly and unexpectedly ‘talking back’, like Doug’s wife, Lake District, where nature announced they are giving Ellie Luscombe MBACP so not addressed his violence? refreshes her soul and fires up fostering next month, Integrative counsellor in Ruth told Doug her notes are her imagination. During on health grounds. Elsa is private practice in London ‘strictly confidential’, which is her long walks, she often aware she will then be the This dilemma immediately brings seriously misleading and leads me receives the insights that only stable presence in this to mind the first session I have to wonder about her competence. lead to her best client work. child’s life. with clients, where I talk about She considers her primary duty Elsa applied for, and has just been offered, a confidentiality and the potential of care is towards her client, but counselling job in Cumbria. breaches to it: serious risk of harm seems unaware that, legally, public She would like to take to self or others. In this case, this interest overrides individual client WHAT CAN the plunge and move ELSA DO THAT applies to Doug’s wife and unborn confidentiality. The rights of the north, but her new WOULD BE BEST child. There is a clear professional unborn child and his partner employer would FOR HER AND FOR HER obligation here to breach rightly trump Doug’s right to like her to take CURRENT CLIENTS? confidentiality, as the safety of confidentiality. By not explaining up her post as Please email your responses Doug’s wife and baby are at risk. to Doug, from the beginning, that soon possible – (300 words maximum) to John Daniel The consequences for Doug his wife’s safety is more important within a month at [email protected] by in this scenario are the loss of than his confidentiality, Ruth has at most. 3rd January 2018. The editor reserves the important relationships with his actually provided a space, not of A few months right to cut and edit contributions. Readers ago, a client are welcome to send in suggestions wife and unborn child. Maybe safety, but of the very secrecy in who has been for dilemmas to be considered for experiencing this could be a which abuse flourishes. She can seeing Elsa about a publication, but they will not be turning point for him. If Ruth put this right now by going into bullying line manager answered personally. resists the police request, it this in great detail with Doug.

THERAPY TODAY 41 NOVEMBER 2017 My ideal supervisor If you’d like to join In this month’s Talking Point, we asked our Talking Point panel, email therapytoday@ readers to tell us what qualities they look thinkpublishing.co.uk for in their supervisor, and why

Mo Perkins Karin Brauner Family relationship coach, therapist, supervisor and trainer Bilingual integrative counsellor in private practice and part- It’s really important to me that my supervisor has time care worker with children already achieved everything I am trying to achieve. with disabilities My ideal supervisor is someone who They need to be several steps ahead of me, based on can offer the qualities of holding and supporting me along with challenging the principle that you can only take your client as far and telling me what is what: someone as you have gone yourself. You can’t pull people up if who allows me to talk about my mistakes, to rant and ‘go off on one’; you’re on the same level. So, for example, they would someone who is compassionate, have to be running a thriving counselling/coaching caring and empathic, and gives me a chance to explain what I mean if business, and be creative and forward-thinking. Obviously, I haven’t done so clearly. It’s very they also need to have heaps of knowledge and skill in important that I don’t feel I have to censor myself in supervision – that I working with families, using a fusion of coaching and can say whatever comes into my head therapy. They need to be able to challenge, support and about my clients or what is going on in the room, and that the supervisor develop me in all the areas in which I practise. I currently will listen and explore that with have a separate business coach – I find it helpful to have me, and not judge me. My current supervisor is very good at modelling those two perspectives – but, ideally, I’d like all of that self-care and self-awareness, which I wrapped up in one person. think is important. She is also good at checking that I am OK with what she has said, and if something hasn’t been right for me, she cares and she wants to fix it. She’s willing to accept John Bassett it if I feel she has got it wrong. She Psychodynamic psychotherapist in private practice also listens if I need to vent about my The best way to describe what I look but I come out feeling somehow personal stuff, and share something for in a supervisor is to talk about the rinsed, and knocked about a bit. I of herself in that too. Looking at one I’ve got. I walk in the room and appreciate her ability to put her finger what I don’t want in a supervisor, we’re working straight away. But she on the unconscious processes going I don’t want them to use the space also provides space for me to reflect on between me and the client, and to process their own stuff – the place and think. I want that space to think pinpoint my unconscious defences and time for that is in their own about what is going on in the room and where I may be colluding with therapy. And I need my supervisor between me and her, and between the client to avoid certain issues. to meet me where I am – I’ve had me and the client, as well as to be She’s also often slightly ahead of supervisors who have delivered a challenged. Our sessions are very the curve – she can spot things in a double message, pushing me to go full; it’s very subtle how she works client’s presentation that I haven’t seen beyond my skills and competence, yet also undermining me.

