BACP Therapy Today April 2021

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APRIL 2021 | VOLUME 32 | ISSUE 3 THERAPY TODAY

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Page 47

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Picking up the pieces Helping clients identify and survive abusive relationships

APRIL 2021, VOLUME 32, ISSUE 3

Irvin Yalom on love, life and death // Coming back stronger after burnout Sharing poetry in the therapy room // Working with client preferences

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Contents, 1 VERSION

Contents April 2021

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Upfront

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Welcome News round-up CPD and events Spotlight Reactions The month From the Chair

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Main features

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‘The more regrets one has about life, looking back, the greater anxiety one has about dying’ Irvin Yalom (‘The big interview’, pages 24-29)

We have this one session to make a connection Page 47

Picking up the pieces Helping clients identify and survive abusive relationships

Irvin Yalom on love, life and death // Coming back stronger after burnout Sharing poetry in the therapy room // Working with client preferences

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Opportunities

On the cover..

Radhika Holmström explores the role of therapists in the domestic abuse crisis (pages 20–23)

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Regulars It changed my life Talking point The bookshelf Dilemmas Supervision Analyse me

APRIL 2021 | VOLUME 32 | ISSUE 3

Picking up the pieces

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The big issue Radhika Holmström reports on the increase in domestic violence during lockdown The big interview Celebrated psychotherapist and author Irvin Yalom on love, life and death Working with client preferences Mick Cooper and John Norcross discuss clients’ autonomy to shape their sessions From breakdown to breakthrough Therapists can come back stronger after burnout, says Kitty Willis Poetry in the therapy room Anupama Garg explores how sharing poetry with clients can help to create relational depth A lost cause?

Counselling can be both effective and appropriate for those living with dementia, says Sarah Baker

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Contact us by emailing: therapytoday@thinkpublishing.co.uk

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’m almost embarrassed to admit that, until I read Catherine Jackson’s interview with the legendary Irvin Yalom, I wasn’t aware that the world’s most famous living psychotherapist is actually a psychiatrist by profession. Of course, if you’ve ever read any of his books based on his practice, you’ll know Yalom is somewhat maverick in his approach – he has no qualms about self-disclosure and flexing other boundaries such as meeting clients outside of the room. Yet what he creates is exceptional, and he combines a gift for human connection with a talent for writing and storytelling. For me and, I am guessing, for thousands of other practitioners, reading Yalom’s books provided a beacon of hope during the early years of training, promising that, at some point, all this hard work would pay off in the creation of human connections like no other. It seems that, at the age of (almost) 90, Yalom is still creating those connections. Don’t miss our extraordinary ‘Big interview’ this issue, starting on page 24.

Whatever your views about ‘maverick’ approaches, one of the appeals of our profession is that it allows creativity, as this issue of Therapy Today – like every issue – showcases. In our ‘Presenting issues’ feature (pages 42–45), Sarah Baker describes using finger puppets and baking equipment to facilitate self-expression in clients suffering from dementia. Ruth Allen, meanwhile, works with nature, body and movement as part of the therapeutic process (‘Analyse me’, page 74). And in our ‘Counselling changes lives’ piece (pages 39–41), Anupama Garg describes how she wrote poetry as a way of processing and understanding clients’ experiences, then tentatively explored whether it would be helpful – and ethical – to share that work in a therapy session.

Her leap of faith paid off with a deepening of the therapeutic connection and a ready reciprocation from some clients to write and share their own poems.

No matter how grounded we may feel in one particular therapeutic model or approach, few of us believe that ‘one size

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fits all’ in therapy or coaching. Our work, after all, is shaped by our clients’ needs, and no two clients’ experiences and emotions are the same. Most practitioners include a ‘meta’ element to their work, checking in with the client about how the process of therapy is suiting them. But would a structured way of doing this be more fruitful? Professors Mick Cooper and John Norcross think so, and share in this issue a practical and instructive guide to working with client preferences, based on their research.

As the authors point out, clients are as much as 50% less likely to drop out of therapy when the treatment matches their preferences The facilitated (see pages 32–35). storytelling that In every issue, we include a client’s account of their experience of therapy is at the heart of in our ‘It changed my life’ column. This all therapeutic month’s, written by Georgina Lawton, came about after I read a moving piece work truly has she’d written for The Guardian about the power to discovering that she wasn’t just ‘darkskinned’, as her white Anglo-Irish parents change lives had always told her, but was mixed race, the result of her mother’s brief affair with a black man. I am delighted that Georgina agreed to share her experiences of therapy and how it played a pivotal role in helping her come to terms with her fractured identity, process the loss of the man she grew up thinking was her father, and rebuild her relationship with her mother. Don’t miss this extraordinary example of how the facilitated storytelling that is at the heart of all therapeutic work truly has the power to change lives (page 30).

Sally Brown Editor

Contributing to Therapy Today We welcome submissions from members. To submit, please send a paragraph synopsis of your proposed article to the editor at sally.brown@thinkpublishing.co.uk. Please note, we currently do not publish poetry. For further guidelines, see www.bacp.co.uk/bacp-journals/author-guidelines

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Editor Sally Brown e: sally.brown@thinkpublishing.co.uk Art Director George Walker Copy Editor Catherine Jackson Consultant Editor Rachel Shattock Dawson Reviews Editor Jeanine Connor Chief Sub-editor Marion Thompson Production Director Justin Masters Group Account Director Rachel Walder Executive Director Jackie Scully Sales Executive Sonal Mistry d: 020 3771 7247 e: sonal.mistry@thinkpublishing.co.uk Sustainability Therapy Today LV SULQWHG RQ 3()& FHUWLƓHG SDSHU IURP VXVWDLQDEO\ managed forests and produced using suppliers who conform to ISO14001, an industrial, environmental standard that ensures commitment to low carbon emissions and environmentally sensitive waste management. Both the cover and inner pages can be widely recycled.

Therapy Today is published on behalf of the British Association for Counselling and Psychotherapy by Think, Capital House, 25 Chapel Street, London NW1 5DH t: 020 3771 7200 w: www.thinkpublishing.co.uk Printed by: Walstead Roche ISSN: 1748-7846 Subscriptions Annual UK subscription £76; overseas subscription £95 (for 10 issues). Single issues £8.50 (UK) or £13.50 (overseas).

All BACP members receive a hard copy free of charge as part of their membership. t: 01455 883300 e: bacp@bacp.co.uk Changed your address? Email bacp@bacp.co.uk BACP BACP House, 15 St John’s Business Park, Lutterworth, Leicestershire LE17 4HB t: 01455 883300 e: bacp@bacp.co.uk w: www.bacp.co.uk

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Disclaimer Views expressed in the journal and signed by a writer are the views of the writer, not necessarily those of Think, BACP or the contributor’s HPSOR\HU XQOHVV VSHFLƓFDOO\ VWDWHG Publication in this journal does not imply endorsement of the writer’s views by Think or BACP. Similarly, publication of advertisements and advertising material does not constitute endorsement by Think or BACP. Reasonable care has been taken to avoid errors, but no liability will be accepted for any errors that may occur. If you visit a website from a link in the journal, the BACP privacy policy does not apply. We recommend that you examine privacy statements of any third-party websites to understand their privacy procedures.

Case studies All case studies in this journal, unless otherwise stated, are permissioned, disguised, adapted or FRPSRVLWHV WR SURWHFW FRQƓGHQWLDOLW\

Copyright Apart from fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright, Designs and Patents Act 1998, no part of this publication may be reproduced, stored or transmitted in any form by any means without the prior permission in writing of the publisher, or in accordance with the terms of licences issued by the Copyright Clearance Centre (CCC), the Copyright Licensing Agency (CLA), and other organisations authorised by the publisher to administer reprographic reproduction rights. Individual and organisational members of BACP may make photocopies for teaching purposes free of charge, provided these copies are not for resale. © British Association for Counselling and Psychotherapy

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2021 AGM: Your chance to shape our future

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FROM THE CEO

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At the time of writing, the UK Government has just announced its roadmap out of lockdown, which we hope is a light DW WKH HQG RI WKH WXQQHO LQ WKLV GLIƓFXOW period that’s had such an impact on us all.

There’s still a fair amount of uncertainty as we move forward and we’ll continue to PRQLWRU RIƓFLDO JXLGDQFH WR HQVXUH RXU website is updated with information that might affect you over the coming months.

You may remember that the Professional Standards Authority (PSA) recently held a consultation on its accredited registers SURJUDPPH 7KLV LV WKH ƓUVW WLPH WKH 36$ has held a consultation looking into the effectiveness of the programme and we were pleased to provide an organisational response as part of this. Our response was helpfully informed by your feedback to our own survey and you can read more about this on page 9.

We’re continuing to honour our commitment to ensuring you receive more communication on the SCoPEd project.

Starting in this issue (see page 7), we’re EHJLQQLQJ WKH ƓUVW RI D VHULHV RI QHZV updates that look at the framework in PRUH GHWDLO :H KRSH WKDW \RXōOO ƓQG them informative and that they’ll help to provide some clarity around key areas for you as members.

We’re already starting to think about this year’s AGM and we’re hopeful that we’ll get to see some of you at the event LQ 1RYHPEHU <RX FDQ ƓQG RXW PRUH about the AGM on our website over the coming weeks.

Hadyn Williams BACP CEO

We’re pleased to announce that the 2021 AGM will take place on Friday 5 November. This year, we’ll be looking for a new Trustee to join the BACP Board of Governors and will soon be asking for candidate nominations. Our Board is the governing body of BACP and is responsible for the development of overall strategy and policy, and for making sure that the delivery of all the Association’s activities have met our strategic objectives. We want all of our members to feel supported by and connected to BACP, and to positively engage with the work of your Association. Becoming a Trustee is a great opportunity to be actively involved and have a real LQŴXHQFH RQ RXU FROOHFWLYH IXWXUH :HōG XUJH \RX DOO to get involved in this year’s election process, whether that be standing for election as a Trustee or using your vote to choose who you’d like to represent your views on the Board. As always, we’ll be inviting nominations from members from across the four nations that BACP represents.

Finally, members will also have the opportunity to raise resolutions and motions for consideration as part of the 2021 AGM process. This is another important way to share your issues, concerns and ideas, and to KHOS LQŴXHQFH DQG VKDSH WKH IXWXUH VWUDWHJLF GLUHFWLRQ of the organisation. We’re committed to ensuring that we communicate with and engage our members in such a way as to ensure that you feel informed and involved in the 2021 AGM. So look out for more information and regular updates on how to get involved in the very near future. In the meantime, if you’ve any questions please don’t hesitate to contact us at governance@bacp.co.uk

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SCOPED NEWS UPDATE

¢ SCoPEd – an enabling framework? / Ã Ã Ì i wÀÃÌ > ÃiÀ ià v iÜà ի`>ÌiÃ Ü V >Ì Ã i v Ì i `iÌ> v - * ` > ` Ü >Ì Ì Ü i> v À Ì iÀ>« ÃÌð " i v Ì i Li iwÌà v - * ` Ã Ì >Ì Ì½ i >L i Ì i à Ã] Ü i`}i > ` ÌÀ> } Þ Õ > Ài>`Þ >Ûi >à > Ƃ * i LiÀ Ì Li ÀiV } Ãi`° Ì Ã `ià } i` Ì Li > i >L } vÀ> iÜ À Ì >Ì i > Vià V>ÀiiÀ `iÛi « i Ì > ` «À }ÀiÃà «« ÀÌÕ Ì ið 7i Õ `iÀÃÌ> ` Ì iÀi >Ài V ViÀ à >L ÕÌ Ã i i i i Ìà v - * `] > ` Ì iÀi½Ã Ài Ü À Üi V> ` Ì iÝ« > Ì i vÀ> iÜ À Ài V i>À Þ° 7i Ü Ì >Ì Ã i v Þ Õ vii Ì i vÀ> iÜ À >Þ ÀiÃÌÀ VÌ Þ ÕÀ «À viÃà > «À>VÌ Vi > ` Ì iÀà vii - * ` ` Ü }À>`iÃ Ü >Ì Þ Õ½Ài >L i Ì ` >à > Ì iÀ>« ÃÌ° 7i½` i Ì Ài>ÃÃÕÀi Þ Õ Ì >Ì Ì Ã Ã ½Ì Ì i V>Ãi° / i V Õ Ã Ü Ì Ì i vÀ> iÜ À Ài«ÀiÃi Ì Ì i Õ µÕ> wV>Ì Ã] Ü i`}i > ` iÝ«iÀ i Vi ÀiµÕ Ài` Ì i ÌiÀ Ì i>V V Õ ] L>Ãi` Ì i >«« } v iÝ ÃÌ } ÌÀ> } À ÕÌið À iÝ> « i] v Þ Õ Ã Ì V Õ Ƃ] Þ Õ >Þ Üi `iÛi « >`` Ì > à à > ` V «iÌi ViÃ Ì >Ì Ã Ì V Õ ]

v Ü } « ÃÌ µÕ> vÞ } iÝ«iÀ i Vi > ` ÌÀ> }° ÜiÛiÀ] Þ Õ½ Þ Li >L i Ì «À }ÀiÃà vÕ Þ Ì V Õ Ü i Þ Õ½Ài >L i Ì iÛ `i Vi > Ì i V «iÌi Vià > ` >Ãà V >Ìi` «À>VÌ Vi ÃÌ> `>À`à ­Ãii ->À> ½Ã V>Ãi ÃÌÕ`Þ] À } Ì] v À > iÝ> « i®° ̽à i Þ Ì >Ì Ì Ã Ü Li Ì i V>Ãi v À > Þ Ì iÀ>« ÃÌÃ] >Ã Ì iÞ½Ài V Ì Õ> Þ i>À } > ` `iÛi « } Ì i À Ü i`}i° / i Ã> i «À V « i >«« iÃ Ì V Õ Ì iÀ>« ÃÌà `i ÛiÀ } V Õ V «iÌi Við 7i Ü> Ì Ì «À Û `i Ài>ÃÃÕÀ> Vi Ì >Ì - * ` Ü ½Ì ÀiÃÌÀ VÌ i LiÀà vÀ «À>VÌ Ã } Ü Ì Ì i À ÌÀ> } À V «iÌi Vi iÛi à q Ì >«Ã Ü >Ì > Ài>`Þ iÝ ÃÌà > ` } Ûià > ÃÌÀÕVÌÕÀi v À Þ ÕÀ `iÛi « i Ì° v Þ Õ½Ài ÌiÀiÃÌi` i>À } Ài >L ÕÌ Ì i - * ` vÀ> iÜ À ] Û Ã Ì www.bacp.co.uk/SCoPEd Ü iÀi Þ Õ V> w ` Ƃ+Ã] V>Ãi ÃÌÕ` ià > ` ÕÀ Ûi +EƂ ÃiÃà °

PROFESSIONAL CONDUCT ¢ BACP’s Public Protection Committee holds delegated responsibility for the public protection processes of the Register. You FDQ ƓQG RXW PRUH DERXW WKH &RPPLWWHH and its work at www.bacp.co.uk/about-

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¢ SCoPEd case study: Sarah ->À> V « iÌi` > iÛi { ` « > V ÕÀÃi V Õ Ãi }° " Vi µÕ> wi`] Ã i Õ `iÀÌ

iÀ iÀÌ wV>Ìi v *À wV i VÞ >ÃÃiÃà i Ì Ì LiV i > Ƃ * Ài} ÃÌiÀi` i LiÀ] > ` à Ìà V Õ Ƃ° - Vi µÕ> vÞ }] ->À> >Ã Ü À i` >à > Ì iÀ>« ÃÌ] >«« Þ } Ì i à à à i i>À i` `ÕÀ } ÌÀ> }° ƂÌ Ì i Ã> i Ì i] à i½Ã V Ì Õi` Ì `iÛi « iÀ Ü i`}i > ` à à > ` Õ `iÀÌ> i * ÌÀ> } Ì >Ì >«Ã Ì > «>ÀÌ VÕ >À V «iÌi Vi À V «iÌi Vià V Õ ° iV>ÕÃi à i à >L i Ì Ã Ü Ã i½Ã }> i` Ì Ã Ü i`}i Ì À Õ} ÃÕLÃÌ> Ì Ûi * À >`` Ì > ÌÀ> }] à i½Ã >L i Ì «À>VÌ Ãi Ì Ã >`` Ì > V Õ V «iÌi Vi iÌ V> Þ] ÃÕ«« ÀÌi` LÞ ÃÕ«iÀÛ Ã ] Ü i Li } > V Õ Ƃ Ì iÀ>« ÃÌ° / à V Õ ` Li > ÃÌi«« } ÃÌ i v À ->À> Ì Ûi Ì V Õ ] À Ì V Õ ` ÀiyiVÌ Ì >Ì Ã i à `i ÛiÀ } > «>ÀÌ VÕ >À ëiV > Ã Ü i Li } > V Õ Ƃ Ì iÀ>« ÃÌ°

us/protecting-the-public/bacp-register /governance-of-the-bacp-register ¢ BACP’s Professional Conduct Notices can be found at www.bacp.co.uk/ professional-conduct-notices

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MEMBERS MAKING A DIFFERENCE SUBS

Connecting through creative expression

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Online therapy, the easing of coronavirus restrictions and school counselling were among the themes that our members spoke about in the media recently.

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DQG 'HSXW\ &KLHI ([HFXWLYH WDONHG WR %%& 5DGLR /LYH listeners about the role of online therapy during COVID-19. Fiona was a guest on Chiles on Friday WR GLVFXVV KRZ RXU PHPEHUV DQG WKHLU FOLHQWV KDYH DGDSWHG WR WKH SDQGHPLF 2XU PHPEHUV ZHUH LQ GHPDQG WR VSHDN DERXW WKH LPSDFW RQ SHRSOH RI WKH 3ULPH 0LQLVWHUōV SODQV IRU WKH HDVLQJ RI ORFNGRZQ UHVWULFWLRQV Lorraine Collins • shared her H[SHUWLVH ZLWK %%& 5DGLR 6RPHUVHW DQG %%& 5DGLR 6ROHQW ZKLOH Naomi Watkins-Ligudzinska FRQWULEXWHG WR D IHDWXUH RQ %%& /RRN 1RUWK The Sunday Times VSRNH WR Alison Hotchkiss DERXW WKH LPSDFW RI ORFNGRZQ RQ FKLOGUHQ DQG \RXQJ SHRSOH DQG RXU VFKRRO FRXQVHOOLQJ FDPSDLJQ DQG to Louise Tyler DERXW ƓQGLQJ ORYH RQ GDWLQJ DSSV /RXLVH DOVR VSRNH WR the Daily Mail DERXW EHUHDYHPHQW DQG JULHYLQJ GXULQJ WKH SDQGHPLF • Susie Pinchin FRQWULEXWHG WR DQ DUWLFOH LQ The Independent about the UHDVRQV EHKLQG SHRSOH DWWHQGLQJ ORFNGRZQ SDUWLHV +RZ WR VSRW VLJQV RI EXUQRXW ZDV GLVFXVVHG in Childcare Professional PDJD]LQH E\ Lina Mookerjee DQG VKH VKDUHG WLSV RQ FRSLQJ ZLWK WKH SDQGHPLF LQ Positive News PDJD]LQH Katriona O’Connor • VSRNH WR Glamour PDJD]LQH DERXW KRZ WKHUDS\ FDQ VXSSRUW SHRSOH ZLWK ERUGHUOLQH personality disorder. Glamour DOVR WDONHG WR Katerina Georgiou DERXW FRPPLWPHQW LVVXHV LQ UHODWLRQVKLSV Lindsay George VKDUHG KHU WKRXJKWV DQG DGYLFH DERXW FRSLQJ ZLWK DEDQGRQPHQW LQ Cosmopolitan PDJD]LQH $Q DUWLFOH LQ The Daily Telegraph DERXW WKH YDOXH RI VROLWXGH LQFOXGHG DQ LQWHUYLHZ ZLWK Rachel Shattock Dawson •.

• Rosjke Hasseldine VSRNH WR HuffPost UK DERXW PRWKHU GDXJKWHU UHODWLRQVKLSV If you’re interested in becoming a BACP media spokesperson, email media@bacp.co.uk.

We’re particularly looking for members from Scotland, Wales and Northern Ireland, and from the north and north east of England.

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Kim Etherington, PhD, MBACP (Senior Accred and Fellow) has been drawn to creative writing from childhood when poetry was a way to express her feelings. So, after being invited to offer a keynote based on her book, Trauma, the Body and Transformation (Jessica Kingsley Publishers) at a conference run by Lapidus International, a community that advances writing for wellbeing, she felt she had found her tribe. ‘I was blown away – there was a whole world of writers, therapists and others who used creative expression of some kind to nurture wellbeing,’ says Kim. Lapidus International celebrates its 25th anniversary this year and has members in North America, Israel, Australia and Europe, as well as throughout the UK. ‘We’re a community of practitioners who integrate writing into our practice,’ says Kim. ‘Around half of our members are therapists and others are writers and poets working in education, community or health projects, such as creative writing groups in prisons or in hospices. There are local groups across the UK who meet and work on their own projects.’

