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Journal of Psychotherapy and Counselling Psychology Reflections Reflections Research Centre

Volume 3 Number 1 January 2018

ISSN 2054-457X


Editor

Editorial Board

Dr Maria Luca School of Psychotherapy & Psychology, Regent’s University London, Inner Circle, Regent’s Park, London NW1 4NS, UK

Dr Marie Adams, Metanoia Institute, London, UK Dr Meg-John Barker, Open University, London, UK Dr Michael Berry, McGill University Health Centre, Montreal, QC, Canada Dr James Davies, University of Roehampton, UK Dr Lisa Doodson, Regent’s University London, UK Dr Stelios Gkouskos, University of East London, UK Dr Ralph Goldstein, British Psychological Society’s Register of Psychologists specialising in Psychotherapy [with senior status], UK Professor Brett Kahr, Tavistock Relationships, Tavistock Institute of Medical Psychology and Regent’s University London, UK Dr Elaine Kasket, Regent’s University London, UK Professor Desa Markovic, Regent’s University London, UK Professor Martin Milton, Regent’s University London, UK Dr Lyndsey Moon, University of Roehampton, UK Dr Christina Richards, Nottinghamshire Healthcare Foundation NHS Trust, UK Dr Michael Worrell, Central and North West London NHS Foundation Trust, UK

lucam@regents.ac.uk

Managing Editor Professor Helen Cowie Emeritus Professor, Faculty of Health and Medical Sciences, University of Surrey, UK h.cowie@surrey.ac.uk

Book Reviews and Series Editor Jane Wynn Owen janewynnowen@btconnect.com

Editorial Assistant Shirley Paul School of Psychotherapy & Psychology, Regent’s University London, Inner Circle, Regent’s Park, London NW1 4NS, UK pauls@regents.ac.uk

International Editorial Advisory Board Dr Geoff Denham, La Trobe University, Melbourne, Australia Dr Andrew Geeves, Macquarie University, Sydney, Australia Dr Theodoros Giovazolias, University of Crete, Greece Dr Dennis Greenwood, University of Brighton, UK Dr Martin Lečbych, Palacký University, Olomouc, Czech Republic Professor John Nuttall, Regent’s University London, UK Andrea Sabbadini, British Psychoanalytical Society, London, UK Professor Carla Willig, City, University of London, London, UK

Aims and Scope The Journal of Psychotherapy and Counselling Psychology Reflections (JPCPR) is an international peer-reviewed journal, underpinned by the aspiration for a non-doctrinaire, pluralistic attitude to psychotherapy and counselling psychology. It aims to provide a forum for open debate and encourages submissions from different traditions, epistemological positions and theoretical modalities enabling the development of a more open, reflective thinking to

philosophy, theory and practice of psychotherapy and counselling psychology. JPCPR encourages critical, broad and experimental interpositions in discussions on psychotherapy and counselling psychology. It tends to transcend the methodological and metatheoretical divisions. We welcome submissions using both quantitative and qualitative methods, including ethnographic, autobiographical, and single patient or organisational case studies.


Journal of Psychotherapy and Counselling Psychology Reflections Volume 3 • Number 1 • January 2018

CONTENTS Editorial............................................................................................................................................................ 2 ‘Supreme Values Reside in the Soul’ - Reflections on Values and Psychotherapy John Nuttall....................................................................................................................................................... 3 Training High Intensity CBT Therapists in Other Modalities of Therapy: Can We Change Their Minds? Michael Worrell, Rebecca Samuels and Rita Woo................................................................................ 9 Diagnosis and Recovery: Twin Impostors of Mental Health? Ralph Goldstein ............................................................................................................................................ 17 How do People Understand their Engagement in Sado-Masochistic Sexual Activities? Julie Burchill and Desa Markovic............................................................................................................ 23 My Experience as a Trainee on an Integrative Training Programme Adam Knowles.............................................................................................................................................. 29 Feelings from Training: Angst, Annoyance, Infantilisation and Sadness Ben Scanlan................................................................................................................................................... 31 Conference Report Spirituality, Compassion and Mental Health Conference Chris Burford................................................................................................................................................. 33 Book Reviews............................................................................................................................................... 35 Author Information...................................................................................................................................... 37 Announcements.......................................................................................................................................... 39

regents.ac.uk/reflections


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EDITORIAL This month, the Journal of Psychotherapy and Counselling Psychology Reflections is celebrating its second anniversary with the publication of its fifth issue. The contributions continue to reach the scholarly standards we aim for and include research and theory papers authored by experienced clinicians, academics and trainees. Regular readers of this journal will notice the depth of topics covered. I have taken this opportunity to refresh other aspects of the journal and introduce a couple of new sections. In addition to the usual peer-reviewed articles, there is a section exploring the experience of trainee psychotherapists. These articles offer insights into the challenges students face during their long training. Adam Knowles discusses his experience as a trainee on an integrative training programme, while Ben Scanlan reflects on his own student experience by way of analysing his encounters with angst, annoyance and infantilisation during training. I encourage more therapists to submit brief papers that sketch their own encounters with training. So to this issue. In the first article, John Nuttall discusses values and how they apply to the psychotherapeutic endeavour. He states that, ‘Values embrace the broader principles associated with living and being in the world’ (p. 3). He proposes that supreme values reside in the soul of each psychotherapist and influence the way that they perceive, understand and approach their work. Michael Worrell’s paper addresses a quantitative and qualitative investigation into the experience of trainee high-intensity CBT therapists who engage in a brief training programme concerning ‘other modalities of therapy.’ According to Worrell, ‘[this] paper explores the extent to which participation in this training changes trainees’ minds regarding the relevance of these modalities to their practice as CBT therapists’ (p. 9). The author believes that a more open dialogue between CBT therapists, IAPT workers and the ‘wider field of psychological therapies’ (p. 15) requires a change in attitude

amongst those who train high-intensity CBT therapists so that they might better dialogue with trainers from other treatment modalities. The next article focuses on the question of whether ‘diagnosis’ and ‘recovery’ might be the ‘twin imposters of mental health’. To this end, Ralph Goldstein invites counselling psychology and psychotherapy professionals to modernise their classification procedures: ‘Two developments will be suggested here. Firstly, that both diagnosis and recovery may be conceived — indeed must be — in the same pragmatic manner by adopting a functional approach both to diagnosis and to recovery’ (p. 17). He argues for the need to ‘find a psychological and psychiatric methodology that is consistent with evolutionary biology’ (p. 17). Julie Burchill and Desa Markovic delve into people’s understanding of their own willingness to engage in sado-masochistic sexual activities. The article is based on an ‘Interpretive Phenomenological Analysis’. Burchill and Markovic found that consensual kink activities sometimes facilitate the expression of emotion, physicality and sexuality in a way that may be beneficial to mental health (p. 23). The final pieces in this issue are Chris Burford’s report on the Spirituality, Compassion and Mental Health Conference (University of Huddersfield, July 2017), Martin Milton’s book review of Counselling transgender and nonbinary youth: the essential guide and Amita Sehgal’s book review of A web of sorrow: mistrust, jealousy, lovelessness, shamelessness, regret and hopelessness. I particularly hope that you enjoy this issue of Psychotherapy and Counselling Psychology Reflections and, as always, welcome your feedback as well as contributions. Dr Maria Luca Editor


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‘SUPREME VALUES RESIDE IN THE SOUL’ REFLECTIONS ON VALUES AND PSYCHOTHERAPY John Nuttall

Abstract Values, which should not be confused with virtues, embrace the broader principles of what might be considered the good and bad of living and being in the world. Allport (1961) identified six categories of life values: economic, political, scientific, aesthetic, social, and spiritual. The balance of these categories will vary across cultural and historical divides but Jung was in no doubt that ‘supreme values reside in the soul’ (Jung, 1970a, para. 14). In the West, the first three categories seem to dominate our existence and now encroach on the provision of psychological therapies in the guise of managed care systems such as IAPT. Determining the balance of these value for our personal lives and for the profession requires a reflective and reflexive attitude that can be engendered by recourse to philosophy, cultural aphorism, and poetry. Such reflection helps us tolerate and understand our duplex nature – the unconscious v. conscious, doing v. being, chaos v. order. There is a coincidence of opposites in ourselves, in our lives, and in the provision of our vocation that requires care, understanding and recalibration of our balance of values. The article espouses and concludes with an attitude framework to help in this endeavour and admonishes that the great mystery of values for living involves a long and deep search into our own souls. Keywords: Values, supreme values, IAPT, duplex nature, power, aspiration, solicitude Values are generally understood to be those fundamental ideas and principles of what is considered good and evil in ourselves and the world at large. These should not be confused with virtues, which might be more specifically defined as those attributes that represent moral excellence or righteousness, or indeed any admirable quality, feature or trait. Values embrace the broader principles associated with living and being in the world. As such they embrace the spectrum of what might be considered virtues and vices, and different people, societies, cultures, and epochs have, and have had, differing values or sets of values. Oscar Wilde (1892) described a cynic as ‘a man who knows the price of everything and the value of nothing’ and it seems, nowadays, that monetary value is the common metric we place on almost everything, and by which we, in the West at least, assess our lives. Economic laws, which seem inevitably to control our lives, even lead us to reduce the analysis of health and well-being to a monetary base so that comparative value judgements can be made about illnesses and resource allocation. Wilde’s adage raises the issue about how we value artefacts, social or other, and the different sets of values that exist in our current world. We seem to place economic values ahead of those concerning the social, the aesthetic or the spiritual. Economic values are now arguably driving the

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very heart of our being as monetary reward becomes almost the only means by which we seek to satisfy our narcissistic hunger for recognition. Our industrial and commercial leaders are now rated by the level of their pay packets and the bonus culture feeds our greed for recognition to the point of being morbidly obese. Gordon Allport (1961), one of the founding fathers of the Humanistic Psychology movement, distinguished six categories of life values – economic, political, scientific, aesthetic, social, and spiritual. He made no judgement as to whether one set had or should have more importance than another. These categories, if universal, probably have different roles or emphases across cultural and historical divide. Nevertheless, it is interesting to speculate what criteria might be used to determine whether or not such categories might or should have a hierarchy. The issue has the potential of collapsing into a kind of anarchic relativism whereby no one set of values can be judged superior to another. I wondered if there were a number of higher-order principles that might avoid this. I decided to look at the influences that have shaped my values, which have come from a range of cultures, epochs and disciplines.

Professor John Nuttall, School of Psychotherapy & Psychology, Regent’s University London, Inner Circle, Regent’s Park, London NW1 4NS

nuttallj@regents.ac.uk


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It is not unusual nowadays for people to regularly change career, the country in which they live, their religion and even their cultural affiliation. No doubt each one of Allport’s categories has become figure or ground at some point in our lives and perhaps the best we can do is accept the dialectic tension this evokes. We can take support for such equivocation from the psychologist C. G. Jung who wrote the following retrospective in his autobiography: The older I have become, the less I have understood or had insight into or know about myself. I am astonished, disappointed, pleased with myself. I am distressed, depressed, rapturous. I am all these things at once and cannot add up the sum. I am incapable of determining ultimate worth or worthlessness; I have no judgement about myself and my life. There is nothing I am quite sure about. I have no convictions – not about anything really. (Jung, 1995, p. 392) Notwithstanding this declaration from such a wise man there have been attempts by other wise men to identify superordinate values throughout the ages. A prominent example is the founding fathers of the US constitution and the still contemporary example of the concept of inalienable rights. In ancient times, Plato and Aristotle argued that all the virtues (such as the cardinal virtues of courage, wisdom, justice and temperance) needed to be pursued and mastered simultaneously – the so-called thesis of the unity of virtues. I am not sure this kind of unity is achievable for value categories since they must by definition embrace gradations of good and bad, and are often in conflict with one another. They are, at best, in some kind of dialectic tension. This is exemplified by the current crisis in the Middle East where, surely, there is a clash of value categories – the political versus economic versus cultural and spiritual. Determining the relative worth of different value categories also presupposes that our rational abilities can override our instinctual nature, the part of ourselves Jung called the ‘Shadow’, a dominant archetype of the collective unconscious. He pointed out: There is an unconscious psychic reality which demonstrably influences consciousness and its contents…We still go on thinking and acting as before, as if we are simplex and not duplex. Accordingly, we imagine ourselves to be innocuous, reasonable and humane. It needs only an almost imperceptible disturbance of equilibrium in a few of our rulers’ heads to plunge the world into blood, fire and radioactivity. (Jung, 1970b, para. 561) He is clearly referring here to the potential at that time of nuclear war; but it need not be limited to such major catastrophes – the recent economic crisis, the turn against gay rights, gender inequality, are all examples of our cognition being subject to arcane, archetypal and unconscious influence. The new discipline of behavioural economics has highlighted how innate cognitive bias, particularly loss aversion, paradoxically induces further risky behaviours (Shefrin, 2000). Recent research with primates suggests that such biases have primordial ‘archetypal’ origins (Santos & Rosati, 2015). Neuroscience suggests that our sense of right and wrong might be hardwired at birth – again suggesting instinctual or archetypal influence (Hauser, 2006). Our duplex nature is recognised in all the major religions and certainly is a characteristic of Western syncretism. Almost all the creation myths incorporate some kind of battle between broadly good and evil at some stage. Heraclitus declared, ‘strife is the father and king of all things’. Empedocles posited that the four ancient elements were held together by strife between love and hate. We see parallels today in modern

science in the concept of matter and anti-matter, dark matter and dark energy and so on. Complexity theory now asserts that chaos has order at its core. Benoit Mandelbrot, the famous chaos theorist said, ‘My life seemed to be a series of events and accidents. Yet when I look back I see a pattern’ (Jameson, 2004). The psychologist, Erich Fromm, highlighted another dimension of our duplex nature. In his book, To Have or To Be (Fromm, 1976), he argued that there are two basic and opposed modes of existence. One is aimed at having and owning, and the other at being and living. This aspect of our nature has also been recognised in various traditions and is perhaps manifest in the effect economic growth is having on our daily lives and the environment. It is present in the story of the Garden of Eden in that Adam’s desire to have (knowledge) forfeited his right to be carefree, and he was cast out ‘to do’ for himself. In recompense most of the world’s religions espouse values associated with the absence of material possessions and desires. Fromm (1976) declared that, ‘For the first time in history the physical survival of the human race depends on a radical change of the human heart’ (p. 19). This is also exemplified in the current antagonism between the desire for economic growth and the negative corollary of global warming, air pollution and mental ill health. This duplex nature was recognised as far back as the time of Lao Tzu and the Tao Te Ching. A poem attributed to him says: Always we hope Someone else has the answer, Some other place will be better, Some other time it will all turn out. This is it. No one else has the answer, no other place will be better, and it has already turned out. At the centre of your being, You have the answer. You know who you are And you know what you want. There is no need to run outside for better seeing. Nor to peer from a window. Rather abide at the centre of your being; For the more you leave it, the less you learn. Search your heart and see The way to do is to be. These perspectives suggest that values are an essential part of our being, our soul, as well as being manifest in our behaviours. In another poem he asserts ‘you are the master of your life and death, what you do is what you are’. This ‘duplexity’ in human nature is an example of what the alchemists called the coincidentia oppositorum – the coincidence of opposites. The concept in the Western tradition is associated with Heraclitus who pointed out that ‘the path up and down the mountain is one and the same’. So, what one person considers good might well be considered bad by someone else, or have unintended bad consequences. Bertrand Russell (2004) in an essay called ‘The Harm That Good Men Do’ argued that virtue does not always have desirable consequences and satirically defined a good man as ‘one whose opinions and activities are pleasing to the holders of power’ (p. 94). We see this in the Roman Catholic Church’s condemnation of contraception and the effect this has on the spread of HIV. Also, perhaps, in our financial system where the assumed virtues of self-regulation arguably resulted in the latest financial crisis. In the provision


Journal of Psychotherapy and Counselling Psychology Reflections

of mental healthcare the concept of ‘managed care’ presents an underlying contraction in terms. Its manifestation in the form of the Improving Access to Psychological Therapies (IAPT) scheme has arguably introduced a ‘fetished target culture’ that ‘simultaneously subverts the very care mandated’ (Rizq, 2012, p. 7). An old Cherokee proverb asserts: There is a battle of two wolves in all of us. One is evil, it is anger, jealousy, greed, resentment, lies, inferiority and ego. The other is good. It is joy, peace, love, hope, humility, kindness, empathy, and truth. Which wolf wins? The one you feed. To help accommodate this duplexity I resort to a number of aphorisms from different epochs. Heraclitus: ‘It belongs to all men to know themselves and to think well’. The stoic Marcus Aurelius exhorts, ‘Look inward. Don’t let the true nature or value of anything elude you’ (2003, p. 77). These adages advocate reflection that acknowledges our duplex nature. The Sufi mystic Rumi (1997) elaborates this further: This being human is a guest-house. Every morning a new arrival. A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor. Welcome and entertain them all! Even if they’re a crowd of sorrows, Who violently sweep your house empty of its furniture. Still, treat each guest honourably. He may be clearing you out for some new delight. The dark thought, the shame, the malice, meet them at the door laughing, and invite them in. Be grateful for whoever comes, because each has been sent as a guide from beyond. The key principle that emerges from this understanding is that we must be willing to reflect upon our being and doing to gain self-knowledge and its corollary autonomy. This is not the kind of autonomy that leads to wanton behaviour but the kind that springs from reflection and being self-aware, and of being free from, and understanding the potential impact of, our shadow and our dark side. This brings the ability to be responsive to the present without the guilt associated with the past, or the fear of the future. Tony Benn (HC Deb, 2001) exhorted this kind of reflection in his contemplations on power. He posed five questions: What power have you got? Where did you get it from? In whose interests do you exercise it? To whom are you accountable? How can we get rid of you? A useful addition to this list, in my view, would be, ‘what motivates you to want such power?’ These are all relevant questions for contemporary psychotherapy. Despite the conviction of adherents to the various theoretical models of therapy there is still no clear evidence that one therapeutic approach is more effective than another. Clarkson (2003) asserts, ‘the bulk of research points to the fact that the most important factor in effective psychotherapeutic work is the relationship between the client and the therapist’ (p. xvi). Indeed, the fact that over 450 approaches have been identified ‘and are claiming to have grasped the essentials of psychological functioning provides prima facia evidence that no one theory is correct’ (Polkinghorne, 1992, p. 158). The duplexity referred to above and the resultant power struggle of values is exemplified in the term ‘managed care’, which, in the UK, manifests in the NHS IAPT scheme mentioned above (Nuttall, 2016). It

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has emerged from the dominance of economic, political and scientific values as illustrated by David Clark’s address at the 2016 BPS Conference entitled, ‘Developing and Disseminating Effective Psychological Therapies: Science, Economics and Politics.’ The result has seen the rise to power of so-called evidence based practice, of manualised systems of treatment for mental distress that are measured at every point for efficacy and effective delivery, and are supported by an edifice of bureaucracy that has more to do with containing the anxiety of its designers and managers than treating the nation’s mental health. As one management guru pointed out, ‘efficiency is concerned with doing things right. Effectiveness is doing the right things’ (Drucker, 1993), and once entrenched such bureaucratic edifices might be efficient, but quite ineffective. They can be difficult to remove and cry out for Tony Benn’s analysis. The dominance of these values has upset the aesthetic, social and spiritual values arguably at the core of psychotherapy and has delivered a ‘perversion of care…used to mask the unbearable feelings of helplessness in the face of our limitations when trying to help those in psychological distress’ (Rizq, 2012, p.7). At the individual level, psychological research suggests that our experience of things or events is invariably comparative. Things are usually better or worse, more or less exciting, tasty, or important to us than something else. The basis of these judgements might be determined by the value categories Allport identified, within which the innate antagonism is ironically illustrated in Wilde’s adage. The implication is that we are constantly engaged in some kind of selection or prioritising process so that as one stimulus becomes figure others become ground in a never ending cycle of Gestalts. Couple this with the psychoanalytic concept of transference and behavioural psychology’s principles of operant conditioning and you have the perfect storm by which values are transmitted and sustained. The client brings preconceptions to the consulting room with associated selection criteria. These in turn can be reforced or refuted by the therapist; either way values are communicated and received. As individuals, or therapists, we influence and are influenced by others by selectively attending to only certain aspects of the encounter. How more significant is an intervention when it is the only one of the session? The communication is only implicit, but its effect is all the more charged when the transaction conveys ‘ulterior’ values (Berne, 1974, p. 23), hidden from consciousness. Thus, relational psychology now considers satisfying relationship to be the human’s key motivational drive (Wachtel, 2008). The developmental importance of relationship was pioneered in the UK by psychoanalysts Klein and Fairbairn, and in the US by the humanistic psychologist Rogers, whose core conditions of empathy, congruence and unconditional positive regard are universally accepted interpersonal competences for ‘any situation in which the development of the person is a goal’ (Rogers, 1990, p. 135). Another source of insight has been the mythical Sufi figure of Mulla Nasrudin. Most of his allegories date from around the twelfth century and are based in humour, yet are still studied by mystics today. It is thought that if you listen to seven Nasrudin stories consecutively you will reach enlightenment (Shah, 1971). One story concerns our ability to acknowledge the values of others (p. 70): The Mulla walked into a shop one day. ‘First things first,’ said Nasrudin; ‘did you see me walk into your shop?’ ‘of course.’ ‘Have you ever seen me before?’ ‘Never in my life.’ ‘Then how do you know it is me?’ demanded Nasrudin. Volume 3, Number 1, January 2018