THERAPY TODAY 42 NOVEMBER 2017 Talking point

Caz Binstead Counsellor and mindfulness- based cognitive therapist in private practice, and supervisor on a clinical training programme A really important quality for me in a supervisor is someone who embodies openness and curiosity within a contained, ‘It’s really important to me that my supervisor trusting space. It is paramount to me that I feel safe enough has already achieved everything I am trying to to fully explore my client work, achieve. They need to be several steps ahead of the intersubjective relationship, and myself when relevant. This me... on the principle that you can only take means good boundaries, strong your client as far as you have gone yourself ’ grounding in experience, a non-judgmental attitude and SHUTTERSTOCK a lightness of touch. I don’t want someone who tells me Darren Magee what to do, but they need Integrative counsellor and supervisor in private practice to have the confidence and I’ve been seeing my current supervisor for several years. That continuity knowledge of me as a person and familiarity is important because it means she doesn’t just know my and a therapist to support and working methods and practice, but she knows me, in a wider sense, so is also challenge and inspire me. aware of other factors that may be influencing my work at that moment. So, I find these characteristics in if I’m talking about a client I’m having difficulties with, she can bring the my two supervisors, who both, conversation back to what it is bringing up in me that I haven’t thought of, and individually, bring important she can help me tap into other skill sets and other strengths that I can draw ‘extras’ that I find useful. One of on, as well as my counselling skills. She is also very versatile – she has been my supervisors knows the BACP able to adapt to my needs when I’ve been in other roles – in management ethical guidelines like the back positions, for example. She can draw on a vast range of models of supervision. of her hand, and helps me bring She was recommended to me by a colleague who said, with a bit of a glint them to bear on my practice. The in his eye, that she could be quite ‘motherly’. I realised when we met that other is a chartered psychologist he didn’t mean apple-pie motherly, more Mary Poppins – apple-pie with a as well as a psychotherapist, and hint of steel. he challenges me intellectually.

Nicola Logan Person-centred, integrative counsellor and supervisor, working in private practice and in an NHS occupational health service coming, before it’s even manifested My ideal supervisor needs to know where I’m coming from: they need to be in the session. I work a lot with trained in, or have a good understanding of, person-centred practice. When metaphor and symbolism, which she I was training, the tutors used the metaphor of a harbour – they held us so we encourages, but also keeps in check; could take risks and learn in a safe place. Supervision continues to provide I like that light and shade. I have a me with that harbour, that place of calm and reflection where I can talk things colleague who has two supervisors, through and work out my strategies before going back out into the stormy one Freudian and one Kleinian, and waters. I have to feel a rapport with my supervisor. Genuineness and honesty she takes the same clients to both; are very important, and a readiness to challenge me. I also want them to be she says it helps her find where she able to walk the walk and talk the talk – to speak from experience. I’ve had is between them. I think there is several supervisors; they’ve all been very different. To me, it’s like following a definitely some value in that. line of lanterns down a path. As a supervisor myself, I believe that when you become aware that you are no longer meeting the needs of your supervisee, you have to have that conversation, and light them on their way.

THERAPY TODAY 43 NOVEMBER 2017 Self-care

‘Therapeutic work in Cambodia, a post-genocide nation, is very demanding, and vicarious trauma certainly takes its toll’

HOW DO YOU TAKE CARE OF YOURSELF? Lynne Barnett immerses herself in photography to relieve stress and refresh her focus