Stepping back from her work at the University of Bristol, teaching and supervising doctoral and master’s candidates, freed up time for Kim to devote to Lapidus and, with a small group of other dedicated volunteers, she has helped to create the newly launched LIRIC (Lapidus International Research Innovation Community) – an online, open-access, peer-reviewed journal dedicated WR DGYDQFLQJ WKH ƓHOG RI ZULWLQJ IRU ZHOOEHLQJ Ō:H DUH trying to showcase those who are working with words in a wide range of ways,’ she says. Alongside, there is the Lapidus Living Research Community (LLRC), which meets once a month. ‘It’s an arena for Lapidus members who are interested in research (some very experienced and others with little or no experience). We share knowledge and practices and invite speakers,’ says Kim. The inaugural issue of LIRIC came out in December 2020 and the journal will initially be published annually.

The submission process is now open for the next issue.

For more information, see lapidus.org.uk

APRIL 2021

News, 2

Listening to our members :H UHFHQWO\ KHOG WKH ƓUVW of our dedicated listening workshops, which focused on ‘Championing members through our policy and campaign work’. If you were unable to attend the live event, you can now watch the session on our on-demand service by visiting www.bacp.co.uk/listening.

Our ‘Making research work for members’ workshop takes place on Friday 23 April 2021, with ‘Creating a supportive member experience’ following on Friday 21 May 2021. We’re looking forward to seeing lots of you at these events and answering your questions on the day.

We’ll be adding details of our future workshops shortly, so keep an eye on our website and e-bulletins for more information. Our listening workshops are already proving to be popular, so make sure you book early if you’d like to attend.

Working on your behalf ■ We’re working hard to

highlight the critical role of counselling and psychotherapy in Wales and Scotland ahead of elections in both countries in May. As part of this, we published manifestos to demonstrate how our members can help the nations respond to the mental health challenges of the COVID-19 pandemic. Our big focus in our manifesto for Scotland was to close the gap in support for all ages by investing in targeted community provision that uses the experience of our members to help meet the growing demand for mental health support.

In Wales, we’ve sought to address some of the long-standing barriers to the availability of timely and adequately resourced mental health support. You can read the latest updates on our policy work across the four nations at: www.bacp.co.uk/aboutus/advancing-theprofession/influencingdecision-makers/ four-nations

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■ We championed

■ Thank you to the 9,100

the benefits of counselling in the workplace at this year’s Health and Wellbeing at Work conference, held virtually this year. It is the UK’s largest conference dedicated to improving the health, wellbeing, safety, behaviour and culture of today’s workforce. We sponsored the event and had an exhibition stand, and a number of speakers highlighted the role of workplace counselling and its benefits. Kris Ambler (above), our Workplace Lead, said: ‘It’s vitally important that we continue to represent our members at this flagship health and wellbeing event. The event is attended by key figures in the world of workplace health and attracts potential employers from across the sectors. It presents a unique opportunity for us to promote the value of counselling and showcase the competence of our members.’

members who completed our Professional Standards Authority (PSA) accredited register consultation member survey, the results of which helped inform our answers to the consultation questions before we submitted our response to the PSA in February. Key points in our response included considerations on protecting the public, ensuring a wider choice of therapy options for clients, and our stance on the evidence of effectiveness of occupations. We also commented on the endorsement of occupations and our thoughts on the future vision for the PSA register. You can read the full response to the consultation at www.bacp.co.uk/ media/10817/ bacpresponse topsaconsultation.pdf and view the full response from our member survey at www.bacp.co.uk/ media/10818/psaaccredited-registerssurvey-report1.pdf

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BACP Events/CPD, 1

Research Conference

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The 2021 BACP Research Conference, ‘Promoting collaboration in research, policy and practice’, will take place on Saturday 15 May and is co-hosted by the University of Salford. There will be two keynote speakers – Michael Barkham on ‘The results of the PRaCTICED trial and implications for person-centred experiential therapy’, and Mick Cooper on ‘What’s a nice existential boy doing running an RCT? Lessons from the ETHOS trial of school-based humanistic counselling’.

This online event will feature 23 presentations delivered across three strands. After each presentation, you’ll be able to join the presenter for a live Q&A session using the online chatroom. Along with presentations on research collaborations and partnerships, you’ll hear the most up-to-date research on the impact of

COVID-19 in the counselling profession, remote working, school-based counselling, resilience and student mental health, among other topics.

You’ll also have access to research forums, a pre-conference workshop on Friday 14 May, live workshops and a conference poster exhibition.

The Research Conference costs £25 for members and includes an on-demand service with symposiums, additional presentations and the opportunity to catch up on any presentations you missed on the day. To book, visit www.bacp.co.uk/events-andresources/research/conference

CYP&F Conference on demand The on-demand service of this year’s Children, Young People and Families (CYP&F) Conference, ‘Weathering the storm – counselling in a changing climate’, held on 27 March 2021 is now available to view. This event provided a forward-facing look ahead at what the future holds, sharing good practice and exploring new opportunities emerging for the CYP&F profession. The event included two keynote speakers – Mick Cooper (above) on ‘School-Based Counselling: Does it work? Is it cost-effective? And what are the processes of change? Findings from the ETHOS trial’, and Adrienne Katz on ‘Refuge and risk: exploring the online lives of vulnerable young people’. For more information and access to the on-demand service, visit www.bacp.co.uk/events/onlinecypf2021online-cypf-2021-weathering-the-storm-counselling-in-a-changing-climate

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When words are not enough This year’s Private Practice Conference, ‘When words are not enough: using creative approaches to therapy’, takes place on Saturday 25 September 2021. This online event will feature two keynote speakers and seven workshops that focus on the theme of creativity.

During the COVID-19 pandemic, creativity has increasingly become a go-to resource for both clients and therapists, whether it’s listening to music, writing poetry, exploring nature trails, cooking, drawing, painting, colouring, dancing or singing. The aim of the conference is to explore how creativity can play a part in therapy and offer DQRWKHU RSSRUWXQLW\ IRU UHŴHFWLRQ and development.

On the day, there’ll be the opportunity to network with your peers in an online chatroom and interact with presenters in our live Q&A segments. The recordings will be available from our on-demand service after the event, to catch up if you missed any presentations on the day. The cost is £25 for members. To book, visit www. bacp.co.uk/events/ppc250921bacp-private-practiceconference-2021

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Charlie Duncan takes Sally Brown behind the scenes at BACP’s research department

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esearch is relevant for every member, says Charlie Duncan, BACP Senior Research Fellow – not just for students and academics. ‘It’s relevant because the ultimate aim of all the research we do at BACP is more paid jobs for members and more equitable and easier access to counselling for clients,’ she says. ‘When I started in the department eight years ago, few members seemed engaged with research. But last year we held our annual Research Conference online for the first time, and more than 2,000 people signed up to watch. There is still work to be done in making it more accessible and relevant, but we have come a long way.’

A psychology graduate, Charlie joined BACP’s research department as an intern and now combines her role as a senior research fellow with her PhD research, which is informed by the findings of ETHOS, the Effectiveness and Costeffectiveness Trial of Humanistic Counselling in Schools. Charlie was part of the team who put together the bid for ETHOS, which gained funding in 2015. ‘My PhD is based on some of the data collected as part of this trial: namely, the goals that young people set for school-based counselling.

I like that goals give clients the opportunity to determine what a good outcome for counselling looks like for them,’ she says. ‘I’m still in the early stages of my data analysis, but I can tell you that improvement towards personal goals is one of the areas that school-based counselling really has an impact on.’

BACP’s research department works on several projects at a time – a mixture of both ‘internal’ and ‘external’, says Charlie. ‘An internal project would usually be something to do with members directly, such as designing and distributing member surveys, working on our annual Research Conference or responding to member enquiries about research-related issues. An external project would usually be one where we work with an external partner, such as a university or another organisation. One example of this would be ETHOS, which involved the universities of Manchester, Sheffield and Kent, the London School of Economics, Metanoia Institute, the National Children’s Bureau and the Manchesterbased Clinical Trials Unit (MAHSC-CTU).’

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‘The ultimate aim of all the research we do at BACP is more paid jobs for members and more equitable access to counselling’

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Other current areas of focus for BACP’s research team include counselling for older adults and counselling services in higher and further education. And there are opportunities for members to get directly involved, says Charlie: ‘The Advancing Practice through Tracking (AdaPT) project is one example – members can request a free licence to use an online system, Pragmatic Tracker, to help build an evidence base for the effectiveness of counselling and psychotherapy in private practice.’

A good starting point for any practitioner wondering if research is for them is listening to the audio recording ‘Making research work for you’, on the BACP CPD hub. Charlie has also sourced and shared examples of how research can be integrated into practice as a contributor to a recently published book, Enjoying Research in Counselling and Psychotherapy (Palgrave). ‘We’ve also started a “Did you know? Research digest” initiative, which combines a synopsis of some of the recent relevant research in counselling and psychotherapy with member stories of how they integrate research into their practice (available on the BACP website – see below for link). And for members who are undertaking a PhD (or even just thinking about it), we’ve recently set up a Postgraduate Research Forum where, once a month, we discuss a wide range of issues. It’s a great way to bounce ideas around and get feedback from your peers.’

If you want to find out more about how you can join the forum, email the research department at research@bacp.co.uk.

But it’s worth remembering that research does not always have to involve formal study, says Charlie. ‘How many times have you noticed something in your practice, perhaps with a particular client, that’s changed the way you work with them on some level? Just this recognition that something else might be helpful and changing practice accordingly is research – it’s the evolving of practice based on knowledge.’

To join a live workshop with BACP’s research GHSDUWPHQW RQ $SULO WR ƓQG RXW PRUH DERXW LWV ZRUN DQG IRU PRUH LQIRUPDWLRQ RQ DOO %$&3 UHVHDUFK SURMHFWV JR WR www.bacp. co.uk/events-and-resources/research

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Your feedback on Therapy Today articles

Email your views on Therapy Today articles to therapytoday@thinkpublishing.co.uk

LETTER OF THE MONTH

Courage to speak out

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, DP ZULWLQJ LQ UHVSRQVH WR WKH DUWLFOH E\ 0D[ 0DUQDX Ō&RPLQJ RXW DV DQ DXWLVWLF WKHUDSLVWō Therapy Today )HEUXDU\ , ZLVK WR WKDQN KHU IRU KDYLQJ WKH FRXUDJH WR VSHDN RXW DERXW KHU QHXURGLYHUJHQFH LQ D SURIHVVLRQDO FRQWH[W It is one thing to admit a disability in order to obtain assistance, but another HQWLUHO\ WR ULVN GLVFULPLQDWLRQ LQ D SURIHVVLRQDO FRQWH[W , DP FXUUHQWO\ WUDLQLQJ LQ WKH ƓQDO \HDU RI D FRXQVHOOLQJ GLSORPD DQG UHFHLYHG D GLDJQRVLV RI $VSHUJHUōV VRPH PRQWKV DJR 7KLV KDV EHHQ D UHYHODWLRQ WR KHOS PDNH VHQVH RI P\ GLIIHUHQFH DQG WR DFFHSW P\ ŌZD\ RI EHLQJō ZLWKRXW VKDPH , KDYH EHHQ EOHVVHG ZLWK WKH VXSSRUW RI WKRVH DURXQG PH SHUVRQDO DQG SURIHVVLRQDO LQFOXGLQJ P\ WXWRU DQG SHHUV , KDSSLO\ WDNH XS 0D[ōV FKDOOHQJH WR ŌFRPH RXWō E\ ZULWLQJ WKLV UHVSRQVH IRU WKH ZLGHU FRXQVHOOLQJ FRPPXQLW\ WR UHDG 6R PXFK RI ZKDW 0D[ ZULWHV UHVRQDWHV ZLWK PH DQG LW KDV EHHQ HQFRXUDJLQJ to hear that someone who is neurodivergent can enjoy a successful career as a WKHUDSLVW 'XH WR XQKHOSIXO VWHUHRW\SHV DVVRFLDWHG ZLWK $VSHUJHUōV WKHUH KDYH been times where I have questioned my suitability for the counselling role DOWKRXJK P\ FOLHQW ZRUN DQG SHUVRQDO GHYHORSPHQW LV JRLQJ ZHOO , KDYH OHDUQW WR UHFRJQLVH WKH XQLTXH strengths and challenges that the condition brings both to the counselling room and to my life LQ JHQHUDO +HDULQJ IURP 0D[ KDV strengthened my resolve to move IRUZDUG LQ WKH FRXQVHOOLQJ SURIHVVLRQ Mark Misselbrook, ƓQDO \HDU WUDLQHH &3&$% OHYHO GLSORPD LQ WKHUDSHXWLF FRXQVHOOLQJ

Knowledge gap I’d like to thank Max Marnau (‘Coming out as an autistic therapist’, Therapy Today, February 2021) for relating her story with relevant and thorough detail, and for opening the discussion about autistic therapists and clients. I agree that therapists who are autistic, neurodivergent or can easily ‘wire into’ autistic clients are greatly needed. But I question her optimism that all neurotypical (NT) counsellors may be able to work with both NT and autistic clients, as she is able to. Marnau’s decades of accommodating the NT world (giving her the ability to speak ‘neurotypical

fluently’), along with an abundance of autistic empathy, have served her well in providing therapy to any client, neurodivergent or NT. I fear the same does not apply to many NT counsellors. Over the past 20 years of working with this rewarding client group, I have met many clients who report, often bitterly, that their experience of counselling has been at best not particularly useful and at worst damaging. Why? The majority of NT counsellors do not have experience of an autistic perspective, which is vital for a beneficial therapeutic relationship. It should not be the responsibility of the client to explain autism to the counsellor.

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Interestingly, in the same issue, Michele Ablett makes a pertinent observation (‘The power of psychoeducation’): ‘Know your subject and introduce psychoeducation in an interesting and timely manner.’ Good psychoeducation with an autistic client can be the first time they have been offered information that explains their different reactions to the everyday things that NTs accommodate without a problem. Such shared understanding marks the beginning of a beneficial therapeutic relationship. What is vital is a passion for helping a unique autistic client make sense of their world, and to become the very best authentic, autistic person they can be.

Jan Livesey BACP (Snr Accred), co-founder, Understanding Autism North West I read with joy Max Marnau’s article about coming out as an autistic therapist. I too am an autistic therapist, having also discovered my autistic identity late in life – in my case, before beginning my counselling training.

So often articles about autism are written by neurotypicals (NTs), ‘NTsplaining’ the spectrum using words like disorder and impairment, and focusing on deficits rather than strengths and advantages. It was a delight to read an article that did not make me cringe with the inappropriateness of the language and talked about the positives of being autistic.

‘Vive la différence!’

So, I was saddened and rather surprised when I read the ‘News round-up’ in the same issue and saw the term ‘neurodiversity’ being misused and described as an ‘impairment’ in the report entitled ‘Empowering disabled clients’.

First, the use of the term ‘neurodiversity’ was incorrect on a basic linguistic level.

Diversity is a property of groups and requires variability within groups. A group can be diverse; an individual cannot. ‘People with neurodiversity’, as written in the BACP ‘Working with disability’ resource this article refers to, simply does not make sense. Dr Nick Walker defines neurodiversity as ‘the diversity of human brains and minds – the infinite

We are weakened as a profession by the spectacle of some groups claiming to be better than others and splitting off… We, of all professions, should surely have the insight to acknowledge that our status-driven infighting is absurd

variation in neurocognitive functioning within our species.’1 Neurodiversity is not a trait possessed by an individual. If an individual diverges from what society has decided is ‘normal’ in terms of their neurological functioning, they are neurodivergent.

Second, neurodiversity acknowledges differences in the ways brains think and learn as normal variation, rather than impairments or deficits, and includes neurotypicals as well as those with minority neurological variants such as autism. Of course, some autistic people may also have an impairment (as defined within the medical model), as may some non-autistic people, and some will consider themselves disabled. But, as Max stated, ‘When you have met one autistic person, you have met one autistic person.’ Generalisations about neurodiversity (or even neurodivergence) being an impairment are at best insensitive and at worst harmful. Language is powerful, please use it carefully.

Dr Shirley Moore MBACP REFERENCE 1. Walker, N. Neurodiversity: Some basic terms and GHƓQLWLRQV 1HXURFRVPRSROLWDQLVP 6HSWHPEHU KWWS ELW O\ E4&\4)

BACP comment: Thank you for bringing to our attention the error in the use of the term neurodiversity in this resource. We have taken your comments on board and have amended the resource accordingly.

SCoPEd rationale I would like to commend BACP for commissioning and publishing Catherine Jackson’s article (Therapy Today, March 2021).

It sets out clearly and honestly the background to SCoPEd, which most colleagues are unaware of, I find. It also sets out the rationale for SCoPEd in a constructive way.

Like many counsellors, I was appalled at the hierarchy implicit in the first version of SCoPEd, which demoted me below psychotherapists – but hang on! When I am doing sex therapy or sex addiction therapy,

I become a ‘therapist’, so where do I fit then?

BACP’s initial response to the outrage at the hierarchical structure of SCoPEd was disingenuous at best, which left me feeling very angry. After reading the article, my anger has been replaced by a willingness to engage with the SCoPEd process, because the article highlights how we are weakened as a profession by the spectacle of some groups claiming to be better than others and splitting off. The ‘People’s Front of Judea’ sketch in Monty Python’s The Life of Brian (available on YouTube) brilliantly satirises this splitting off into different groups, each claiming to be superior, so familiar in religion and politics.

We, of all professions, should surely have the insight to acknowledge that our status-driven infighting is absurd and rightly invites derision from funders and other professions.

I have worked as a counsellor for more than 30 years. For many years, I combined working as a volunteer counsellor with a demanding career in a very different field. I moved into paid work in private practice 12 years ago, after taking early retirement. My varied experience and the fact that I am coming to the later stages of my second career hopefully give me a reasonably detached view of the future of our profession. What I feel passionately about is the welfare of clients, in particular the many hundreds of clients who have put their trust in me. The clients who come to me almost always complete their work and achieve their goals.

They say that I have helped them and often refer others to me. Despite working full time as a counsellor and therapist, I am almost always fully booked, sometimes with a waiting list, and, based on BACP’s earning survey, I am a very high earner.

By any reasonable measure, I have made a success of my counselling career, and I believe the clients I have worked with have benefited.

Yet I started by doing the basic Relate training while working full time. With a young family to support and co-parent, I had neither the time nor the money to do a full-time degree course.

The fact that I now hold multiple qualifications as a counsellor, sex therapist, sex addiction therapist and supervisor, and I have three

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accreditations, including BACP, shows that it is possible to develop in stages – and yet the current iteration of SCoPEd still seems to discriminate against this developmental path by favouring those who have done a single course of 450 hours.

I hope that the views expressed in the article come to fruition and that we, as a profession, show that we can manage and value difference, that we can work together and that we can put the welfare of clients ahead of demeaning squabbles about status.

Michael Stock BACP (Accred), COSRT (Snr Accred), COSRT supervisor (Accred)

Psychiatric drugs I have a few points to make regarding the interview by Catherine Jackson with Dr Joanna Moncrieff (‘The big interview’, Therapy Today, February 2021). I was diagnosed with schizo-affective bipolar disorder almost 13 years ago and currently take a range of psychiatric medication, which has involved years of trial and error to find the right balance and is a significant factor in my ability to function and thus train to be a counsellor.

A lot has been said about the efficacy of clinical work with clients who are taking psychiatric drugs and whether they can engage fully with the therapist due to the ‘flatness’ and ‘fuzzy mind’ effects that a percentage of them feel due to the medication.

The issue thus arises of the clients’ need for therapeutic support along with the need for medical treatment to reach some sort of compromise, to ensure the client resumes some normality in daily functioning. It is a tricky balance to strike and may sometimes result in either a client’s unsuitability to receive therapy or even monotonous and continuous therapy sessions with little or no progress, which potentially challenges a client’s confidence in the therapist or therapy itself, through no fault of either party.

I have encountered personal acquaintances who are firm in their belief that psychiatric drugs do not help, and that they can manage without these medications. It makes me

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wonder about the placebo effect of these drugs, with medication to some patients offering hope of recovery and perhaps a quick fix to take away the pain. A lot of expectation is pinned onto modern-day medicine. This interview has evoked a desire in me to look further into this, and it also makes me wonder about my own progress and journey – what made me better? Was it the medication, therapy, or my own drive and sheer hard work in carving out a future for myself? Or was it a combination of these factors?

Sanaa Ahmed, trainee counsellor

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In the February 2021 issue of Therapy Today, I found both ‘The big interview’ with Dr Joanna Moncrieff and ‘Messages from the body’ by Dr Jean Penman interesting. Having spent several years researching the (unexpected) connections between these two topics – the effects of psychiatric drugs and persistent physical symptoms – I would like to add some comments that I believe are pertinent for therapists, and that I and other campaigners are flagging up for urgent attention.

It is notable that Penman’s article addresses a scenario where the presenting referral problem is unexpected persistent physical symptoms (uPPS). She starts from that point, and describes working with a client to explore the lifetime psychological issues that may have resulted in these physical symptoms. This is an understandable approach and she mentions good outcomes.