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Another story concerns where we should seek our values (p. 62): On one occasion a neighbour found him down on his knees looking for something. ‘What have you lost Mulla?’ ‘My key’ said Nasrudin. After a few minutes of searching, the neighbour said, ‘Where did you drop it?’ ‘At home’, said the Mulla. ‘Then why, for heaven’s sake are you looking here?’ ‘There’s more light here’ replied Nasrudin. Do we find it easier to seek answers in the street of economic, political and scientific values, rather than look at home for more aesthetic, social or spiritual values? There is an old Kabbalistic aphorism that says ‘as it is below, so too is it above’, meaning equally perhaps ‘as within, so without’. It is the psychotherapist and organisational consultant in me that wants to resolve the problem of the hierarchy of value categories by understanding what can emanate from within rather than be imposed from without. Hopefully, if we can identify qualities that help this process then these might reverberate throughout mankind. Jung asserted, ‘but were it not a fact of experience that supreme values reside in the soul, psychology would not interest me in the least, for the soul would then be nothing but a miserable vapour’ (Jung, 1970a, para. 14). Rumi (1999) believed: There are two kinds of intelligence: One acquired as a child in school memorises facts and concepts from books and what the teacher says. Collecting information from the traditional sciences as well as the new sciences. With such intelligence you rise in the world. You get ranked ahead or behind others in Regard to your competence in retaining information. You stroll with this intelligence in and out of fields of knowledge, getting always more marks on your preserving tablets. There is another kind of tablet. One already completed and preserved inside you. A spring overflowing its spring box. A freshness in the centre of your chest. This, other intelligence does not turn yellow or stagnate. It’s fluid, and it doesn’t move from outside to inside through The conduits of plumbing learning. This second kind of knowing is a fountainhead From within you moving out. Seneca, another Roman Stoic, argued that wisdom was the most perfect of the virtues. He believed in the long run the perfectly wise person would act in harmony with all the virtues. Reconciling, understanding and, on occasions, tolerating diverse values requires a particular attitude, which Russell (2004) espoused when studying a philosopher: The right attitude is neither reverence nor contempt, but first a kind of hypothetical sympathy, until it is possible to know what it feels like to believe in his theories, and only then a revival of the critical attitude, which should resemble, as far as possible, the state of mind of a person abandoning opinions which he has hitherto held. Contempt interferes with the first part of this process, and reverence with the second (p. 58). In this vein I wondered if there were a set of qualities sine qua non that move from within to without that might lead to beneficent values. So, what might constitute ‘beneficent values’ in the practice of psychotherapy? Psychotherapy is a relational process (Clarkson, 2003) with different facets of relationship. It is a developmental process that aims to be healing and make people better. But this essay raises the question about what we mean by ‘better’, or ‘good’

development, and how our own values might impose on these meanings. Not so long ago being gay was considered a developmental perversion that required psychological intervention to make people better, aversion therapy being one such intervention. Now the professions consider it unethical to even wonder if it has a psychological foundation. As discussed in the opening paragraph values are constructs of the era, culture, inheritance et al and the aim of this essay is not to espouse any one set of values, but to propose a number of attributes or qualities that might help reflection on values and form the basis, not of value-free psychotherapy, but of values-aware psychotherapists. Professionals who have seriously reflected on their beliefs, prejudices and biases, and come to terms with their Shadow in order to avoid, as far as possible, imposing their values on their clients. Four qualities emerged for me. The first relates to the logistics of individuation and the development of self-awareness, self-acceptance and autonomy. It involves gaining awareness of disagreeable aspects of the self and accepting them for what they are – thoughts and feelings that may be unwanted and are in the broad sense aspects of our Shadow. Thus we can avoid the derived behaviours which ultimately determine, as Lao Tzu asserts, ‘who we are’. This allows the next quality to flourish with advantage. Aspiration enables us to be self-directed and gives us the capacity to choose our behaviours, goals and needs – our values. This may be an organismic faculty in us all, which provides motivation, drive and curiosity. Existentially, it situates us on the cusp of the future, at a point where we can decide not to be determined by the past or present but be drawn forward by our potential. The next is solicitude. Existentially this a fundamental condition of human Being (Heidegger, 1962). For me this involves love and care for ourselves and others. It brings the willingness and ability to acknowledge and understand, if not always accept, the Shadow in others. This allows us enjoyment in life and to engage and relate to others; to have empathy for, and understand the values of others without losing autonomy or the aspiration to be who we want to be. The fourth concerns congruence – one of the core conditions of humanistic counselling. This involves feeling ‘joined up’ and connected and brings the ability to be tolerant, hold ambivalence and paradox and remain optimistic in the face of disappointment or when our goals and values are challenged. This may involve adaptation of our values, objectives and relationships whilst maintaining autonomy, purpose, and caring. Notwithstanding these qualities, against all efforts we do impose, or at least, transmit our values to our clients. The way we dress, decorate the room, speak, will resonate with the client’s own duplex nature just as these things did in their childhood. ‘You are complicit whatever you do in supporting or suppressing values or value-clarification in yourself and your client’ (Clarkson, 2003, p. 183). Some time ago I came across a small book called The Invitation (Oriah, 2006). It is a book in the manner of The Dark Night of the Soul by St John of the Cross. The author, a native Canadian, had come through a difficult period in her life and was inspired to write a poignant poem from which she developed a series of meditations and interpretations. I present this poem as a way of demonstrating the human qualities which, I think, can help us determine a useful balance of values. They are probably also the qualities that clients require of a ‘good-enough object’ in the person of a psychotherapist (Scharff & Scharff, 1998).


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The Invitation by Oriah Mountain Dreamer It doesn’t interest me what you do for a living. I want to know what you ache for, and if you dare to dream of meeting your heart’s longing. It doesn’t interest me how old you are. I want to know if you will risk looking like a fool for love, for your dream, for the adventure of being alive It doesn’t interest me what planets are squaring your moon. I want to know if you have touched the centre of your own sorrow, if you have been opened by life’s betrayals or have become shrivelled and closed from fear of further pain! I want to know if you can sit with pain, mine or your own, without moving to hide it or fade it, or fix it. I want to know if you can be with joy, mine or your own. If you can dance with wildness and let the ecstasy fill you to the tips of your fingers and toes without cautioning us to be careful, to be realistic, to remember the limitations of being human. It doesn’t interest me if the story you are telling me is true. I want to know if you can disappoint another to be true to yourself; if you can bear the accusation of betrayal and not betray your own soul; if you can be faithless and therefore trustworthy. I want to know if you can see beauty even when it’s not pretty, every day, and if you can source your own life from its presence. I want to know if you can live with failure, yours and mine, and still stand on the edge of the lake and shout to the silver of the full moon, ‘Yes!’ It doesn’t interest me to know where you live or how much money you have. I want to know if you can get up, after the night of grief and despair, weary and bruised to the bone, and do what needs to be done to feed the children. It doesn’t interest me who you know or how you came to be here. I want to know if you will stand in the centre of the fire with me and not shrink back. It doesn’t interest me where or what or with whom you have studied. I want to know what sustains you, from the inside, when all else falls away. I want to know if you can be alone with yourself and if you truly like the company you keep in the empty moments. The mysterium magnum of values for living is a longissima via with twists and turns. It is a road that hopefully starts here at Regent’s University London and ends with us finding that ‘supreme values reside in the soul’ (Jung, 1970a, para. 14).

Heidegger, M. (1962). Being and time. (J. Macquarrie & E. Robinson, Trans.). Oxford, UK: Blackwell. (Original work published 1927)

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Jameson, V. (2004) ‘A fractal life’. New Scientist, November, 2004.

Allport, G. W. (1961). Patterns and growth in personality. New York, NY: Holt, Rinehart & Winston. Aurelius, M. (2003). Meditations. (G. Hays, Trans.). London, UK: Phoenix. Berne, E. (1974). What do you say after you say hello? The psychology of human destiny. London, UK: Corgi Books. Clark, D. (2016, April). Developing and disseminating effective psychological therapies: Science, economics and politics. Keynote address, Annual Conference of the British Psychological Society (BPS), Nottingham, UK. Clarkson, P. (2003). The therapeutic relationship (2nd ed.). London, UK: Whurr. Drucker, P. F. (1993). The effective executive. New York, NY: HarperCollins.

House of Commons. (2001). March 22 Debate (vol 365, col 509-511). Retrieved from https://publications.parliament.uk/pa/ cm200001/cmhansrd/vo010322/debtext/10322-13.htm Jung, C. G. (1970a). The collected works of C. G. Jung: Psychology and alchemy (Vol. 12). Abingdon, UK: Routledge. (Original work published 1944) Jung, C. G. (1970b). The undiscovered self. In The collected works of C. G. Jung: Civilization in transition (Vol. 10, pp. 245-306). Princeton, NJ: Princeton UP. (Original work published 1957) Jung, C. G. (1995). Memories, dreams, reflections. London, UK: Fontana Press. (Original work published in 1963) Nuttall, J. (2016). ‘Working in partnership with IAPT’. In J. Lees (Ed.), The future of psychological therapy: From managed care to transformational practice. London, UK: Routledge. Oriah (2006). The invitation. New York, NY: HarperCollins. (Original work published 1995)

Fromm, E. (1976). To have or to be? New York, NY: Harper & Row.

Polkinghorne, D. E. (1992). ‘Postmodern epistemology of practice’. In S. Kvale (Ed.), Psychology and postmodernism (pp. 146-165). London, UK: Sage.

Hauser, M. D. (2006). Moral minds: The nature of right and wrong. New York, NY: HarperCollins.

Rizq, R. (2012). The perversion of care: Psychological therapies in a time of IAPT. Psychodynamic Practice, 18(1), 7-24. Volume 3, Number 1, January 2018


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Rogers, C. R. (1990). The Carl Rogers reader. H. Kirschenbaum & V. L. Henderson (Eds.). London, UK: Constable.

Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy. New York, NY: Guildford.

Rumi, J. -D. (1997). The illuminated Rumi. (C. Barks, Trans.). New York, NY: Broadway Books.

Wilde, O. (1892). Lady Windermere’s fan. I. Small (Ed.). London, UK: Bloomsbury.

Rumi, J. -D. (1999). The essential Rumi. (C. Barks, Trans.). London, UK: Penguin Books. Russell, B. (2004). ‘The harm that good men do’. In Sceptical essays (pp. 90-100). London, UK: Routledge. (Original work published 1928) Santos, L. R., & Rosati, A. G. (2016). Evolutionary roots of human decision making. Annual Review of Psychology, 66, 321-347. Scharff, D. E., & Scharff, J. S. (1998). Object relations individual therapy. London, UK: Karnac Books. Shah, I. (1971). The Sufis. New York, NY: Anchor Books. Shefrin, H. (Ed.). (2000). Beyond greed and fear: Understanding behavioral finance and the psychology of investing. Oxford, UK: Oxford University Press.


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TRAINING HIGH INTENSITY CBT THERAPISTS IN OTHER MODALITIES OF THERAPY: CAN WE CHANGE THEIR MINDS? Michael Worrell, Rebecca Samuels and Rita Woo

Abstract The Improving Access to Psychological Therapies Programme (IAPT) in England has had a major impact on the provision of psychological therapies at a primary care level. It has also had a very large impact of the training of psychological therapists. These developments have drawn considerable criticism from a range of sources. One important focus of such criticisms has been the apparent exclusive focus on CBT to the exclusion of other perspectives. This paper concerns a quantitative and qualitative investigation into the experience of trainee high-intensity CBT therapists who engage in a brief training programme concerning other modalities of therapy. The paper explores the extent to which participation in this training changes trainees’ minds regarding the relevance of these modalities to their practice as CBT therapists. Additionally, the paper explores what aspects of each modality are experienced by trainees as relevant and helpful, versus those that are experienced as inconsistent or unhelpful. Results of this investigation are discussed in terms of criticisms of IAPT and CBT as the primary modality of therapy offered in IAPT. Keywords: IAPT, high-intensity CBT therapists, training, psychodynamic, humanistic and systemic therapies Introduction Over the past decade in England, the provision of publicly funded psychological therapy has been vastly transformed with the introduction and expansion of the Improving Access to Psychological Therapies (IAPT) programme. The IAPT programme was developed following the findings of the Depression Report (London School of Economics and Political Science, 2006) which argued that a large-scale expansion of evidence-based psychological therapies would have both economic and social benefits as well as clear benefits for people suffering from common mental health problems such as depression and anxiety.

Contacts:

Whilst IAPT services show some variation in their organisation and manner of delivery (Clark, 2011), they all tend to share several key features that characterise the programme: 1. Therapies are restricted to those recommended in the relevant guidelines of the National Institute for Clinical Evidence. The NICE guidelines have, controversially, supported the use of specific forms of psychological therapy as opposed to others. cognitive behavioural therapy has been recommended for depression and anxiety ‘disorders’. Other forms of therapy including interpersonal psychotherapy, behavioural couples therapy, counselling for depression (a manualised form of humanistic/person centred therapy), and dynamic interpersonal therapy (a psychodynamic model) are recommended for depression but not for anxiety.

Dr Michael Worrell, corresponding author, Consultant Clinical Psychologist, Director of Postgraduate CBT Training, Central and North West London NHS Foundation Trust (CNWL) Rebecca Samuels, Assistant Psychologist, Central and North West London NHS Foundation Trust (CNWL) Dr Rita Woo, Clinical Psychologist and BABCP accredited CBT Therapist

michael.worrell@nhs.net


10

2. IAPT services operate according to a ‘stepped care’ model, whereby clients are offered the least intensive form of psychological intervention appropriate to their level of need. The initial steps of this model are carried out by what has come to be known as ‘psychological wellbeing practitioners’ (PWPs), who deliver ‘low-intensity interventions’ which are primarily in the form of ‘guided self-help’ or computer-based CBT. Clients presenting with more moderate-to-severe difficulties, and those who do not respond to low-intensity interventions, are ‘stepped up’ to be treated by ‘high-intensity’ psychological therapists offering the range of NICE-recommended therapies. 3. The services are characterised by a heavy emphasis on progress and outcome monitoring, whereby clients are asked to complete session-by-session measures on scales assessing current levels of depression and anxiety. These session-by-session measures are used in regular ‘outcome focused supervision’ of PWPs, and regular clinical supervision of high-intensity therapists. The programme set itself some fairly ambitious access and outcome targets with an overall target of 50% of clients moving to what it defined as ‘recovery’. In its most recent report (NHS England, 2016), it has been stated that between April 2015 and March 2016, 953,522 clients entered treatment (at any level of the stepped care system), 537,131 clients completed a course of treatment and of those who completed 46.3% have moved to recovery. The development of the IAPT programme has involved not only a reconfiguration of primary and secondary care services, but also a significant expansion in training of psychological therapists. The 2015 NHS Adult IAPT workforce census (NHS, 2016) reported that just fewer than 7,000 therapists were employed in services, having completed one of the recognised training programmes, with 36% of the workforce comprising psychological wellbeing practitioners and 62% comprising of high-intensity therapists and 2% employment support workers. The IAPT initiative has established a new form of psychological therapist: the psychological wellbeing practitioner (PWP). To qualify as a PWP, trainees complete a one year postgraduate certificate which is delivered according to a national curriculum (Richards & Whyte, 2009). Upon qualification, PWPs are employed at ‘Step 2’ which is characterised by ‘low contact–high volume (Clark, 2011). The core principles of PWP interventions are cognitivebehavioural in nature. However, the role of the PWP is explicitly not that of a traditional psychological therapist. Specifically, the model involves the delivery of a core set of seven self-help protocols. The role of the PWP is much closer to that of a ‘coach’ (Turpin, 2010) and largely deemphasises the role of the therapeutic relationship as being a primary vehicle of change. The training of high-intensity CBT therapists, by contrast, is specifically focused on the development of core competencies as a CBT psychotherapist. This includes training and supervision focused on the more relational aspects of psychological therapy.

Critiques of IAPT and CBT The IAPT programme and CBT have attracted considerable criticism from a range of sources. For example, Watts (2016) argues that CBT is complicit in a neo-liberal ideology that insists upon the proceduralisation of practice and the surveillance of therapists and clients. Watts also laments the effects of IAPT on the standing of psychotherapists working

from other perspectives. Watts (2016, p. 95) states: ‘This ‘new workforce’ of ‘competent professionals’ carries in its discourse an implicit criticism of other therapies as being old and incompetent’. Lees (2016) also sees grave dangers in the IAPT initiative including the possibility that knowledge embodied in other forms of psychological therapy will be lost: Over one hundred years of the development of the therapy profession may be forgotten, as attempts are made to develop a one-sided and uni-dimensional ‘psychological therapy’ professional culture. (p. 168) House (2016), in a similar vein, states: There exists an incommensurability between, on the one hand, the state’s drive for standardisation and common, universal standards of service provision in state therapy and, on the other hand, flexible responsiveness to the particularities and uniqueness of each client’s experience. (p. 149) These criticisms, if true, certainly present a challenge to those, including the present authors, involved in attempts to train high-intensity CBT therapists. An explicit aim of such training has always been to develop within trainees both a critical and informed perspective on the field of CBT (its history, unresolved issues and contradictions), as well as an ability to work with clients in a flexible collaborative manner, that is focussed principally on the uniqueness of the client’s experience. High-intensity CBT therapists are not trained to become ‘psycho-technicians’ working in the service of state interests. At times these critiques have been characterised by a degree of polarisation. Nuttall (2016), for example, describes a ‘clash of values’ whereby the older counselling services and professionals have worked from a set of values that are more ‘social’, ‘spiritual’ and ‘aesthetic’, in contrast to the values of IAPT, that are more ‘political’ and ‘economic’, and concerned with measurement and control. There is much in this analysis as well as the critiques of House and others that is worthy of further examination and debate. However, of some concern is the tendency to equate the institutional features of the IAPT programme with the perspective of CBT as a model of therapy, such that they are seen as essentially being one and the same thing. As Paul Gilbert, a key theorist in contemporary CBT, has been at pains to point out, ‘CBT is a model for therapy, not a science of mind or a service model.’ (2009, p. 400). Does CBT, as a perspective on therapy rather than a service model, take a dismissive or attacking position in relation to other modalities of therapy as Watts (2016) and others contend? In our experience as CBT trainers this is not the case. Indeed, Beck’s early work on cognitive therapy for depression (Beck et al., 1979) appears to be at pains to point out the extent to which cognitive therapy needs to be understood in relation to these other models. Beck et al. (1979, p. 25) state: The aspiring cognitive therapist must be, first, a good psychotherapist…We have found that therapists with diverse backgrounds and experience can conduct cognitive therapy successfully. Therapists who have practiced psychodynamic therapy frequently are empathic and sensitive to and skilful in dealing with transference reactions. Beck et al. (1979) also argue that humanistic therapists are well placed to learn cognitive therapy as the relational qualifies (empathy, congruence and unconditional positive regard) are the very same qualities that need to be


Journal of Psychotherapy and Counselling Psychology Reflections

embodied by cognitive therapists in their work with clients. Additionally, Beck et al appear to be alert to the danger inherent in the ‘technology’ of CBT for producing rigid formulaic therapists: They are so eager to master the technical aspects that they parrot their role models…instead of integrating the therapy approach into their own natural style. They thus appear like robots, busily engaged in uttering clichés or employing ‘gimmicks’. (1979, p.28) Prior to IAPT, CBT training tended to be delivered at a postqualification level to individuals who were already trained, experienced and registered as clinical and counselling psychologists, psychotherapists, counsellors, occupational therapists etc. In most instances these individuals had already completed substantial training and experience in a range of psychotherapeutic modalities. As within this framework PWPs are not recognised as having a core mental health profession, and as they frequently lack this wider exposure to the broad field of psychotherapies, this has presented a challenge to CBT training programmes to adapt their methods of training in order to effectively support these individuals to begin and complete training. Whilst the initial design of the IAPT programme envisioned the role of the PWP being a sustainable and long term one, a recent pattern has emerged such that the PWP workforce has been characterised by a higher degree of turnover. Additionally, the PWP workforce has been found to consist primarily of younger white females with undergraduate psychology degrees (NHS, 2016). The NHS IAPT Workforce census 2015 identified this as problematic as this indicates that the workforce is far from being representative of the population it serves. Whilst to some extent the turnover of PWPs may be related to the nature of the role (a high clinical case load in a context of a high degree on monitoring of clinical outcomes), it is also likely the case that many who enter the PWP workforce are doing so with the intention of subsequently training as high-intensity therapists or clinical psychologists. The PWP role has increasingly become a stepping stone into an NHS psychological therapy career. In the London region, an increasingly larger percentage of the intake of high-intensity training consists of trainees whose only professional background in psychological therapy has been that of PWP. Evidence from our own training programme indicates that PWPs as a group, do well on high-intensity training despite encountering an initial ‘gap’ whereby they experience difficulties learning how to work psychotherapeutically in a more dialogical, collaborative and flexible fashion. It is possible that, due to the entry requirement of PWP training (a background in clinical practice of counselling or therapy is not a key requirement – although some PWPs certainly do have such a background), combined with a training and a work role that emphasises highly structured, time limited and psychoeducational ‘coaching’ interventions, preconditions such trainees with a tendency to over emphasise the more structural, technical and directive aspects of the therapy at the expense of the more relational and dialogical aspects.