Figen Murray’s article on self-care self-care. This wise young woman pointed out (May, 2017) made me smile. I bring similar that, as an educated person, I should know knitted teddy bears to Cambodia, where I better. She said that having such compassion currently live and work as a volunteer. They was wonderful, but not if it caused burnout. are made by a team of wonderful knitters She paraphrased my own words. I was indeed from churches in the UK, who have found new confusing my learners. The catalyst for change meaning, purpose and value in life through was her parting comment: ‘Anyway, sister, you reaching out in this way to the children here in cannot die until you finish teaching me. So Cambodia. They call it their ‘knitting ministry’. please self-care!’ About Lynne Therapeutic work in Cambodia, a post- So, mindful of her warning, I have since genocide nation, is very demanding, and actively improved my self-care strategies. Lynne Barnett is a counsellor and vicarious trauma certainly takes its toll. Part A ‘camera day’, as I call them, helps me lose Director of the Centre of my role is teaching self-awareness and myself in nature and creativity. I thoroughly for Health Counselling self-care, but tending to my own needs is often enjoy photography and use the photographs at the University of the first thing I overlook when faced with the to complement my creative reflective writing Puthisastra, Phnom absolute poverty and enormous need around – another love of mine. As my eye fixes on a Penh, Cambodia. She me. To me, the historical and current trauma subject through the lens, my stress just drifts has lived in Cambodia in Cambodia is on a par with a metatastic away and I refocus on beauty. There is such for three and a half years, and has been growth or nuclear fallout. a thrill in capturing those precious scenes volunteering there Recently, one of my Cambodian trainees and interactions, and in so doing, I refresh on short-term visits challenged me on this double standard in my focus on life. since 2005.

How do you take care of yourself? Email [email protected]

THERAPY TODAY 44 NOVEMBER 2017 From the Chair

‘We will continue to robustly question both the methodologies used by NICE to derive its recommendations and the recommendations themselves. We are not prepared to accept that counselling is a second-rate therapy for depression’

ack in July, I raised the potential threat to counselling is perverse, because the NICE guideline aims to improve NHS from the current revision of the NICE guideline on treatment for adults with depression, and the IAPT data, which depression in adults. BACP was one of a number is massive and based on actual NHS patients, evidences how of mental health organisations that feared a repeat adults with depression experience NHS treatment. Why NICE Bof what happened in 2009, when we had to fight to stop should ignore these data is hard to understand. Notably, the counselling being dropped as a recommended intervention data also show that, in IAPT, counselling is just as effective for depression in the NHS. In September, I was able to give the as CBT. good news that counselling was back in the consultation draft. Third, network meta-analysis is a newer, highly complex The final revised guideline will be released in the New Year. form of meta-analysis – the best methods to do this are still But that doesn’t mean we can now put it all behind us. being debated and developed. With respect to the depression Counselling may be in the current draft guideline (and guideline, the NICE network meta-analysis relies on important this may still change before January), but it remains a assumptions that BACP believes may be flawed, casting doubt second-tier intervention for depression. CBT is still the on the trustworthiness of the findings. Given that different primary, preferred option, and counselling is recommended conclusions about ‘counselling’ were drawn by three other only for mild-to-moderate depression. recent, major meta-analytic studies, the grounds for the BACP questions this, based on a number of concerns NICE recommendations for counselling seem shaky.1-3 about the NICE guideline process. I want to focus here on the We will continue to robustly question both methodology from which the guideline was derived. the methodologies used by NICE to derive its First, we question the statistical model used by NICE to inform recommendations and the recommendations its recommendations. Technically, it is known as a network themselves. We are not prepared to accept that meta-analysis of randomised control trials (RCTs). Professor Pim counselling is a second-rate therapy for depression. Cuijpers, considered the world expert on RCTs on treatment of adult depression, has recently argued that there can be no REFERENCES

confidence in the findings of any RCTs of treatments for adult 1. Cuijpers P. Are all psychotherapies depression to date, nor in any meta-analytic study derived from equally effective in the treatment of adult them, because they are either too small, or they are influenced depression? The lack of statistical power of 1 comparative outcome studies. Evidence- by bias, or both. Yet the draft guideline nonetheless makes Based Mental Health 2016; 19: 39–42. confident assertions about ‘best’ treatments for adult depression. 2. Barth J, Munder T, Gerger H et Second, the guideline recommendations exclude evidence al. Comparative efficacy of seven psychotherapeutic interventions for

CHARLIE BEST from large practice data sets – including IAPT’s own data. This patients with depression: a network meta-analysis. PLoS Medicine 2013; 10(5): e1001454. 3. Linde K, Rücker G, Sigterman K et al. Comparative effectiveness of psychological treatments for depressive disorders in email Twitter primary care: network meta-analysis. [email protected] @Reeves_Therapy BMC Family Practice 2015; 16(1): 103. @BACP

BACP board and officers

Chair Andrew Reeves President David Weaver Interim Deputy Chair Caryl Sibbett Governors Natalie Bailey, Eddie Carden, Sophie-Grace Chappell, Myira Khan, Andrew Kinder, Vanessa Stirum, Mhairi Thurston Chief Executive Hadyn Williams Deputy Chief Executives Cris Holmes, Nancy Rowland