It is also notable that the symptoms that Penman says are the common presenting persistent physical symptoms – and for which she mentions using the PHQ-15 screener – happen to map very closely onto the effects on the body of prescribed antidepressants, mentioned by Moncrieff to be ‘largely unknown’.

My article on the British Journal of General Practice1 website describes how doctors, psychiatrists, psychologists and therapists are being trained to believe that their patients are ‘somatising’ – experiencing psychological distress in the form of somatic (physical)

symptoms and seeking medical help for these symptoms, which may be initiated and/or perpetuated by emotional responses such as anxiety and depression. Doctors are led to believe that their patients are suffering ‘medically unexplained’ somatic/functional symptoms (filed under DSM psychiatric disorders) of unknown aetiology, such as chronic fatigue, IBS, fibromyalgia etc. The patients’ earlier diagnosis of depression or anxiety is used to validate the psychosomatic label.

Penman describes her trauma-focused therapy approach. Patients may indeed have unresolved trauma issues, which may have been numbed and actually further exacerbated by the effects of the drugs that were initially prescribed for presenting trauma symptoms, possibly taken over many years and perhaps switched or withdrawn from, with withdrawal symptoms also commonly being misdiagnosed as ‘unexplained’. This importance of the effects of ‘the meds’ is being missed – and needs to be recognised by therapists in order to support clients appropriately.

Marion Brown, retired psychotherapist and campaigner, @Recover2Renew REFERENCE 1. Brown M. Unexplained physical symptoms: what is being missed? British Journal of General Practice (online) 25 April 2019. http://bit.ly/3b2RQCN

I just wanted to thank Dr Penman for her article ‘Messages from the body’ (Therapy Today, February 2021). It was heartening to read how others are working therapeutically with persistent symptoms such as pain. I have

Volunteering by choice I would like to take issue with a statement in ‘Dilemmas’ in the February 2021 issue of Therapy Today, regarding working for free. I agree that counsellors should be paid. However, the statement about seeing oneself as either a ‘benevolent philanthropist’ or a ‘professional with hard-earned qualifications’ grated on me.

I am a volunteer counsellor in a charity offering low-cost sessions and I have a small private practice. I have a hard-earned master’s degree and several years of experience, and I choose to be a ‘benevolent philanthropist’ because I want to be of service to those who cannot afford £40+ per hour, but who need support just as much.

To imply that choosing to provide one’s services for free is somehow unprofessional undermines the many counsellors who are providing a valuable service.

Sarah Toothill MBACP, MA Stephen Hitchcock, BACP’s Ethics Consultant, replies: I can see how the phrase ‘whether as a benevolent philanthropist or as

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recently been involved in group consultations with patients diagnosed with fibromyalgia in primary care in Berkshire. These groups initially started with a GP to help facilitate further support in the absence of stronger pain relief.

However, it soon became apparent that there was not only physical but emotional pain in the room.

Alongside medication and support in a group setting, we have been working with the patients’ relationship to pain, past traumas and tracking the autonomic nervous system. We have found that, in some cases, GP appointments and medications have reduced, and some patients have reported a better quality of life. I agree wholeheartedly with exploring the benefit of therapeutic support in reducing the severity of physical symptoms and the possibility of contributing to more effective pathways of care.

We are looking forward to keeping in touch with Dr Penman as work develops.

Vanessa Dent MBACP, integrative counsellor

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My concern is that, as a profession, we are going to remain in the cabin and turn our back on the larger, luxurious building, where we once enjoyed the open spaces and a greater range of opportunities

a professional with hard-earned qualifications, skills and experience’ might have come across as a binary choice that had to be made between those two options. My intention was to suggest some possibilities to prompt the correspondent to reflect on how they saw themselves and their role, not to imply that those two self-perceptions were mutually exclusive. The main point I was making was that counsellors shouldn’t be expected to work for nothing, and that there is a danger that volunteers might be exploited and their goodwill (or their need for experience) taken advantage of by employers or charities. I certainly would not wish to undermine the invaluable service that is provided by the many highly qualified volunteers in the counselling/psychotherapy professions.

I found February’s ‘Dilemmas’ on money matters really interesting. The issues raised are common to all counsellors/psychotherapists and the advice offered constructive. I do feel, however, that a standardisation of fees charged across the professions would be helpful. The standardised fees could be graded according to various criteria. As a consequence, the ‘dilemmas’ regarding fee charging for counsellors/psychotherapists could be reduced, as it would take the issue of money off the shoulders of the practitioner.

Ornella Bushell MBACP

Post-COVID insights I write in response to the article by Jude Kiley-Morgan (‘Seeking solace in togetherness’, Therapy Today, February 2021). I work in a bereavement support team within a specialist NHS palliative care centre. After working only via phone from late March last year, we were able to ‘reopen’ for in-person counselling in July 2020, thanks to various new infection control provisions, and we have been open in this way ever since. Relatively few of our clients have requested phone or video-call appointments since. Some have been nervous about coming in, but most have been relieved and grateful to meet again in the flesh.

Counsellors were required to wear visors as well as masks – engaging with people

with our chairs at two metres’ distance and with much of our faces covered has been interesting! I have come to treasure the privilege of seeing and meeting people.

After many weeks of just using the phone, plus a few video calls of variable quality, it was a relief to see whole-body language again.

We are also required to clean our new ‘wipeable’ seats between each appointment.

I have come to see this as an opportunity for mindful preparation of a ‘sacred’ space for an honoured guest – not always an aspiration that I remember or achieve, but I think an intention well worth returning to each new day.

I envisage taking insights about eyes and chairs (and maybe many others still to come?) into my post-COVID therapeutic practices.

Keith Duckett MBACP (Accred), lead counsellor/team leader, Bereavement Support Team, Walsall Palliative Care Centre

Working online I feel compelled to reply to Peter Hudson’s letter (‘Reactions’, Therapy Today, February 2021). It is positive to hear him recognise that online counselling opens up access to clients who may otherwise never feel or be able to access therapy, but I was saddened to hear his experience of forming an online therapeutic relationship is one that offers ‘a pale copy of the real thing’. My own experience of counselling online since gaining my online counselling qualification in 2011 is that the therapeutic relationship formed through all the different media (video, audio, instant messaging and email) can be rich and deeply connecting.

Training in online counselling enables us to offer clients a broader range of means to communicate and connect. It creates a far greater level of choice, flexibility and autonomy for the client to meet the counsellor more equally, in a medium that they feel most able to express themselves fully in, and also to find a counsellor who best suits their needs, wherever they might be located.

Online counselling respects the client’s desire to engage in the therapeutic process in a way that feels safe enough for them to open

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up about their vulnerabilities, aspects of themselves, their experiences and thoughts that they are too fearful of being judged or rejected for to risk expressing in person. Indeed, for many, it is this freeing up and disinhibition effect of online counselling that enables them to reveal their many and hidden layers and thence leads to a deeply meaningful connection and beneficial process of growth and change.

Sarah Worley-James MBACP (Snr Accred), counsellor and supervisor, honorary fellow and former Chair of the Association for Counselling and Therapy Online (ACTO) I was interested to read Barry McInnes’ and Justin Havens’ counterarguments to Peter Hudson’s earlier letter highlighting ‘online danger’ (‘Reactions’, Therapy Today, March 2021). I was shocked when I realised that they were actually stating (particularly Justin) that online work will be their preferred option in the future when we will be able to return to face-to-face work.

It reminded me of a story I once read in an in-flight magazine many years ago, which is relevant to this discussion. A Canadian family had to move out of their home after a fire had caused severe damage. While it was being repaired, they stayed in a small steel cabin in their garden. The cabin had running water, electricity and some small windows. After about a year, when they could move back into the renovated home (now in much better condition than before the fire), they had grown so used to the cabin and adapted to its compactness that they decided to stay.

My concern is that, as a profession, we are going to remain in the cabin and turn our back on the larger, luxurious building where we once enjoyed the open spaces and a greater range of facilities and opportunities. As much as I respect other people’s preferences (certainly clients’), I will leave you with a quote from the house owner, spoken about a year later. It went something like this, ‘While the cabin lets in more than enough adequate light through the gauze windows, I am very aware that the restored house behind me has far-reaching views.’

Martin Bulpitt MBACP (Accred)

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The month Mental health and the human experience in the arts, media and online

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Rescheduled to 2021 due to the coronavirus pandemic, the 11th edition of the Liverpool Biennial festival of contemporary art explores notions of the body, drawing on non-Western ways of thinking. Contributing artists from all across the globe address three themes – stomach (as a primary organ engaging with the world), porosity (borders and the skin) and kin (social connectivity).

Their artworks seek to challenge conventional understanding of the LQGLYLGXDO DV D GHƓQHG VHOI VXIƓFLHQW HQWLW\ DQG present the body instead DV D ŴXLG RUJDQLVP WKDW LV continuously shaped by and shaping its environment. The media they use employ the VDPH ŴXLGLW\ Ŋ VRXQG YLGHR metal and rubber, discarded and found objects, live plants, textile, photography and dance, as well as more conventional paint – to explore the interface between body, sense, community and self. Curated by Manuela Moscoso, the free programme continues until 6 June in locations across Liverpool. bit.ly/3pOIsHf

Books

MEMORABLE MEMOIRS The Madness of Grief: a memoir of love and loss (Weidenfeld, out now) is an honest account from Richard Coles, the pop star turned vicar and broadcaster, of life after the sudden death of his partner, David.

The actor Sharon Stone recounts how she rebuilt her life after suffering a stroke and reconciled with her family after a childhood of violence in The Beauty of Living Twice $OOHQ 8QZLQ RXW QRZ

In The Power of Hope (Bantam Press, out $SULO 79 SUHVHQWHU .DWH *DUUDZD\ UHFRXQWV WKH SHUVRQDO LPSDFW RI &29,' ZKLFK KDV OHIW her husband, Derek Draper, in a medically induced coma since March 2020.

Delicacy: a memoir about cake and death +HDGOLQH RXW $SULO LV :HOVK FRPHGLDQ DQG DFWRU Katy Wix’s darkly comic memoir about binge-eating, fat-shaming, female pain and grief at losing loved ones.

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In this moving programme, Esther Rantzen’s sensitive interviews with people who have lost parents, spouses, siblings and children are interwoven with her own experience of bereavement.

It starts with her admitting that she still hasn’t cleared out the KRPH RIƓFH RI KHU ODWH KXVEDQG Desmond Wilcox, 20 years after he died. Through a series of interviews, we hear about the diversity of the grieving process, what helps and what doesn’t.

Esther’s personal pet hate is being told, ‘Desmond would have wanted you to be happy.’

Esther Rantzen: Living with grief is available on my5.tv.

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The Month, 1 JELLYFISH FEATURE FILM LTD 2020

Know of an event that would interest Therapy Today readers?

Email therapytoday@thinkpublishing.co.uk

Film

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Video

In this hard-hitting portrait of a Margate-based young carer, 15-year-old Sarah struggles to keep her younger siblings in school while also working to buy food, and making sure her mentally ill, single-parent mother remembers to sign on so WKHLU EHQHƓWV DUHQōW VWRSSHG 6DUDK LV VXUURXQGHG E\ DGXOWV ZKR HLWKHU FDQōW VHH past her abrasive defences or exploit her vulnerability; there are no heroes in this story – but Cyril Nri plays a drama teacher who sees her potential. He encourages her to write a stand-up routine for a school talent show, and mining her own H[SHULHQFHV DV PDWHULDO KDV DQ H[SORVLYH HIIHFW ,WōV QRW DQ HDV\ ZDWFK EXW D UHPLQGHU WR DOZD\V ORRN IRU WKH VRXUFH RI FKLOGUHQōV DQJHU 5HOHDVHG LQ LWōV QRZ DYDLODEOH RQ BBC iPlayer.

Therapy by robot

Podcast picks

Can talking to a robot really help in the same way as talking to another human being when you’re anxious, lonely and depressed? It seems so, according to the accumulating evidence on therapy bots. In this mind-opening contribution to the online forum The Conversation, researcher Laken Brooks, doctoral student of English at the University of Florida, says millions of people derive huge comfort from talking to a robot programmed to make soothing and encouraging responses that make them feel they matter and someone cares.

7KH ƓUVW WKHUDS\ ERW (/,=$ ZDV created in 1966 by computer scientist Joseph Weizenbaum, using a Rogerian approach of mirroring clients’ statements.

It was so successful that even Weizenbaum’s secretary, who NQHZ (/,=$ ZDV D URERW DUUDQJHG to have private sessions with her.

These days there are numerous chatbots offering scripted therapy to good effect – although, as Brooks reveals, they can sometimes get it very badly wrong. bit.ly/3shOu4O

Listening to learn In this episode of his lockdown interview show, Grounded, Louis Theroux talks to musician and actor Tahliah Debrett Barnett, EHWWHU NQRZQ DV ).$ WZLJV $V ZHOO DV KHU PXVLFDO LQŴXHQFHV VKH explores her experience of growing up mixedrace in predominantly white Gloucestershire, and how success and celebrity don’t protect you from coercive FRQWURO $YDLODEOH RQ BBC Sounds. bbc.in/2NRdkcQ

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In For All I Care, Nwando Ebizie, in discussion with artist, writer and activist Dolly Sen and Stephani Hatch, professor of sociology and epidemiology at the Institute of Science, King’s College London, asks if caring collectively can address existing inequalities in access to health and healthcare.

Episode 3 of a powerful %$/7,& &HQWUH IRU &RQWHPSRUDU\ $UW collaboration with the Wellcome Collection. bit.ly/3dwbcBW

You Don’t Know Me, hosted by Chloe Combi, journalist and author, offers insight into the lives of teenagers today through their own experiences and in their own words, with expert commentaries.

The series covers topics that matter to many young people today, such as body image, sexuality, popularity, porn, school, race, feminism and cancel FXOWXUH $YDLODEOH RQ most podcast platforms. bit.ly/3sknh1j

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It was encouraging to learn of a campaign for amendments to the Domestic Abuse Bill to include an emphasis on mental health, the effect of continued exposure to abuse and the impact on children and young people. Counsellors and psychotherapists who work with domestic abuse, or who are familiar with the effect of adverse childhood experiences on young people and adults, will recognise the significance of this amendment.

The updated Domestic Abuse Bill is currently progressing through parliament, and I was particularly interested to follow a debate in the House of Lords in February on another potential amendment,1 one regarding the regulation of our profession, and the potential for controlling or coercive behaviour by individual counsellors and psychotherapists. I listened with intrigue to the lines of argument pushing for convictions and sentencing on abuse and coercion, whether a counselling relationship could be considered ‘domestic’ if sessions were held outside the home, and whether or not the therapist could be deemed ‘intimately’ connected to the client.

As fascinating as it was to listen to this debate, it was also excruciating to witness our profession characterised in broadbrush terms by descriptions such as ‘charlatans’ and ‘quacks’. I found it difficult to hear both as a practitioner and as Chair of BACP, knowing that members have made an enormous investment in training, supervision, CPD, placement hours and research. Counsellors and psychotherapists provide valuable support to clients who may have suffered various forms of abuse or coercion. It’s hard not to wonder at

the impact on the trust that underpins that support if we are labelled potential perpetrators of abuse and coercion.

This amendment to the Bill was considered an inappropriate vehicle to address regulation of the profession and was withdrawn. Despite this withdrawal, and irrespective of which side of the regulation debate you may sit, it is inevitable that the embers of this discussion will continue to burn. This is why it becomes all the more important for us as a profession to strongly position ourselves so that we may help shape the narrative at this crucial moment.

Debates like this demonstrate we have much more work to do for attitudes towards our profession to truly shift, even though we have seen mental health being discussed much more openly and much more widely. The mental health crisis was happening before the

Natalie Bailey Chair of BACP

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pandemic hit, but addressing mental wellbeing has become even more of a priority for us now, as we recognise the long-term impact of COVID-19. It is ironic that, at a time when counselling and psychotherapy are becoming more mainstream, it is also the time when the hard work, skill and expertise of the many thousands in our membership are being tainted, dismissed and labelled ‘charlatan’ because of the unacceptable activity of a few.

Sadly, there are rogue therapists whose activities detract from the overall good reputation of the profession, and this is a serious concern. Terms such as ‘gaslighting’ and similar phrases that are in use more frequently nowadays are sometimes directed towards us. The threat of the ‘rogue’ therapist is deemed real enough to make it a topical plot line in media dramatisations.

BACP takes steps to ensure the public has appropriate information on reasons to choose a suitably qualified therapist from a Professional Standards Authority (PSA) accredited register such as our own, where registrants agree to adhere to a code of ethics and, in the event of a complaint, we have a robust complaints process.

Our recent comprehensive response to the PSA’s consultation on the accredited registers scheme, which was informed by members’ responses, highlights some important recommendations and actions.

We will continue to work robustly and purposefully with the PSA to enable the development of the regulatory environment for our profession that best supports the reputation of counselling and psychotherapy, and of our members.

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was in a relationship for seven years; there was abuse on every level including sexual, HPRWLRQDO ƓQDQFLDO DQG coercive control,’ says Nadia.* ‘I managed to end the relationship when I realised that the alternative was suicide.

But nothing prepared me for the aftermath. I was at sea, with no direction; I had lost my whole self. However, I knew I had to repair and recover. I recognised that I was traumatised so I looked for a therapist who was experienced in that area. Eventually, I found someone who ZDV TXDOLƓHG $W WKDW SRLQW , WUXVWHG no one, but I felt able to talk to her.

Complex trauma is hard to unravel but for me, it is a long-term investment.’

In April last year, the World Health Organisation (WHO) announced a ‘shadow pandemic’1 – violence against women and girls. Not all of this may have been domestic violence – violence within the home – and not all domestic violence is exclusively perpetrated against women, but the startling rise in levels and/or severity of domestic violence under the COVID-19 pandemic has shocked many people. What is the breakdown of the situation and where GR WKHUDSLVWV DQG FRXQVHOORUV ƓW LQ" The increase since early 2020 is partly in numbers and partly in degree.

7KH 2IƓFH IRU 1DWLRQDO 6WDWLVWLFV (ONS) reports an increase in demand for domestic abuse services during the pandemic, particularly affecting helplines as lockdown measures eased.

However, as the ONS report says, this does not necessarily indicate an increase in the number of people who are experiencing abuse, but ‘perhaps an increase in the severity of abuse being experienced, and a lack of available coping mechanisms such as

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the ability to leave the home to escape the abuse, or attend counselling’.2 Sociologists Dr Katrin Hohl (City, University of London) and Dr Kelly Johnson (Durham University) have also looked at the reported rise, comparing the data from the start of lockdown with data from the previous couple of years.3 They found that police-recorded domestic abuse has been steadily rising – it is a long-term trend – but that a number of perpetrators are using

of highest-risk cases being discussed by professionals actually decreased between April and June 2020, very probably because people experiencing abuse were unable to contact the police. ‘One thing that has made it very hard during lockdown is that the things that were helping make life bearable for many women have been closed down. Meeting a friend, going to work, going to a yoga class, being involved in school, having relatively easy access to other services or activities that give you some kind of support or self-esteem – those aren’t there,’ says Helen Hayes, a trustee of the specialist mental health charity Woman’s Trust. ‘It’s also been

‘What has made it very hard during lockdown is that the things that were helping make life bearable for women have been closed down’ GLIƓFXOW IRU ZRPHQ ZKR UHFHQWO\ OHIW DQ abusive situation but don’t have new support structures yet. We’re seeing higher levels of complex distress. And the kind of abuse they’re experiencing if they’ve left is increasing, in the form of abusive messages from perpetrators with more time on their hands.’

Mental health connection

the lockdown rules to intensify and/ or conceal abuse, and that lockdown has made it much harder for abuse survivors to leave the home.

What counsellors working on the ground report is that their services have been put severely under pressure. Calls to helplines certainly went up dramatically, and Women’s Aid’s network of refuges anticipates a continuing spike in demand. ‘We run one of the biggest advice lines, and we

received an increasing number of calls from women as lockdown approached,’ says Asalet Tulaz, counselling service manager with Solace Women’s Aid. Another record surge in calls came at the beginning of May last year, when lockdown started to ease and, presumably, survivors could get a little more privacy to call.

That surge at the end of May GHPRQVWUDWHV D SRLQW ŴDJJHG XS LQ WKH 216 ƓJXUHV Ŋ WKH WRWDO QXPEHU

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Successive studies have shown, to nobody’s surprise, that domestic DEXVH LQŴLFWV FRQVLGHUDEOH PHQWDO DQG psychological damage. In fact, a lot of DEXVH GRHVQōW WDNH WKH IRUP RI D ƓVW LQ the face; it is the manipulation and/or gaslighting that accompanies or even replaces the physical abuse. ‘Coercive or controlling behaviour’ is now recognised as a criminal offence, but in practice it is still often going unrecognised.

‘I think it’s such a complex dynamic that it trickles down into every aspect of life,’ says Birmingham-based counsellor Kiran Mahboob. ‘A lot of the

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time, people tend to end up blaming themselves, because the abuser’s behaviours don’t make a lot of rational sense. Abusers tend to repeat and repeat, until you think maybe they have a point. It’s just a downward spiral again, where you feel that you’re the one who is the problem.’