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allows PWPs and others to bring together documentary evidence in a ‘KSA portfolio’ that they have attained a range of competencies and a body of knowledge equivalent to that possessed by individuals who do have a core mental health professional background. A key criterion of the KSA framework is ‘Knowledge of other modalities of therapy’ in which applicants for CBT training needs to be able to demonstrate ‘Understanding the historical context and implications for intervention’ of at least four modalities of therapy including psychodynamic, humanistic and systemic models. Additionally this understanding needs to be acquired through ‘a minimum certificate level training, as part of a coherent delivery method, or a stream through several modules, equating to at least three full days of training developing knowledge and skills. As a group of trainers, our view has been that the KSA framework not only provides a coherent method of widening access to CBT training for individuals with a non-standard professional background, but also provides an opportunity for contributing to the pre-CBT training preparation of PWPs by providing additional input that seeks to establish such understanding, and furthermore to do so in a way that effectively demonstrates the relevance of such other modalities for the theory and practice of contemporary CBT. This paper describes the development and evaluation of this ‘KSA training’ programme and explores the extent to which this training may have potential benefits in preparing individuals with a background as PWPs for high-intensity CBT training. Initially developed due to pragmatic needs to assist PWPs and others prepare for advanced, high-intensity CBT training and to meet the pre-training requirements of the KSA framework, a three-day training programme was developed to introduce these trainees to three other modalities of therapy. Rather than set this at an introductory, certificate level however, which had the potential for this to be a primarily conceptual and historical overview (thereby contributing to the risk identified by Watts that such approaches will be viewed as old and ineffective), the training programme was designed to meet the following criteria: 1. The training was set at the same level as that which would be provided in the first year of a doctoral program in either clinical or counselling psychology. That is, the quality of the training day was designed to be at a doctoral level in terms of its clinical and theoretical focus, although in terms of quantity or duration of training this is much less than would be provided on a doctoral course (a doctoral counselling psychology programme, for example, would often have an entire module devoted to specific perspectives rather than a single day). 2. Each day of the course, covering a specific perspective on therapy – psychodynamic, humanistic and systemic – would emphasise that model’s relation to CBT including areas of contact and influence as well as areas of difference and conflict. 3. Each day would include an extended experiential element so that trainees were able to gain a ‘taste’ of that approach rather than just an intellectual appreciation.

A new ‘pre-training’ programme on other modalities of therapy

4. The training would be delivered by trainers who had training and experience in the practice of both the specific modality of therapy as well as CBT.

The British Association for Behavioural and Cognitive Psychotherapies (BABCP), in fulfilling its role of gatekeeper for the profession and setting appropriate entry standards for training as a CBT therapist, have developed what is known as the ‘Knowledge Skills and Attitudes framework’ (BABCP, 2017) which, as a form of accreditation of prior learning,

For example, during the session on humanistic therapy, the day included both an historical overview of humanistic models, research evidence for their effectiveness and links to CBT theory and practice as well as experiential exercises where trainees were encouraged to ‘just listen’ to another describe an experience where they experienced a ‘strong Volume 3, Number 1, January 2018


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emotional reaction’ and to pay attention to what this ‘just listening’ felt like from their own embodied stance.

Aims of the study For several years this programme had been successfully delivered and positive participant feedback was obtained. Additionally, trainees had been highly successful in using the training to help them meet the relevant criterion in the ‘KSA portfolio’. However, we became interested in the question of to what extent trainees experienced the content of each of the training days as relevant to their subsequent CBT training and practice? The present study was designed to obtain both quantitative and qualitative information concerning trainees’ experience of the training. The results of this study have the potential to inform not only future revision and developments of the course itself, but also potentially to support the evolution of the high-intensity CBT training in order to assist PWPs and others to more readily learn the more experiential, dialogical and relationship based aspects of CBT thereby ‘closing the gap’ between themselves and other professionals who enter CBT training with a wider experience of different psychotherapeutic models. In our view, ensuring that CBT therapists are not only well trained in CBT but have a well-developed understanding of other modalities of therapy and their relation and relevance to CBT, will ensure that the concerns of Lees (2016) and others are at least to some extent addressed. The following questions guided this research: 1. To what extent did participants’ beliefs concerning the relevance of these other modalities of therapy change as a result of attending the training? Our hypothesis was that trainees would initially believe that each of these models held little relevance for them as CBT trainees and that this belief would change as a result of the training so that each of these models would be viewed as far more directly relevant. 2. What did trainees find in each of the models that they would like to ‘carry forward’ into their practice as CBT therapists? 3. What aspects of each of the models did they believe would be incompatible with their practice as CBT therapists?

Method Participants The participants in this study included 87 high-intensity CBT trainees in London who were enrolled at the CBT Training Centre. The sample was selected based on their need to fulfil the ‘knowledge of other modalities of therapy’ criterion of their KSA portfolio. The sample included two cohorts: 53 participants from the 2016 cohort and 34 participants from the 2017 cohort. 82% of the total sample were female and 17% were male between the ages of 25-55 (M = 33.08, SD = 7.89). At the time of enrolment, the majority of the sample were psychological wellbeing practitioners (73%). Other professions included; assistant psychologists, research assistants, support workers and nurses. Materials and design The participants completed anonymised questionnaires following each training day. The participants were asked to rate how ‘relevant’ they thought the mode of therapy was to their work as a CBT therapist, before and after training using a 7 point Likert scale. Following this, three qualitative

questions asked: 1. What aspects of the model (psychodynamic, humanistic, and systemic) they would like to be able to carry forward into their CBT work? 2. What aspects of the model did they see as incompatible or not relevant to their work as CBT therapists? 3. What they thought might help them to carry the useful aspects forward? The aims of the study were explained during the training day and the option not to participate was made clearly available. Consent was assumed upon receipt of the form and as the forms are anonymised there were no confidentiality issues. Attendance was monitored from the daily registers, and demographic information was obtained from the Centre’s records. This is a within-participant design assessing the relevance of each mode of therapy offered. The independent variable is the mode of therapy and the outcome variable is how relevant/useful the therapy is for CBT training. As it is not required for the trainees to attend all three training days (if for example the trainee had attended an equivalent training elsewhere), the sample contained three separate groups across both years. Therefore there were six separate conditions, a condition each for systemic, psychodynamic and humanistic therapy for the 2016 cohort and a condition each for the 2017 cohort. However, as both cohorts followed the same procedure and had similar demographics their data were combined. Procedure Following the end of each training day, the trainees were given time to complete the forms and were handed in. As the feedback forms are not compulsory the data contains only those who completed the form. The total sample for each cohort is an amalgamation of all three days of registers. Analyses The analysis was conducted in two parts. A paired sample t-test was conducted to compare how relevant the participants found each therapy before and after the training. A content analysis was conducted to assess common themes. Ethics statement This project was conducted in the form of a ‘routine service evaluation’ and was not classified as research within the NHS research ethics guidance. As such this audit project did not require consideration in an NHS or university ethics panel.

Results A paired sample t-test was conducted to compare the relevance rating before and after the psychodynamic, systemic and humanistic/existential teaching. For the psychodynamic model, there was a significant difference between the pre training (M = 2.67, SD = 1.34) and post training scores (M = 5.4, SD = 1.04); t (77) = 20.62, p<0.001, d = -2.73, 95% CI [-2.99, -2.47]. For the systemic model, there was a significant difference between the pre training (M = 3.03, SD = 1.51) and post training scores (M = 5.45, SD = 1.06); t (64) = -13.57, p<0.001, d = -2.42, 95% CI [-2.77, -2.06]. For the humanistic model, there was a significant difference between the pre training (M = 2.89, SD = 1.65) and post training scores (M = 5.76, SD = 0.99); t (76) = 18.25, p<0.001, d = -2.87, 95% CI [-3.18, 2.55]. This suggests that the students found the psychodynamic, systemic and humanistic models significantly more relevant post training than pre training. (See Figure 1).


Journal of Psychotherapy and Counselling Psychology Reflections

13

7 6

Theme

5

Q1: Aspects to carry forward?

4

72

‘Use of transference/counter transference within treatment sessions.’

Developmental history

61.3

‘Acknowledgment of developmental history and influence of this on client now’

Humanistic

Defence mechanisms

48

‘Looking out for defence mechanisms’

Post Training Average

Formulation

6.7

‘Understanding formulations in a different way’

Self-reflection

5.3

‘Thinking about my emotional reactions to client - increased awareness.’

2 1 0

Systemic

Pre Training Average

Quote

Transference/ Countertransference

3

Psychodynamic

Frequency (%)

Figure 1. Pre and post training relevance score average difference for the psychodynamic, systemic and humanistic/ existential modes of therapy.

Q2: Aspects experienced as not relevant/incompatible? In terms of non-response rates, there was a 13.8% no response rate for psychodynamic, 6.9% for systemic and 14.5% for humanistic. Content analysis We presented participants with three open questions related to what aspects of the model the students would like to use in their work, what aspects they did not see as relevant and what they thought would help them to carry the useful aspects forward. The most common answers for each question for every mode of therapy were coded into common themes. The initial coding was completed by one of the researchers RS and was subsequently checked for consistency by a second researcher MW. The frequency of themes was counted in order to understand the prevalence of themes. For the psychodynamic model, five main themes were found for question one, two and three. For question one the most important thing to carry forward was issues surrounding transference/countertransference, followed closely by the relevance of developmental history and defence mechanisms. For question two, interpretations/dreams were deemed most irrelevant/incompatible, followed by structure of sessions. A small proportion found all aspects to be relevant. For question three, to help them carry the ideas forward it was found ongoing supervision was the most important. (See Table 1).

Interpretations/ dreams

33.3

‘I have difficulty with a therapist interpreting a client’s problem and reflecting this back. I feel like this should be collaborative’

Structure/ duration of sessions

21.3

‘Having a free flowing unstructured or less structured session in terms of agenda’

All relevant

12

Unconscious processes

10.7

‘I don’t see the unconscious processes as being particularly relevant’

Formulation/ assessment

8

‘Some aspects of formulation/ assessment’

‘All relevant’

Q3: How can this be carried forward? Supervision

44

‘Having time and space to reflect my own processes in supervision’

Self-awareness/ reflection

18.7

‘An awareness in applying these with clients in the room’

Training

17.3

‘Extra training. In house/ professional’

Reading

16

‘Reading relevant books’

Practice

8

‘Practice - observing how these can be used in CBT practice with clients, when it would be helpful to use them.’

Table 1: Overview of content analysis for psychodynamic model

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For the systemic model, five main themes were found for question one, three for question two, and four for question three. The aspects students were most likely to carry forward were ‘circular causality/questioning’, followed by the use of genograms, thinking of clients within a system/context and their wider field of relationships. The aspects experienced as most irrelevant was the use ‘reflective groups’. This was followed by some finding it being incompatible with the IAPT service context. However, a small proportion found all aspects to be relevant. Similarly to psychodynamic, the majority of the sample found that further supervision would help them carry this forward into their work, followed by a quarter of the sample finding further training would be useful. Theme

Frequency (%)

Quote

For the humanistic model, seven main themes were found for question one, four for question two and five for question three. The majority of sample found ‘exploring client’s emotions’ the most important thing to carry forward, followed by focusing on ‘the here and now’ and adopting ‘active listening’. Interestingly, the most common response to what aspects do they see as most irrelevant, the sample responded that all aspects were relevant. This was followed by some students finding the lack of structure not conducive to CBT. In order to carry this forward the students found self-study and supervision equally as important, followed by further training. Theme

Frequency (%)

Quote

Q1: Aspects to carry forward? Exploring emotion

64.9

‘Using emotion to explore themes with client. Imagery and the two chair technique’

Focus on the here and now

24.7

‘Focus on the here and now processes’

‘Genograms - I think this is very helpful to visualise relationships within the family quite quickly.’

Active listening/ giving space

20.8

‘Allowing clients space to give them a chance to talk without much interruption’

40.7

‘Understanding and exploring other members of the system and not just focusing on the individual’

Inter-relational aspects

18.2

‘Inter-relational disclosing how you feel’

Relationships/ mapping relationships

Increased awareness/ choice

16.9

33.3

‘Focus on the impact of relationships. Useful to track changes looking at impact on relationships’

‘Helping clients to increase their awareness of self’

Therapeutic relationship

14.3

‘The importance of the therapeutic relationship’

Team reflections

8.6

13

‘Taking a person centred approach’

Q1: Aspects to carry forward? Circular causality/ questioning

46.9

Genograms

42

Client within system/context

‘Clients view of the problem is just one perspective its helpful to show circular causality if appropriate’

‘Reflective team - would be really good model to use for supervision’

Q2: Aspects experienced as not relevant/incompatible? Reflective groups/ teams

34.6

Incompatibility with IAPT All relevant

‘Working as a group of therapists -

All relevant

28.6

12.3

‘It will be difficult to incorporate systemic principles within the timeframe allowed in IAPT CBT’

‘I think all relevant if used in small doses at appropriate times’

Lack of structure

20.8

‘No structure, no goal setting, would be impossible’

8.6

‘All seem relevant to consider and integrate into CBT work’

Incompatibility with CBT

14.3

‘Time consuming, incompatible with IAPT targets’

Existential aspects

11.7

‘I found it more difficult to consider how/would include elements of existential approaches’

Supervision

56.8

‘Use of reflective teams in supervision’

Training/CPD

24.7

‘More training’

Self-directed study

Q2: Aspects experienced as not relevant/incompatible?

though I wish I could.’

Q3: How can this be carried forward?

Practice

Person centred therapy

16

13.6

‘Using circular questioning and being aware of systemic issues during formulation’ ‘To read more information to increase knowledge and understanding’

Table 2: Overview of content analysis for systemic model

Q3: How can this be carried forward?

Self-study

24.7

‘Further exploration of different types of humanistic approaches through watching videos/attending seminars/talking real life cases with people who specialise in approaches.’

Supervision

24.7

‘Experienced supervisor in humanistic approach’

Further training

19.5

‘Training in how to work with current emotions as I currently would not know how to respond’

Practice

18.2

‘I would like to try some of the techniques especially the 2 chair technique. Also how to stay with emotions’

Reflection

11.7

‘To reflect on my practical/clinical work to help me progress further’

Table 3: Overview of content analysis for humanistic/existential model


Journal of Psychotherapy and Counselling Psychology Reflections

Discussion This research aimed to explore how some additional input on other modalities of therapy would be experienced as relevant and useful to individual about to embark on an intensive training course in CBT. A number of features of the results are particularly worthy of note and further reflection. Firstly, our hypotheses that attendance at these training events would significantly change participants’ beliefs regarding the relevance of these models to their practice as CBT therapists was strongly supported. Of particular note, was the finding that the participants’ initial preconceptions appeared, across all models, to indicate that they regarded these models as largely irrelevant to their subsequent training and practice as CBT therapists. This finding in itself is of some concern and tends to lend some support to the contentions of Lees (2016) and others regarding the narrowing of perspectives that may be a feature of IAPT. However, in our view the strong and consistent finding that trainees, as a result of their engagement in the KSA training, changed their minds on this, is a reason for optimism. Across each of the models, participants reported that they experienced aspects of the model as directly relevant to their practice. From the humanistic model participants particularly valued the focus on emotion as an important contribution to CBT practice. Additionally, participants valued the notion of giving their clients greater space and time to reflect, without the need for the therapist ‘jumping in’ as often and placing emphasis instead on attitudes and stances that support a greater ability to listen actively. This is consistent with contemporary developments in CBT itself that has come to value the centrality of emotion in both theory and practice and has moved some distance away from a predominantly ‘rational’ perspective. For example, the work of Safran (1998) and Power (2010) has been particularly valuable in widening the perspective and practice of contemporary CBT through a greater focus on both emotion process and emotion theory. From the psychodynamic session, participants particularly valued the emphasis on transference and counter transference and also the emphasis on paying more attention to their own experience. Both of these are consistent with contemporary developments within the CBT literature. For example, Bennett-Levy et al (2009) have suggested that in CBT training it is important to pay more attention to reflective processes and focus upon the ‘self of the therapist’. These authors have developed a process known as ‘selfpractice/self-reflection’ in which trainees are encouraged to explore the impact of CBT interventions upon themselves prior to any attempt to apply such interventions to clients. It is held that such a reflective training process can help trainees developed more empathically attuned ways of working. Understanding and working with processes of transference-countertransference has also received attention in contemporary CBT. For example, Leahy (2015) has argued that concepts of transference-countertransference need not be restricted to a psychodynamic perspective. Leahy has provided a widened understanding of the role of ‘emotion schemas’ in CBT. In this model, the schematic beliefs and associated emotions and behaviours of both therapist and client are understood as interacting in multiple ways providing a perspective on processes of transferencecountertransference consistent with the basic assumptions of the CBT model.

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From the systemic perspective, participants seemed to greater value the possibility of substantially widening the range of factors that could be taken into account in their understanding and formulations of client’s difficulties. The greater attention to contextual factors and the possibility of making use of strategies of ‘circular questioning’ were seen as helpful for their practice as CBT therapists. Again, this is consistent with important strands in contemporary CBT where, for example, it has been argued that CBT therapists need to pay greater attention to a wider range of contextual factors rather than focussing exclusively or primarily upon internal cognitive structures and processes or a restricted range of behavioural responses or indeed upon an assessment process reliant upon notions of ‘diagnosis’ (see for example Bruch, 2015). At the same time, participants noted that there were elements of each model that would be difficult to carry forward into an IAPT context. For example, the feedback on humanistic models indicated that some participants struggled with what they saw as an unclear structure and less clearly defined goals. This aspect of the feedback is of some concern as in fact IAPT services often include a more structured humanistic approach for (Sanders & Hill, 2014) that has been shown to be both effective and capable of expressing key humanistic values within a more structured and goal focussed context. The great majority of participants also indicated an interest and desire to learn more about other modalities of therapy. Rather than hoping to enter what Lees (2016) referred to as a ‘uni-dimensional psychological therapy culture’ these trainees appeared interested in becoming well-trained, well-informed psychotherapists who are aware of the range of psychological therapies. Of some interest is the finding of the NHS (2016) workforce census that showed that 40% of high-intensity therapists are now qualified in more than one modality of therapy. Thus, as IAPT develops further, the role of the high-intensity therapist appears to be expanding to include a far greater degree of flexibility and openness to a variety of psychotherapeutic perspectives. Training initiatives such as the one described and evaluated here, have the potential to further support such developments. There are many limitations of the current research. The participants were at the beginning states of a demanding training and were characteristically optimistic and enthusiastic about receiving training. They also had a significant hurdle to deal with in the form of the KSA portfolio and thus may have been somewhat predisposed to respond positively to this freely provided training input. There is nothing however in the way the KSA portfolio is constructed or assessed that requires that participants demonstrate a positive view of other modalities. Additionally, the present research cannot demonstrate that the teaching on other modalities had in fact any actual impact on the ease with which CBT trainees subsequently learnt the more relational, interpersonal and dialogical aspects of CBT. This remains an important topic of future research. In our view, a key aspect of what has made the other modalities training successful is that is has been presented by trainers who are knowledgeable and sympathetic towards these models as well as proficient in CBT. It is entirely possible to present such training from a primarily critical and sceptical perspective, as it may be to present CBT within training programmes that teach Humanistic, Psychodynamic or Systemic therapy. The further development of dialogue between CBT therapists, IAPT workers and the wider field of psychological therapies may be facilitated by taking a more open dialogical stance.