THERAPY TODAY 45 NOVEMBER 2017 BACP round–up

Our monthly digest of BACP news, updates and events

New member logos

You can now download your stationery printed with your old new-look logos and certificates logo on, or you’re not able to from the members’ area of our update everything straight away. Plan your CPD for 2018 website, to promote your work We’re hoping to have completed Why not start planning your 2018 CPD schedule to the public. Your new logo the changeover to our new look by registering your interest for some of our incorporates the same information by the end of 2017, so if you could conferences and events? as your current one, but has been aim for the same deadline, that Highlights for 2018 include our children updated to reflect our new look. would be really helpful. and young people conference, ‘Working If you have an entry on our Find Going forward, we’ll be with Children in their World: a practitioner’s a Therapist directory, your logo contacting you more by email. response’, on Saturday 24 February in London. there has also been updated. To help us keep in touch with you On Thursday 8 March, in Manchester, we’re When you’ve downloaded your about your membership, please holding an event called ‘Working Effectively new logo, you’ll be able to start make sure you have your most with Trauma in Healthcare Settings’. using it on your own website and up-to-date email address saved We’re looking for members to present at stationery. Don’t worry if you have in the members’ area. these events, so if you’d like to deliver a session, email [email protected] Our 24th Annual Research Conference is on 11–12 May in London, titled ‘Counselling Our response to Changes Lives: research that impacts practice’. NICE guidance We’re delighted that Professor Robert Elliott We’ve recently responded to (University of Strathclyde) is to present the the draft NICE guidance on Friday keynote address on ‘Evidence and Politics depression in adults, which was in the Humanistic-Experiential Psychotherapies: published for consultation in a love-hate story’, and Professor Dr Pim Cuijpers July. We raised many concerns (Vrije Universiteit Amsterdam) will be our with the proposed guideline, keynote speaker on Saturday, with a paper on including NICE’s privileging of ‘Four Decades of Research on Counselling for RCT evidence, failure to include Depression: directions for the future’. A key large, standardised, routine topic of discussion will be how research from datasets, and assumptions of the cost-effectiveness routine practice can provide new insights into of the recommended interventions. the therapeutic process. You can read our full response on our website, at www.bacp.co.uk/policy/campaigns If you’d like to attend any of these events, Thank you to all members who shared with us your views email [email protected] or call us on on what the proposed changes mean for you and your clients. 01455 883300.

THERAPY TODAY 46 NOVEMBER 2017 Nancy Rowland leaves BACP Nancy Rowland, Deputy Chief Executive Officer for the past two years and before that Director of Research, Policy and Professional Practice, is leaving BACP. She has been with the association since she was appointed Head of Research in 2003. Announcing her decision, Hadyn Williams, BACP Chief Executive Officer, said: ‘After more than two years of transformation at BACP Self-care guidance at the senior leadership level, and To mark World Mental Health Day on Tuesday 10 October, we asked members after 13 years’ service in research, to tell us how you take care of yourself. The theme this year, set by the World policy and professional practice, Federation for Mental Health, was ‘mental health in the workplace’. Nancy has decided it is now time We thought you would like to know some of the things members told us. to leave BACP. While this will be a Heather Coppell, a student member from Wrexham, said: ‘I try to walk daily, at least massive loss to the organisation, 20 minutes, and hike up mountains on a weekend, also doing something creative.’ Nancy has promised to remain For registered MBACP Sara Matthews, the recipe for self-care is: ‘Know my early connected to us and will continue warning signs that there are unmet needs or feelings. Work four days a week only. to promote BACP and everything it Hoover (weird but true). Time alone. Cats.’ Jo Allen, student member from Derby, stands for with her usual vigour and said: ‘Pacing myself and planning my day and working week carefully. Trying to passion. I know you will want to join get outside, even just for 10 minutes a day.’ me in wishing Nancy success and We’re putting together some guidance for members on self-care. This resource happiness for the future.’ is now ready for review and we’re looking for members who would like to join Cristian Holmes has been a focus group to give us feedback on how it might be improved. If you’d like to appointed to a new, combined be involved, email [email protected]. We expect to publish the guidance role of Deputy Chief Executive towards the end of the year – we’ll let you know when it’s available. and Chief Operating Officer.