A number of dedicated agencies supporting domestic abuse survivors approach this using a trauma model and, like other forms of trauma, the impact lasts long after the damage is LQŴLFWHG Ō,W RIWHQ DIIHFWV KRZ SHRSOH conduct their relationships in the future – and very often there are children involved, so that means ongoing contact with the abuser,’ says Catherine Mulcaster, an integrative coachtherapist who works with Living Your /LIH D %HGIRUGVKLUH EDVHG QRW IRU SURƓW service for people affected by trauma. Ō,WōV QRW WKH FDVH WKDW VRPHRQH LV KHOSHG to leave and then all is well. The picture is so much more complicated,’ adds +D\HV Ō$EXVH DIIHFWV SHRSOH LQ PDQ\ and complex ways and the impact is long-term anxiety and depression, low self-esteem and other complex trauma responses.’

There are links with mental health in other ways. Researchers from the Institute of Psychiatry, King’s College London have reviewed VXFFHVVLYH VWXGLHV WKDW ƓQG WKDW SHRSOH who are already experiencing mental health problems are more likely to be abused,4 and there’s also evidence that people who perpetrate domestic violence may have mental health problems.5 None of this is surprising, but it all adds up to a quite complex picture. It also means that a number of people may be seeking counselling as a result of abuse in their past, even if they don’t recognise it as having been abuse.

Others may have current unrecognised abuse that has left them feeling that there is something profoundly wrong with them or how they perceive the world and themselves.

Race and disability Overall, more than half (53%) of the respondents surveyed for Women’s Aid

on the effect of the pandemic said that their mental health had been affected.6 Solace reports that anxiety has increased ŌPDVVLYHO\ō DORQJ ZLWK DOFRKRO DQG HDWLQJ disorders. Women in some social groups have been particularly badly affected.

Domestic abuse isn’t limited to socioeconomic or racial groups (in fact, LW LV DUJXDEO\ LGHQWLƓHG OHVV LQ ZKLWH middle-class families, especially when it is more psychological than physical) but it is also the case that black, Asian and minority ethnic women often face particular barriers to getting abuse UHFRJQLVHG RU ƓQGLQJ VXSSRUW Ashiana Network provides support to women from ethnic minority communities, including three refuges DQG D FRXQVHOOLQJ VHUYLFH Ō,W VWDUWHG in 1989, mainly with women from the South Asian community, and then broadened out to support other minority communities,’ says clinical lead Molleka 6LPPV Ō,I ZRPHQ JR WR D JHQHULF VHUYLFH they may not feel their background, traditions and culture are being heard.

We wanted to provide something where women felt that their own experiences DQG FXOWXUHV ZHUH EHLQJ UHŴHFWHG DQG understood, so that they could express themselves and have their needs met.

And our counsellors are able to offer Bengali, Hindi and Urdu at the moment, so we can support women who don’t KDYH (QJOLVK DV D ƓUVW ODQJXDJH DQG PD\ be even more isolated as a result.’ Both Ashiana and the charity Imkaan, which also focuses on violence against black and ethnic minority women and girls, report a dramatic increase in referrals since lockdown.

A report from the disabled women’s collective Sisters of Frida describes how the pandemic and lockdown have also disproportionately affected disabled women – often because they cannot go outside the house, either because of mobility issues or because they are more vulnerable.7 And, statistically, disabled women and women with long-term illnesses are far more likely to be subjected to domestic abuse. Ō, WKLQN ORFNGRZQ JDYH DQ H[FXVH WR perpetrators to control even more, and control using health as an excuse

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not to leave the house and not to communicate with friends as well,’ says Asalet Tulaz from Solace.

The other group that is, of course, hugely affected by domestic abuse is children. There have in fact been fewer referrals for medical help – but again, this is probably because children have not been able to talk to a trusted adult in private.8 The #SortItOut campaign, of which BACP is a member, is calling for immediate action to reduce the GDPDJLQJ LPSDFW RI SDUHQWDO FRQŴLFW on children.

Dr Jo Casebourne is Chief Executive of the Early Intervention Foundation, a charity that champions and supports the use of effective early intervention to improve the lives of children and \RXQJ SHRSOH Ō:LWQHVVLQJ GRPHVWLF abuse has similar effects to being the WDUJHW ō VKH VD\V Ō,W KDV D ELJ LPSDFW RQ children’s mental health, putting them at greater risk of being involved in substance abuse, antisocial behaviour, GLIƓFXOWLHV IRUPLQJ UHODWLRQVKLSV and so on. The statistics show that 15,000 children in the UK are at risk of domestic abuse in any two-week period, and obviously we think the numbers will be increased under ORFNGRZQ WKH ƓQDQFLDO SUHVVXUHV WKH stress and home schooling all raise the SUHVVXUH DQG PDNH FRQŴLFW DQG DEXVH more likely.’

Remote working The shift to delivering remotely has EHHQ SUREOHPDWLF LQ VRPH ZD\V Ō:HōYH KDG WR EH PRUH ŴH[LEOH DERXW WLPHV and availability and to be able to cancel sessions at short notice, both because of alleged perpetrators and because

‘Abuse affects people in many ways and the impact is long-term anxiety and depression, low self-esteem and other complex trauma’

children may be around,’ says Simms. Ō$ ORW RI WKH WDQJLEOH WKLQJV ZH FDQ suggest to clients aren’t available – going to the gym or visiting a friend, for instance – so we’ve had to focus more on the mental and emotional work. And for women who have left the danger but are now increasingly isolated within their homes, the reduced contact with their support network has made them much more prone to ŴDVKEDFNV RI DEXVH DQG WKHLU PHQWDO health worsening.’

On the other hand, Tulaz points out WKDW ŌLW KDV LQFUHDVHG VRPH OHYHOV RI access to our service, especially for women who have escaped that situation but still have travel issues. A phone or video call at home is so much easier. In that sense it did increase some access.’

This very much bears out the broader ƓQGLQJV RI :RPHQōV $LG However, another team of researchers from the Institute of Psychiatry has pointed out that mental health services more widely are often missing the opportunity to identify domestic abuse in the clients they’re seeing.9 Ō2IWHQ it’s missed, and people can present to services with depression and anxiety, but what’s actually going on is not picked up,’ says Hayes. So what are the implications for practitioners working LQ ŌPDLQVWUHDPō WKHUDS\"

The past and the present Sometimes it’s possible to work out from things that clients say that abuse may be a factor in the way they see themselves and the world. Clues PD\ EH VHHQ LQ ŌSDWWHUQV RI FRQŴLFW RU GLIƓFXOW\ ZKLFK VHHP YHU\ RQH VLGHG where you’re getting a sense of abuse of power or abuse of control, or arguments where somehow she has to change her ways,’ Hayes suggests.

But, she points out, the effects of the abuse can also present in different ZD\V Ō0DQ\ ZRPHQ DUH LQ D VWDWH RI constant low-level trauma. They may be a bit unreliable, or a bit vague or give stories that don’t add up or be unreliable about turning up on time.

Therapists get quite concerned about this kind of thing and often

can decide the client has serious issues and isn’t committed to the therapy. It’s actually about trauma, and a dissociative process and a level of anxiety and distress.’

Mahboob recommends work on maintaining an emotionally safe relationship for the client, so they can EH YXOQHUDEOH Ō,I WKH\ IHDU MXGJPHQW people may not be honest about what is happening to them. But if the client is comfortable enough with you challenging them, in a very gentle way, they may be able to explore the unhealthiness of the relationship and maybe the lack of boundaries that are there, without making them deal with something they’re not ready for. If it’s done very gently and kindly, it can enable them to explore it and talk it through.’

Where this isn’t appropriate is in FRXSOHV WKHUDS\ Ō7KH DEXVHG SHUVRQ can’t speak openly, and if they even hint at it they’ll pay for it when they get home. Abusers can present a perfectly reasonable account and be very charming, so the therapist is drawn into the whole dynamic,’ says Hayes. And she also cautions against just encouraging someone to leave, pointing out that the risk of serious harm – including being killed – is often DW WKH SRLQW RI OHDYLQJ Ō/HDYLQJ PD\ not be the answer for some, and for others it’s only the beginning. It’s a process, not a beginning. There’s a whole practical process to be handled, and a whole psychological, emotional and relational process to manage. How do you deal with the immediate and the ZLGHU IDOORXW RI OHDYLQJ"ō On the other hand, Hayes and others feel that if therapists do suspect that abuse is happening, it is within the therapist’s remit to help by referring clients to agencies that are skilled in this work, which may well involve doing some basic research themselves LQWR ZKDW KHOS LV DYDLODEOH ORFDOO\ Ō,I you have any suspicions, please ask if everything is OK at home,’ says Tulaz. Ō$QG SOHDVH IHHO UHDG\ WR JLYH RXW numbers. It’s usually seen as something happening behind doors, and by

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not asking questions we’re actually increasing what is happening behind doors. It’s everyone’s responsibility.’ * &OLHQWōV QDPH DQG LGHQWLƓDEOH GHWDLOV KDYH been changed.

REFERENCES 1. A statement by Phumzile MlamboNgcuka, Executive Director of UN. Violence against women and girls: the shadow pandemic. World Health Organization, 2020; 6 April. 2. Trevillion et al. Experiences of domestic violence and mental disorders: a systematic review and meta-analysis. PLoS One 2012; 7(12). doi: 10.1371/journal.pone.0051740.

3. Bhavsar et al. Lockdown, domestic abuse perpetration, and mental health care: gaps in training, research, and policy. British Journal of Psychiatry 2011; 198(3):189-94. doi: 10.1192/bjp. bp.109.072389. 4. 2IƓFH IRU 1DWLRQDO Statistics. Domestic abuse during the coronavirus (COVID-19) pandemic.

England and Wales. 2020: November.

5. Hohl K, Johnson K. A crisis exposed – how COVID-19 is impacting domestic abuse reported to the police. News, City University, London; 2020, 22 December.

6. Davidge S. A perfect storm: the impact of the COVID-19 pandemic on domestic abuse survivors and the services supporting them. London: Women’s Aid; 2020. 7. Lisney et al. The impact of COVID-19 on disabled women from Sisters of Frida. Sisters of Frida 2020, April. 8. Garstang et al. Effect of COVID-19 lockdown on child protection medical assessments: a retrospective observational study in Birmingham, UK. BMJ Open 2020; 10:e042867. doi: 10.1136/bmjopen-2020-042867.

9. Rose et al. Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study. British Journal of Psychiatry 2011; 198(3):189-94. doi: 10. 1192/bjp. bp.109.072389.

About the author Radhika Holmström is a journalist specialising in health, mental health and learning disability issues. www.radhika-holmstrom.com

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‘The more regrets one has about life, looking back, the greater anxiety one has about dying’

©FIRST RUN FEATURES/COURTESY EVERETT COLLECTION

Celebrated psychotherapist Irvin Yalom talks to Catherine Jackson about his work and losing Marilyn, the love of his life Catherine Jackson: I want to start by thanking you, on my own behalf but also on behalf of the 50,000 members of BACP. I know this is one of the very few interviews you are giving to promote the new book you co-wrote with your wife, Marilyn, who very sadly GLHG EHIRUH LW ZDV ƓQLVKHG :H DUH so honoured that you have agreed to include us.

instance in which ‘sharing your thoughts and personal feelings was not helpful to the patient’. I think, in the UK, many counsellors suffer what you might call ‘self-disclosure anxiety’ – ‘How much of myself is it ethical/therapeutic to share with my clients? When does sharing become inappropriate self-disclosure?’

What is your view about the use of self in therapy?

Irvin Yalom: Well, do keep in mind, I am an author and I have this new book out, so you are doing me a favour as well. Please know that this isn’t all charity on my part!

IY: Let me tell you what I’ve been doing over the past year or so. I’m no longer doing longterm therapy because I’m too old. I’m going to be 90 next birthday and the memory slips away, and actually for four, five years before that, I was already limiting my therapy to one year, so now I’m limiting it to just one session. And in that one session, I invariably do some self-disclosure.

We will talk about the patient and what brought them to therapy and then, at some point, I will talk about myself in various ways, and 100% of the time I find it catalyses the therapy. It makes things go better. People are much more able and willing to talk if I reveal something about myself.

CJ: So, let’s get going with the questions. A recurrent theme in your work is how much your patients respond to your sharing something of your own life that demonstrates that you too have been there. In your memoir, Becoming Myself, you write that, ‘Your own self is your major instrument’. You also write that you cannot think of a single

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And that is linked to my working very much in the here and now with every patient. By this I mean, I spend a lot of time looking at what’s happening in the room between me and the patient, what’s going on between the two of us. So invariably, in my one-hour consultations now, and in my therapy before that, I will at some point say, in essence, ‘Let’s move into the here and now. How are things going between the two of us? How do you think we are doing?

Do you think I’m pushing too hard?’ That kind of thing. And we begin to talk about their feelings and I will share my feelings with the patient as they share their feelings about me.

A story I often share with patients is of my own childhood. I see a lot of patients who have a very troubled, unhappy early life, with a difficult parent or parents, and I want to reassure them that what happens in your early life can be extremely important and lasting in influencing you as a person in later life. I cite the work of John Bowlby and psychotherapists like Melanie Klein, and then I talk about my own early life – that my father came to the US from a little village in Russia. He was poor, he was uneducated, he had little money, and he opened up a small grocery store in a poor neighbourhood in Washington DC, and we lived above the store. Washington was segregated in those days – there were black neighbourhoods and white neighbourhoods, and the store was in the middle of a black neighbourhood, so I couldn’t socialise much with local kids because my mother would never let them into the house or let me go into their homes. So I had a very restricted first 14 years of life. I spent a lot of my life in the library and reading books in our flat above the shop. Now, I had a lot of anxiety in my life and I’ve been in therapy six times. In fact, I’m in therapy right now, and it’s being very helpful to me with my grief.

‘I work very much in the here and now with every patient. I spend a lot of time looking at what’s happening in the room between us’

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Then I tell the story of my wife, whose parents came from another little village in Russia, and her father opened up a grocery store in Washington DC one block away from my father’s store. But Marilyn’s father bought them an apartment in a more affluent part of town, because he felt it was too dangerous to live above the store. So she had a very different childhood, with a good education and dancing lessons and elocution lessons and lots of friends, and she never even knew what anxiety was, never had to see a therapist… Nature ran this experiment with us, in a sense.

So I tell the patient, with the kind of background you had, the effect can be quite lasting. So don’t stint yourself. You may need to be in therapy several times and it will be helpful to you. Don’t feel badly and that you shouldn’t be in therapy. The effects of the early deprivation that you had can be very longlasting. Then, in the second part of the session, I’ll bring the session back to the here and now and ask them how they feel about me telling them the story about my past, what was that like for them, what are they feeling about me now, how do they feel we are doing? And it’s like a jet propulsion – they are talking so much more openly about themselves and their parents and their early lives. I find this extremely effective.

THE WRONG JOB? CJ: In Staring at the Sun, you write that you are guided not by 19th-century psychologists and psychiatrists but by Ancient Greek philosophers – especially Epicurus, who you call a ‘proto existential therapist’. You write: ‘The philosopher treats the soul’; that their goal is ‘to alleviate human misery’. In Becoming Myself, you say you studied

psychiatry because of your love of literature, your belief that psychiatry ‘offered proximity to all the great writers I loved’ and that ‘many of the issues my patients struggled with… were often more cogently addressed by novelists and philosophers than members of my RZQ ƓHOGō <RX VD\ \RX ŌORQJHG WR EH D writer’. Do you ever think you chose the wrong job in becoming a psychiatrist and psychotherapist?

IY: Obviously I have some kind of writing talent, there’s no question about that, because the books are very successful. So sometimes I do think, ‘Maybe I should have been a writer’, a professional writer. At undergraduate school, I was in such a rush to qualify so I could marry Marilyn – I wanted to marry her from age 14 and I was so convinced some other richer, better-qualified man would carry her off that I just took straight pre-med courses. I had only a couple of opportunities to take other courses and each time I chose a course in literature. So yes, I’ve often thought, ‘Did I choose the wrong profession?’ And I always answer myself, ‘Yes, I could have been a writer – but I’m not sure I’d have any material to write about if I had!’

Writing is a great pleasure that I have always had and I am reading all the time. Right now I am reading John Banville’s novel Snow, and I am just exalted as I look at his lines and how he describes people. Banville and Ian McEwan are my two most favourite writers – I love so much the way they put sentences together.

CJ: So, which do you rate most in your published work? Your novels or your therapy books?

IY: I’ve been so down and depressed after my wife’s death and then, after two or three months of bereavement, I picked up one of my own books – Mama and the Meaning of Life, a book of therapy stories – and I found a story in it called ‘Seven advanced lessons in the therapy of grief’.

And I thought, ’What? I wrote a book about the therapy of grief?’ I’d forgotten all about it. And it was terribly useful. It was about a patient who had lost her husband and she was very angry at me all the time because, she said, I didn’t know what she was going through; I couldn’t understand because I hadn’t experienced it myself. She’d say, ‘How can you help me if you haven’t been through all this? How can you

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know what I’m going through?’ And I’d yell back – because we’d fight all the time – ‘So I’ve got to be depressed to work with depressed people?’

But now I see that she was right. Now I have the experience of this block that she had and how she felt. So I’ve been helped by reading my own books! And I love those stories.

But my greatest joy of all was writing the novels. I just loved being in the middle of those novels. I wrote four of them and they were all great experiences in my life.

RETIREMENT CJ: You are approaching 90, yet you clearly haven’t retired; you’ve just changed how you work. Most people long for retirement, yet you still see clients and you’re writing yet another book. What keeps you working?

IY: I love the work. I love the therapy. I love the connections with people. Psychotherapy gives me so many ideas about how to get inside the human dilemma. And I feel I still have so much

to offer another person. Right now, it’s a bleak time for everyone, but with Marilyn’s death, it’s an especially bleak time for me. I feel very lonely; my daughter comes over two days a week and spends that time with me, and I see my other children and grandchildren when I can. They live further away. But I am working on a book right now and it’s a lifesaver. I love to write and I sit in my office and sometimes I look up and realise I’ve been here for four hours and never even got up. It was the same when Marilyn was dying and we started on our book together.

I tell the story in the book, of when she was first diagnosed with multiple myeloma, a cancer of the plasma cells, in 2019. The drugs precipitated a stroke and she nearly died then. When we returned home from hospital, she told me, ‘I have a book in mind that we should write together. I want to document the difficult days and months before us.’ She said she thought it could be of some use to other couples going through such an experience.

I said I’d already started on a book, as she knew.

And she replied, ‘Oh, no, no – you’re not writing that book. You’re writing this one with me! It’ll be our book that will be unlike any other book because it entails two minds, rather than one.’

CJ: So, can you tell us – what is this other new book that you’re now working on?

could manage, and only because you had to, and you are now talking about one session! I wonder what you think it is possible to achieve in that time frame and how?

IY: I’m not suggesting a single session is better.

I am just saying, this is all I can do right now.

If I had a better memory, I’d be doing longer therapy. But someone in my position, who has this much influence, I feel it is a good thing for me to be doing something. Right now I am very much at the stage in my life where I want to give something to people. The majority of the people I see are therapists who want to have a single session with me because they read my books and they put me in an exalted position. Now, I don’t think I deserve all that, but I know I am in a

‘I love the work.

Psychotherapy gives me so many ideas about how to get inside the human dilemma’

IY: It just came upon me. I like doing these

position where my words can be tremendously helpful to them. I have a great deal of power, and I want to give them something that will be helpful to them. I am certainly not suggesting that this is the way that therapy should be done.

Not at all. It’s something I can offer at this time and I take great pleasure in that.

CJ: I was very tickled by a comment you made in your memoir, Becoming Myself – this was back in 2017. You wrote: ‘As I age, audiences get larger and larger and I wonder, why such a rush to see me?’ You seemed to be suggesting the rush is curiosity prompted by the predicted imminence of your death, and I wondered that it didn’t occur to you that this was a sign of your ever-growing international fame?

INFLUENCES CJ: But turning to your psychotherapy URRWV DQG LQŴXHQFHV \RXōYH VDLG WKDW while training, you chose not to enrol in any postgraduate psychotherapy courses – no Freudian, Jungian or Lacanian analytic trainings. ‘I was entirely free of governing rules and guided only by my results, which I carefully monitored.’ What have been \RXU PDLQ LQŴXHQFHV" Wedding day, June 1956

single-session consultations very much and I ask the patients to drop me an email afterwards, telling me how they’re doing and giving me some feedback on how I’ve done in the consultation and what I could have done differently, and I am astounded by how often they say it has changed their life. After these consultations, quite often a story will pop into my mind and I’ve been writing them up, five or six pages, and so I decided I’d do a book of them. I have about 25 – my story of the therapy set alongside their perspective. I did it with one patient a long time ago, which I published as Every Day Gets a Little Closer; she wrote her summary, I wrote mine and we’d exchange them. So I was investigating this self-disclosure way back then.