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References BABCP. (2017). Guidelines for assembling and assessing KSA portfolios or evidence for course assessment. Retrieved from http://www.babcp.com/files/Accreditation/KSA/KSA-PortfolioGuidelines-V1-050913.pdf Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford. Bennett-Levy, J., Thwaites, R., Chaddock, A., & Davis, M. (2009). Reflective practice in cognitive behavioural therapy: The engine of lifelong learning. In J. Stedmon & R. Dallos (Eds.), Reflective practice in psychotherapy and counselling (pp. 115-135). Maidenhead, UK: Open University Press. Bruch, M. (Ed.). (2015). Beyond diagnosis: Case formulation in cognitive behavioural therapy (2nd ed.). Chichester, UK: Wiley-Blackwell. Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: The IAPT experience. International Review of Psychiatry, 23(4), 318-327. http://doi.org/10.3109/09540261.2011.606803 Gilbert, P. (2009). Moving beyond cognitive behaviour therapy. The Psychologist, 22(5), 400-403. House, R. (2016). Beyond the measurable: Alternatives to managed care in research and practice. In J. Lees (Ed.), The future of psychological therapy: From managed care to transformational practice (pp. 146-164). Abingdon, UK: Routledge. Leahy, R. L. (2015). Emotional schema therapy. New York, NY: Guilford. Lees, J. (Ed.) (2016). The future of psychological therapy: From managed care to transformational practice. Abingdon, UK: Routledge. London School of Economics and Political Science. Centre for Economic Performance. Mental Health Policy Group. (2006). The depression report: A new deal for depression and anxiety disorders. London, UK: LSE Research Online. NHS England. (2016). Psychological therapies: Annual report on the use of IAPT services 2015-2016. London, UK: NHS Digital. Nuttall, J. (2016). Working in partnership with IAPT. In J. Lees (Ed.), The future of psychological therapy: From managed care to transformational practice (pp. 102-116). Abingdon, UK: Routledge. Power, M. (2010). Emotion-focused cognitive therapy. Chichester, UK: Wiley-Blackwell. Richards, D. A., & White, M. (2009). Reach out: National programme educator materials to support the delivery of training for practitioners delivering low-intensity interventions (2nd ed.). London, UK: Rethink. Safran, J. D. (1998). Widening the scope of cognitive therapy: The therapeutic relationship, emotion, and the process of change. Northvale, NJ: Aronson. Sanders, P., & Hill, A. (2014). Counselling for depression: A person-centred and experiential approach to practice. London, UK: Sage. Turpin, G. (Ed.). (2010). Good practice guidance on the use of self-help materials within IAPT services. London, UK: IAPT [NHS England]. Watts, J. (2016). IAPT and the ideal image. In J. Lees (Ed.), The future of psychological therapy: From managed care to transformational practice (pp. 84-101). Abingdon, UK: Routledge.


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DIAGNOSIS AND RECOVERY: TWIN IMPOSTORS OF MENTAL HEALTH? Ralph Goldstein

Abstract Since the publication of The American Diagnostic and Statistical Manual of Mental Disorders version 5 in 2013, there has been a wave of critical protest, especially in Britain and especially amongst psychologists. My aim is not to rehearse the mostly sensible criticisms, but to ask what should we be doing about the situation. Should we not be able to find a useful classificatory procedure that helps both professionals and patients to understand both diagnosis and recovery in the same terms? Only when we can do this will the current system be superseded — improve it or live with it. After all, science proceeds by replacing older theories and systems with newer ones that seem to do a better job. Keywords: Psychiatric diagnosis and recovery, psychology, vagueness, fuzzy logic The fact is that the current systems do work for some people some of the time; for example, in medico-legal settings and pharmaceutical research settings. Psychiatric medication is effective some of the time, but the way that we approach psychiatric diagnosis and recovery are different in the sense that only rarely are the same formal procedures used at diagnosis and discharge. Two developments will be suggested here. Firstly, that both diagnosis and recovery may be conceived — indeed must be — in the same pragmatic manner by adopting a functional approach both to diagnosis and to recovery. This functional approach has the great benefit of unifying how we might conceive of both common physical problems and mental problems. Secondly, since psychological and psychiatric judgements are inherently vague in a technical sense, we should find a means — namely, fuzzy logic — to work with vagueness in formal terms. We might then be able to adequately fix our classificatory systems along the lines discussed here.

What about diagnosis? Illness is what the patient — the suffering person — presents; disease is the category, an internal state which is either an impairment or limitation of normal function, or a limit caused by environmental agents (Boorse, 1997). Thus, disease is only definable after the event; there is no way of completely defining a disease — of saying what properties constitute disease in advance, as we might for the properties of a square. Real life categories seem to be much more difficult to define than artificial constructs …and real life constructs are the interesting ones. Therefore, there seem to be three

Contact:

Dr Ralph Goldstein

central concepts to keep in mind: 1. We should understand there exist multiple models of medical diagnoses as will be shown below. 2. Do we understand which of these models are common to both medicine and psychiatry? 3. The opposite of health is much wider than absence of disease as we already know in mental health. Perhaps the challenge is to change the bathwater whilst keeping the baby? In this light my intention is to suggest that mental health can live alongside physical health, conceptually-speaking. Accordingly, it will be necessary to devote some space to discussing details of some problematic physical ailments and whether they are diseases properly speaking. In order to give space to these questions, it is important to avoid setting up a straw man as, for example, Wade and Halligan (2004) did when they introduced their argument: The biomedical model of illness, which has dominated health care for the past century, cannot fully explain many forms of illness. This failure stems partly from three assumptions: all illness has a single underlying cause, disease (pathology) is always the single cause, and removal or attenuation of the disease will result in a return to health. (2004, p. 1398, para. 1) The original pioneer in medicine and public health was Rudolph Virchow (see Silver, 1987) in Prussia in 1848, the year of revolutions in Europe. It is essentially his model of disease that is quoted as the medical model, but usually incompletely.

rgoldst@marton.plus.com


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Virchow’s seminal work took place in Upper Silesia following a typhus outbreak in 1848. This experience led him to claim it was not bacteria alone, but abnormal stimuli acting on the cells that caused disease. Virchow insisted upon the part played by the cells, even in the pathogenesis of infectious disorders and that what constituted tuberculosis was not only the tubercle bacillus, but the reaction of the organism, that is to say, of the cells, to the bacillus. It is this insistence on a two-sided relationship between organism and pathogen that tends to be neglected.

Medical problems affecting quality of life Virchow and others clearly show both environmental factors and internal factors operate together in varying degrees to cause illness. However, there are as we know only too well a number of ailments (to borrow a non-technical word) which have an increasing prevalence and an absence of a single cause, such as a bacillus or virus or organ failure. These deviations from the Virchow model leave open the possibility of some analogy between these ailments and mental illnesses. Let us consider three diagnostic groupings, which present different challenges for medicine, including a difficulty in being recognised at all. • Allergies may be among the best examples of such processes. • Irritable Bowel Syndrome – a functional diagnosis. Food becomes something that sets off undesirable or excessive cellular processes as well as beneficial ones. • Nasal polyps can be visualised and require surgery and are thus proximally related to the presenting symptoms. Allergic disease might be considered as belonging within the Virchow model because allergens are environmental factors and sensitivity is an internal factor. Hence only some individuals suffer from some allergic responses some of the time. Seasonality is an obvious, although by no means unique, example of such an internal-external dynamic. But there is a complexity in that it is common to find people who suffer allergic responses without much indication of an internal physiological response. Specifically, levels of immunoglobulin E and of eosinophils in the blood might be more or less normal whilst a person is showing symptoms — not signs — consistent with allergic disease. Clinical practice then proceeds in ways we would all recognise; an effort is made to rule out alternative explanations or diagnoses, before an empirical test of treatment for allergic disease is tried. This pragmatic procedure — differential diagnosis — is something psychologists attempt in the course of formulating and reformulating the troubles presented by the person they are working with (Johnstone & Dallos, 2013). People presenting with the set of symptoms which have now become known as signs of irritable bowel syndrome were often frustrated because they were unable to obtain a diagnosis and hence unable to find effective help. They were often told that their problems reflected some vague and unaddressed psychological issue, such as ‘anxiety’ or ‘stress’. Many leaflets available even today list psychological issues ahead of physiological ones. Once again the empiricism of systematic differential diagnosis can reveal that in the absence of known disease entities and in the absence of psychological problems conducive to disturbance of digestion, symptoms are frequently and reliably alleviated by dietary changes. However, it is conceptually quite difficult to see how this syndrome can be accommodated by the Virchow model. It is not easy to say whether the person who can control their symptoms reliably through diet is healthy as distinct from unwell. What is clear is that there is no sense

in which the person is cured by a ‘healthy diet’, although occasionally a specific sensitivity to some food will disappear after some years of being consistently avoided. Nasal polyps generally require surgery, because they can obstruct the nasal passages completely and because they cause other persistent and problematic symptoms. Sometimes a single surgical procedure is sufficient in a lifetime, but occasionally surgery may be repeated as many as twenty times or more. No clear-cut factor has been identified as causing the growth of polyps and, whilst corticosteroids can be helpful in treating the symptoms and slowing regrowth, nothing has been identified as an internal factor predisposing a person to produce polyps. Stammberger (1999) concluded his brief review of the condition and prospects for treatment by writing; ‘Nasal polyposis appears not to be a disease per se but rather the result, or expression, of an underlying mucosal disorder, the cause of which is not yet fully understood’. So a functional description of a condition can underlie surgery; there is more to medicine than the Virchow model, or as critics like to refer to it as ‘the medical model’. The anatomy of the nasal passages is quite complicated and there are a number of distinct locations in which polyps can grow and they vary in type. Not all are associated with allergic indicators such as raised eosinophils. The accepted number of types of polyps is five (e.g. Stammberger, 1999) and the interesting thing about this fact is the parallel suggested with psychiatric diagnoses, such as the subdivisions of depression. Not only do these functional divisions turn out to be useful, but there is space for consideration of the individual patient. Thus, Gosepath and Mann (2005) could state unequivocally that ‘The challenge of treating CRS [Chronic Rhinosinusistis / polyposis] today is to offer patients a therapeutical concept that includes individually relevant etiological factors, but is based on well-standardized and validated pathways of medical and/or surgical therapy’. Often implicit in psychological criticisms of ‘the medical model’ is the idea that there is no possibility of individualised treatment; clearly there is no reason why that should be true. Briefly observing the relative prevalence of some of these kinds of complaints is interesting and odd. Firstly, we should note that a significant number of people suffer both asthmatic symptoms and nasal polyps rather as psychiatric patients tend to suffer comorbidity. The following figures are from the USA CDC and represent life-time prevalence, except for the figures on allergies, which are British. • Allergies; UK figures from 2011; in any one year more than 20% of the population are actively allergic; • Irritable bowel syndrome; USA — about 10% at any one time in 2011; • Nasal polyps 5%; and of • Functional psychoses; schizophrenia about 1% and bipolar disorder about 4%. And finally, • Depression ranges between 4.5% of white men to 11.5% of US men of all races. These figures clearly support a view that a considerable burden of often serious, even fatal, diseases exist which do not conform to the classical, Virchow model of disease. These classifications are arrived at by functional methods as is the case for psychiatric diagnoses. So for example, we can compare diagnostic criteria for Irritable Bowel Syndrome (IBS) and Post-Traumatic Stress Disorder (PTSD).


Journal of Psychotherapy and Counselling Psychology Reflections

Diagnostic Criteria for IBS — (adapted from Hadley and Gaarder, 2005) Abdominal discomfort or pain, for at least 12 weeks in the preceding 12 months, with two of the following features: • Relief with defecation, • Onset associated with a change in stool frequency, • and so on …. These additional symptoms cumulatively support the diagnosis of IBS: • Abnormal stool frequency Diagnostic Criteria for PTSD — (adapted from ICD–10) a. Exposure to a stressful event or situation (…) of exceptionally threatening or catastrophic nature, which … cause pervasive distress … b. Persistent remembering or ‘reliving’ the stressor by intrusive flash backs, vivid memories, recurring dreams, or by experiencing distress when exposed …to the stressor. c. Actual or preferred avoidance of circumstances resembling or associated with the stressor. d. Either (a) or (b): and so on … The key here is to observe the same structuring and grouping together of criteria that together might support a diagnosis, irrespective of whether a physical or mental health problem is under review. The question to be kept in mind is whether these kinds of criteria are able to support reliable categorisation.

What about recovery? The notion behind framing diagnosis and recovery as twins is based on two facts; namely, that the main purpose of accurate and reliable diagnosis is concerned with selecting an effective treatment by eliminating alternative diagnoses and, secondly, that judging recovery depends critically on a change in diagnosis. To maintain that a patient has recovered means that the original diagnosis has been withdrawn and not substituted by a new diagnosis. The obvious problem is that psychiatric diagnosis is bivalent; one either suffers from depression or one does not. There is no genuine conceptual space for degree of disease in the system and so it makes no sense to speak of partial recovery. Successful treatment with drugs critically depends on diagnosis and successful psychotherapy depends on a highly differentiated understanding of the presenting problems and their implications. Nevertheless, in clinical practice the question is always in the form of wondering whether the patient is well enough to be discharged from treatment. The difficulties are summarised in Table 1. Assume some treatment Disease

Recovery

Health

Biological

Bacterium

Immune Response

No bacterium

Medical

Signs and symptoms

Fewer signs and sypmtoms

Symptoms free

Cultural

Incapacity

More control

Independence

Table 1: Is there a disease; is there some Recovery?

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It seems clear that in a perfect world the first line of Table 1 would apply under a version of the Virchow model, but the notion of health is problematic. Virchow himself recognised that poverty in Silesia had a major part to play in the spread of typhus; the end of the epidemic did not magically restore the peasantry to a state of health, but rather a state of non-disease as more nearly described in the second line of the table. The wider medical model is best represented by this same line, which is sufficiently broad in its formulation to accommodate a range including organ failure and nasal polyps. The final line of the table indicates our problem in the world of psychology and psychiatry where many symptoms are in fact indicators of cultural and social needs and, as such, subject to social change over time. These difficulties were sensitively and thoroughly examined by Albee and a version of his thoughts was published (Albee, 1996). One problem dissected by Albee was the fact that, in contrast to classical diseases consistent with the Virchow model, mental health problems have an unclear onset, vague time course and unclear recovery. This observation is unarguable as far as it goes, but when physical health problems such as those described here are considered then precisely the same problems arise. The moral of these tales seems to be quite simple; that claiming recovery depends on the implicit model of disease. So to complement the notion of functional diagnosis there exist cases of functional cures, such as the situation with HIV where the virus becomes undetectable and a person’s health status stabilises without the need for pharmacotherapy; see for example, Saez-Cirion et al. (2013). The distinguishing characteristic between a so-called sterilising cure and a functional cure rests on whether a pathogen has been completely removed. In these HIV cases the disease is not completely absent; the diagnosis itself has not been rescinded. Perhaps the notion of functional cure might be much more appropriate to mental health contexts — see the last line of Table 1 — than simply ‘cure’ or the more ambiguous ‘recovery’ or even ‘rehabilitation’. In a bivalent system some recovery is no true recovery, if the diagnosis still applies. Critically, we should not fall into the trap of supposing these points only apply to new and problematic diseases, because chicken pox and its relationship to shingles is a familiar reminder of how we are not cured in the sterilising sense, for the virus has found itself a reservoir, usually in spinal nerves, and can erupt into shingles in adulthood. Recovery from chicken pox is in fact a case of a functional cure. The case of drug dependency may again be illustrative; for someone to talk of being ‘in recovery’ has little meaning clinically and still carries the (stigmatising) sense of actually still being in a state of dis-ease. However, if a more technically precise term came into common usage, there would be benefits to each individual, to clinicians and to a psychological science. As an example, it may be that the concept of restoration to pre-morbid functioning might be worthy of investigation. The scientific benefits are gains in the accuracy of empirical description, which would in turn lead to clinical benefits. For example, functional descriptions of depression and recovery would better account for dual diagnoses and for the empirical finding that a previous depression or psychotic episode is a good predictor of the next one. An example of how such descriptions might be achieved in principle is given below. There are also negative arguments for a change of approach, not the least being that most ‘gold-standard’ research is in fact invalid, because recovery was partial and there is no clear indication in many randomised control trials that the diagnosis was rescinded. It is quite clear that clinical significance, even when defined in careful statistical terms as worked out by Jacobson and Truax (1991), belongs in a different logical Volume 3, Number 1, January 2018


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category from withdrawing a diagnosis. We should be clear about our clinical and research aims; the reality is that we are testing ways of categorising problems, offering a kind of treatment — drugs, sparks, words — and hoping for some degree of change. But, in any particular endeavour, does this degree of change reflect a reliable improvement or a functional cure? In short, the aims of any given research should be made explicit. This completes the case for claiming that some new thinking is required beyond the very real importance of differential diagnosis.

Next steps? The truncated illustrations of the diagnostic criteria for PTSD and IBS serve as a reminder that multiple measurement is always required in making a functional diagnosis. It should follow that symmetrical procedures lead to decisions concerning functional cure. To some extent this is in fact always the case, but the situation is complex. Multiple criteria are used to make a binary diagnosis; the presence or absence, say, of a functional psychosis. Absence of diagnosis does not in fact mean absence of any symptoms, just insufficient symptoms to meet the criteria listed in whichever diagnostic manual is being used. However, the claim that some treatment was helpful also does not mean the absence of a possibly clinically meaningful weight of symptoms. Clearly, at the heart of many of our current clinical and research discussions is a vagueness about what we mean when we assert a diagnosis or claim some recovery. One of the most widely used inventories in mental health is the Beck Depression Inventory, but if one looks carefully at the scoring categories, even a score of zero does not mean the absence of depression. More will be said about this below. Instead of dealing only with statistical uncertainty we need to learn to work with conceptual uncertainty, so a new approach must begin by making a virtue of the vagueness of our multiple measurements. Therefore, the next steps require us to accept that there are many medical categories and that we should: • Investigate the relationship of similarity between instances of a category that brings them together to constitute the category. • This means that categories are inherently vague, especially at the boundaries which is consistent with psychological studies of concept acquisition. The categories of disease and recovery have been shown to be of this kind. • So membership of a category can be considered in terms of gradients of membership. Think of the category of birds or colours as good everyday examples. Not all birds can fly.

Fuzzy logic: set theory for vague sets Consider that there are people who clearly suffer from asthma, those that clearly do not and some who have some asthma. The binary system of psychiatric nosology does not have a parallel here. However, in a crisp set, an item falls into or out of the set without any uncertainty. Where there is uncertainty, or vagueness, we have so-called fuzzy sets first introduced by Zadeh in 1965. There is uncertainty about the degree to which a given patient belongs in one or other, or even several, sets. Membership in the set of depressed people is fuzzy in that a person is depressed to some degree and well to some lesser degree. The uncertainty here refers to the degree of membership of a given set and not to the statistical likelihood, or probability, of being in the depressed set, say. The application of fuzzy set theory is now all around us; control

of central heating systems and control of a car’s automatic gearbox are most often programmed using fuzzy logic. These ideas have not gone unnoticed in medicine, but fuzzy logic is almost completely absent in the broad subject of psychology. For the case of medicine in general, Sadegh-Zadeh (2008) proposed a prototype resemblance theory of disease which diverges from current conceptions by searching for the best examples of a category, i.e. its prototype, rather than for common features of diseases, i.e. individual diseases. A relationship of similarity is then constructed between the condition as presenting and a prototype. This relationship is worked out using fuzzy set theory. Seising (2006) has written a helpful and clear summary of such thinking in medicine, which is simpler and more historically organised than Sadegh-Zadeh, who is more directly technical in his exposition. A cognate concept has been quite fruitful in a branch of social science (e.g. qualitative case analysis, see Wagemann & Schneider, 2012). In these applications classical set theory based on the logic of sets rather than mathematical treatments of sets has been applied to topics arising in education and politics. The obvious application of these techniques in the context described here is to ask what measures best predict benefits due to psychotherapy. Statistical approaches permit conclusions about the average benefits, but permit almost no conclusions about individual benefit. Equally, no conclusions about therapeutic failures are possible; the failure to reject the null hypothesis does not permit any conclusion beyond the immediate failure of the current experiment. What would be really helpful is a method which allowed some progress to be made in improving outcomes for the apparent failures of therapy, by which is meant those results that were not consistently covered by the set of measures signifying good outcome. In such an approach, there would be space for the patient’s own assessments. More generally, the primary aim of fuzzy Qualitative Case Analysis [fs/QCA] consists in modelling the outcome to be explained as the result of different combinations of causal conditions. Therefore, fs/QCA represents a good methodological choice in research situations in which:- (a) hypotheses on the existence of necessary and/or sufficient conditions exist, i.e. when the underlying causal structure is believed to be equifinal and conjunctural; (b) the number of cases and the quality of data are too low to apply common (let alone advanced) statistical techniques to unravel complex causal structures; and (c) the researcher holds good case knowledge and wants to make use of it in the entire research process, and (d) careful thought has been given to the definition and measurement of key concepts (Ragin, 2000). This description could almost have been written with psychotherapy in mind, for what we really would like to do is bring our craft, our case-knowledge, to bear in thinking about what we mean when we say that a person is ready to end a therapeutic episode. What kinds of assessments would really reflect the structure of a therapeutic episode and reflect a benefit that a person who had wished for therapy might themselves agree was beneficial? An example of fuzzy inference Perhaps a concrete example from everyday experience might help to illustrate the procedures involved in fuzzy logic. The software used was the Octave Fuzzy Logic Toolkit (Markowsky, 2014). The important point about this software is that it is free and open source; anyone can make use of it on any computer running a version of the operating system GNU/ Linux. The essential democratic point is that everyone including researchers in private practice, without access to official computing resources, can work on these problems. The logic is shown in Figure 1.