Older people and mental health We recently carried out a survey group would be open to counselling or looking at whether older people psychotherapy if it was recommended. seek help from health professionals Our President, David Weaver, said: for anxiety or depression, and what ‘Older people with common mental response they receive when they do so. health conditions are more likely to Worryingly, more than half those be on drug therapies and less likely to aged over 55 who had sought help be receiving psychological treatment, from a healthcare professional with compared with other age groups. This symptoms of depression and nearly isn’t fair, and we want to see increased two-thirds of those with symptoms of access to psychological therapies for anxiety weren’t referred for counselling our ageing population.’ or any other talking therapy. Yet the Read more about the survey on survey also showed that 68% of this age our website at www.bacp.co.uk SHUTTERSTOCK

THERAPY TODAY 47 NOVEMBER 2017 BACP round–up

Royal reception BACP members were among the 350 to so many going through difficult guests who attended a reception at times in their lives. Buckingham Palace on World Mental The Duke of Cambridge said: ‘You Health Day, 10 October, to recognise have all been invited to the palace and celebrate their work and that of their to recognise that, in the UK, we now colleagues and professions in the mental accept that the health of our minds health sector. is as essential as the health of our Gender, We’re delighted to report that bodies. We know that none of the recent sexual and BACP members John Cowley, Myira work we have supported through our Khan, Debra Gordon, Martin Hogg, Heads Together campaign would have relationship Professors Sue Wheeler and John been possible without the people in diversity McLeod, Carmel Mullan-Hartley and this very room.’ Kate Anthony were among those Prince Harry said: ‘All of you helped We have just published a representing the counselling professions change the language around this new resource on ‘Gender, at the reception, which was hosted by issue, shifting away from fear and Sexual and Relationship the Duke and Duchess of Cambridge shame, to a more open and optimistic Diversity’ (GSDR), the and Prince Harry, in their roles as sense about what we can achieve first in a new stream of founders of the national Heads Together when we simply start talking. All of publications on Good campaign, to thank people in the you showed what is possible when Practice across the sector for the support they provide we get our Heads Together.’ Counselling Professions. The resource is written by Dr Meg-John Barker, Older people lead Senior Lecturer in Jeremy Bacon, our new Lead for Older Psychology at the Open People, joins us this month. University, therapist Jeremy will be taking work forward on and activist-academic this important strand of our strategy to specialising in sex, gender improve access to talking therapies for and relationships and older people. author of many academic Jeremy comes to BACP with a strong books and papers on background in mental health, advocacy these topics. and working with older people. His The resource explores previous job was Project Manager for current cultural attitudes the British Lung Foundation’s Breathe and understandings of Easy national network of support groups GSDR, offers in-depth for people with lung conditions. explanations of gender, Jeremy will be taking forward work on sex, sexuality and diverse the important strand of our strategy to relationships, and improve access to talking therapies for summarises key principles older people. and good practice for He said: ‘Leading the BACP’s Older culturally competent People Strategy is a task that I take on Jeremy will be presenting on counselling work in with relish. With over three million older ‘Psychological therapies for older this field. people in the UK living with a mental people’: public perception, barriers The resource is health problem, it’s vital that the value to access and the evidence’ at a major available for members of counselling and psychotherapy is conference on improving psychological to download free at understood and communicated to a therapies for older people, on 27 www.bacp.co.uk wide range of audiences.’ November in London. bit.ly/2zrM0WP