CJ: There is a lot of controversy about single-session counselling. You are the psychotherapist who a few years back said that one year was the shortest you

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IY: The approach that I was most influenced

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by is the interpersonal approach, looking at interpersonal relationships. There was a very influential US therapist named Harry Stack Sullivan; he was stationed in Baltimore, where I took my training, and he began the switch in approach from the early psychoanalysts. So you are looking not at the first few early years of life but at the connections that person has with other people throughout their life. Another major influence was Karen Horney, a German psychoanalyst and psychiatrist who moved to New York in the 1940s, and, of course, Rollo May, who was my therapist for several years and after became a close and dear friend.

What I am interested in is my patients’ interpersonal history – their relationships with family, friends, colleagues, the people around them. And you need to remember, I started out in group psychotherapy. From the very beginning of my training I was very influenced by a teacher named Jerome Frank, a very wonderful man. He was one of the pioneers of group therapy, and group therapy totally uses the interpersonal approach. The therapist observes how the patients use the group to play out how they relate to other people and it is invaluable for that. So, if I belong to any school, it’s the interpersonal school. In fact, the latest edition of my book on group therapy has just come out now – 800 pages. This is the sixth time I have done that, though for the past couple of editions I worked with a co-writer – a lot of my life has been spent on that work.

CJ: Yes, I was very struck by your observation in your latest book of how powerful it was to have observers of the group therapy, watching from another room, and that, while the group therapy participants were very interested in what the observers saw and said about them, when you switched their roles and the participants observed your discussions with the therapists, they were not at all keen on being observed!

IY: Yes, I always arranged it so the patients could watch my discussions with the trainee therapists after the group sessions, and the young therapists were very much put out by that. They didn’t like being observed by the patients but I really pushed them into doing that. I have always believed in that openness. It’s always been part of my relationship to patients.

Irvin and Marilyn with their four children in 1976

I want to have a human relationship with people. I have never wanted to be some distant, silent person who is listening to them but not sharing with them.

LESSONS ABOUT LIVING CJ: I’d like to turn now to your new book, A Matter of Death and Life. I am deeply struck by what you write about your life without Marilyn. You talk about your sense of being very much alone now that there can ‘be no sharing with Marilyn’.

This is something that will resonate with a lot of bereaved people.

CJ: In Staring at the Sun, you write about the paradox of death – that it can be a catalyst to transform a person’s life. You quote a dying patient with cancer: ‘What a pity I had to wait till now, till my body was riddled with cancer, to learn how to live.’ Your work has always focused on death and existentialism and yet is joyful DQG OLIH DIƓUPLQJ ,V UHWDLQLQJ DQ DFXWH awareness of death the key to that joy?

IY: When Marilyn died, I realised how much I

IY: Right now in my consultations, I see a lot

still had to learn about life – I had to learn how to live as an independent, separate adult. I realised that I’d done so much in my life – becoming a doctor, taking care of patients, teaching students, writing books, fathering and raising four loving, generous and creative children – but I’d never lived as an independent adult. I’m not referring to loneliness. I want to stress that. It’s a matter of learning that something can have value and interest and importance even if I am the only one who experiences it, even if I cannot share it with Marilyn.

This is something I also say to patients.

There are times when I think, when I die, I’ll be joining Marilyn, and that thought always gives me comfort. And that is so bizarre, because I am a committed atheist; I always have been. So the thought that I’ll be joining Marilyn is totally absurd. But still, the idea of it gives me some comfort and I am sure that is a big part of the

of people who are wanting to consult with me about death anxiety, and I’ve been talking about that quite a bit. Almost invariably we make the link that a great deal of death anxiety is very much associated with a sense of regret about the way they’ve lived their life. The more regrets one has about life, looking back, the greater anxiety one has about dying. And that is usually where I go; I look at that link.

I can learn from my own life. As I look back on my life, as I’ve been doing this past year in my grief, I have virtually zero death anxiety.

Whereas I had it so much earlier in my life. In Staring at the Sun, I wrote a whole book about it! But now I am old and I look back on my life, I don’t have any regrets at all. I look at the books I’ve written, I married this extraordinary woman, had four children whom I love very much, I have lots of grandchildren and I just have no regrets. When I started out, I couldn’t

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comfort that religion has offered people all through the centuries – those religions that offer some kind of continuation.

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‘I couldn’t have done better. And now I am approaching death and I know I am not going to last much longer, I don’t have any regret about it’ have imagined I’d do as well in life as I have done. I couldn’t have done better. And now I am approaching death and my memory is slipping away and I know I am not going to last much longer, I don’t have any regret about it.

A GOOD DEATH CJ: You tell us that Marilyn essentially chose to end her own life, which is legal in your part of the US. Does a ‘good death’ mean an acceptance of death rather than resisting it? I wonder if, in Western societies generally, we have lost that acceptance. Medical practice now seems predicated on preserving life at any cost and Western societies seem so very reluctant to allow people to choose to die. Do you think that acceptance is what makes a ‘good death’?

IY: Yes, I think so. It was a very wise choice on her part and I am so glad it was legally possible for her to do that. She had a good death.

Maybe it could have been two or three weeks earlier – she was so uncomfortable in those last weeks. But the law in California does allow it; if you have a doctor’s diagnosis that you have a terminal illness, they can assist you in dying. It’s a physician-assisted suicide. Some states do not permit it and in some – Oregon, for example – you don’t have to have a terminal disease; you can have a physician-assisted death if you just feel it is time to end your life. I am all in favour of that. It was a very good death for her. She wanted her children and me to be there at her bedside when she took the drink that enabled her to die. I counted 17 breaths after she took the drink, so her death was immediate and very, very gentle. I can’t forget it; it’s engraved upon my mind, so clearly, that scene.

CJ: You describe very powerfully, in the part of the book that you completed after her death, how hard it was for you to support that decision because it took Marilyn from you. You also write about considering suicide yourself, to accompany her, and you ask, how could you do that to your children and family? But I was particularly struck by what you then say: What would be the impact on your patients? I’m going to end this interview with the direct quote, as I think it says so much about you, how you work and your integrity and honesty, which I think are the hallmarks of your approach. You say, ‘So many times I’ve beamed with pleasure as I watched them [my patients] gradually improve and re-enter life. Ending my own life would be such a betrayal of their work, of our work. I helped them survive their pain and suffering and then, when faced with their situation, I choose to cop out. No, I cannot do that. Helping my patients is at the core of my life.’

About Irvin Yalom Irvin David Yalom is an American existential psychotherapist who is emeritus professor of psychiatry at Stanford University, as well as WKH DXWKRU RI QLQH ƓFWLRQ DQG HLJKW QRQ ƓFWLRQ LQWHUQDWLRQDOO\ bestselling books, including Love’s Executioner, The Gift of Therapy, Becoming Myself and When Nietzsche Wept. His latest, A Matter of Death and Life, was written with his wife of 65 years, Marilyn, before her death in November 2019.

A Matter of Death and Life: love, loss and what matters in the end, by Irvin D Yalom and Marilyn Yalom, is published by Piatkus.

IY: Yes, at one point I describe a young woman, in her 20s, who came to me for a single consultation. She told me her problem was that she was in love with two men – her husband and her lover – and she couldn’t decide which one of them the ‘real’ her ‘really’ loved. And I asked her to permit me to ramble for a minute; I told her that getting involved in her life temporarily diverted me from my own. And I told her what our discussion stirred up for me.

I described how, weeks after Marilyn’s death, I still had this strange experience that, when something happened, I had to tell Marilyn about it. It was as though things didn’t become ‘real’ until Marilyn knew about them. And, of course, that was entirely irrational, because Marilyn no longer existed. And I said to the young woman that I had finally understood this: ‘I and only I have to take full responsibility for determining reality’; that living is now my task, my job, my responsibility.

CJ: As Marilyn writes in the book, ‘Ultimately, I have come to the understanding that one stays alive not only for oneself but also for others.’

Thank you, Irvin. And I very much look forward to the next book.

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About the interviewer Catherine Jackson is a freelance journalist specialising in counselling and mental health.

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It changed my life, 1

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had insisted that the therapist my mother and I needed to see should be black and female. But, although our first counsellor did fit those criteria, she was not a good fit for us. The first time we arrived at our session, we received a telling off for using the doorbell. ‘I asked you not to disturb me if you’re early.

I’m with a client.’ We apologised and waited outside in the cold. During the second session, I was asked to ‘stop shouting’ during a difficult exchange with my mother. I could not stop, and so we didn’t go back. A year later, we gave therapy another go. This therapist was a white woman who had been recommended to me by my mother, yet I was dubious. ‘She won’t understand,’ I told friends. ‘I’ll feel isolated.’

I saw race as an important factor in my therapy journey. This is because I had grown up in a white household, with parents who offered no explanation as to why I appeared black. ‘You might be a genetic throwback,’ my mother had said. But other than that, race and its meaning went completely unacknowledged in our Surrey home for 23 years, unless I pressed. But, with each passing year, race was more dogged in its pursuit of me. When I reached university, I still didn’t know who I was, and when my beloved father died of cancer in 2016, when I was 22, I knew I could no longer uphold a nebulous family narrative. Dad’s death became the catalyst for uncovering the truth. A series of painful DNA tests proved that Mum had been concealing an affair with a black man she had once known.

In those early therapy sessions, I was startled by the potency of my rage. I had been robbed of both my identity and my biological ties to my father and his family – I wasn’t sure a white therapist would fully understand the losses. My mother was initially adamant that I was over-exaggerating the impact of this racial denial, and she felt exposed by my decision to write about it in a national newspaper.

I couldn’t understand her lack of empathy, yet reserved judgment on my father, whose memory I refused to tarnish. In those early sessions, our therapist – who was around the same age as Mum – unpacked my mother’s childhood in rural, Catholic

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Ireland in the 1970s. It was infuriating at first, waiting for Mum to play racial catch-up as I described how I’d staunchly defended our family for years, and how an otherwise happy childhood was marred by accounts of othering and racism that I’d endured alone. But I realised that reflecting on her upbringing helped Mum empathise with my loss of identity. I learned that the religious guilt Mum carried around as a result of betraying her husband had become all-consuming, morphing into shame and blinding her to my pain.

I learned to let go of my anger.

I also discovered that it did not matter that our fantastic, gentle therapist was white. She successfully encouraged my emotionally introverted mother to open up so Mum could relate to me – and her shame dissolved. I also began seeing a brilliant, black female therapist who helped me piece together my fractured identity and who made me realise that both my mother and father had been complicit in their decision to raise me in a colour-blind household.

I began to see them both not as just parents, but people – flawed and imperfect like me – each raised in stoic households in Ireland and Britain, and who were united in their silence around my race because they couldn’t process the deceit between them. My mother had been freed from the awkwardness of discussing her infidelity by my father, who had never once challenged her. As a result, my race had been overlooked as a way of accepting it and keeping the family intact. My own therapist helped me understand what I had lost in that process, but also how I had benefited. Our joint therapist helped my mother and I reflect on my dad’s incredible love for us all and reconnect as two people grieving a monumental loss.

I had always been closer to my father growing up, but through therapy I discovered that there had long been an invisible, concrete wall between my mother and I as a result of the silence around my heritage.

Dismantling that wall, brick by brick, week by week, was the most agonising yet rewarding process. But, with the help of two incredible female counsellors, my relationship with my mother – and myself – is better than before.

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‘I saw race as an important factor in my therapy journey’

About the author Georgina Lawton is a former Guardian columnist, now freelance journalist, who has contributed to gal-dem, Vice, Stylist and The Independent. Her memoir, Raceless: in search of family, identity, and the truth about where I belong, is published

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LI WKLV DVVHVVPHQW WDNHV SODFH WRZDUGV WKH HQG RI WKDW VHVVLRQ Ŋ FOLHQWV RIWHQ FRPH WR WKHUDS\ DQ[LRXV RU ZLWK WKHLU RZQ DFFRXQWV WKDW WKH\ ZDQW WR RIŴRDG DQG LW PD\ EH D IHZ VHVVLRQV EHIRUH WKH\ DUH UHDG\ WR VD\ VRPHWKLQJ RI ZKDW WKH\ SUHIHU :H UHFRPPHQG WKDW WKH FOLHQWVō WUHDWPHQW JRDOV WKH ŌZKHUHō EH HVWDEOLVKHG EHIRUH DVFHUWDLQLQJ WKHLU SUHIHUHQFHV WKH ŌKRZō

There are many ways that clients can EH LQYLWHG WR H[SUHVV WKHLU SUHIHUHQFHV IRU LQVWDQFH \RX PLJKW DVN ● Ō:KDW GR \RX WKLQN WKDW ZH FDQ GR KHUH WKDW PLJKW EH KHOSIXO WR \RX" 'R \RX KDYH DQ\ VHQVH RI ZKDW ZRXOGQōW EH KHOSIXO"ō ● Ō:KDW ZRXOG \RX OLNH LQ RXU ZRUN WRJHWKHU" :KDW NLQG RI SUHIHUHQFHV GR \RX KDYH"ō ● Ō7U\ WKLV EULHI H[HUFLVH &ORVH \RXU H\HV EUHDWKH GHHSO\ D IHZ WLPHV DQG LPDJLQH LQ \RXU PLQGōV H\H ZKDW \RX ZRXOG VWURQJO\ OLNH WR KDSSHQ LQ KHUH :KDW ZRXOG , LGHDOO\ GR" :KDW ZRXOG , QRW GR"ō ● Ō/HWōV WKLQN WRJHWKHU DERXW KRZ \RX PLJKW JHW ZKDW \RX ZDQW IURP WKHUDS\ :KLFK WUHDWPHQW PHWKRG" :KDW W\SH RI WKHUDS\ UHODWLRQVKLS" :KDW W\SH RI RXW RI RIƓFH DFWLYLWLHV Ŋ VHOI KHOS H[HUFLVH DSSV DQG VR RQ"ō $VVHVVPHQW RI FOLHQW SUHIHUHQFHV FDQ DOVR WDNH SODFH EHIRUH WKDW LQWDNH PHHWLQJ )RU LQVWDQFH LQ DQ LQLWLDO SKRQH FRQYHUVDWLRQ D SURVSHFWLYH WKHUDSLVW PD\ DVN DERXW SDUWLFXODU WUHDWPHQW SUHIHUHQFHV RU SUHIHUHQFHV DERXW WKH WKHUDSLVW WR HQVXUH WKHUH LV D EDVLF FRPSDWLELOLW\ EHIRUH PRYLQJ IRUZDUG 6FKHGXOHG UHYLHZ VHVVLRQV DUH DQRWKHU SRLQW DW ZKLFK FOLHQWV PD\ EH DVNHG DERXW WKHLU SUHIHUHQFHV DQG ZKHWKHU WKH WKHUDSLVWōV PHWKRGV DQG VW\OH VHHP

‘I already work with clients’ preferences.

I don’t need to do more’ ,QWHUHVWLQJO\ LQ WKH PHGLFDO ƓHOG GRFWRUV WHQG WR WKLQN WKHUHōV PRUH VKDUHG GHFLVLRQ PDNLQJ JRLQJ RQ WKDQ GR patients.6 7KH GLIIHUHQFH PD\ FRPH

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to be of help. And, of course, there may be occasions during therapy sessions where it is appropriate and helpful to discuss client preference – for example, at the start of sessions, when the therapy is not progressing well, when there is an alliance rupture, or when the ending approaches. In fact, recursive assessment of preferences often becomes part of routine outcome monitoring.

Based on the research and our clinical experience,2 we offer several principles of good practice in preference assessment: ● Focus on strong preferences – what clients might really want and really dislike – rather than milder or more moderate preferences. It’s the former where accommodation or non-accommodation is most likely to count. ● Ask clients what worked and did not work in previous therapies, if they have had them. It’s often the most simple and natural way in to identifying what might be helpful now. ● Preference assessment needs to be framed within the context of a respectful, warm, collaborative therapeutic relationship; if not, it may be little more than a sterile data-gathering exercise. ● Make it clear that asking about preferences is a normal part of counselling and psychotherapy.

Clients may be surprised to be asked and assume that therapy is like other, practitioner-led ‘treatments’. ● Actively invite clients to share their preferences. Given client deference (see above), it’s not enough just to assume that, if they have preferences, they’ll verbalise them. ● Be part of the dialogue yourself.

Shared decision making means shared – you need to work with the client to help decide, together, what might be best for them. ● %H FRQƓGHQW Ŋ DW LWV ZRUVW SUHIHUHQFH assessment can communicate to clients that we don’t know how to help them and that it’s their responsibility to decide. So the message we want to communicate to clients is, ‘We’ve got lots of ideas about how to help you, but we’re really interested in your ideas

too. I am the therapy professional but you are the expert on you.’ ● Suggest alternatives through ‘scaffolding’. Clients can easily feel overwhelmed if they’re presented with a ‘blank sheet of paper’ and asked, ‘What do you want?’ Rather, it is often KHOSIXO WR VXJJHVW WZR RU WKUHH VSHFLƓF alternatives, such as, ‘We could talk about your grandmother this session, or perhaps you would like to focus on your boyfriend?’ ● Don’t ‘overcook’ it. If clients do not have ideas about what will help them or seem reluctant to talk about it, then move on. You can come back to their preferences later on in the therapeutic process, if it seems appropriate. ● Tailor the tailoring – some clients, some of the time, want to have their preferences assessed and accommodated; others do not. So adjust the amount of preference work to the individual client – there is no RQH VL]H WKDW ƓWV DOO HYHQ ZKHQ LW comes to the client’s preferences.

Through our research, we have developed a tool to assess strong client preferences, the Cooper-Norcross Inventory of Preferences (C-NIP).8 This measure, now translated into more than 10 languages and freely available for use digitally or on paper,9 invites clients to express their preferences for therapy along four dimensions: ● therapist directiveness vs client directiveness ● emotional intensity vs emotional reserve ● past orientation vs present orientation ● warm support vs focused challenge.

7KH PHDVXUH WDNHV FOLHQWV DERXW ƓYH minutes to complete and can be immediately scored in session to indicate whether the client has strong preferences on any of these dimensions. This then serves as the basis for discussion about how the therapist and client can work together. Our research suggests that FOLHQWV JHQHUDOO\ ƓQG WKH & 1,3 KHOSIXO supporting their ability to articulate how they want to proceed in treatment. And, they often say, it feels good to be asked.

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Working with client preferences Once clients’ preferences are assessed, there is the question of how they are accommodated – or not – into the therapeutic work. We suggest four possibilities: adopt, adapt, alternative, or another.

Adopt means that we integrate the client’s strong preferences, pretty much as they are, into therapy, bearing in mind, of course, that these preferences (and our scope of practice) may change over time.

Adapt is offering something along the lines of what the client wanted, but adjusted to take into account our own views of what might prove most effective, the research evidence, ethical considerations, or the limits of our own scope of practice. In the case of Hamza,* for example, there was a small but VLJQLƓFDQW PLVPDWFK EHWZHHQ ZKDW he wanted from treatment and the therapist’s understanding of what might be most helpful for him.

Hamza presented with high levels of depression and anxiety and was becoming increasingly withdrawn from his college and social environment.

The therapist’s view, based on an understanding of core behavioural principles, was that Hamza needed to be encouraged to get out and re-engage with his world. The more he withdrew, the more anxious and isolated he became. Hamza sensed this pattern as well. However, he also indicated that, based on a previous episode of CBT, it was unhelpful for him to be told by a therapist, ‘If you don’t do what I’m suggesting, you’re not going to get better.’ He said that it left him feeling guilty, ashamed and even less FRQƓGHQW WR JR RXW LQWR WKH ZRUOG 7KH DGDSWDWLRQ FKDOOHQJH ZDV WR ƓQG methods of communicating to Hamza that he could change his behaviours, without implying that he was ‘bad’ or ‘wrong’ if he did not. A delicate balance needed to be struck between helping Hamza own some responsibility and, at the same time, avoiding his strong dislike of feeling blamed.2 The third option is to respectfully propose alternatives to patients’ strong

likes and dislikes. This would be when we believe their preferences will not be most suited to the particular context, or when we do not think it will produce the desired results. Just because clients want something does not mean that we should automatically provide it. Ethical, legal and clinical constraints still bind us to responsible and effective practice.

In some cases, for instance, clients may be unconsciously trying to recreate a problematic relationship or to test the therapy’s frame. Three ‘e’s may be helpful when proposing alternatives to clients2: ● Explain your reasoning for not accommodating or adapting. ● Empathise with probable patient disappointment. ● Educate the client about the proposed alternative, so that they understand why it is being proposed.

When a client’s strong preferences prove congruent with the research evidence and best practices but not our own scope of practice, then referral becomes a strong possibility.2 This is a practice that students often receive little training in, but it is an essential competence, given our inevitable limits and our desire for clients to have the best therapy possible. Some helpful pointers for therapists may be: ● Accept your limits as a practitioner – see onward referral as a sign of your commitment to your clients’ mental health rather than as an indication of your failings. ● Be aware that some clients may experience onward referral as a sign of rejection or an indication that their mental health problems are incurable.