Journal of Psychotherapy and Counselling Psychology Reflections

Input 1 Service (0-10)

Input 2 Food (0-10)

Rule 1

If service is poor or food is rancid, then tip is cheap

Rule 2

If service is good, then tip is average

Rule 3

If service is excellent or food is delicious, then tip is generous

The inputs are crisp (non-fuzzy) numbers limited to a specific range

All rules are evaluated in parallel using fuzzy reasoning

The results of the combined and distilled (defuzzified)

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Output Tip (5-25%)

The result is a crisp (non-fuzzy) number

Figure 1. Dinner for two. A 2 input, 1 output, 3 rule system As an initial trial of fuzzy rules and outcomes applied to an NHS context, I present here data collected from one person enrolled in a time-limited personal construct therapy. The study by Craig (2011) was an extended inquiry using multiple measurements to clarify beneficial processes in psychotherapy. The reasoning runs as follows: • If the Beck score is minimal and • Personal Questionnaire score is Low and • the General Health Questionnaire score is non-case and the CORE score is non-case then • Recovery is a mild-recovery. In fact the actual measured Beck depression inventory score after 16 sessions of therapy was 19 and the defuzzified possibility of recovery was 20 using the same scale. Hence the degree to which this person was depressed, as calculated from the other measures as listed, was essentially the same as the actual measured score at the end of therapy. The graph in Figure 2, adapted from the scoring system provided with the BDI portrays the range of meanings intended by the verbal descriptions. So ‘mild recovery’ covers a range around the score of 19 and 20, but we can readily see how mildness is on the boundary of the set of moderate scores. This boundary is in reality fuzzy or vague, despite the arbitrary cut-offs provided in the scoring system of the BDI. All kinds of other measures could have been considered, including some that formed part of the original research. This demonstrates in principal that it is possible to assess the degree to which someone belongs in the set of depressed people, or not, at the end of therapy, but analogous procedures could also be undertaken at the beginning of therapy. The important point here is that decisions about membership in a set can be arrived at using multiple measurement of many kinds. We do not have to rely on the psychometric properties of a single favoured inventory to provide us with data that we can sensibly interpret. min-BDI mild-BDI mod-BDI severe-BDI

Degree of membership

1 0.8

A former chair of the BPS Psychotherapy Section, John Marzillier, concluded recently (Marzillier, 2014, p. 32) that ‘interpretation of psychotherapy outcome research is difficult’. He went on to suggest that given what the people who come to see us might really want – not merely, or only, symptom reduction – then it might actually be better if psychological treatments were excluded from NICE Guidelines altogether. Furthermore, whilst I agree with almost all of Marzillier’s criticisms, and many others based on either the limitations or misapplications of frequentist statistics, questions concerning the outcomes of the various psychotherapies are too important to be allowed to wither away. I propose that the ideas which have only been presented in outline here are worthy of further detailed study.

Conclusion It turns out that there are indeed methods to hand that allow us to treat vagueness in new and helpful ways, which apply not only to outcomes of treatment, but in principle to diagnostic systems. There is, therefore, no need to throw out both the nosological baby with the medical bathwater, but, more constructively, to renew the waters by coming to an understanding of how conceptually similar are our experiences of both common mental and physical ailments. This is important for many reasons; not the least of which is the need to find a psychological and psychiatric methodology that is consistent with evolutionary biology. We would need some very good reasons indeed to have one system for physical disease, which included neurological degenerative disorders, and quite another for mental ailments, such as the functional psychoses and depression. In principle, the only alternative would be to propose a new set of categories of disorders of mind as distinct from disorders of neural tissue, like the distinction between hardware and software in a computer. This might be an impossible pursuit, not least because of the problems of deciding what constitutes a mind and, yet more difficult, what we might mean by disorders of mind.

References Albee, G. (1996). Searching for the magic marker: An illness like any other? Psychotherapy Section Newsletter.

0.6 0.4

Boorse, C. (1997). What is disease? In (pp. 3–134). Totowa, NJ: Humana Press.

0.2 0 0

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Figure 2.

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Craig, M. (2011). Abductive reasoning as a method for drawing inferences to the best explanation of change processes in psychotherapy Unpublished doctoral dissertation. Regents University London. Gosepath, J., & Mann, W. (2005). Current concepts in therapy of chronic rhinosinusitis and nasal polyposis. ORL, 67, 125–136. Volume 3, Number 1, January 2018


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Hadley, S. K., & Gaarder, S. M. (2005). Treatment of irritable bowel syndrome. American Family Physician, 72(12), 2501-2506. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. J. Consulting and Clinical Psychology, 59 (1), 12-19. Johnstone, L., & Dallos, R. (2013). Formulation in psychology and psychotherapy: Making sense of people’s problems (2nd ed.). Hove, UK: Routledge. Markowsky, L. (2014). Octave fuzzy logic toolkit (Tech. Rep.). Marzillier, J. (2014). The flawed nature of evidence-based psychotherapy. Psychotherapy Section Review, 51, 25–33. Ragin, C. C. (2000). Fuzzy-set social science. Chicago: University of Chicago. Sadegh-Zadeh, K. (2008). The prototype resemblance theory of disease. Journal of Medicine and Philosophy, 33(2), 106-139. Saez-Cirion, A., Bacchus, C., Hocqueloux, L., Avettand-Fenoel, V., Girault, I., et al. (2013). Post-treatment hiv-1 controllers with a long-term virological remission after the interruption of early initiated antiretroviral therapy anrs visconti study. PLoS Pathog. Seising, R. (2006). From vagueness in medical thought to the foundations of fuzzy reasoning in medical diagnosis. Artificial Intelligence in Medicine. Silver, G. A. (1987). Virchow, the heroic model in medicine: Health policy by accolade. American Journal of Public Health, 77(1), 82–88. Stammberger, H. (1999). Surgical treatment of nasal polyps: past, present and future. Allergy, 53/54, 7-11. Wade, D.T. and Halligan, P.W. (2004). Do biomedical models of illness make for good healthcare systems? British Medical Journal, 329, 1398–401. Wagemann, C., & Schneider, C. (2012). Set-theoretic methods for the social sciences: A guide to qualitative comparative analysis. Cambridge: Cambridge UP.


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HOW DO PEOPLE UNDERSTAND THEIR ENGAGEMENT IN SADO-MASOCHISTIC SEXUAL ACTIVITIES? Julie Burchill and Desa Markovic 

Abstract Sado-masochistic (SM) sexual activities have historically been considered manifestations of psychopathology. However, recent quantitative research challenges this dominant discourse, finding that individuals who engage in SM sex might even enjoy enhanced mental wellbeing. This study explores the experiences of people practising SM and their understandings of their engagement in these activities. Six individuals participated in semi-structured interviews and data were analysed in line with interpretive phenomenological analysis (IPA). Participants unanimously gave narratives of overcoming and emancipation that were sometimes connected with coming out as kinky. Data analysis suggested that consensual kink activities may sometimes facilitate expression of emotion, physicality and sexuality, and such expressions may at times be beneficial to mental wellbeing. Keywords: BDSM, bondage, domination, sadism, masochism, kink, sado-masochistic sexual activities Notes on terminology BDSM is used as an umbrella term referring to a range of activities and dynamics, including: bondage and discipline, domination and submission, sadism and masochism and typically ‘involving the use and exchange of power in an eroticised relationship’ (Connan, 2010, p. 11). The terms SM, BDSM and kink are used interchangeably, referring to both physical activities and psychological play, e.g. roleplay. Practitioners are referred to as kinksters or SMers. ‘Erotic’ is used interchangeably with ‘sexualised’.

Introduction Much current psychiatric and psychotherapeutic theory, legislature and wider social attitudes construct BDSM as perverse and pathological (Langdridge & Barker, 2013). It is not rare for kinksters to lose their jobs, housing and children in custody disputes through bias regarding their kink practices (Moser & Kleinplatz, 2006). In recent years, a new psychotherapeutic discourse of BDSM has emerged promoting ‘affirmative ethical approaches to diverse consensual bodily practices’ (Denkinson, 2011, p. 2). This new approach engages with kink phenomenologically, researching the experiences of kink communities from their

Contacts:

perspectives. As a result of such research findings, certain theorists now construct some kink play as being closer to ‘extreme leisure activities’ than to sex (Newmahr, 2010, p. 313). A quantitative study by Wismeijer and van Assen (2013) found that kinksters experience better mental wellbeing on a range of measures than a control, non-kinky (vanilla) population. This finding questions the dominant discourse of kink as pathological. The present study explores how kinky people manage their mental health in the face of considerable adversity and how SMers understand their kink activities, looking at meaningmaking from their lived experience. Evidence indicates that clients frequently censor their kink during therapy, and sometimes receive inadequate care when they do disclose it (Kolmes, Stock, & Moser, 2006, pp 313-315). Many kinksters, afraid of being misunderstood and misperceived as having a pathology, experience barriers to disclosing kink (Denkinson, 2011, p. 49). While much literature focuses on the debate regarding whether kink is pathological, one might question what is being ignored. Is psychotherapy failing kinky clients due to the lack of research to inform clinicians’ understanding of their experiences? Is deeper engagement possible?

Professor Desa Markovic, Professor in Psychotherapy and Head of Programme, MA Psychotherapy & Counselling, Regent’s University London

markovicd@regents.ac.uk

Julie Burchill, BACP Psychotherapist

jhburchill@yahoo.co.uk


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Literature review This section summarises selected literature on the topic, categorising it in certain distinct themes. Compulsion to repeat Repetition compulsion has been posited as a causal explanation for kinky sex, since the 1920s, when Freud observed the tendency to repeat – in play, dreams and fantasy – traumatic experiences, recasting oneself as an active agent. Stoller was also influential in associating kink with the compulsion to repeat in the 1970s and 80s. For instance, an individual who was spanked as a child for discipline may enjoy being spanked as an adult in scenes he deliberately arranges, actively constructing a scenario wherein originally he was helpless. Thus, BDSM is conceptualised as an attempt to master early trauma by reliving its material under scripted circumstances (Stoller, 1985, p. 8). This discourse has become pervasive as the standard account for SM, leaving kink widely conceptualised as sexual, rooted in childhood trauma or abuse, pathological, and compulsive. Such pejorative conceptualisations of consensual bodily practices may have their roots in the historical view that sex for procreation is normal, whereas sex for pleasure is perverse. Indeed, an early meaning of the term perverse, referred to sex outside the aim of procreation (Nobus, 2006, p. 7). Sexual transgression and otherness There is some consensus that kink contravenes social mores. Some argue that kinky sexual excitement and pleasure arise exclusively from transgressive acts (De Masi, 2003, p. 16). Given the constantly shifting boundaries of consensus, there is no absolute point for transgressive sex, nor for sexual normality. Kink is often portrayed as other, as though in binary relation to ‘normal sex’. Arguably, it is a false dichotomy, and individuals’ liking for physical sensation could be better considered as falling on a spectrum of preferences rather than in two polarised camps. In terms of the ‘othering’ of kink, Langdridge and Barker (2013) observe that SM occupies an extraordinary place within the popular imagination… variously represented as madness, criminality and/or comedy. The widespread conceptualisation of kink as ‘weird sex’ may also function to maintain BDSM as ‘other’ - people may avoid learning more about it for fear of appearing prurient. Pillai-Friedman, Pollitt and Castaldo (2015) write that, ‘In the practice of BDSM, emotions and behaviours that are normally considered unhealthy and undesirable, namely, shame, powerlessness, domination, submission, receiving pain, giving pain, giving up control, are normalised and eroticised’ (p. 200). Since kink can take people willingly to unusual emotional places, it could be hypothesised that SMers may integrate and own their emotions and personal capacity for aggression through their kink practices. A common theme within mainstream media depictions of kink is its potential for healing. Barker, Gupta and Iantaffi (2007) comment that ‘healing narratives’ are a frequent trope whereby fictional characters are ‘taken from a place of psychological and/or physical ill health to one of emotional stability and/or general wellbeing through BDSM relationships and practices’ (Langdridge & Barker, 2013, p. 207-208). It has been argued that healing narratives consciously invert the psycho-medical discourse of harm and that ‘kink as healing’ may be ‘threatening the mainstream hierarchies of authority since, instead of going to a counsellor or doctor, the BDSMers choose to take the control, power and responsibility of healing upon themselves’ (p. 217).

Consent culture Langdridge and Barker (2013) distinguish sexual acts that are transgressive (kinky) from those that are coercive (p. 4-8) by way of emphasising the importance placed on consent within BDSM communities. Some contributors advocate a repositioning of attitudes towards consent, shifting from the present cultural norm in which sexual acts may be implicitly agreed to until prohibited by the word no to a new norm where an active, explicit yes is sought. Barker borrows the term enthusiastic consent from Pervocracy (2011) and argues for moving from ‘no means no’ to ‘yes means yes’ (Barker, 2013, p. 898-904). According to Barker (2013), much kink literature explores how possible it is for people in a submissive state to express their wishes assertively (p. 905). Feminist critiques highlight inherent power differentials between genders as reflected in kink play (p. 898). Therefore, there is a call for a shift from an emphasis on limits to consent as ‘a relational dialogue’ (p. 904). BDSM and good mental health Wismeijer and van Assen (2013) found that BDSMers were better psychologically adjusted than a non-BDSM control group across the ‘Big Five’ personality dimensions (neuroticism, extraversion, openness to experience, agreeableness and conscientiousness) and demonstrated more adaptive attachment styles, rejection sensitivity and subjective wellbeing. The authors conclude that, ‘BDSM may be thought of as recreational leisure, rather than the expression of psychopathological processes’ (p. 1943).

Methodology Research data consists of six in-depth interviews (see Table 1). A phenomenological approach was selected for its ability to bring new understandings of the ‘world in its appearing’ (Langdridge & Hagger-Johnson, 2009, p. 386). Contrasting with other research methods that aim at universality, IPA focuses on singularity of experience. We wished to attend to sense-making on SM material, bracketing existing theories where possible. Finlay (2012) views the researcher’s task as ‘to engage the phenomenological attitude to go beyond participants’ words and reflections in order to capture something of implicit horizons of meaning and prereflective experience’ (p. 185). Prereflective experience refers to experience as it occurs, unfettered as much as possible by existing knowledge (Willig, 2001, p. 53). IPA seeks idiographic accounts of people’s views and perceptions, ‘how participants themselves as individuals make sense of their experiences’ (Finlay, 2011, p. 141). Giorgi (2011) has argued that ‘IPA’s hesitation to proclaim fixed methods’ gives researchers insufficient instruction as to how the interpretive process should be undertaken, making replication of results impossible. Smith, Flowers and Larkin (2009) propose that IPA prioritises the subjective voice and idiosyncrasies in deriving meaning from experience. While IPA does not aim at universality, its logic is that similarities in different participants’ accounts demonstrate proximity to the essential qualities of the phenomenon under exploration. In other words, precisely because of IPA’s idiosyncratic focus, similarities between participants may be attributed to the essence of the phenomenon. The use of extended verbatim quotes in IPA data analysis is a means of keeping interpretations grounded in participants’ own words. It has also been argued that ‘delving deeper into the particular also takes us closer to the universal’ (Warnock, as cited in Smith, 2004, p. 42).


Journal of Psychotherapy and Counselling Psychology Reflections

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Participants Participants were recruited through researchers’ social network, Pink Therapy newsletter and social media (Twitter). An overview of the participants is shown here: Pseudonym

Gender

Sexual Age Bracket Psychological Play: Orientation

Physical Play (Pain):

Dominant (Top), Submissive (Bottom) or Alternating (Switch)?

Giving (Sadism) or Receiving (Masochism)?

Ella

Female

Gay

20s

Top

Giving

Martha

Female

Gay

30s

Top

Giving

Jamie

Male

Bisexual

30s

Bottom

Both

Zara

Female

Bisexual

30s

Top

Both

Seani

Male

Straight

40s

Top

Both

Giles

Male

Bisexual

40s

Switch

Both

Table 1: Participants’ background Ethical considerations Participants’ names were changed to maintain confidentiality, except for Seani Love, who agreed to be interviewed only on the condition that his professional name was used. All signed an agreement to participate and acknowledge their right to withdraw from the research up to publication. Due to the personal nature of the subject, we considered possible referral to kink-aware therapists, should the interview open up any areas of thought or feelings that they may want help with. However, no questions went unanswered and participants seemed genuinely comfortable and engaged with the process. Some later said that they quite enjoyed talking about the subject and that the interview inspired them to consider new ideas. Participant demographics and analytic procedure Interviews were semi-structured and open questions were asked in order to elucidate material. Of the six participants, three were British, one was West African, one Spanish and one Australian. Perhaps because the research advert was included in a therapy newsletter, half of participants were connected to psychotherapy (i.e. participants included two psychotherapists and one psychiatrist). The recordings were listened to several times and transcripts refined and amended until all verbal and non-verbal material

had been captured. An initial noting was made of the most immediately striking concepts emerging from each interview. This round of analysis produced a subjective condensing of data into key themes. A second round of analysis involved systematic line-by-line descriptive noting of each interview. Each line of text in the remaining material was condensed into a few words, aiming to capture the essence of the communication. This produced over 1500 different brief summaries of content, each of which were then clustered into broadly similar concepts in order to identify repeated thematic material. Emergent themes from all interviews were then placed into superordinate and subordinate categories as presented in the figure below. The nature of the material felt rich and touched upon a broader range of topics than had been anticipated. Writing up interpretations involved close, thorough readings of the data, a process which revealed further links between different participants’ accounts and was therefore used to further develop interpretations.

Data analysis This section reports on superordinate and subordinate themes emerging from data analysis:

First Fantasies and First Encounters

Relationship

Beyond Sex

Physicality

Mental Wellbeing

Kink within Society

Imagination inspired by reading

Building trust

Not erotic

Intense physical sensations

Kink and mental wellbeing

Overcoming social pressures

Early experiences of rejection

Communication in Self-expression

Creativity

Power

Experiences of therapy

Gender

Connection

Altered states of consciousness

Strong emotional responses

An indefinable essence

Control

Kink/Vanilla overlap

Overcoming painful experiences

Figure 1. Superordinate and subordinate themes Volume 3, Number 1, January 2018


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First fantasies and encounters Imagination inspired by reading Participants unanimously referred to reading, researching and fantasising about kink long before practising it. There was often a sense of nostalgia as participants regularly reported feeling intrigued by kink themes during childhood. As Zara states, ‘I found a book that I’d had when I was a kid with a picture of Prometheus, chained to the rock, having his liver pecked out …I used to love that picture so much…I used to think a lot about chaining up terrible, awful men’. Early experiences of rejection Like other participants, Seani attributes kink aspects of his sexuality to frequent sexual rejections experienced as a teenager: ‘When that much rejection comes on, I started fantasising about forcing people to enjoy sex with me, forcing women to orgasm, forcing them to feel the pleasure of it… You don’t want to have sex with me? I’m gonna make you and you’re gonna enjoy it…!’

Relationship Building trust It was frequently expressed that BDSM requires the establishment of deep trust with play partners. For example, Giles described his play as ‘a gradual increasing of trust’: ‘It’s a bit like sharing dreams, hopes and vulnerabilities with someone. It feels more vulnerable and rewarding and I wouldn’t just do that with anyone.’ Communication in self-expression Ella described her kink journey as beginning within intimate relationships that later evolved into her attendance at play parties: ‘It has provided a lot of other ways in which to express how I feel about somebody …it feels like another language’. Self-expression is understood to be a significant element of kink. Giles and Ella referred to embodied self-expression, communicating to others through gesture, gaze and touch, as well as expressing things that are perhaps ineffable. Seani felt that his first experiences of kink allowed for a new form of selfexpression: ‘I accessed a part of myself that I hadn’t before. We didn’t have this language back then’. Connection Martha spoke of an opening up of possibilities: ‘For me, it’s a different moment of connection… I can connect with someone in BDSM and not in sex’.