THERAPY TODAY 48 NOVEMBER 2017 Training curriculum for counselling young people We are pleased to announce that BACP’s Counselling Young People (11–18 Years) Training Curriculum is now available to download. This curriculum is an evidence- informed curriculum framework for working with young people aged 11–18 years. The curriculum is underpinned by BACP’s Competences for Humanistic Counselling with Young People (11-18 years) and is have successfully completed the Introduction intended for training providers who want to Counselling Young People (Stage 1), or PROFESSIONAL to deliver training courses for counselling for those who can evidence, via a formalised CONDUCT NOTICES young people in a variety of contexts. The APL procedure, that they have acquired curriculum is designed to be flexible to equivalent knowledge and understanding meet the diverse needs of different training through previous CPD and/or prior Findings, providers and potential students. experience of counselling young people. decision The curriculum is divided into three stages: Stage 3: Additional Subject Areas covers optional subject areas for higher level and and sanction Stage 1: Introduction to Counselling Young top-up awards. These subject areas can also Theresa Jacobs People is for post-qualified counsellors be delivered as CPD training workshops for Reference No: 552348 who wish to work towards a qualification qualified young people’s counsellors. Somerset BA1 in counselling young people, and also The complaint against the for current counselling students on adult- The curriculum and competences can above individual member/ focused, accredited training courses who be downloaded from the BACP website. If registrant was heard wish to undertake some of their placement you have any questions or feedback about under BACP’s Professional hours with young people. the curriculum, please contact Caroline Conduct Procedure and the Stage 2: Formal Award in Counselling Young Jesper, Professional Standards Development Professional Conduct Panel People is for post-qualified counsellors who Facilitator, at [email protected] considered the alleged breaches of the BACP Ethical Framework for the Competences From May 2019, As with the Basic Young Counselling Professions. accredited courses that People Competences, the The Panel made a for working allow students to take elements in Stage 1 of number of findings and was with young up practice placements the young people training unanimous in its decision working with children and curriculum can be delivered that these findings amount people young people will need and assessed in three ways: to serious professional to refer to the elements in as a separate module/unit misconduct, given the During the development Stage 1 of the Counselling to the accredited course, behaviour of Ms Jacobs and of our Counselling Young Young People (11–18 years) as a distinct award, or in the gravity of the findings. People (11–18 years) Training Curriculum. collaboration with a CYP The Panel found some Training Curriculum, we We hope this 18-month placement provider. evidence of mitigation reviewed the Basic Young transition period will give All of the requirements in and would have imposed People Competences. accredited courses time our previous statement on a sanction had Ms Jacobs The outcome is a more to make any necessary CYP practice placements still been in membership. relevant and coherent adjustments before the remain the same. You set of competences for Basic Young People can find out more on our Full details can be found counsellors starting to work Competences are removed website at www.bacp. at www.bacp.co.uk/ with this age group. from our website. co.uk/accreditation prof_conduct/notices/

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THERAPY TODAY 49 NOVEMBER 2017 BACP round–up

BACP accreditation Newly accredited members, services and courses

We would like to congratulate the following Senior accredited Accreditation Barbara Penn on achieving their BACP accredited status: counsellor/ reinstated Louise Power psychotherapist William Hanmer-Lloyd Julie-Ann Scott Counsellor/ Joanne Marks Ian Tromp Helen Gerolaki Kate Sloan psychotherapist Jo Moloney Jennifer Smallwood Mary Sutton Joanne Allmand Sabrina Mudie Members not Gillian Thomas Zoe Aston Emma Mullaly Senior accredited renewing Williamina Winwood Clodagh Boyd Lorna Nash supervisor of accreditation Sharon Cassidy Maxine O’Brien individuals Counsellor/ New and renewed James Chapman Dominic Quinn Johanna Kosterink psychotherapist accredited services Caroline Chessher Sarah Saatzer Maeve Allison We would like Jane Chilvers Cecilie Sasu IACP/BACP Jocelyn Ashton to congratulate Timothy Dalton Colin Scott recognition of Nathalie Bearryman the following Katharine Edwards Ivana Sharp accreditation Susan Bentley organisational Christine Graham Elaine Sherrington counsellor/ Caroline Brown members on Melanie Hallows Johanna Sikkel psychotherapist Linda Cox achieving and/or Connie Harvey Billi Silverstein Collette Mayers Glynwen Lewis renewing their BACP Frances Jebb Nicola Springle Caroline Togher Pauline Low accredited status: Yvonne Jepson Polly Wong Sandra McDerment Services Lesley Kipps Francesca Mettam Mind in Tower Hamlets Karen Klosinski Alys Mikolajczyk & Newham (MiTHN) Sean Lowden Nick Papé Savana Inc Ltd

All of the details listed are correct at time of going to print. Please be aware that BACP may have more than one member with the same name. To check whether someone is a registered accredited member, please visit the BACP Register at www.bacpregister.org.uk/check_register For a full list of current accredited services and courses please visit the relevant BACP accreditation directories at www.bacp.co.uk/

EVENTS CALENDAR

27 November 14 February 8 March 24 March Professional Professional Working effectively with Professional development day development day trauma in healthcare settings development day Societal rape: myths Integrating artwork into Manchester Supervision: relationship, and traumatic reactions your counselling practice authority and ethics With Sally French With Pauline Andrew 12 March With Steve Page Norwich Norwich Professional Southampton development day 22 January 24 February Working with partners of 17 April Coaching specific client CYP Conference trans-identified people Working with critical groups, identifying your Working with children With Tina Clark incidents: prepared, not niche and marketing your in their world Cardiff scared – are you ready to offer effectively London respond? London Edinburgh