Make it clear that it is due to your competency boundaries as a therapist, rather than their failure as a client. ● Refer onwards in a collaborative way with clients so that it is experienced as a shared and empowering experience, rather than as something imposed on them. ● Provide concrete suggestions and VSHFLƓF UHVRXUFHV DV RSSRVHG WR vague referrals to other services. This may mean you need to be up to date on other resources in your community

– for instance, low-cost CBT practitioners or substance misuse programmes – before having these discussions with clients. ● Obtain proper permission or releases so that you can communicate with other practitioners or services to ensure continuity of care and personalisation, where possible.2 Assessing and accommodating clients’ preferences are, at heart, about creating a more egalitarian, empowering and responsive relationship that enables clients to use counselling and psychotherapy most effectively. Both research and practice attest to the success of preference work.

But there is still much more to learn. :KLFK FOLHQWV LQ ZKLFK VLWXDWLRQV EHQHƓW the most (and least) from preference work? How can we most effectively help clients articulate their preferences?

Answering these kinds of questions is part of a wider movement towards personalised care, in which our clients are treated as unique human beings ZLWK VSHFLƓF DQG LQGLYLGXDO GHVLUHV When we ask clients about their preferences, as with Buber’s ‘I -Thou attitude’,10 ZH DIƓUP WKHP DV DJHQWLF participants or partners who have the power – and right – to direct their own process of change. This is certainly not the only means of conveying such valuing and respect to our clients, but it becomes an integral part of a deeply DIƓUPLQJ HPSRZHULQJ UHODWLRQVKLS ■ &OLHQWVō QDPHV DQG LGHQWLƓDEOH GHWDLOV KDYH EHHQ changed to safeguard anonymity.

Personalizing Psychotherapy: assessing and accommodating patient preferences (APA), by John C Norcross and Mick Cooper, is available with a 40% discount and free standard delivery from www.eurospanbookstore. com/personalizingpsychotherapy.html with the code ‘Psychotherapy40’.

Open to customers in the UK, Europe, Middle East and Africa. Valid until 30 April 2021.

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REFERENCES 1. Norcross J C & Wampold BE (eds).

Preferences in psychotherapy relationships that work. New York: Oxford University Press; 2019. 2. Norcross J C & Cooper M. Personalizing psychotherapy: assessing and accommodating patient preferences.

Washington: APA; 2021. 3. BACP. Ethical framework for the counselling professions.

Lutterworth: BACP; 2018. 4. Swift J & Callahan J. Early psychotherapy processes: an examination of client and trainee clinician perspective convergence. Clinical Psychology & Psychotherapy 2009; 16(3) 228-236.

5. Cooper M et al. Psychotherapy preferences of laypersons and mental health professionals: whose therapy is it? Psychotherapy 2019; 56: 205-216. 6. Health Foundation. Helping people share decision making. London: Health Foundation; 2012. 7. Rennie DL. Clients’ deference in psychotherapy. Journal of Counseling Psychology 1994; 41(4): 427-437. 8. Cooper M & Norcross J C. A brief, multidimensional measure of clients’ therapy preferences: the Cooper-Norcross Inventory of Preferences (C-NIP). International Journal of Clinical and Health Psychology 2016; 16(1): 87-98. 9. Available free from www.c-nip.net 10. Buber M. I and thou (2nd ed). Edinburgh: T & T Clark Ltd; 1958.

About the authors Dr John C Norcross is Distinguished Professor of Psychology and Chair at the University of Scranton, Clinical Professor of Psychiatry at SUNY Upstate Medical University and a clinical psychologist. Dr Norcross has co-written or edited 22 books, including Psychotherapy Relationships that Work and Handbook of Psychotherapy Integration.

Mick Cooper is Professor of Counselling Psychology at the University of Roehampton, and Director of the Centre for Research in Social and Psychological Transformation (CREST). A BACP Fellow and a chartered psychologist, Mick is the author and editor of a range of texts on person-centred, existential and relational approaches to therapy.

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From breakdown Owning up to burnout can be hard for therapists, but addressing it can ultimately lead to personal growth, says Kitty Willis

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am a psychotherapist and, some years ago, I experienced burnout. At the time, it felt as though I had hit a brick wall. My life fell apart.

I was in a state of confusion and chaos, with no idea of what had happened to me. During my recovery, Leonard Cohen’s song ‘Anthem’ brought me encouragement in the dark days after I had stopped work and my life was on hold. The words, ‘There is a crack, a crack in everything; that is how the light gets in’ gave me hope of a better future. My own experience and working with clients who have suffered with this syndrome has led me to believe that this illness, while difficult and often misunderstood, can be turned into a healing and life-giving experience.

In 2019, burnout was recognised as an official medical diagnosis by the World Health Organisation where it was related specifically to the workplace, defined as ‘a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed’.1 It was not classified as a medical condition but as a syndrome. I would argue that this description of burnout as relating only to the workplace falls short of an accurate description. While burnout was the result of their work environment for some of my clients, others were not unduly stressed at work but had stressors in other areas of their lives that in combination led to burnout.

Symptoms include extreme fatigue, severe aches and pains, muscle weakness, shaking, nervousness, depression, disorientation, sleep disturbances and digestive upset.

Researchers from the Karolinska Institute in Sweden found that severe cases of burnout can alter neural pathways, ultimately causing a vicious circle of neurological dysfunction.2 There are other characteristics associated with it as well – an overwhelming sense of hopelessness, feelings of futility or meaninglessness and disintegration of identity, confusion, bewilderment and a sense of being lost. These descriptions have an existential flavour to them, and it is this that has led me to the conclusion that burnout could also be thought of as affecting the soul or the self.

Wounded healer Jung first identified the phenomenon of the ‘wounded healer’: that people who had suffered were both drawn to and qualified to help others who likewise had been injured in life. In my experience, it is a privilege to be a wounded healer. Therapeutic work often brings healing to the therapist as well as the people they care for. But there can be a cost when caring for others. Carers can drown themselves in a sea of unending giving and fail to recognise when they are going beyond their

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own capacity. A fellow practitioner who had had burnout said, ‘I may have been conscious somewhere at the back of my mind that significant things needed attending to in my own life. First, I ignored the symptoms, then I did not want to admit that I did not know what to do, so delayed telling anyone. I was also very resistant to the idea that I might have a mental illness and it was only when I could not function anymore that I sought help.’

Counsellors can become wounded healers through trauma such as domestic violence, sexual abuse, life-threatening illness or other devastating experiences. Or the trauma may be more low-key, in the form of ongoing negative childhood experiences. Winnicott believed that, from the very beginning of life, some children need to adapt to meet the needs of their primary caregivers in order to get their own needs met, resulting in the development of a ‘false self ’ as a defensive mechanism. 3 If this continues into adult life, those individuals may end up in one of the caring professions, implementing wellestablished patterns of putting others before themselves. They may then be exposed to secondary trauma through counselling victims of trauma, or be at greater risk of burnout when under pressure because they have been unable to learn to look after themselves in appropriate ways.

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to breakthrough This was true for one of my clients who I shall call Tony,* who was a counsellor and a coach. His mother had borderline personality disorder and, although he had been in therapy during his training, he continued to struggle with his own self-care. He had worked hard for 10 years in an organisation helping young offenders that was always struggling financially. Eventually the pressure and expectation that he would keep going, reducing his income and working longer hours, became too much. Like many in the caring professions, he had bought into the idea that he must always be self-sacrificing, saying yes to impossible demands, despite stress, exhaustion and burnout, when he really wanted to say no. Tony reached the point where his boundaries were not holding. He thought that he ‘could not listen to anyone with a problem ever again’. He stopped work.

He found it hard to admit to himself that he had not responded earlier to his body when he had begun to feel exhausted. He did not want to consult his GP because he believed that, as a therapist, he should be able to heal himself. Eventually he realised he had to get help, and came to me for counselling.

In the counselling room, he often struggled to find appropriate words as his capacity to think had diminished considerably, so I encouraged him to try sandplay work.

I have noticed that sandplay has a unique kinaesthetic quality that can benefit clients who are in distress by giving them a sensory experience that helps them to regulate themselves. It is also a very gentle

and containing medium to use, which is important when working with fragile clients who need safety. Tony engaged well and during one very powerful session when the sandplay reminded him of a beach, he revealed that his younger brother had drowned, aged eight, while on holiday. Tony had always felt responsible for his brother’s death. We worked through this tragic event and thought about how his heightened sense of guilt and responsibility had impacted his life and had now contributed to his illness.

Tony then took a break and went hillwalking. When he returned after three weeks, he was much calmer and more energised, extolling the value of solitude and silence. As Anthony Storr says, ‘In a culture in which interpersonal relationships are generally considered to provide the answer to every form of distress, it is sometimes difficult to persuade well-meaning helpers that solitude can be as therapeutic as emotional support.’4 For the next few months, Tony alternated between weeks away in solitude and exploring some of the painful experiences of his earlier life in therapy. I was grateful for the breaks in the work with him because much

of his story had resonated with my own. This gave me time to explore my own inner world more deeply in my own therapy so that I could continue to be of help to him.

Progress was slow until Tony began to talk about feeling renewed and enthusiastic about life again. Sparks of humour enlivened our sessions and a sense of playfulness emerged in our work. He started to go out more (prelockdowns), joined a choir and a cookery club, and connected with his friends again. Towards the end of our work, he decided not to return to work as a counsellor and has now become a carpenter and cabinetmaker.

Restorative practices Tony’s life had significantly altered through his experience of burnout. He had not been able to contemplate change early on because of his deep insecurity and vulnerability, but as he recovered, he made changes that he recognised as essential to his wellbeing.

On reflection, there were several key elements to our work – the recollection of the events and memories around his childhood and his brother’s death; his exploration of what had led to burnout

‘I was grateful for the breaks in the work with him because much of his story had resonated with my own. This gave me time to explore my own inner world in my own therapy’ THERAPY TODAY

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and his development of a healthy understanding and subsequent practice of self-care, and his engagement with play and creativity in the counselling room, which spilled into his external world. In conjunction with therapy, he had engaged with restorative practices. Some of these practices he had never experienced before, like time alone in solitude and silence, singing, cooking and, eventually, working with wood.

Medical treatments may be helpful to our clients when wanting to recover from burnout, but other conventional approaches to healing are often beneficial, such as engagement with play and creativity, nature, music, the arts, friendship and working with animals, to name a few. Other people find help in other forms of holistic healing. Through talking to other sufferers of burnout, I learnt that they found yoga, acupuncture, homeopathy, mindfulness and prayer helpful, alongside counselling and psychotherapy.

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One of my clients who sought holistic healing was Alison.* At the assessment, she presented with panic attacks when driving that made it impossible for her to drive anywhere. Her doctor had diagnosed her with high levels of anxiety and encouraged her to seek therapy. She was not convinced by this diagnosis. She knew she was exhausted and was finding it very difficult to concentrate.

She could not sleep at night. She felt very disoriented and her world felt chaotic and out of control. ‘Everything seems pointless,’ she said to me. She also consulted a homeopathic doctor whose holistic approach she trusted.

Alison was a businesswoman and, although she had a challenging job, there were other factors apart from her career that had led to her experiencing extreme stress. She had been in an abusive marriage, which led to a horrible divorce. The year before, her new partner had nearly died of a mysterious illness, which reactivated her memories of her mother’s

death when she was 10 years old. She had not processed any of these events.

Alison’s initial use of therapy was similar to Tony’s, although it was done in a different sequence. Her first wish was to explore the cause of her illness, because she was determined never to experience anything like this again. She recognised her need to establish firm boundaries and overcome the feeling that she was being selfish if she did not accede to the demands of family, friends and work colleagues. As she worked with me, she learned to say no. This gave her back some of the control she felt she had lost.

Later in the counselling, when she was exploring the hitherto unexpressed grief around her mother’s death, she used clay to enable her to express her anger. She loved this medium so much that she began to go to pottery classes. I had a sense of her inner child being activated. As Jungian analyst Jacqueline Wright says, ‘The archetype of the Child is related to the hope and promise for new beginnings.’ 5 Her engagement with creativity enabled her to feel that she was reconnecting to a part of herself that she had lost. Through the pottery class, she developed a network of new friendships, which was a significant factor in her recovery.

Like Tony, Alison made significant changes in her life, although she did return to her previous job. She told me that she felt she had become much more self-aware and was now confident that she would recognise any signs that indicated she might burn out again.

It was clear that her self-care had improved considerably. She had engaged in play and creativity in therapy, which led her to take on creative activities outside the therapy room. She made new friendships that were supportive for her, and she discovered the joy of owning pets.

* Clients have given permission for their stories to be told in this article. Their names DQG LGHQWLƓDEOH GHWDLOV KDYH EHHQ FKDQJHG

REFERENCES 1. World Health Organization. ,QWHUQDWLRQDO &ODVVLƓFDWLRQ RI 'LVHDVHV WK UHY ,&' :+2 2. Michel A. Burnout and the brain.

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3. :LQQLFRWW ': (JR GLVWRUWLRQ LQ terms of the true and false self. The maturational processes and the IDFLOLWDWLQJ HQYLURQPHQW 0DGLVRQ &7 ,QWHUQDWLRQDO 8QLYHUVLW\ 3UHVV ,QF 4. 6WRUU $ 6ROLWXGH /RQGRQ +DUSHU&ROOLQV 5. Wright J. Answering the call of the inner child. Jung Society of Atlanta 1HZVOHWWHU ZLQWHU

About the author

Personal growth I now realise how important burnout has been for me. It has taken time to learn the lessons

‘I am confident that clients will be able to find ways out of states of breakdown and discover opportunities to break through to changed and improved ways of living’ THERAPY TODAY

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that this experience offered me. Among many, the lessons that stand out most have been learning to balance my energy, to play regularly, to be grateful for beautiful things in life and to live as much as I can in the present, both in my therapeutic work and in my daily life. I am confident that, through counselling and psychotherapy, clients will be able to find ways out of states of breakdown and discover opportunities to break through to changed and improved ways of living. It may be that, after the current pandemic, the medical profession and the Government will be more aware of the deep distress that burnout brings.

It is my hope that we will become better equipped to support those suffering with burnout to find breakthrough.

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Kitty Willis MBACP (Snr Accred) is an integrative psychotherapist and supervisor who runs small group experiential workshops, including ‘The Pathway to Burnout’. For more information, see www.kittywillis.com/ supervision-training. If you are interested in having a further conversation about burnout, contact Kitty on mcickwillis@gmail.com

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y r t e Po e in th

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Anupama Garg explores how sharing poetry with clients can help to create relational depth s an integrative counsellor and therapist, I am often deeply moved during the sessions by my clients’ experiences of struggles with chronic illnesses, bereavements, relationship losses, assaults and so on. Until recently, I generally, like many other therapists, dealt with vicariously generated emotions within me through distractions such as going for walks or mindfulness exercise. However, I struggled with some of my clients’ material recently.

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It contained themes of motherhood and racial other(ing) that are personal to me as a mother and an Indian-origin therapist and academic whose work focuses on race-related discrimination at work and family wellbeing.1 I resorted to processing vicarious emotions related to these themes by writing poetry to get clarity.

Writing poetry wasn’t alien to me since I have written it organically and occasionally since my teenage years to deal with times of extreme joy or adversity in my personal

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life, including moving away from my family in India and living in the UK. By organically, I mean I wasn’t inspired by any particular therapeutic process or a school of thought when I started writing to clarify my own thinking as a teenager. It was a spontaneous process that came out of my habit of seeking isolation and scribbling when troubled, and needing clarity of thought to move forward.

Now, as a therapist, I am aware that there is a whole branch of poetry therapy in the US,2 and that Bolton3 and Mazza4 have written

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extensively about the benefits of writing poetry for therapeutic purposes by clients.

Even quantitative research studies have shown therapeutic benefits of clients writing either poetry or prose.2 Hence, I do ask my clients, particularly those dealing with chronic adverse life circumstances, to keep a journal and write whatever comes to their mind. This is in line with what most health professionals preferred in Bolton’s work with them.3 Many of my clients have written journals and have benefited from their greater engagement in the therapeutic process as a result.

Sharing poems with clients ART PRODUCTION CLIENT

To deal with vicarious emotions generated within me as I ‘trawl(ed)’2 or reached within myself to capture emotions and find words to describe them, leading to drafting and redrafting of verses, I wondered how my clients would react to this poetry if I shared it with them. Would they see it as me stealing their story or as an affront to the authenticity of their experiences?

I was aware of Bolton’s3, 5 work, where she encouraged and trained health professionals to write as a way of reflecting on their work with patients, enhance their understandings of patients and for their own benefit, but their writing was not directly used in their work with patients. Therefore, I was concerned that, by sharing my poems with clients, albeit based on what they had discussed with me and related to them, I might become the centre of attention in the therapeutic work, instead of them. I saw my latter concern as partly unnecessary since: 1) my poems are just forms of empathy, to communicate my respect for clients, and I am being truly congruent in sharing them with them, all qualities deemed central to successful therapeutic work by Rogers.6 2) I would only share my poems if clients agreed, and would use them judiciously for their benefit.

I told three of my clients that I write poems based on my understandings of what they had discussed during the sessions. To my surprise, all three reacted positively and were curious and wanted to hear what I had written. I told them that I would read them my poems now and then. I explained that it was not going to be every session, only when I had written something and thought it might benefit them

or when it seemed they were stuck. The aim was to draw attention – with empathy and congruence – to paths untravelled by them and to prompt cognitive restructuring through seeding new ways of thinking.

Encouraged by these invitations and satisfied by my theoretical arguments (as already discussed), I shared my first poem with Emily.* Emily’s teenage daughter had been suffering from anorexia for the past couple of years, and Emily had concerns ranging from her daughter’s self-harming and recovery to her own worth as a mother.

In one session, she described her fears for her daughter’s survival. I heard her pain and fears and wrote the following descriptive poem. After asking Emily’s permission, I read it to her during the next session, since she was again worried about her daughter’s physical health, particularly due to the COVID-19 pandemic.

Collateral damage My daughter is gripped by the anorexia vice: thinned out ghostly pale walking stick a bag of bones held together by her lanugoed skin.

She can’t trust herself and I can’t trust her either.

I keep a watch don’t let her walk but still, she is disappearing.

I can’t feed her she wouldn’t feed herself so tight is her anorexia-vice grip.

She is so frail I walk to wake her every morning and pray she is alive.

Doctors say she needs a hospital bed to be force-fed.

As they look I pray for a non-COVID hospital bed.

If a bed is not found soon it would be anorexia vice jammed tight by COVID squeezing both of us out!

With tears in her eyes, Emily listened and seemed to move with its rhythm. She reiterated that her fear of not finding her daughter alive is very real for her. She focused on my use of metaphorical imagery related to the ‘anorexia vice’ and we discussed it.

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’My poems are just forms of empathy, to communicate my respect for clients, and I am being truly congruent in sharing them with them’ This could perhaps be described as an outward expression of a deep pleasure that we humans feel when one understands another deeply. Emily and I felt connected by threads woven with the gossamer of words between us during this period. This deep resonance is perhaps what is described as an experience of working at relational depth by Cooper,7 and

by Schore, in neuro-psychobiological terms,8 as right-brain to right-connection mediated by left-brain.

This encouraged Emily to write poetry too.

She felt that it was simply about expressing how she felt, not about the literary quality or linguistic correctness of what she had written.

So, feeling freed, she composed and read out to me her poem, ‘Being a Mum’, during our penultimate session.

Being a mum When is it going to stop?

Where is it going to end?

The negotiating The bargaining The relentless obsession with food, calories and weight I’m tired and weary and can’t see the end When will life be fun again?

Will I ever again be carefree?

I keep going because I have to Because it’s my duty as a parent and a mum But I hate it I hate the manipulation, the hospital visits, the phone calls about calories and weight gain The interruptions in my day The negativity and the demands The evenings that are no longer mine I hate the guilt that comes with being a mum A working mum A mum trying to do her best

But feeling like she is somehow failing Failing not only the daughter that is ill But the daughter that is well The one that has witnessed so much anger and disruption The innocent one in all this She is the light and brightness in my life For her I must keep positive and strong Otherwise her life is blighted too It is enough to have one daughter whose life is on hold I needn’t let it be two.

(Emily*) Here she acknowledged her frustrations with her anorexic daughter’s manipulations, her weariness in being a mum in these circumstances and the wanting of time for herself and the guilt associated with that want.

It was a breakthrough in terms of her honesty to self and an acknowledgement of her own needs. This is how, as Bolton says, ‘every poem breaks a silence that had to be overcome…’3 The very act of acknowledging her needs – simply wanting a free, relaxing evening – was an act of confronting the humanness that is at the heart of being a less than perfect mother.

This led to discussions about how normal and human her frustrations were, about everything she had done for her daughters until now and how she had been with her daughter with anorexia, and what she saw as a ‘good mother’. These discussions and her struggles touched my heart as both a mother and a daughter, and I composed and read the following poem out to her during our last session. It is written from her anorexic daughter’s perspective and imagines what she might remember and say to Emily in the future.