Beyond sex Not erotic Participants unanimously acknowledged that their kink activities are not always erotic. Ella said: ‘…It’s a different place to connect, emotionally and spiritually, but beyond sex. Sometimes sex takes away from the experience.’ Seani described his frequent desire for physical impact: ‘I can go to a friend and say I need some punches and it shakes me up a bit energetically or emotionally. And I wouldn’t say that’s sex’. Creativity The following activities were spontaneously described as analogous to kink play: cooking, climbing, dancing, eating, MaiJong, taking cocaine, spinning poi and jumping out of aircraft. A sense of creativity and leisure within kink came through clearly; for example, Giles likened kink to cooking: [Kink is akin to] ‘creating things and doing it with people, sort of hitting at a flavour, or a taste, or a reaction’. As Giles reflected, ‘I could see mixing texture or clothing or physical feeling or temperatures with play’. Altered states of consciousness Zara said: ‘BDSM gets me where many of my drug experiences have got me. It’s a different type of altered state of consciousness’. For Seani, receiving impact play can be ‘really beautiful, meditative and trance-like’.

An indefinable essence A theme common to most interviews was a belief that some quality of kink is not wholly comprehensible. This quality, for instance, is present in Martha’s account of her first kink experience; of sitting at home alone, reading The Story of O in one sitting as a teenager, she recalls that, ‘it impressed [her] a lot, in a way [she] could not explain, even in this moment’. Similarly, Jamie described how many of his fetishes contain ‘a trope of rejection’ that could be ‘hard for people to understand’: ‘But if you can recreate that experience in a theatrical way, and have control over it ... it’s all lovely and complicated and I don’t completely understand it myself…’ Giles reflected: ‘It’s something I just know I like, in a quite visceral, physical way. And it’s difficult to explain’.

Control, power, embodied and emotional experiences Control Several participants understood kink as a conscious means of either negotiating power and personal control or mediating one’s own position in relation to existing power structures. Different forms of oppression were referenced, such as: low income (Zara), being female in a gendered world (Martha), and commercial exploitation (Giles). For Jamie, kink gives him a degree of control over his life. He explained that some of the health conditions from which he suffers can sometimes lead him to behave in compulsive or disorganised ways. He states: ‘If someone else is making decisions for you, for example, if someone tells you to do your work, those behaviours go away, even if it’s because it’s part of a scene, those things get done.’ Giles spoke of kink scenes occasionally taking him to the ‘edges of control’, which he felt had been a peak experience. Power Power was referred to in terms of not only exchanges of dominance between SMers, but also the position of kink as a subculture within the wider society. Jamie said: ‘S & M is a revolutionary practice, it allows us to take power structures out of society and politics, put them in the bedroom, exercise our needs there and then go out and be free people.’ The power aspects of kink can involve higher risks for Giles: ‘With psychological play, it is more explicit about power-play. I’m more careful with it. Because it feels more risky’. For Seani, kink involves a conscious engagement with the power dynamics of everyday life. And for Martha: ‘We play with power every day, in every relationship. But we’re not always conscious. We don’t talk about it. We don’t negotiate that power’. Overcoming painful life experiences Ella experienced corporal punishment as a child, which she felt linked to her kink interest, whereas Zara mentioned experiencing sexual violence as an adult, which she felt was unrelated to her kink. For Seani and Jamie, interactions with females during their respective childhoods and adolescences were sometimes remembered as emotionally painful and felt to be related to their kink. Jamie suspected that his kink may have originated from his child-minder’s daughters being ‘mean’ to him. Kink allows Seani to ‘heal those teenage wounds that most boys have’. Physicality and emotionality Giles commented: ‘As far as I can tell, for some people there’s a lot of internal, headstrong feelings. And for other people, it’s very physical.’ This distinction whereby some kinksters relate more bodily or more emotionally to kink was echoed throughout the data. A visceral sense of embodiment came through strongly in certain interviews and much less so in others.


Journal of Psychotherapy and Counselling Psychology Reflections

Intense sensations Martha described that, for her, bondage brings relaxation: ‘When I’m tied up …I focus; I’m in my body; I’m in my sensations …it’s a moment of the here and now where I stop.’ Giles described embodied experience thusly: ‘I like receiving strong sensation, sometimes afterwards I feel like I’ve rowed a rowing race’. Strong emotions Jamie and Ella refer to the possibility of expressing strong emotion to their play-partners. Jamie stated: ‘I always feel like a stronger, better, fuller, happier, more hopeful person after I’ve been in subspace and come out of it than I did before’. Conversely, Ella reported that it was, ‘a very heavily emotion-filled experience’.

Kink within society Overcoming societal pressures through kink The progression from shame to emancipation and pleasure ran through each interviewee’s account in varying degrees. For example, Jamie explained that his first sexual experiences were not kinky because he thought that men are not supposed to be submissive: While ‘[f]ear, shame and secrecy characterised [his] experience of [kink] for twenty years’, Jamie later realised that it was not something to be ashamed of. He explained that he now feels good about his kinkiness, a revolutionary psychological shift for him: ‘I think that’s only because my partner was willing to try things and did not look disgusted when I even suggested them.’

Gender and consent A theme on power differentials between genders was spontaneously referred to by every participant, often in the context of consent and negotiation in kink practice. There was unanimous acknowledgment that power differences should be taken into consideration. Participants considered negotiation to be crucial, in addition to ‘checking in and aftercare’ as well as ‘safe play or risk-aware play’. Several participants referred to the notion of positive consent. For Seani, sex is safe only when he knows that his partner can communicate her boundaries. For Martha, she will no longer play kink with men and avoids the heteronormative kink scene due to feeling an inherent gender power differential: ‘How am I going to give you power in this, if you already think you have it?’ Kink / vanilla overlap The blurring of distinctions between kink and vanilla sensations was emphasised, and the false dichotomy of kink as opposed to vanilla was often questioned. Zara felt that, ‘most people probably are far kinkier than they think’, while Giles commented: ‘I think lots of people are into variations in sexuality that could be called kink. So it’s a bit fuzzy. I think people who fantasise about being held more tightly, or scratched slightly harder during sex; that bodily sensation is on the edges of what would be kink.’ Martha found that ‘some people suddenly notice that they do some BDSM plays in their usual sex’ and that ‘the limit is not as clear as people suppose’. The perspectives offered here raise questions as to why kink is regarded as other in relation to conventional sexual practices.

Kink and mental health Kink and mental wellbeing Participants understood kink as giving them many benefits, including possibilities for self-expression, communication, trust, exploration, curiosity, letting go, relaxation, release, catharsis, stimulation, giving pleasure, serving someone, being used or useful, control, happiness, exhilaration, euphoria, peak experience, intimacy, deep connection, healing wounds, celebration, joy, conquest, fierceness, expressing masculinity, femininity, sexual arousal, physicality, play-fighting, physical achievement, competence, and ‘it’s hard to explain!’

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How kink has been received in therapy Most participants had disclosed their kink interests to a therapist at some stage. These experiences were varied, ranging in description from ‘woefully unhelpful’ (Zara) to positive, valued encounters. Ella described her therapist as ‘somebody that’s not shy to go there, so [she hadn’t] felt like [she had] to censor or embellish something’. Conversely, Seani reported that, ‘[i]t was very scary the first time [he] talked to a therapist about it: ‘I was cautious because I heard a lot of horrible stories about that. But one day I just said everything, about being a pagan, being polyamorous and everything about being kinky. And, I felt I dumped too much on one person at one time, so I didn’t see that therapist again’. Zara recalled how her therapist conflated her experience of sexual violence with her engagement in kink whereas the two had ‘always been very separate’. She described the therapist’s emphasis upon ‘fixing’ her as unhelpful. Giles expressed how difficult it can be to find specialist therapy which encompasses an understanding of kink bodily practices.

Discussion It is not being suggested that the themes identified above are generalisable beyond the current group of participants, but, rather, that the frequent similarities between participants’ accounts may point to certain essential phenomena within BDSM. Given the idiographic nature of IPA, it is hoped that this study would allow participants’ subjective voices to help further researchers’ understanding of kink. Does kink arise from eroticised traumatic early experience? There was variation within the data regarding perspectives of BDSM activity as repetition of eroticised, painful early experiences. Ella felt some connection, though not direct causality, between her kink and her childhood experiences of corporal punishment. Furthermore, Ella revealed that she does not always feel her kink is sexual. To some extent, Ella’s account is consistent with Freud and Stoller’s perspectives of BDSM as repeating painful early experience. However, her experience does not fully support the concept of eroticised distress (Freud, 1955, p. 16; Stoller, 1985, p. 8). For Jamie, his unrequited crushes and experiences of girls being mean to him during childhood were felt to be linked to his submissiveness. Similarly, Seani felt that sexual rejections during adolescence led to his fantasies of dominating women. Ella and Zara gave examples of transforming earlier negative experiences into pleasurable encounters through kink play (e.g. Ella reprocessed her experience of corporal punishment, while Zara reclaimed relationship breakup). The ways in which participants referred to the relationship between painful earlier experiences and their kink were not consistent with the literature. While theory highlights pathology and damage, participants emphasised their own creative solutions to painful situations, a finding that may indicate participants’ emotional resourcefulness and buoyance. Giles and Martha, however, did not account for their kink in this way: Giles was somewhat mystified by his own interest (i.e. ‘I think humans are complicated’), whereas Martha attributed her kink to a lifelong interest in power. No participants made any reference to experiences of childhood sexual abuse. Is kink compulsive? Participants did not express feeling compelled to have BDSM encounters. And while they did not intend to stop practising BDSM, participants did not refer to their kinks as problematic. They all envisaged that their kink play would reoccur in future and did not indicate any concern. Volume 3, Number 1, January 2018


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The fact that participants had no intention of ceasing their kink play could be construed as ‘repetition compulsion’. However, we would argue that most who enjoy vanilla sex prefer to do so repeatedly, yet are not thereby considered to be pathologically compulsive. Perhaps a taste for kink could better be thought of as an enduring sexual preference.

Barker, M., Gupta, C. and Iantaffi, A. (2007). The power of play: The potentials and pitfalls in healing narratives of BDSM. In D. Langdridge and M. Barker (Eds.), Safe, sane and consensual: Contemporary perspectives on sadomasochism (pp. 197-216). Basingstoke, UK: Palgrave Macmillan. Connan, S. (2010). A kink in the process. Therapy Today, 21(6), 11-15.

And while compulsion and sexual addiction did not appear in the data, participants routinely admitted using kink in the service of feeling better in some way. Several participants revealed that they no longer had much vanilla sex wherein kink was entirely absent. Other participants, however, including Seani reported feeling that getting his kink needs met had enhanced his experience of vanilla sex.

De Masi, F. (2003). The sadomasochistic perversion: The entity and the theories. (P. Slotkin, Trans.). London, UK: Karnac. (Original work published 1999)

Non-sexual kink play While kink is widely conceptualised as sexual, the data indicate a high prevalence of non-sexual kink play. Some participants were themselves surprised to find, upon consideration, that their BDSM play is occasionally non-erotic.

Finlay, L. (2011). Phenomenology for therapists: Researching the lived world. Chichester, UK: Wiley-Blackwell.

Identities – kink understood as fluid or sedimented? The findings suggest that kink can be predominantly physical, emotional or psychological. Individuals who connect with kink in a predominantly emotional way are likely to consider ‘being kinky’ as a part of their identity: ‘I am this’ rather than ‘I do this’. Narratives of overcoming Transformational or healing properties of kink were occasionally referenced; Seani, for example, described kink as ‘still healing those teenage wounds that most boys have’. However, much more common were narratives of overcoming through kink play, be it painful experiences from childhood, adolescence and/or adulthood, or simply overcoming the social stigma surrounding BDSM. Embodied kink experiences were felt to be linked to histories, ‘senses of self’ and personal narratives. Narratives of overcoming position kink as a response to external challenges rather than as a means to heal from emotional pain or internal pathology. These narratives locate widespread problems of living (such as financial hardship or relationship breakup), and personal solutions to navigating such challenges without playing into notions of kink as sickness.

Conclusion The data support as well as challenge some concepts from the existing body of kink literature. Certain findings were discordant with much of the received wisdom on SM, including the high prevalence of non-sexual kink play. Some, but not all, participants felt that their preference for kink was somewhat linked to early (childhood) experiences. Participants understood their engagement in SM practices as being occasionally linked to affect-regulation and/or mood enhancement. All participants stated that their kink play is at times non-erotic. Kink practices appeared to have created opportunities for self-expression and forming connection with others. Narratives of overcoming oppression were also very prevalent in participants’ accounts. By way of revealing certain aspects of participants’ understanding of their kinkiness (e.g. affect regulation, self-expression, connection and overcoming oppression) this research helps to illuminate recent quantitative findings suggesting that kinksters may enjoy better mental health than their vanilla counterparts.

References Barker, M. (2013). Consent is a grey area? A comparison of understandings of consent in Fifty Shades of Grey and on the BDSM blogosphere. Sexualities, 16(8), 896-914.

Denkinson, G. (2011). What barriers, if any, to entering counselling or psychotherapy do SMers perceive as related to their identity, interests and practices (Master’s thesis). Retrieved from OpenThesis.org. (601586)

Finlay, L. (2012). Unfolding the phenomenological research process: Iterative stages of ‘seeing afresh’. Journal of Humanistic Psychology, 53(2), 172-201. https://doi. org/10.1177/0022167812453877 Freud, S. (1955). Beyond the pleasure principle. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 18, pp. 7-64). London, UK: Hogarth. (Original work published 1920). Giorgi, A. (2011). IPA and science: A response to Jonathan Smith. Journal of Phenomenological Psychology, 42(2), 195-216.

https://doi.org/10.1163/156916211x599762

Kolmes, K., Stock, W., and Moser, C. (2006). Investigating bias in psychotherapy with BDSM clients. Journal of Homosexuality, 50(2-3), 301-324. https://doi.org/10.1300/J082v50n02_15 Langdridge, D., and Barker, M. (Eds.). (2013). Safe, sane and consensual: Contemporary perspectives on sadomasochism (2nd ed.). Basingstoke, UK: Palgrave Macmillan. Langdridge, D., and Hagger-Johnson, G. (2009). Introduction to research methods and data analysis in psychology (2nd ed). Harlow, UK: Pearson Education. Moser, C., and Kleinplatz, P. (2006). DSM-IV-TR and the paraphilias: an argument for removal. Journal of Psychology and Human Sexuality, 17(3-4), 91-109. https://doi.org/10.1300/J056v17n03_05 Newmahr, S. (2010). Rethinking kink: Sadomasochism as serious leisure. Qualitative Sociology, 33(3), 313-331. https://doi.

org/10.1007/s11133-010-9158-9

Nobus, D. (2006). Locating perversion, dislocating psychoanalysis. In D. Nobus and L. Downing (Eds.), Perversion: Psychoanalytic perspectives / Perspectives on psychoanalysis (pp. 3-18). London, UK: Karnac. Pervocracy, C. (2011, July 16). How to not be creepy. [Web log comment]. Retrieved from http://pervocracy.blogspot. co.uk/2011/07/how-to-not-be-creepy.html Pillai-Friedman, S., Pollitt, J.L., and Castaldo, A. (2015). Becoming kink-aware - a necessity for sexuality professionals. Sexual and Relationship Therapy, 30(2), 196-210. https://doi.org/10.1080/146819 94.2014.975681 Smith, J. A. (2004). Reflecting on the development of interpretative henomenological analysis and its contribution to qualitative

research in psychology. Qualitative Research in Psychology, 1(1), 39-54.

Smith, J. A., Flowers, P., and Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method and research. London, UK: SAGE. Stoller, R. J. (1985). Observing the erotic imagination. New Haven, CT: Yale University Press. Willig, C. (2001). Introducing qualitative research in psychology: Adventures in theory and method. Buckingham, UK: Open University Press. Wismeijer, A. A., and van Assen, M. A. (2013). Psychological characteristics of BDSM practitioners. Journal of Sexual

Medicine, 10(8), 1943-1952. https://doi.org/10.1111/jsm.12192


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MY EXPERIENCE AS A TRAINEE ON AN INTEGRATIVE TRAINING PROGRAMME Adam Knowles

Abstract This is a personal and critical reflection on my recent integrative training in psychotherapy. While the overall experience was enthralling and unnerving, I highlight two areas for further consideration while acknowledging the difficulties in so doing. First, the wish that a greater diversity of topics could be incorporated, particularly from non-Western therapeutic traditions. Second, that integrative training could be open to a broader range of trainees, many of whom are prevented primarily by the current costs. The latter problem propagates the first. Left unresolved, our best future therapists may be trained not integratively but in the monoculture of CBT and IAPT. Noting that the integrative mindset is clearer when contrasted with that of pluralism, I conclude with a reflection that this paper itself provides evidence of a successful training programme. Keywords: Integrative training, Rogers, transpersonal, diversity, placement I recently completed the taught components of the integrative MA in Psychotherapy and Counselling at Regent’s University London. This training comprises three approaches in equal measure: psychodynamic, existential and humanistic/ integrative. Here I reflect upon that training critically. This was my first time in a group whose aim was to facilitate all participants’ personal development, including my own. It was enthralling at times, unnerving at others. Three years spent learning the best ideas of the past hundred years in psychotherapy was worthwhile. My course covered this in appropriate depth within a limited time. There are two things about my training that I want to highlight for further thought. I’ve reviewed other training providers locally and nationally and think these concerns not unique to Regent’s course. I realise that that adding something to a course means leaving something else out because time and resources, personal and institutional, will remain limited. So, no solutions here, but, as in my work as a psychotherapist, I try to ask the right questions.

barely detectable. There’s discussion of linking right with left-brain in terms of the benefit of integrating intuitive and logical aspects of ourselves, but little of East meets West in terms of points of contact and divergence between European psychotherapy and older systems of well-being from elsewhere in the world. Instructors generally taught transpersonal and transcultural approaches to gender and diversity as an interesting additional perspective rather than an essential underpinning thread. The training made diversity itself into an ‘other’, covered separately near the end of the term, disclosing its marginal status. I wonder what an integrative training might gain from consistent integration instead. Diversity is not for later, or for others.

Training as an integrative psychotherapist remains a luxury

Non-Western approaches to what we call psychotherapy are overlooked

I am white, European, middle-class (northern roots notwithstanding), cisgender and aged 25 - 40. In 2008, UKCP revealed that 98% of their members are White; in contrast, only 69% of Londoners are White (The Minster Centre, 2017). As professionals, this is a problem we need to address.

Shamanism, tarot, Kabbala, Buddhism, Tao, and yoga offer valuable insight into our work as therapists (Leung, 2011). They offer systematic insight into being human, yet seem to have been excluded from the programme more by default than intention. It would seem that one either trains with a school that prioritises a transpersonal approach, such as psychosynthesis, or the insights of such an approach are

My training will cost me £50,000 and five years, excluding earnings lost due to being available only three days a week. Part of this time will be devoted to completing over 450 hours of unpaid placement work. If training as an integrative psychotherapist is only financially viable for people like me, the psychotherapeutic profession will continue to propagate the problem of limited diversity.

Contact:

Adam Knowles, Psychotherapist

therapy@acdinternet.com


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The Psychotherapy and Counselling Union (PCU) is currently campaigning for placement providers to pay trainee therapists (Psychotherapy and Counselling Union, 2017). While bringing its own problems, I think this requires urgent consideration. UKCP, under Martin Pollecoff, has also made laudable moves in this direction recently by offering students free memberships and bursaries (UK Council for Psychotherapy, 2017). I’m lucky to have found a placement offering open-ended work in a pluralistic setting with a genuine interest in my development as a psychotherapist. From what my colleagues tell me, this is the exception rather than the rule. The quality of the placement has a profound effect on the overall training and yet is often left to chance and market forces. Advanced training in integrative therapy is competing with an offer from the NHS to train High-Intensity Therapists (The Central London CBT Training Centre, 2014). There are no course fees, and the NHS currently pays new trainees £26,000 per annum plus London Weighting and guarantees employment for new graduates. Allow me to characterise the therapists produced by this process as the opposite of integrative. They pursue a single approach, a monoculture. Instructed to direct their clients, they coax PHQ-9 and GAD-7 measures upwards each session via specific, targeted CBT interventions. It is necessary work that helps a lot of people, but if it’s the only option for therapists who wish to train without living in poverty, the impoverished approach of High Intensity CBT will remain the default option for clients. Related to this, my training could have taken a clearer stance on the difference between the integrative approach and the pluralistic. I don’t recall a single mention of the latter. For instance, it was Rogers’s position that the core conditions are not only necessary but sufficient. His attempt was not to provide a bedrock on which to build other things but a distinct, comprehensive model characterised by what it leaves out (Patterson, 1990). Adding things back, whether psychoeducation, conceptual models or therapist expertise, is inconsistent with Rogers’s model. The idea of doing so is an example of what happens when integration and pluralism are confused. Contradictory ideas cannot be integrated. What I am unable to integrate into my practice can still be valid, but is best left to others. My experience in training has been that integrative too often means credulous when it should mean discerning. I consider myself both integrative and pluralistic. Being clearer about the difference has become essential. In summary, I have not trained as an integrative therapist. Rather, I am a therapist trained to integrate. I am not a noun but a verb; a process, not a thing. My existential tutors would be proud. I take up what I find useful, leave to others what doesn’t fit, and oppose that with which I disagree. In those terms, my training has, as I’ve hopefully demonstrated in this writing, been remarkably effective.