THERAPY TODAY 50 NOVEMBER 2017 The questionnaire

What do you do for self-care? when doleful, Leonard Cohen; when I practise mindfulness daily, do yoga, poetic, Dylan; when maudlin, Sandy running, the odd gym session; I share Denny; when spiritual, Bach; for Analyse food and talk with friends and family; dancing, ska and R&B; when romantic, I read and think; I’ve been in a blokes’ jazz standards like Ella. I no more have book club for 16+ years; I watch films a favourite music than I follow one and plays, walk, have an addiction therapeutic modality. to charity shops... the list goes on. What’s the longest you’ve seen Why do you think therapy works? a client? Therapy can only work if a client Over 10 years, with a few clients, and About Graham me is reached emotionally and feels they still mostly keep in touch, Often, contained, met, and, dare I say it, profound changes have taken place Now: a child and cared for, as well as understood. A later on, although, of course, with adolescent and Graham Music bit of experience in the therapist many clients, change is miles quicker. adult therapist. I also write (The Good Life helps, I think, and an odd mixture of speaks for himself And what’s the shortest? (Routledge, 2014); humility and confidence, but we have A few months, due to a mismatch (Nurturing Natures to remain alive, curious and able to I did not recognise sufficiently. In Routledge, 2016), Why did you become a therapist/ hold on to hope while never shirking truth, there was probably something teach, supervise, am a counsellor? For the right and wrong difficulty. Easy! about how I felt about them that I mindfulness teacher, and try to retain an reasons. I honed my initial skills in the What client presentation do was not able to acknowledge but cauldron of family life, where vigilance that got transmitted. ordinary life. I am an you most dread walking inveterate pessimist and predicting moods were assets. through your door? What’s the most recent therapy and cynic striving to Later, when some of my omnipotence Either of the polar opposites of very textbook you’ve read (and can be an optimist and subsided, I needed my own therapy, flat, dampened down people, or recommend)? open-hearted. and, grateful if still omnipotent, people often labelled as borderline I enjoyed Patricia Coughlin’s Formerly: I had an I risked venturing into this field. personality disordered. But dread Maximising Effectiveness in Dynamic entrepreneurial past – I have remained constantly also signals learning points and Psychotherapy (Routledge, 2016), I (mis)spent much of my 20s buying and fascinated and smitten ever since. challenge, which are always the a model that challenged me. I am selling antiques Where do you work? beauty of this work. now reading a very different sort of and bric-a-brac on I do some private work, mainly with What gives your life meaning? book, Deirdre Fay on Attachment- street markets. adults, at home, in a quiet basement Loving and being loved, friendship, based Yoga & Mediation for Trauma First paid job: consulting room. The bulk of my work and feeling enough inner security to Recovery (WW Norton, 2017) – but I stacking supermarket has been in NHS settings, for years explore, be curious and be stimulated always have a Winnicott book nearby. shelves. at the Tavistock and Portman NHS by new ideas. When will you retire? Trust, with maltreated children and What is your favourite piece of Hopefully, with my last breath! Retire young people, many of whom music, and why? really means retreating, and there is Who would you are also perpetrators. It depends on my mood. As Kit always a need for that in life, but even like to answer the How do you work? Bollas explained, music can be a if I don’t stay in the NHS for many questionnaire? Email Probably psychodynamic, but I transformational object, helping us more years, I hope always to your suggestions to the editor at hate silos and believe passionately find self-states we need to access. So, retain my interest and passion therapytoday@ that there is no best way of being a when fired up, it might be The Clash; in psychology and this work. thinkpublishing.co.uk therapist. For example, I integrate humanistic as well as mindfulness and other approaches, alongside psychoanalytic ones, and am especially influenced by the relational school and neurobiology. What’s your special interest? I have a passion for child development, neurobiology and What’s the most recent CPD activity you’ve undertaken? Was it worthwhile? linking new findings to clinical It was a yoga and meditation retreat in Umbria, practice. Currently, my interests centre on the body, addictive in a wonderful setting, with beautiful food, good states and capacities such as practices, nice people – what’s not to like? self-regulation and interoception.

THERAPY TODAY 74 NOVEMBER 2017