’In my experience, the sharing of clients’ and therapists’ poetic compositions in therapy helps to deepen the client– therapist relationship’

Mother You are the mother who stood by me despite my strong anorexia-fuelled rejection of you.

I hit at the core of your concept of motherhood but you still stood by me.

You are the mother who admired my artwork and laughed at my jokes despite my anorexia-fuelled rage.

You are the mother who gave me hugs despite me shunning you in front of others.

You are the mother who visited me in the hospital despite my orders to desist.

So, you are the steadfast mother who didn’t leave my side, who I admire and am grateful for.

In this way, I used poetry to validate and help Emily appreciate what she did as a mother for her daughter with anorexia instead of focusing on what she didn’t or couldn’t do as her mother. I see this type of validation of clients, through juxtapositioning what clients have done or do against their frustrations of what they could be or do better, as a part of my normal cognitive restructuring work.

Since Emily and I both read our compositions during the sessions, in Mazza4 and Bolton’s3 terms, both of us benefited from the release of emotional tension through creative expression, recitation and performance.

As a therapist, this process helped me to integrate my vicarious feelings into my cognitive schemas and developed ‘compassion satisfaction’ within me. I see this therapeutic ‘spin-off’ 3 for the composer/writer as a way of preventing secondary traumatisation and a form of therapist self-care.

It is my experience that the sharing of clients’ and therapists’ poetic compositions in therapy, based on clients’ narratives, helps to deepen the client–therapist relationship, which is a foundation for optimum healing for the client, as well as being a source of creative expression for both clients and therapists. In particular, it offers clients a way to process material outside of the therapy sessions and develop their own

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poetry writing process. As a bonus, it can help therapists process vicarious emotions and so protect against secondary traumatisation and become a form of self-care.

7KH FOLHQWōV QDPH DQG LGHQWLƓDEOH GHWDLOV KDYH been changed and she has given permission for her poems to be used in this article.

REFERENCES 1. Garg A. Racism at work: Indian origin doctors’ and their wives well-being. [Unpublished PhD dissertation]. Lancaster: University of Lancaster; 2007. 2. Bolton G, Howlett S, Lago C, Wright JK (eds).

Writing cures: an introductory handbook of writing in counselling and psychotherapy. Hove: Brunner Routledge; 2004. 3. Bolton G. ‘Every poem breaks a silence that had to be overcome’: the therapeutic power of poetry writing. Feminist Review 1999; 62: 118-33. 4. Mazza NF. Poetry therapy: an investigation of a multidimensional clinical model. Arts Psychotherapy 2013; 40(1): 53-60.

5. %ROWRQ * 6WRULHV DW ZRUN UHŴHFWLYH writing for practitioners. Lancet 1999; 354: 241-43. 6. Rogers CR. The QHFHVVDU\ DQG VXIƓFLHQW FRQGLWLRQV of therapeutic personality change.

Psychotherapy 2007; 44(3):240–48.

7. Cooper M. Working at relational depth. Therapy Today 2005; 7: 16-20.

8. Schore A. Therapeutic alliance and emotional communication, right brain to right brain. PsychAlive; 2014, May 13. bit.ly/3776nL8

About the author Dr Anupama Garg (MBACP Accred; EMDR Europe Accred) is an integrative counsellor, psychotherapist and academic. Her therapeutic interests include attachmentinformed EMDR trauma work, PTSD, anxiety, panic attacks, work-related stress and general life challenges such as loss. Contact: agarg. psychotherapy@gmail.com

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Counselling Changes Lives, 2

Counselling changes lives

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A lost cause?

Counselling can be both effective and appropriate for people living with dementia, says Sarah Baker

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s counselling appropriate or effective for people living with dementia? Only in the very earliest stage, according to Government policy on dementia care and services. The current NICE guideline section on ‘Interventions to promote cognition, independence and wellbeing’ recommends avoiding interpersonal therapy to improve cognition, and otherwise makes no mention of counselling interventions at all.1 BACP’s Counselling for People with Dementia policy briefing, however, states that ‘despite limited research into counselling for people with dementia, there is growing evidence of its value in case studies and counselling literature’ and recommends that ‘action is required to ensure that access to choice of talking therapy is made available to people living with dementia who have anxiety or depression or who wish to explore issues of identity and to make plans for the future’.2 In a previous article in Therapy Today, I explored aspects of the experience of living with dementia and a person-centred approach to working with this client group.3 This article expands on this and other counselling approaches that I believe may be beneficial.

SHUTTERSTOCK

The purpose of therapy Cheston and Bender state that the purpose of therapy for people with dementia is ‘to improve people’s sense of wellbeing; to increase the resources they have available to relate to their physical and interpersonal world; and to improve their quality of life’, which includes maintaining a sense of personal and social identity.4 However, they stress that, before this work can begin, it is necessary to promote a sense of emotional security as ‘a major therapeutic goal’, and as ‘a worthwhile therapeutic task in its own right’ that ‘legitimises therapeutic work with the very cognitively damaged, and calls for the development of many approaches, especially ones that are less verbally dependent, or non-verbal’.4 During a trainee placement with an agency dedicated to counselling older people, including people with dementia, I sketched out a framework for approaches I believed could be beneficial for people with dementia (updated and expanded here), based on Clarkson’s seven-level model for integrative counselling.5 The model offers both a holistic view of the client as a person in most aspects of human functioning and a comprehensive, integrative

view of psychotherapy with its multiplicity of emphases and applications to the person in the wider context of their existence.5 There is no hierarchy implied in the levels, so perhaps ‘modes’ would be a better description.

cannot be conveyed in words, but which can be experienced physically and emotionally by both parties. It may also be beneficial by evoking the innate sense of safety mediated by synchronous activity with others.

Body-experiencing

Emotional

The first level is physiological, such as bodyexperiencing, use of the senses and ‘here and now’ experiencing. Relevant approaches might include mindfulness, anxiety management and relaxation, grounding, focusing (on the ‘felt sense’), mirroring, sculpts, amplifying and other Gestalt experiments involving movement, enhancing sensory awareness, sensorimotor psychotherapy and pre-therapy.

Ogden and Fisher state that, while most psychotherapy depends on a client’s verbal narrative, ‘the story told by the “somatic narrative” – gesture, posture, prosody, facial expressions, eye gaze, and movement – is arguably more significant than the story told by words’.6 This is especially true with clients for whom verbal communication has become fragmented. Sensorimotor psychotherapy offers many insights that can aid two-way communication, build relationships and transform experience in non-verbal ways.

I have found insights from pre-therapy helpful when working with contact-impaired clients – those who have lost the connection between consciousness and experience and have therefore lost the capacity for psychological contact, which is ‘the first condition of a therapeutic relationship’.7 Perception tends to be concrete and immediate, so the therapist describes the client’s posture, gesture and expression verbally to them, mirroring them to provide additional cues.

While this may seem mechanistic, if done with openness and empathy, it can be a powerful way of accessing a client’s lived experience that

The second level is emotional. Approaches might include embodying the core conditions, a reparative attachment relationship, creating a ‘safe place’ in the counselling setting, resolution therapy (see below), exploring emotions through pictures, artwork, music and poetry, celebratory activities, and ‘being with’ in silence.

Resolution therapy, in Cheston and Bender’s words, ‘encourages carers to empathise with the hidden meanings and feelings which are thought to lie behind the confusion expressed by people with dementia’, and ‘… provides tentative reflections and acknowledgements of the dementia sufferer’s feelings’ whereby ‘if accurate and delivered with sensitivity and patience, the person’s feelings begin to become clearer and the reasons behind apparently confused behaviours begin to emerge’.4 For example, an 84-year-old lady was leaning out of a wheelchair in her bedroom at an assessment unit, agitated and repeatedly calling out for her mother. Her daughter told me her grandmother had died 30 years earlier and that her mother had just been moved to the unit from a local hospital, where she had become attached to her key nurse, who she called ‘Ma’. She was now alone, with only occasional glimpses of hurrying members of the unit staff passing her door. Her recent history suggested that she was likely to be feeling lonely and insecure in a strange place, and probably anxious because she was no longer getting care and contact from ‘Ma’, which may have reminded her of being cared for by her mother when she was unwell as a child. I took her the cup of tea that was due to be served to everyone and sat with her while she drank it, reflecting out loud that it must be very strange for her to find herself here and alone, after being on a busy hospital ward surrounded by people, and would she like some company? She smiled at me, patted my hand and said ‘Ma’, and we sat in relaxed and companionable silence for a while, before I wheeled her around the unit on an orientation tour.

I have also encountered an ethical issue raised by Kewell,8 that if a family are paying for counselling for their loved one who has

’She smiled at me, patted my hand and said “Ma”, and we sat in relaxed and companionable silence’ THERAPY TODAY

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dementia, does sitting in silence, perhaps while the client sinks into reverie or sleep, constitute value for money? I would argue that this may be appropriate therapy for a client suffering from attachment trauma who needs the reparative experience of an attuned witness.

This is frequently what is missing when a person with dementia is surrounded by carers who are too busy or insufficiently trained to take time to really attend, for however long it takes, to the feeling tone, vocal utterance and facial or bodily expression that convey whatever need is being communicated in that moment.

often be overridden by the accepted routines and procedures of the institution. Imagine, for example, being unable to walk and being wheeled to the communal lounge every morning with a talk show blaring out from the television, when you have always preferred your own space and company and to listen to classical music. As mental healthcare professionals, we were frequently asked to advise on ‘challenging behaviour’, such as shouting and aggression, from agitated clients in similar predicaments.

Rational

Nominative ART PRODUCTION CLIENT

The third level is nominative and may include working with metaphor, projective exercises, working with ‘configurations of self’,9 and internal family systems therapy. Cheston and Bender4 believe that people with dementia unconsciously use metaphor, especially storytelling, as a way of processing loss and change, and that it’s important to attend and respond empathically to the thematic meaning of the language, rather than be distracted by the literal content or factual accuracy. A word of caution about using metaphorical expressions, though: as people with dementia begin to lose higher-level cognitive functioning, thinking tends to become very concrete. For example, during a reminiscence session with a highly intelligent, articulate, former school teacher, I handed her an old-fashioned fire grate brush with a brass handle and a cover pulled down over the bristles, saying, ‘Does that ring a bell with you, Betty?’ She looked at me uncomprehendingly for a moment, then tipped the brush upside down and said, ‘But a bell can’t ring with its tummy full of bristles, can it?’

Lipinska9 writes movingly of her work assisting people with dementia to negotiate the changes in self-concept implicit in the

changes and losses imposed by dementia. In my experience, where dementia erodes a person’s habitual social façade and ego defences, they may become devastatingly exposed emotionally: for example, the meek and mildmannered grandmother who, when taken into residential care, swore like a trooper at her carers, or the husband who ‘didn’t do emotions’ but wept uncontrollably every time his wife visited him. It may then be appropriate to work gently with the parts holding emotion that have ‘escaped’ from repression and those that may rise up to censure and shame them, in a bid to restore harmony and balance to the evolving system.10 For example, I used a selection of character finger puppets to facilitate the latter client’s reflection on those polarised parts of himself. He put a dragon on one forefinger and a knight on the other, both poised for battle, but as we sought to understand the point of view of each part in turn and negotiate a compromise, he moved them both to the same hand, and as we sat in silence to digest the content of the session, he began to stroke them both gently with the other hand.

Normative

’People with dementia unconsciously use metaphor as a way of processing loss and change’

The fourth level is normative and might involve working with cultural and societal expectations and pressures and consensual reality, supportive group work, which can be particularly helpful for newly diagnosed people,11 and advocacy. While supporting a client’s ability to make their own needs known is the ideal aim, where this is compromised, it may facilitate the client’s psychological wellbeing to offer to bring to staff or family’s attention individual unmet needs that can

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The fifth level is rational, and may include developing insight, information-giving, problem-solving and cognitive behavioural therapy (although the cognitive processing abilities required for this are only likely to be available to people in the earliest stages of dementia). Developing insight also needs to be approached sensitively, as often people use denial as a way of coping with the existential threat of dementia.11

Theoretical The sixth level is theoretical – for example, exploring life scripts and narratives, reminiscence work and storytelling. Where a client has communication difficulties, it can be useful, with their permission, to consult family and carers in an initial assessment that includes biographical details of a client’s life and their interests, preferences and dislikes, as this can help us ‘tune in’ to what may otherwise seem obscure. For example, some clients may habitually perform elements of well-learnt activities from former work or domestic roles, usually at the familiar time of day – a sliding of both palms back and forth across a table may be revealed as rolling out pastry for a woman described as ‘a champion pie-maker’, or repetitive counting may turn out to be a former accountant totting up figures in a company ledger.

In the latter case, the gentleman concerned had early-onset dementia, and the first signs were that he was making mistakes, with financial consequences for the company.

Repetitive counting seemed to be an expression of his unresolved anxiety about no longer being able to succeed at a task at which he was once highly competent. In the case of the champion pie-maker, she mostly sat silent and expressionless in an armchair with an

unfocused gaze, or at a table, rolling out her pastry. She could no longer verbalise fluently and expressed herself in single words or short phrases, so I engaged her in reminiscence, using baking implements I had brought with me (a rolling pin, a sieve, a biscuit cutter). I know that sustaining a sensory and procedural connection with a significant part of her biography and identity in this way improved her wellbeing, because she made eye contact with me and became animated as I introduced the objects one by one, smiled as she demonstrated to me how to use them, and laughed with delight, applauding me as I followed her lead and imitated her actions with them. No observer could doubt that we were having a therapeutic session, although it may not have looked much like counselling as we know it.

Transpersonal The final level is transpersonal. This may include working at relational depth, dreamwork, bereavement counselling and end-oflife care. Lipinska9 writes at length about what she calls ‘spirit-core’ relating – a depth encounter ‘where growth and change can take place that is somehow pre-verbal, presymbolic, non-intellectual, essentially spiritual’ and not dependent on ‘memory, history, role or functionality’. That has also been my experience.

Creative working

ALONA SAVCHUK/SHUTTERSTOCK

As I explored in an earlier article in Therapy Today,12 working creatively allows a client’s symbolic expressions to become concrete and visible to both client and counsellor and taps into ‘the world of spontaneous knowing,

’A “do not disturb” sign may serve to remind care staff that this is agreed “private time” for the resident’

nothing to do with thoughts’. Thus, a client’s difficulty with verbal communication may be bypassed, ‘as long as the counsellor is able to “make a bridge” between the client and their creation’,13 and thoughts and concepts that tend to slip away and dissolve may be held in the client’s awareness, despite waning memory and concentration.

Practical considerations Both Kewell8 and Chapman14 explore the fine balancing act often required to retain the goodwill of staff in care homes without being recruited into their culture or breaking client confidentiality. If sessions are to be held in a care home, it is important to think through in advance how maintaining privacy and confidentiality may best be negotiated with carers and documented in a resident’s care plan. A ‘do not disturb’ sign on the closed door may help as an additional reminder to care staff that this is agreed ‘private time’ for the resident. Flexibility may also be needed to facilitate engagement according to a client’s mood, concentration span and level of alertness. For example, a walk round the garden or other experience known to be soothing for the person may help calm agitation sufficiently for them to engage with therapy (one gentleman found watching the fish in his aquarium was soothing). Sessions may need to be shortened or held at different times of day if the allotted time coincides with a client’s tendency to be tired, distracted or restless.

It can also be helpful to start each session by tactfully reminding the client who you are and why you are there, checking that they wish to proceed and providing a recap of previous sessions (Lipinska calls this being ‘the keeper of memories’).9 Living with dementia is a profound process of losing connection – between neurons in the brain, between consciousness and experience, between past, present and future, with significant others and society, with a place called home, and with long-established patterns of self-care, roles and leisure activities.

Eventually, without an attuned, sustaining presence, it means losing connection with a sense of being. I hope I have demonstrated that counselling people who are living with dementia is a worthwhile undertaking that has the potential to improve wellbeing, enable growth, and sustain vital connections for quality of life despite cognitive decline.

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REFERENCES 1. NICE. Dementia: assessment, management and support for people living with dementia and their carers.

London: NICE; 2018. 2. BACP. Counselling IRU SHRSOH ZLWK GHPHQWLD SROLF\ EULHƓQJ Lutterworth: BACP; 2019. 3. Baker S. Making a difference with dementia.

Therapy Today 2018; 29(3): 26-29.

4. Cheston R & Bender M. Understanding dementia: the man with the worried eyes. London: Jessica Kingsley Publishers; 2007 (pp102, 215-218). 5. Clarkson P. On psychotherapy. London: Whurr Publishers; 1993 (p147). 6. Ogden P & Fisher J. Sensorimotor psychotherapy: interventions for trauma and attachment.

New York: WW Norton and Company, Inc; 2015 (p13). 7. Prouty G, Van Werde D & Pörtner M. Pre-therapy: reaching contact-impaired clients. Ross-on-Wye: PCCS Books; 2010 (p15). 8. Kewell H. Living well and dying well: tales of counselling older people. Monmouth: PCCS Books; 2019 (pp11-15, 19-20).

9. Lipinska D. Person-centred counselling for people with dementia: making sense of self. London: Jessica Kingsley Publishers; 2009 (pp41, 62, 103-109).

10. Schwartz R & Sweezy M. Internal family systems therapy (2nd ed). New York: The Guilford Press; 2020.

11. Cheston C, Jones K & Gilliard J. Group psychotherapy and people with dementia.

Aging and Mental Health 2003; 7(6): 452-461. 12. Baker S. Creative interventions in counselling practice.

Therapy Today 2016; 27(10): 26-30.

13. Silverstone L. Art therapy the personcentred way: art and the development of the person (2nd ed). London: Jessica Kingsley Publishers; 2007 (p7).

14. Chapman F. Counselling and psychotherapy with older people in care: a support guide. London: Jessica Kingsley Publishers; 2018 (pp42-47).

About the author Sarah Baker MBACP (Accred), MACC (Accred) is an integrative and creative counsellor in private practice in Dorset. She was formerly an NHS occupational therapist working mostly with older people and specialising in dementia care for much of her career. She is a volunteer member of BACP’s Older People Expert Reference Group.

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Presenting Issues, 2

Presenting issues

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Getting to know you

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What makes a good assessment session?

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‘Directness rubs against all I hold dear’

PRODUCTION CLIENT

It has taken time to find an assessment style I am comfortable with as directness rubs against all I hold dear within a counselling room. With adult clients, I listen for a sense of the client’s issues and their impact, and any supportive relationships they see in their life. I may ask about risk-taking behaviour, and there will be a gentle questioning about suicide, thoughts and plans. With children and young people, I use a bit of paper divided into sections for ‘Family’, ‘Friends’, ‘Fun’ and ‘Future’, with their name in the middle. Simple and hand-drawn, it’s a physical point for us to huddle round, in the days when we could huddle. I introduce it as my way of getting to know them and who or what they see as important in their world by writing down the details of their life. I have found it useful on many levels – as well as gathering information and assessing risk, it’s a way of breaking the ice or calming the anxious. There are no difficult questions and, by the end of the session, I have a fuller impression of their life. But, more importantly, they have spoken and I have listened. There has been a conversation where the child has been the expert.

Sometimes it is what is not mentioned that prompts a discussion – a missing parent, the lack of fun, or uncertainty over who to call a friend. The ‘Future’ section gives me the opportunity to know their longterm dreams, but also how they think counselling can help them. My hope is that, from there, we start our journey together.