References The Central London CBT Training Centre. (2014). Post Graduate Diploma in Cognitive Behavioural Therapy (IAPT High Intensity Training). Retrieved from http://www.central-london-cbt.com/ courses/post- graduate-diploma-in-cognitive-behaviouraltherapy-iapt-high-intensity Leung, A. C. N. (2011). A shift in paradigm: When East meets West in Psychology [Review of The Oxford Handbook of Chinese Psychology, by M. H. Bond, Ed.]. Psychology International, 22(2), 16-17. doi:10.1037/e519282012-011 The Minster Centre. (2017). The Minster Centre Bursary Scheme 2017. Retrieved from http://www.minstercentre.org.uk/MC_ Bursary_Scheme.asp Patterson, C. H. (1990). On being client-centered. PersonCentered Review, 5. Retrieved from http://www.sageofasheville. com/pub_downloads/ON_BEING_CLIENT-CENTERED.pdf Psychotherapy and Counselling Union (PCU). (2017). Why a union? Retrieved from http://pandcunion.ning.com/ UK Council for Psychotherapy (UKCP). (2017). How to train to be a psychotherapist or psychotherapeutic counsellor. Retrieved from https://www.psychotherapy.org.uk/join/how-to-train/


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FEELINGS FROM TRAINING: ANGST, ANNOYANCE, INFANTILISATION AND SADNESS Ben Scanlan

Abstract In reflecting on the first four years of training there is an exploration of both the positive and negative aspects, including the raft of feelings that are evoked deliberately and seemingly by accident. It is argued that the issues experienced around training, while providing some opportunity for insight, detract from client work and the experience in the room. Keywords: Training, uncertainty, feeling, power Some four years into training as a psychotherapist, and I’m pretty confident in saying that I’m not the only trainee who feels that aspects of the training process and its rules and regulations give rise to feelings of angst, annoyance, infantilisation and sadness. With some attention paid to the more positive training experiences, of which there are several, these negative feelings are explored herein, so as to illuminate potential trainees, trainees, supervisors, educators and administrators alike.

To my mind, clarity over the requirements is like contracting between therapist and client; it’s the one area wherein the onus is on the therapist to give clarity to the client. Similarly, I feel that while, as the ‘client,’ my angst is my own to work out in relation to my way of practising, the organisation (be it UKCP, BACP or an individual training institution) should also provide precision and clarity the contract.

Angst

One is routinely hemmed in by rules when attempting to begin a private practice. Such rules initially serve to protect clients, organisations and us from ourselves, which can only be a good thing. I remember a peer in my initial course suggesting they were going to see somebody privately even before they’d set foot in placement. That these ‘private’ hours cannot be counted towards training at this stage feels right.

My angst is firmly rooted in my current life circumstance. Seeking UKCP accreditation gives me a huge sense of awkward pride, and has really encouraged me to go on a journey within myself which keeps challenging how I am in the world along with my way of relating to everybody I meet. This process has made me anxious – can I really do this? Am I good enough? Can I handle distress? What if I’m not truly helping my clients etc., etc.? Seemingly ‘everyday’ ways of being, such as a desire to be liked or to be seen as a ‘good’ person, have turned into hours of countless self- and peer examination. While this process isn’t an ‘enjoyable’ one, it does feel progressive. So some of the angst is positive and life-changing. Some, however, is not. The concept of hours is one close to my heart, not least due to the pressure to achieve various landmarks. I feel that this is a good thing, a rigorous preparation and so is one of the main reasons why I’ve chosen to go down the UKCP route of accreditation. However, the angst is due to the seemingly constant changes in requirements. The deadlines and landmarks move, as though on quicksand, without rhyme, if not reason. Clarity is not offered. This mirrors therapy. I’m aware that I occupy the position of the angry client who wants answers. I wonder if this angst around the clarity of what’s required detracts, in my case significantly, from what could be brought up within training through exploring more practical and theoretical aspects of psychotherapy, rather than the peripherals.

Contact:

Ben Scanlan

Annoyance

This exclusion, however, extends for the duration of training, limiting the number of private hours (50, in my case) that can be used for accreditation. The prohibition prompts a multitude of questions: Can clients not be trusted if they’re paying for therapy? Why are organisations seen as offering more creditable or valid forms of psychotherapy? Can I, as a therapist, not be trusted outside of an organisational setting and, if not, then why not, when the ethical responsibility for maintaining an adequate private supervisory ratio should ensure the trust in the same way as my accredited colleagues? And, unlike those who train in other helping professions, why can I not see a return on my investment after five years? For me, this experience has been a complete paradigm shift; previously I was funded to do an MSc in project management with no prior experience, and given a full-time job afterwards wherein I earned a respectable salary while I adjusted to the world of megaprojects. I made a lot of mistakes, and while the workplace was a new environment, the idea of having had to do this learning for free is laughable. So too would it be for our colleagues in psychiatry, nursing and even cognitive behavioural therapy. The concept of being a ‘good enough’ therapist is one that permeates my training, as well as that of colleagues training at

ben@benscanlan.com


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other institutions. Wrapped up in this, for me, is the acceptance that there is equality between peers within the profession, a view reinforced by research (Nissen-Lie et al., 2015). This profession wide status quo is seemingly reinforced in a number of organisational settings, including the NHS, wherein there is no explicit acknowledgement to the client that a trainee offers anything different to an accredited therapist aside from a different job title. The concept of ‘experience’ varies both between and within various professional organisations. One can be qualified for the BACP after only 100 hours, yet 350 additional hours are required for one to progress past traineeship with the UKCP. Yes, there is a difference between accreditation and registered membership with the BACP, but to understand this difference requires some legwork. Following accreditation, ‘experience’ is defined according to years rather than hours, a far broader measure which encompasses a huge variety of ways of ‘beinga-therapist.’ This alteration just is what it is rather than being justified.

Infantilisation In training, the scope allowed in selecting what to write about and how to approach both academic and therapeutic aspects of the course increased the reflexivity and consciousness with which I now live. I felt empowered. This view of the trainee as a self-aware adult was reinforced in placement, especially through the supervisory relationship. My course demands roughly one signature for every eight client hours in placement from a supervisor. I’m grateful that the majority of my supervisors, trusting me, readily endorsed my placement hours. This quickness, I feel, is an acceptance on their part that their signature is only a small part of the process; delays only serve to distress the trainee and thereby detract from the work with clients. I certainly didn’t appreciate the importance of securing signatures swiftly until it wasn’t there: one supervisor refused to sign the paperwork, unexpectedly, even after my explaining the tight timeframe for submission due to my progression from one course to another. They were adamant that they had to read every word of my client records and reflections, over 4,000 of them. Perhaps I am being oversensitive, but when trusted by clients who were suicidal and had suffered abuse, as well as by the organisation who had paired us together, this supervisor’s reticence seemed unwarranted. Perhaps my need to control things like my portfolio of hours is born out my uncertainty over exactly what I’m doing. A sense of control over the controllables offsets the lack of control over the uncontrollables. Certainly, being made to wait, and wait, figuratively transported me back to primary school and the power dynamic between teacher and student that exists in early years’ education. The relationship above has ended, and, on reflection, I think that much of this negative feeling results from my own annoyance at having had my focus taken away from the client work, and the subsequent lack of learning about client work on my part, albeit off-set by a greater appreciation of the value of ‘progressive’ supervisor-trainee interactions. Essentially, there is a huge potential for infantilisation in the supervisory relationship, especially in organisations that endow trainees with only a modicum of power, with awkward complaint procedures and a dual supervisor/manager role held by the other. The only feeling that really eclipsed the disempowerment was the huge sense of responsibility and care that I felt when I first sat opposite a client. Still that feeling of care and love for my client still lingers, months and clients down the line. I hope it lingers for the rest of my career.

Sadness As I write, I feel like I sound bitter. I am sad, and that sadness is expressed as bitterness. I’m bitter that this profession is a closed shop, unless one has substantial funding from external means. A rough estimate puts the real cost of training near £50k, not to mention the tiredness and change that is a byproduct of having to earn and learn simultaneously. I’m bitter that I’m restricted in the way in which I can sell my professional skills as a trainee, unless I keep my private practice hidden. I feel acute guilt that I’m privileged enough to have developed this bitterness. I love this profession, and the feelings, connection and sense of oneness possible with clients. I feel that there’s far too much red tape in a profession where there shouldn’t be; in a way, these bureaucratic controls mirror those found within the NHS, wherein client care is a by-product of target-hitting. One result of the current training scheme is that we miss out on the experiences of ‘the Other,’ such as those of black and/or working-class citizens; the barriers and myriad of requirements make the process of training so difficult to understand, and yet academic institutions suggest the route to accreditation in a way which implies an ease where none exists. This presumption of ease only serves to reinforce white, middle-class privilege.

Value of the profession I keep reading that this is a maturing profession. I see and feel this maturation based on my own experiences as a client and in the work, I do with my clients. Yet I fear that what is really being said via this discourse about professionalism is that we as practitioners are becoming sterile and incongruent with what therapy can and should be. Too many of us are driven by the need to ‘demonstrate outcomes,’ a raison d’être which is reinforced by the bureaucracy around accreditation. Life is depressing and anxiety-provoking; the very training given to budding UKCP psychotherapists invokes these very feelings. The training, however, does help one learn how to tolerate the frustration, uncertainty and confusion that is often experienced when working with clients. My concern is that this can be obtained simply by way of the material being taught and the experience of working with clients; the seeming inefficiency caused by ill-considered bureaucracy around the training could be reduced. As a profession wanting to be taken seriously, the lack of professional seriousness and clarity within it devalues our individual achievements and makes it more difficult to sell to the wider world.

Conclusions As I swing wildly about looking for certainty in an uncertain world, I realise that a lot of the frustration above informs and comes from my own process of development, and my being in the world. Some of my motivation for writing this piece comes from the need to put ‘pen to paper’ and so cease brooding. Aside from that indulgence, however, there is a broader point to be made: the seeming ‘scattergun approach’ to so much of what is expected of young practitioners often hinders the arduous personal change that one should experience when becoming a psychotherapist.

References Nissen-Lie, H. A., Rønnestad, M. H., Høglend, P. A., Havik, O. E., Solbakken, O. A., Stiles, T. C., & Monsen, J. T. (2015). Love yourself as a person, doubt yourself as a Therapist? Clinical Psychology & Psychotherapy, 24(1), 48-60. doi:10.1002/cpp.1977


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CONFERENCE REPORT Spirituality, Compassion and Mental Health Conference Chris Burford Setting the scene In July 2017 over 200 delegates principally from across the North but also from other parts of the UK and from overseas, attended the second conference on Spirituality, Compassion and Mental Health. Held at the University of Huddersfield, the conference was jointly organised by the University and the South West Yorkshire Partnership HNS Foundation Trust. I had signed up for the conference mainly out of curiosity because some of my clients have been very open about their spirituality and also because the keynote speaker was Dr Rowan Williams, former Archbishop of Canterbury. I found myself joining a variety of delegates from the health and social care settings, the voluntary sector, faith communities and that included carers, service users, academics, researchers and students. Unbeknown to me, Huddersfield University is home to the Spirituality Special Interest Group (SSIG) and is actively involved in research on spirituality in healthcare. The conference was also the setting for the launch of a newly published book Spiritually Competent Practice in Health Care written by members of the SSIG. For this article I have attempted to briefly introduce and summarise each of the speakers in the order they spoke and in so doing develop the main themes of the conference as they developed on the day. I conclude with some personal reflections. Before proceeding however, I think it is important to name ‘the elephant in the room’ which caused a good deal of comment and some controversy throughout the day namely, the proposition that spirituality is not the same as religion. As the conference progressed one could almost sense a growing desperation for a definition of spirituality to resolve any uncertainty. One possible definition was suggested towards the end of the day, by which time it had become apparent that spirituality was being regarded more as a lived experience than an intellectual concept. Content of the conference The opening session was from Wilf McSherry, Professor of Nursing at Stafford University and an executive member of the British Association for the Study of Spirituality. Drawing on nursing research and referring to Maslow’s ‘hierarchy of needs’, Professor McSherry suggested that care is about the whole person. This involves some understanding and respect for their sense of purpose, values and beliefs and a fundamental respect for their dignity and specialness as human beings. He gave a very salutary example of when the ‘science of nursing overpowers the art’ and the voice of a patient was not heard with tragic consequences.

at the ‘sharp end’ of mental health care. For me this was the most powerful session as she explained how the service reached people at places in Leeds and at times of the day that the institutional healthcare system didn’t. Drawing on Sue Gerhardt, Irvin Yalom and Carl Rodgers, she suggested that, although a contested and loaded word, a relationship of agape love (love of humankind) with visitors and callers (her name for clients) is the only way that healing can occur. Fiona also referred to connecting with those who were literally dying of loneliness and isolation. Controversially, the service was prepared to take risks in allowing mindful and thoughtful touching as a fundamental aspect of humanity but it also acknowledged the difficulties that this creates. She said that the effects of poverty and sexual abuse (the service calculated that probably 80% of the female visitors and callers had been sexually abused) were the root causes of an ever-growing demand for crisis mental health services. In his keynote address entitled ‘Nourishing the spirit: relations, stories, rhythms’, Dr Williams drew on poetry, literature, academic research and philosophy to weave together the significance to mental health of memory – in the body and in the mind – the need for people to have a strong sense of habitat or place of belonging and to have a ‘dependable other’ for support. I found this address highly thought provoking since, with observations such as ‘everyone lives somewhere’ and ‘wellbeing is about being at home in ourselves’, I was strongly reminded of my MA research on an aspect of homelessness and the stories of the five ex-homeless participants that I had interviewed. After lunch, Kevin Bond with a background in nursing and former Chief Executive of NAVIGO, an innovative NHS Mental Health provider, spoke passionately of revolutionising a mental health system through compassion and respect. Giving many examples of NHS organisations he knew, and accepting that there had been improvements, in his opinion the system remained characterised by over diagnosis, dehumanisation, intellectualisation, targets for the sake of targets and strong residual echoes of the supposedly outdated custodial model. He made the point that compassion and spirituality are not somehow ‘other worldly’ but are very down to earth and practical in the way people act towards each other. John Wattis, Visiting Professor of Old Age Psychiatry, considered the challenges in carrying out qualitative research to provide the evidence for a more spiritual approach to care, thereby providing a counterbalance to what he regarded as the dominant overly mechanistic approach. Making the point that there are many definitions in the literature, he also gave the conference their long awaited definition of spirituality from Cook (2004) as follows:

The second talk was from Fiona Venner, Chief Executive of Leeds Survivor-Led Crises Service, about her experiences

Contact: Chris Burford, UKCP accredited psychotherapist, private practice

Spirituality is a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective experience of individuals and within communities, social groups and traditions. It may be experienced as a relationship with that which is intimately ‘inner’, immanent and personal

chris.burford@temenos-therapy.co.uk


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within the self and others, and/or as a relationship within that which is wholly ‘other’, transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with meaning and purpose in life, truth and values.’ (Cook, C. C. H. (2004). Addiction and spirituality. Addiction, 99(5), 539-551.) John Wattis also presented the idea of ‘spiritually competent practice’, which I found very helpful. However, the following definition he provided was more from a nursing perspective and, for me, potentially overemphasises the role of a therapist in achieving change. Spiritually competent practice involves compassionate engagement with the whole person as a unique human being in ways which will provide them with a sense of meaning and purpose, where appropriate connecting or reconnection with a community where they experience a sense of wellbeing, addressing suffering and developing coping strategies to improve their quality of life. This includes the practitioner accepting a person’s belief and values, whether they are religious in foundation or not, and practicing with cultural competency.’ (Rogers, M., & Wattis, J. (2015). Spirituality in nursing practice. Nursing Standard, 29(39), 51-57; based on local research by Jones et al.) Dr Melanie Rogers, Advanced Nurse Practitioner and Senior Lecturer at the University of Huddersfield, spoke of ‘availability and vulnerability’ as ways of putting the client at the centre with totally undivided attention. This I found was a very useful development of Carl Rogers’ core principles. For me, the conference finished on a high with a presentation from representatives of Creative Mind, Phil Waters, the strategic lead, and Debs Taylor, previously a service user and now involved in project development and administration. Creative Minds is a charity encouraging creativity in arts, music, drama, photography, sports, crafts and other leisure activities as a way of enhancing lives. Debs experienced mental ill health all her adult life and is now a nationally acclaimed artist. An inspirational and very down to earth speaker, she also provided a more user-friendly definition of spirituality as ‘everything you are inside’. Personal reflections I didn’t know what to expect from the conference and hopefully this left me more open to hear what was being said. At the outset, I was relieved that the conference content had the credibility of being supported by research, albeit the difficulties of such research were acknowledged. Personally I had no problem accepting the proposition that spirituality is not the same as religion. I have clients for whom spirituality is important from the Hindu and Christian religious traditions and from no religious tradition. The Hindu spiritual outlook seems to be inherently mystical, in that a specialness or sacredness is seen even in the most ordinary things of life. Ironically I find the Christian clients with the strongest sense of religion amongst the most difficult because they tend to hide their vulnerabilities as human beings, their self, behind their intellectual ideas of what they think God wants of and for them. Sometimes this can be that God, for some reason, only wants them to suffer. By contrast I can recall one non-religious client who was very comfortable talking about their spiritual connection with nature and the universe as a way of being fully human. My overwhelming sense from the conference was one of increasing confidence to explore spirituality with clients if they regard it as an important part of who they are and however they might define it.

Copies of the presentation slides from the Spirituality, Compassion and Mental Health Conference can be obtained from Chris Burford at chris.burford@temenos-therapy.co.uk  


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BOOK REVIEWS Irwin Krieger (2017) Counselling transgender and non-binary youth: The essential guide Jessica Kingsley Publishers Review by Martin Milton This book is undoubtedly a useful text, it is written in an accessible and straightforward style, covering a significant amount in short space of time and I am sure that trainees and novice therapists will find it of use as well as therapists more experienced in working with diverse experiences of gender. As the book mentions, this is a field changing at pace, as are the social and political worlds around us. There are many strengths of the book and these include its core focus on youth, as well as its attention to family, school and other contexts, insight into the mental health needs of youth who are facing a stigmatising and oppressive world, and the importance of working with allies in health and social contexts. The passion of the writer is very evident and does, I suspect, play a role in drawing the reader in and helping them engage with these different areas.

into a way of thinking that privileges the expert role and underplays the role of subjectivity, individual psychology and the role of the client themselves. For a non-critical reader this may be problematic.

References British Psychological Society. (2012). Guidelines and literature review for psychologists working therapeutically with sexual and gender minority clients. Retrieved from http://www.bps.org. uk/sites/default/files/images/rep_92.pdf Moon, L. (Ed.). (2008). Feeling queer or queer feelings? Radical approaches to counselling sex, sexualities and genders. Abingdon, UK: Routledge. Richards, C., Bouman, W. P., & Barker, M-J. (Eds.). (2017). Genderqueer and non-binary genders: Critical and applied approaches in sexuality, gender and identity. Basingstoke, UK: Palgrave Macmillan. Richards, C, & Barker, M-J. (2013). Sexuality and gender for mental health professionals: A practical guide. London, UK: Sage. 

I want to note an area that I was particularly struck by, and this is the attention that is given to the reader’s own assumptions. This is often the most difficult factor for therapists wanting to work in this domain. The book not only encourages exploration of our underlying world views but also assists by walking readers through personal reflective exercises that help focus our attention on gendered expectations that we are all contaminated by to one degree or another. There are two other issues that I want to draw readers’ attention to. The first is that the book is very US focused and so some of the ideas, practices and recommendations may not to fit easily into UK contexts. This doesn’t negate the value of the book but it does mean it cannot be utilised as ‘the essential guide’ that the sub-title suggests it could be. British readers will need to ensure that they consult the work of such British researchers as Richards, Bouman and Barker (2017), Richards and Barker (2013) and Moon (2008). The British Psychological Society guide (2012) is another useful (and free to members) document to consult. The second issue is the use of language. This may be related to the US roots, but it is worth noting that the book tends to utilise medical terminology whether or not it is referring to formal medical interventions. Of course, it is undoubtedly helpful for the therapist to have an understanding of biology, medical perspectives and medical contexts that affect trans clients (and more widely of course), however, the use of medical terminology to refer to counselling, therapeutic engagement and the human-human encounter sometimes irked, potentially getting in the way of seeing the person as an individual with agency, intentionality and autonomy. I am sure that it is not intended as such but to frame an encounter in this way means that the reader (and practitioner) get lulled

Contact:

Professor Martin Milton, Professor of Counselling Psychology, School of Psychotherapy & Psychology, Regent’s University London

miltonm@regents.ac.uk


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Salman Akhtar (2017) A Web of Sorrow: Mistrust, Jealousy, Lovelessness, Shamelessness, Regret, Hopelessness Karnac Review by Amita Sehgal Salman Akhtar is a psychoanalyst and a psychiatrist, a writer and a poet. In his latest book, A Web of Sorrow, he presents a study of the different emotional states that lead to sorrow. He begins by remarking that the use of the word ‘sorrow’ appears to have slipped from common parlance despite its ubiquitous presence in the world we live in. He links its disappearance from ordinary linguistic exchange to us living in an ‘era of specialisation’, and questions whether we now prefer to ‘speak only of components and catalysts of sorrow? Of loss of hope, of lack of love, of decline of fidelity, or of regret?’ (p. xiv). He concludes that if this is the case then we must deal with component scenarios like mistrust, jealousy, lovelessness, hopelessness, shamelessness and regret, to attend to the sadness that underlies these emotional states. This, he feels, will bring us back to talking about sorrow itself. Akhtar devotes a chapter to each of these six component scenarios. He discusses these emotional states by tracing their developmental origins within the context of psychoanalytic literature, interweaving pertinent insights from general psychology, psychiatry and cultural anthropology. From time to time he offers some clinical examples from his own practice, and draws upon his wide knowledge of films and poetry to further elucidate these topics. He also presents the technical implications of working therapeutically with patients whose mental lives are suffused with these sorts of feelings.

are stereotyped in this way and placed into categorical boxes. Such certainty also extinguishes the possibility that people within a group may have their own, individual responses to sorrow. Akhtar continues, ‘Going to a circus, when feeling suffocated by sorrow, is the sort of thing I have in mind. Trust me, seeing a badly dressed midget on a trapeze can heal a lot, even if momentarily’ (p. 131-132). Did he really mean this, I found myself asking, or is he attempting humour? Either way this last image, like some other illustrations in the book, left me feeling uncomfortable. It appears to suggest that one way of dealing with painful feelings is to laugh at another’s misfortune. This seems oddly placed in a book on sorrow. It almost seems as if Akhtar is countering his own thesis where he is simultaneously attending to the phenomenon of sorrow whilst at the same time distancing himself from it. What is missing from this book is a discussion of the concept of chronic sorrow. People who live with a painful gap between who they have been and who they are now, of who they dreamt themselves to be and who they still long to be, are living with chronic sorrow. Chronic sorrow is a normal, nonpathological state of sadness related to the on-going losses associated with the loss of self. It may be that by focusing on the components of sorrow Akhtar repeats what he wants to avoid, which is to fragment sorrow into its component parts and pathologise the emotion. Overall, A Web of Sorrow is a thought-provoking read, one that deepens our understanding of the sources of sorrow and how these can manifest in the clinical setting. Although I have found aspects of this book uncomfortable to read, it makes an important contribution to psychoanalytic literature on this subject alongside inspiring clinicians to work with humanity, thoughtfulness and patience.

The book is divided into two parts: in Part I, Akhtar describes how sorrow can be felt in response to events that have their origins external to the self, i.e. as a result of painful experiences encountered in social, cultural and also in the clinical realms of life. In this section he discusses mistrust, jealousy and lovelessness. In Part II, Akhtar attends to sorrow arising from within the self and in response to feelings of shamelessness, regret and hopelessness. On a phenomenological and psychodynamic level, he distinguishes between the adaptive growth-promoting, and the pathological maladaptive variants of shame and shamelessness; regret and remorse; hope and hopelessness. Akthar’s writing style is open and engaging and the book is generally easy to read. However from time to time I found him to be quite prescriptive and prone to unsupported generalisations that verged on caricature. Here is one of many examples that can be found throughout the book, ‘To bear sorrow gracefully is the right thing to do. At least that’s what the British would have us believe. But then, they have the same prescription for all feelings: bear them, with grace’ (p. 131). He goes on to state, ‘The Spanish, Portuguese, and Mexicans … seek to transform it into song, afternoon sex, poetry, and high-pitched family drama… Indians visit temples… Italians drink their wine, and Germans try engineering and mathematics…’ (p. 131-132). The ability to differentiate between individual responses to sorrow is circumvented when people

Contact:

Dr Amita Sehgal, The Balint Consultancy, 4th floor Hamilton House, Mabledon Place, London WC1H 9BD

amita.sehgal@icloud.com


Journal of Psychotherapy and Counselling Psychology Reflections

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AUTHOR INFORMATION Julie Burchill holds the MA Psychotherapy & Counselling from Regent’s University London. She has worked in the charity sector in individual and group work in the mental health field, in university mentoring services and is currently working as psychotherapist in private practice. Julie draws on existential and psychoanalytic thinking as influences for her work. Chris Burford completed his training at Regent’s University London in December 2016 with an ADIP and joined UKCP in April 2017. He volunteers at a counselling charity in Yorkshire that has a wide variety of clients and where he is approved by the police to work on their supporting victims programme. He has recently starting working with a counselling service for clergy and religious and after reading John Rowan’s book, The Reality Game, has named his startup practice Temenos (Greek for sacred space). Ralph Goldstein, PhD, pursued academic research into emotional learning theories and hormonal influences on animal brain and behaviour, before accepting a lecturing post at University College of Worcester. But the motivation for all this study was to do clinical work with a Jungian orientation. He has also been chair of the British Psychological Society’s Division of Counselling Psychology [2006--2007] and a member of the group, which devised the Society’s post-qualifying register of psychologists specialising in psychotherapy. Adam Knowles is a psychotherapist (MBACP) working in private practice in London. With an extensive previous career in technology teams and start-ups, he switched into training in psychotherapy at Regent’s University London and is proceeding toward UKCP registration. While identifying as an existential therapist, he maintains an active interest in transpersonal and transcultural approaches as well as issues of diversity (particularly gender) and the socio-cultural context of psychotherapy. Professor Desa Markovic is Head of Psychotherapy & Counselling programmes at Regent’s University London, a UKCP registered systemic psychotherapist and supervisor, COSRT accredited psychosexual therapist and supervisor, and a Fellow of the Sheffield Society for the Study of Sexuality and Relationships. She has held senior academic posts at various training institutes, including Assistant Director of the Institute of Family Therapy, and Senior Practice Consultant at Relate. She presented at national and international conferences and published papers and chapters on the subject of systemic and psychosexual therapy integration. Her book Working with Sexual Issues in Psychotherapy, a Practical Guide Using Social Constructionist Framework was published in September 2017 by Palgrave Macmillan. Professor Martin Milton is Professor of Counselling Psychology at the School of Psychotherapy & Psychology at Regent’s University London. His research interests are related to sexuality, gender and counselling psychology’s social justice agenda. His new book on these topics,The Personal is Political: Stories of difference and psychotherapy’, is published by Palgrave.

Professor John Nuttall, PhD, MA, ADipPsy, is professor of integrative psychotherapy, Head of the School of Psychotherapy & Psychology and Assistant Dean for Research at Regent’s University London. He is also chair and trustee of West London Centre for Counselling where he is an honorary psychotherapist. He is a UKCP and BACP accredited psychotherapist, has a long senior management career in industry and commerce. and is a Certified Management Consultant and Chartered Marketer. He has written widely on psychotherapy and management and his research interests concern the process of personal psychotherapy integration, organisation theory, and the provision of psychotherapy in the community. Rebecca Samuels is an assistant psychologist at Central and North West London NHS Foundation Trust, currently working for the Grenfell Outreach Team and previously for the CBT training department. Rebecca completed an MSc in Clinical Forensic Psychology at Kings College London and a BSc in Psychology at the University of Birmingham. Ben Scanlan is reading for the Advanced Diploma in Existential Psychotherapy and the MA Psychotherapy & Counselling, both at Regent’s University London. In addition to practising privately, he has also held positions in the public and third sectors. He has a special interest in suicide, suicidality and masculinity in modern Western culture. He also provides executive and communication coaching, and has also coached rugby union at a variety of levels over the past fifteen years. Amita Sehgal, MA, PhD, is a couple psychoanalytic psychotherapist accredited by the British Psychoanalytic Council. She is a visiting lecturer at Tavistock Relationships at the Tavistock Institute of Medical Psychology in London, and consultant psychotherapist at The Balint Consultancy in London. Amita has a special interest in the neurobiology of contemporary attachment perspectives in couple psychotherapy. Her on-going interest in the psychological process of separation and divorce informs her commitment to resolving family disputes out of court, in a non-confrontational and constructive manner. She also consults to family lawyers on strengthening client-lawyer relationships, as well as on the emotional impact of family work on themselves as legal professionals. Amita is published in the field of couple psychotherapy. She maintains a private practice in central London. Dr Rita Woo is a clinical psychologist and BABCP accredited CBT therapist. She is Deputy Director of the Postgraduate Diploma in CBT (IAPT) and has provided training and supervision to CBT therapists as well as a diverse range of mental health practitioners. Rita has a special interest in training and supervision issues and has presented on these topics at national and international professional conferences. Dr Michael Worrell is a Consultant Clinical Psychologist at Central and North West London Foundation NHS Trust and is director of the London CBT Training Centre which offers postgraduate training programmes in CBT and cognitive behavioural couple therapy as well as clinical supervision. Michael is an accredited CBT therapist, trainer and supervisor and also completed training in existential-phenomenological therapy at Regent’s University London in the mid-1990s.

Volume 3, Number 1, January 2018


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Journal of Psychotherapy and Counselling Psychology Reflections

Perspectives on suicidal ideation and self-harm: impact on therapists and psychotherapeutic approaches to helping people at risk

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Who should attend? ›› Psychotherapists, counsellors and psychologists ›› Students of psychotherapy and psychology ›› Academics and researchers ›› Universities and FE colleges ›› Education authorities ›› Social services ›› Community safety teams ›› Community support officers ›› Criminal justice practitioners

Psychotherapy & Counselling Psychology Reflections Research Centre

›› Equality and diversity practitioners

5th Annual One-Day Conference

›› Family protection units

Saturday 9 June 2018 09:00 to 16:30 Registration from 08:00 Regent’s University London Inner Circle, Regent’s Park, London NW1 4NS

›› Anti-social behaviour coordinators ›› Family justice centres ›› Health service professionals ›› Outreach and support teams ›› Community and voluntary organisations

Book early! Regent’s staff, students, alumni and RSPP professional members: £105 (£85 if received by 31 March 2018) Public: £150 (£120 if received by 31 March 2018) Non-Regent’s students: £120 (£95 if received by 31 March 2018) For more information: regents.ac.uk/pcprconference Please book online at store.regents.ac.uk

Volume 3, Number 1, January 2018


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CALL FOR PAPERS The Journal of Psychotherapy and Counselling Psychology Reflections is a peer-reviewed publication guided by the aspiration to cultivate a non-doctrinaire, pluralistic attitude to psychotherapy and counselling psychology. It aims to provide a forum for open debate and encourages submissions from different traditions, epistemological positions and theoretical modalities. Our Editorial Board members champion the development of more reflexive thinking in both the theoretical and applied domains of psychotherapy and counselling psychology. We welcome the submission of manuscripts that convey the subtle tensions inherent in applying philosophical constructs to ‘real-world’ practice. The JPCPR explores the following topics: • Contributions from, and debates between, different theoretical approaches to psychotherapy and counselling psychology. • Contemporary issues in psychotherapy and counselling psychology in public, private and voluntary settings. • Research on the practice of psychotherapy and counselling psychology from different theoretical perspectives. • Reviews of books relevant to the field of psychotherapy and counselling psychology. The Journal encourages critical, broad and experimental interpositions in discussions on psychotherapy and counselling psychology that often transcend methodological and meta-theoretical divisions. We welcome submissions that use either quantitative or qualitative methods, including ethnographic, autobiographical and single patient or organisational case studies.

The Editorial Board has recently launched two new series: • A Day in the Life of a Practising Psychotherapist and/ or Counselling Psychologist • My Experience as a Trainee on an Integrative Training Programme If you would like to contribute to either series by describing your personal experience(s) in some 850-950 words, we would be delighted to hear from you.

The next issue of the JPCPR will be published on 30 September 2018, and we invite your submissions for this and subsequent editions. Deadlines for submitting manuscripts are: • September 2018 issue: 31 March 2018* • March 2019 issue: 30 September 2018 All submissions should be made to both JPCPRsubmissions@ regents.ac.uk and pauls@regents.ac.uk. To discuss potential submission topics, please contact: Editor, Dr Maria Luca lucam@regents.ac.uk Managing Editor, Helen Cowie h.cowie@surrrey.ac.uk or Editorial Assistant, Shirley Paul pauls@regents.ac.uk For further information on the Psychotherapy & Counselling Psychology Reflections Research Centre, including submission guidelines and copies of the Journal, visit regents.ac.uk/reflections * Please note that this is a ‘Special Issue’ on ‘Perspectives on Suicidal Ideation and Self-harm: Impact on Therapists and Psychotherapeutic Approaches to Helping People at Risk’.

Subscribe to the Journal of Psychotherapy and Counselling Psychology Reflections (JPCPR)

Open to anyone who has an interest in psychotherapy and counselling psychology, subscription offers the opportunity to gain applied, non-doctrinaire insight into these topics. Different rates are offered for printed and downloadable issues of the Journal. For further information on subscription rates and to subscribe, please visit store.regents.ac.uk/product-catalogue/ university-services/journal-subscriptions


GUIDELINES FOR SUBMITTING A PAPER TO THE JOURNAL OF PSYCHOTHERAPY AND COUNSELLING PSYCHOLOGY REFLECTIONS (JPCPR) In preparing your submission, please refer to the style guide below. Please make sure your full contact details are visible on the outside of all documents you are sending to our Editors. Papers are accepted for consideration provided that you accept the following conditions. We ask authors to assign the rights of copyright in the manuscript they contribute. We welcome submissions on any topic within psychotherapy and counselling psychology that considers the remit of the Journal and that is inclusive of the academic community at large.

Contributions to JPCPR must report original research and will be subjected to review by referees at the discretion of the Editorial Office. We welcome new or recent books which are relevant to the focus of the journal and which you judge would be useful to review for readers. Journal policy prohibits an author from submitting the same manuscript for consideration to another journal and does not allow publication of a manuscript that has been published in whole or in part by another journal. Important note: Manuscripts must adhere to the ethical guidelines for both research and practice of UKCP, BPS, HCPC & BACP.

1. Guidelines

2. Infographics

• Referencing: All manuscripts should follow the referencing guidelines in the 6th edition referencing system of the Publication Manual of the American Psychological Association at: www.apastyle.org/manual/

• All graphics must be supplied in their original format, either as digital artwork or statistical data.

• Language: Papers are accepted only in English. British English spelling and punctuation is preferred. Non-discriminatory language is mandatory. Sexist or racist terms must not be used.

• Abstracts: Structured Abstracts of no more than 250 words are required for all papers submitted. Authors should supply three to six keywords. • Headings: Section headings should be concise. • Word count: A typical manuscript will be 1,500-2,500 words, including references. Longer contributions of 3,500-6,000 words, (27-30 double spaced pages including references) may be published where inclusion of data (e.g., excerpts from interviews) warrant it. Papers that greatly exceed this will be critically reviewed with respect to length. Authors should include a word count with their manuscript. The word count (which includes all text including the abstract, manuscript, notes, tables, figures, etc.) should appear at the end of the manuscript. • Font: All manuscripts must be typed in 12-point font in Arial and double-spaced throughout including the reference section, with wide (3 cm) margins. All pages must be numbered. • Manuscripts should be compiled in the following order: • Title of manuscript • Author(s) name(s) and title(s) • Abstract • Keywords (no more than six) • Correspondence/contact details including author(s) affiliation(s)

You are welcome to include graphs, tables and diagrams in your submission, but the following must be observed when supplying information:

• Any graphics copied from the internet and cited from other publications are not acceptable on their own. • Graphics files must be supplied separately to text. Please do not embed graphics in the text file. • Figures should be numbered in the order in which they appear in the paper (e.g. figure 1, figure 2). In multi-part figures, each part should be clearly labelled (e.g. figure 1(a), figure 1(b)). • Each figure should include a title caption and full source e.g. Figure 1 The incidence of mental health issues in the UK adult population, World Health Organisation, Report on World Mental Health Issues, 2013 • The filename for the graphic should be descriptive of the graphic, e.g. Figure1, Figure2a. • Avoid the use of colour and tints for purely aesthetic reasons.

3. Reproduction of copyright material

As an author, you are required to secure permission if you want to reproduce any figure, table, or extract from the text of another source. This applies to direct reproduction as well as “derivative reproduction” (where you have created a new figure or table which derives substantially from a copyrighted source).

4. Copyright and authors’ rights

• Table(s) with caption(s) (on individual pages)

It is a condition of publication that authors assign copyright or license the publication rights in their manuscripts, including abstracts, to the Psychotherapy and Counselling Psychology Reflections Centre of Regent’s University London. This enables us to ensure full copyright protection and to disseminate the manuscript, and of course the Journal, to the widest possible readership in print and electronic formats as appropriate. Authors are themselves responsible for obtaining permission to reproduce copyright material from other sources.

• Author(s) biographical outline (50 to 100 words)

5. Proofs

• Main text • References • Acknowledgements • Appendices (as appropriate)

• Please supply in a separate file information about your research interests/specialisations - up to five. • Two separate manuscripts must be submitted. • The first version must be a complete version containing all the above together with confirmation in a separate file confirming that the manuscript is not under consideration or submitted to another journal. Use the following statement: I confirm that the manuscript submitted, title:…. is not under consideration or submitted to another journal. • The second version must be entitled ‘For blind review’ and must not contain the author(s)’ name(s) or contact details or any identifiable author(s) information (refer to APA guidelines). This will allow for the second version to be sent anonymously to reviewers.

Manuscripts will be copy-edited for journal house style. Authors will receive page proofs for checking. At this point, no substantial changes can be made to the paper. It is essential that proofs are checked and returned within 48 hours.

6. Submission details

All submissions should be made online to JPCPRsubmissions@regents.ac.uk

7. Disclaimer

Regent’s University London and the Editors make every effort to ensure the accuracy of all the information (the “Content”) contained in its publications. However, any views expressed in this publication are the views of the authors and are not the views of the Editors or of Regent’s University London. Responsibility for confidential material and consent obtained to use in publications is that of the authors.


Journal of Psychotherapy and Counselling Psychology Reflections Volume 3. Number 1. January 2018 Editor: Dr Maria Luca Managing Editor: Professor Helen Cowie Book Reviews and Series Editor: Jane Wynn Owen Editorial................................................................................................................................................................................................................. 2 â&#x20AC;&#x2DC;Supreme Values Reside in the Soulâ&#x20AC;&#x2122; - Reflections on Values and Psychotherapy John Nuttall........................................................................................................................................................................................................... 3 Training High Intensity CBT Therapists in Other Modalities of Therapy: Can We Change Their Minds? Michael Worrell, Rebecca Samuels and Rita Woo..................................................................................................................................... 9 Diagnosis and Recovery: Twin Impostors of Mental Health? Ralph Goldstein ................................................................................................................................................................................................. 17 How do People Understand their Engagement in Sado-Masochistic Sexual Activities? Julie Burchill and Desa Markovic................................................................................................................................................................. 23 My Experience as a Trainee on an Integrative Training Programme Adam Knowles................................................................................................................................................................................................... 29 Feelings from Training: Angst, Annoyance, Infantilisation and Sadness Ben Scanlan........................................................................................................................................................................................................ 31 Conference Report Spirituality, Compassion and Mental Health Conference Chris Burford...................................................................................................................................................................................................... 33 Book Reviews................................................................................................................................................................................ 35 Irwin Krieger (2017) Counselling transgender and non-binary youth: The essential guide Jessica Kingsley Publishers By Martin Milton............................................................................................................................................................................................................................................ 35 Salman Akhtar (2017) A web of sorrow: Mistrust, jealousy, lovelessness, shamelessness, regret, hopelessness Karnac By Amita Sehgal............................................................................................................................................................................................................................................ 36

Author Information....................................................................................................................................................................... 37 Announcements........................................................................................................................................................................... 39 Psychotherapy & Counselling Psychology Reflections Research Centre 5th Annual One-Day Conference, Saturday 9 June 2018............................................................................................................................................................. 39

regents.ac.uk/reflections

ISSN 2054-457X

Journal of Psychotherapy and Counselling Psychology Reflections. Volume 3, number 1  

The Journal of Psychotherapy and Counselling Psychology Reflections (JPCPR) is an international peer-reviewed journal, underpinned by the as...

Journal of Psychotherapy and Counselling Psychology Reflections. Volume 3, number 1  

The Journal of Psychotherapy and Counselling Psychology Reflections (JPCPR) is an international peer-reviewed journal, underpinned by the as...