‘There needs to be an ongoing informal assessment’ $V D SHUVRQ FHQWUHG FRXQVHOORU P\ DLP LV WR SODFH WKH FRUH FRQGLWLRQV RI HPSDWK\ XQFRQGLWLRQDO SRVLWLYH UHJDUG DQG FRQJUXHQFH DW WKH FHQWUH RI WKH WKHUDSHXWLF H[SHULHQFH ZLWK D FOLHQW VWDUWLQJ ZLWK WKH LQLWLDO DVVHVVPHQW 3ULRU WR PHHWLQJ ZH ZLOO KDYH DQ LQLWLDO H[FKDQJH E\ SKRQH RU HPDLO WR KHOS PH DVFHUWDLQ VRPH RI WKH FOLHQWōV QHHGV DQG KRSHV IRU FRXQVHOOLQJ 7KLV FRQWDFW JLYHV PH DQ RSSRUWXQLW\ WR EHJLQ D FRQQHFWLRQ ZLWK D SURVSHFWLYH FOLHQW DQG WR GLVFRYHU ZKDW KDV EURXJKW WKHP WR FRXQVHOOLQJ QRZ ZKHWKHU , PD\ EH D JRRG ƓW IRU WKHLU QHHGV RU D GLIIHUHQW VHUYLFH ZRXOG EH PRUH UHOHYDQW ,I ZH DJUHH WR FRQWLQXH , VHQG WKHP D GRFXPHQW LQIRUPLQJ WKHP DERXW P\ ZD\ RI ZRUNLQJ DQG ZKDW WR H[SHFW IURP FRXQVHOOLQJ DORQJ ZLWK VRPH SUDFWLFDO LQIRUPDWLRQ 7KLV PHDQV WKDW ZKHQ ZH HPEDUN RQ RXU ƓUVW VHVVLRQ WRJHWKHU PXFK RI WKH EDVLF LQIRUPDWLRQ KDV EHHQ JDWKHUHG DQG WKH WUXH ZRUN RI GLVFRYHULQJ ZKR WKH FOLHQW LV DQG HVWDEOLVKLQJ WKH WKHUDSHXWLF UHODWLRQVKLS FDQ SURFHHG , ƓQG WKDW WKHUH QHHGV WR EH DQ RQJRLQJ LQIRUPDO DVVHVVPHQW RI WKHLU QHHGV WKURXJKRXW WKH MRXUQH\ ZLWK WKH FOLHQW DV VRPH RI WKH GHHSHU VKDPH WLQJHG LVVXHV PD\ RQO\ VXUIDFH DV WUXVW GHYHORSV EHWZHHQ FOLHQW DQG FRXQVHOORU Honor Allen, counsellor in private practice

‘It’s still a work in progress’ 0\ ƓUVW H[SHULHQFH RI DVVHVVLQJ FOLHQWV ZDV ZKHQ , VHW XS D FRXQVHOOLQJ VHUYLFH LQ D FKDULW\ IRU \RXQJ SHRSOH :H RIWHQ XVHG VRPH W\SH RI VFRULQJ DV ZHOO DV WKH 5HFRYHU\ 6WDU WRRO IRU PHDVXULQJ FKDQJH DV IXQGHUV UHTXLUHG TXDQWLWDWLYH GDWD , KDYH DOVR ZRUNHG ZLWK DJHQFLHV WKDW UHTXLUH RQJRLQJ DVVHVVPHQW DQG VFRULQJ EXW QRZ , KDYH PRYHG LQWR P\ RZQ SULYDWH SUDFWLFH , ZRXOGQōW GR WKDW JHQHUDOO\ 0\ DVVHVVPHQW VHVVLRQ XVXDOO\ VWDUWV ZLWK VWDQGDUG TXHVWLRQV VXFK DV FRQWDFW DQG PHGLFDWLRQ GHWDLOV DOFRKRO DQG GUXJ XVH DQG FDIIHLQH LQWDNH DV , RIWHQ ƓQG FOLHQWV ZKR GULQN ORWV RI FRIIHH H[SHULHQFH SDOSLWDWLRQV RU VWUXJJOH ZLWK DQ[LHW\ :H JR RQ WR FKDW DERXW ZKDWōV JRLQJ RQ IRU WKH FOLHQW DQG ZKDW WKH\ DUH KRSLQJ IRU IURP FRXQVHOOLQJ DQG DQ\ SULRU H[SHULHQFH RI WKHUDS\ Ŋ VRPHWLPHV WKDW LQYROYHV WDONLQJ DERXW WKH ŌW\SHō RI WKHUDSLHV WKHUH DUH DQG KRZ ZH PLJKW ZRUN WRJHWKHU 7KLV FRQYHUVDWLRQ ZLOO EH YHU\ PXFK JXLGHG E\ ZKDW WKH\ EULQJ ,QLWLDOO\ , RIIHUHG DVVHVVPHQW VHVVLRQV IRU IUHH LQ RUGHU WR DWWUDFW FOLHQWV DQG EXLOG XS P\ SUDFWLFH EXW , GRQōW WKLQN ,ōG IXOO\ WKRXJKW WKURXJK WKH LVVXHV DURXQG YDOXLQJ P\VHOI DQG P\ VHUYLFH DQG , KDYH H[SORUHG WKDW LQ VXSHUYLVLRQ 7KDW OHG WR FKDUJLQJ IRU DVVHVVPHQWV DOEHLW DW RI P\ QRUPDO IHH ,WōV VWLOO D ZRUN LQ SURJUHVV Joanna Burridge, integrative counsellor

Alison Hotchkiss, person-centred counsellor

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Talking Point, 1

Talking point

‘Ultimately, we have this one session to make a connection’ , NQRZ WKHUH DUH SV\FKRG\QDPLF SUDFWLWLRQHUV ZKR ZLOO WXW DW WKH LGHD RI ZULWLQJ GXULQJ D FOLHQW VHVVLRQ EXW , PDNH QRWHV GXULQJ DQ LQLWLDO DVVHVVPHQW , H[SODLQ WKLV WR FOLHQWV DQG QR RQH KDV HYHU REMHFWHG DOWKRXJK ,ōP FRQVFLRXV WKDW ZKLOH ZULWLQJ ,ōP QRW JLYLQJ P\ XQGLYLGHG DWWHQWLRQ DV ,ōG LGHDOO\ OLNH WR 7KLV LV D FRQŴLFW WR EDODQFH EXW , GRQōW WUXVW P\ PHPRU\ DV , RQFH PLJKW KDYH DQG WKHUH DUH LPSRUWDQW GHWDLOV DQG D WLPHOLQH RI OLIH HYHQWV WKDW FDQ EH D ULFK UHVRXUFH LQ VXEVHTXHQW WKLQNLQJ $ VXSHUYLVRU JDYH PH DQ RXWOLQH VKHHW RI NH\ JXLGLQJ TXHVWLRQV PDQ\ \HDUV DJR WR HQVXUH WKDW , GLGQōW IRUJHW WR DVN DERXW PHGLFDWLRQ SUHYLRXV WKHUDSHXWLF RU SV\FKLDWULF KHOS DQG *3 GHWDLOV 0RUH WKDQ \HDUV LQ SUDFWLFH KDYH HQDEOHG PH WR KRQH P\ DVVHVVPHQW WHFKQLTXH , QRZ FRQGXFW DVVHVVPHQWV ZLWK WKLV IRUPDW LQ P\ KHDG DQG DP DEOH WR EH PRUH SUHVHQW WXQLQJ LQWR WKH FOLHQWōV QDUUDWLYH DQG VFULEEOLQJ QRWHV ZKHQ QHFHVVDU\ 2FFDVLRQDOO\ LQVWLQFW WHOOV PH LWōV LQDSSURSULDWH WR ZULWH DW DOO Ŋ LI , VHQVH DPELYDOHQFH RU LI VRPHRQH IHHOV XQFRQWDLQHG RU GHVSHUDWH QHHGLQJ LQVWHDG VLPSO\ WR EH KHDUG DQG KHOG 8OWLPDWHO\ ZH KDYH WKLV RQH VHVVLRQ WR PDNH D FRQQHFWLRQ LI WKH ZRUN LV WR FRQWLQXH Jo Bisseker Barr, psychodynamic counsellor

SHUTTERSTOCK

Many clients reach out to me because I am both a counsellor and a coach. But it is important to hold in mind the difference between coaching and counselling when it comes to assessing clients. For both practices, I see assessment as a continuous process rather than confined to the first session, because it helps track progress and the specific needs of the client. With coaching, I start with a detailed assessment questionnaire that is aimed at empowering the client to set their own goals, and also to clearly map where they are at the start of the coaching work and where they want to be. Referring to this questionnaire throughout the work can help them stay focused and I usually do a more formal assessment midway into the coaching contract, to check progress towards their goals. By contrast, the assessment for counselling clients is aimed at gathering information so I can identify what resources I could use to help the client cope better with their presenting issues and improve their mental health. I do this through a conversation rather than a questionnaire, and I’m looking for insights into the coping mechanisms used by the client, any triggers and their family history. There are some questions and checks that are important to ask every client but I do it in a non-standardised way. It’s important to pay attention to the client’s emotions, body language and patterns of speech as well as their words.

Funmi Oni, personal performance coach and therapeutic counsellor

:KHQ , ƓUVW WUDLQHG DV D FRXSOHV WKHUDSLVW P\ WXWRU VDLG WKH LQLWLDO VHVVLRQ ZDV WKH PRVW FUXFLDO WKHUDSHXWLFDOO\ DV LW KHOG HYHU\WKLQJ \RX QHHGHG WR NQRZ DERXW WKH FRXSOH 1RZ \HDUV ODWHU , VWLOO EHOLHYH WKLV WR EH WUXH 7KH ƓUVW VHVVLRQ LV DOVR P\ IDYRXULWH Ŋ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ƓQG P\VHOI ZLOOLQJ WKHP WR VD\ D NLQG ZRUG (LWKHU ZD\ LWōV DOO SDUW RI WKH DVVHVVPHQW , KDYH FRPH WR XQGHUVWDQG WKDW DVVHVVPHQWV DUH RQO\ P\ REVHUYDWLRQV Ŋ D VWDUWLQJ SRLQW WR H[SORUH Shirlee Kay, individual and couples therapist

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THIS MONTH’S TALKING POINT IS COMPILED BY SALLY BROWN

‘Assessment is a continuous process’

‘Assessments are only a starting point to explore’

APRIL 2021

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VERSION

The bookshelf

REPRO OP

For exclusive publisher discount codes, see www.bacp.co.uk/membership/book-discounts

SUBS ART PRODUCTION REVIEWS COMPILED BY JEANINE CONNOR

CLIENT

Bion and Thoughts Too Deep for Words: psychoanalysis, suggestion, and the language of the unconscious Robert Caper (Routledge, £34.99)

Bipolar Disorder: a guide for you and your loved ones (4th ed) Francis Mark Mondimore (John Hopkins University Press, £17.50)

The New Sexual Landscape and Contemporary Psychoanalysis Danielle Knafo and Rocco Lo Bosco (Confer, £12.99)

This is the clearest description I have ever read of what is unique about psychoanalysis. Putting the mystery of unconscious communication into words is a huge challenge, but Caper succeeds in doing just that.

Starting with analysis of interactional synchrony between adults, and supported by evidence from infant observation, Caper FRQƓUPV ZKDW ZH intuitively sense – that the vibes we get, the ‘song and dance’ of suggestion, often tell us far more about the emotional state of the participants than their actual words.

Caper knew Bion when he lived in Los Angeles in the 1970s and has written widely about his work. Here, in fewer than 100 pages, he traces the roots of suggestion in Freud’s work, Klein’s use of it in her concept of projective LGHQWLƓFDWLRQ DQG %LRQōV UDGLFDO PRYH LQ seeing the value of focusing on it directly in the transference. Caper argues that suggestion is universal and unavoidable, but by observing it in the transference and not acting on it, clients can be helped by seeing the truth of how they are interacting. Psychoanalysis thus aims not to cure or relieve pain directly, but to achieve the more modest goal of psychological development.

This is radically different from other brands of therapy where, as Caper sees it, the transference is exploited in the service of suggestion. He is clear in his mind that you can’t do supportive psychotherapy and psychoanalysis at the same time. Whether or not you agree, I highly recommend this book for practitioners of all modalities who want to be challenged to think about their goals and the role of suggestion in their work.

Jane Cooper is a former senior counsellor at the University of Cambridge

Counselling training does not usually cover psychiatric diagnosis and, even on psychotherapy trainings where this forms part of the syllabus, students may not have learned much about bipolar disorder. So, how are therapists to respond if they are faced with someone who has been diagnosed or suspect a client might have the condition?

This guide provides an array of useful information for patients and their loved ones and also for therapists.

7KH ERRN LV RUJDQLVHG DURXQG ƓYH NH\ DUHDV DQG VWDUWV E\ GHƓQLQJ ELSRODU GLVRUGHU and how it might manifest, including the latest thinking from neuroscience.

Information on treatment options, from medication to brain stimulation treatments, forms the second part. I was pleased to see the author endorse psychotherapy as a way of helping patients come to terms with their diagnosis, learn to regulate affect and improve self-care.

The remaining sections consist of an overview of research into causes of the condition and an exploration of issues facing various sub-groups of clients, including children, women and people diagnosed with borderline personality GLVRUGHU 7KH ƓQDO SDUW RI WKH ERRN DLPV to help clients develop long-term strategies for managing their condition and staying well.

This is a comprehensive handbook and the author’s compassionate stance shines through. I appreciated how sometimes complex information is presented in a straightforward way. The one caveat for me is that the author is US-based and some of the treatment options and information DUH FXOWXUDOO\ VSHFLƓF , ZRXOG VWLOO KLJKO\ recommend it as a useful resource for anyone impacted by bipolar, whether as patient, family member or practitioner within the helping professions.

Anne Gilbert is a Gestalt psychotherapist and supervisor

This clear, densely packed, engagingly written and important book lays out the H[WUDRUGLQDU\ VH[XDO ODQGVFDSH ZH ƓQG ourselves in today. So often we read and study theorists without acknowledging the enormous changes in society that have taken place since their theories were formed, but this book picks up those theories DQG SODFHV WKHP ƓUPO\ in their current context.

As a primer on the sexual issues that have an impact on our clients today, this is an enormously helpful overview. The many issues, theories, counter-theories, debates and evidence raised all come with numerous references for easy follow-up and a number of interesting clinical vignettes.

Knafo and Lo Bosco unpick various aspects of modern sex culture, such as JHQGHU ŴXLGLW\ QRQ KHWHURQRUPDWLYH sexuality, bondage, discipline, dominance, submission and sadomasochism (BDSM), polyamory and technology. They go on to explore the relevance of psychoanalysis in this context and argue strongly for its continued relevance and importance. This is the type of information therapists need in order to be able to meet their clients where they are, not where the therapist’s training manual was 10 years ago.

The book acknowledges that psychoanalysis (and psychotherapy in general) has shifted its focus from sexuality to object relations and attachment theory in recent times, but it makes a compelling case for sexuality’s presence in the therapy room.

The erotic permeates almost every aspect of our social lives, is a fundamental element of our personalities and is largely shaped by our early experiences. To collude with clients to avoid it in the therapy room can be a monumental missed opportunity. I would put this book – or, at the very least, the second chapter, a brilliant overview – on the reading list of any psychotherapy training.

Nick Campion is an integrative psychotherapist in Derby

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The Bookshelf, 1

Reviews The Power of Music: psychoanalytic explorations Roger Kennedy (Phoenix Publishing House, £28.99) The two themes that run through this book comprise an attempt to elicit the factors that enable music to reach the ‘depths of the soul’, and an exploration of those factors in the context of therapy. In doing so, the author discusses the extraordinary power of music and skilful analysis to ‘…reach inchoate areas of the mind and yet try to give them form’. Kennedy quotes Antonio Di Benedetto, who encapsulates the ‘magic’ of both when he writes, ‘In short, music teaches us how to listen to what we cannot say.’

Kennedy guides us on a fascinating journey through child development, neuroscience, musicology and psychoanalysis. Given the ubiquitous ability of humans to appreciate music, it comes as no surprise to learn that we are hardwired for it; babies are more sensitive than adults to aspects of musical rhythm and can hear pitch differences that adults FRPSOHWHO\ PLVV $ GHƓQLQJ FKDUDFWHULVWLF of music is its use of harmonic tension and release. Kennedy draws a parallel with therapy: ‘…the conscious thread of thought has many streams or voices or drafts. Through dialogue, the themes of these voices may become more or less coherent, and in an analytic session, one may be able to tease out the different voices and their origins.’ To revisit the musical context, this exploration of voices could be said to describe the development phase of sonata form, where PXVLFDO WKHPHV ƓUVW LQWURGXFHG DUH ODWHU GHFRQVWUXFWHG DQG PRGLƓHG SULRU WR their reintroduction. This book will be of particular interest to practitioners with a love of music and a curiosity about its power to touch our deepest feelings yet elude explanation.

Omar Sattaur MBACP (Accred) practises in Cheltenham and edits EMDR Therapy Quarterly

Positive Psychology Arts Activities Olena Darewych (Jessica Kingsley, £17.99) This book contains many practical arts activities you can invite your client to engage with in session or use yourself in supervision. There is a list of all the materials you will need to do the activities at the front of the book, which is useful if you like to be organised.

Each activity, such as worksheets and guided meditations, provides an opportunity for playful exploration using positive psychology ideas.

Working on the premise that the more we experience positive feelings about ourselves, the better our wellbeing, each DFWLYLW\ ƓQGV D ZD\ WR PDNH WKLV WKH IRFDO point. Some activities also go deeper into positive psychology and explore the areas that enable that process.

This book could help clients to explore areas in their lives such as cultural identity, gratitude, self-awareness with emotions and spirituality. It’s my kind of book because it’s easy to dip in and out of and each activity is written in the same format, including the materials you need, how to do the activity and discussion points at the end. The post-activity questions act as prompts for exploration, but also provide suggestions for takeaway activities beyond the therapy room.

The book is such a beautiful, practical guide to help practitioners work more creatively with their clients with FRQƓGHQFH ,W KDV HDV\ WR IROORZ instructions and the case examples illustrate their uses in therapy. It is a lovely reminder that we can use imagery and ZRUGV WRJHWKHU DQG VRPHWLPHV ƓQG WKDW connection we are missing. I love the fact that most people will have the necessary materials readily available at home, so you could use this book to work with a client in an online counselling session.

Rachel Charlton MBACP is an integrative counsellor in Devon

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The book that shaped my practice

Adolescence: psychotherapy and the emergent self Mark McConville (Jossey-Bass, 1995) With some experience of working with addicted adults, I’d taken up a post running a young people’s substance misuse service. I asked myself, Ō+RZ GLIƓFXOW FRXOG LW EH"ō 4XLWH GLIƓFXOW ZRXOG EH WKH KRQHVW non-rhetorical answer. This book was a lifesaver, professionally speaking. In it, Mark McConville, ZKR DFFHSWHG KLV ƓUVW DGROHVFHQW facing assignment in a similarly accidental fashion, brings decades of experience to bear in explaining why many helping professionals have found teenagers hard to engage.

He does this by unpacking ‘adolescence’ with skill and profound empathy. It can be more helpfully conceptualised, he suggests, as three organically linked sub-stages. He also illustrates the importance of understanding and, where possible, working with families.

While well-versed in Gestalt theory, this book manages never to mistake map for territory.

I’ve reread it several times and have felt more equipped on each go-around.

David Curl MBACP is a Has a book contributed to shaping and yourtrainer practice? counsellor in Email a few sentences to private practice reviews@thinkpublishing.co.uk

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Dilemmas VERSION REPRO OP

OUR ETHICS TEAM CONSIDERS THIS MONTH’S DILEMMAS:

THIRD PARTIES SUBS

Jealous partner

ART

I’ve been seeing a client for more than D \HDU DERXW UHODWLRQVKLS GLIƓFXOWLHV She now has a new partner who is not comfortable with her being in therapy.

I suspect that he is afraid of what is being said about him. My client has asked if he can come along to one of her sessions, to meet me and experience therapy. , FRQVLGHU P\VHOI D TXDOLƓHG FRXSOHV counsellor, but would this still be OK?

PRODUCTION SHUTTERSTOCK

CLIENT

YOU MAY BE A QUALIFIED couples counsellor but, as you have been working with the one client for more than a year, this is clearly one-to-one and not couples counselling.

Your contract is with your client, not her partner, and if he were to attend a session, the therapeutic relationship you have already established with your client would inevitably be affected. It could undermine her trust in you (ethical principle of ‘Being trustworthy’), and could potentially leave her feeling uncontained and unsafe. She might be feeling pressurised to convey his request, and might be disempowered if you were to agree. This could be a case of coercive control, with which you might be colluding.

The dynamics in operation in such a threeway meeting would be complex and could be difficult to manage as, if your suspicions are correct, he may press you for information.

There would be a serious risk of confidentiality being compromised. You would be entering into a kind of dual relationship with both your client and her partner. As the Ethical Framework advises: ‘Any dual or multiple relationships will be avoided where the risks of harm to the client outweigh any benefits to the client’ (Good Practice, point 33b).

You could try to establish what your client really thinks about her partner’s request to attend. What does she believe are his reasons for wanting to meet you? If he genuinely wants to ‘experience therapy’ for himself, he could

always find his own therapist. Maybe your client would feel hugely relieved if you were to say no, and you could discuss your reasons, which she could pass on. It could lead to fruitful exploration of how she really sees their relationship and a clearer understanding of how to deal with her partner’s possible jealousy or insecurity. Your modelling of boundarykeeping could be empowering for her and, provided it does not make her more vulnerable, it might enable her to find her own ‘no’.

Employee assistance I am becoming increasingly concerned at the amount of reporting that some EAPs are requiring. One recent EAP referral was very concerned about who sees the case notes and IHHGEDFN DQG KRZ FRQƓGHQWLDO LW LV She is not convinced that her identity will be protected. Also, having been recommended by her line manager to access the counselling, she felt under some obligation to do so. To her, it felt as if a box was being ticked and that her employer wanted to be seen to be discharging their duties of staff welfare without acknowledging the real reasons for her feeling stressed at work. I feel that ,ōP FROOXGLQJ ZLWK D ŴDZHG V\VWHP E\ taking a referral such as this.

IT IS IMPORTANT that your client has confidence in you and clearly understands from the outset the terms under which the service is being provided, if effective work is going to be done. She has every right to know who will see any feedback and how confidential it is. As stated in the Ethical Framework (Good Practice, point 30): ‘We will usually provide clients with the information they ought to know in advance in order to make an informed decision about the services they want to receive, how these services will be delivered and how information or data about them will be protected.’

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Also relevant is Good Practice, point 31: ‘We will give careful consideration to how we reach agreement with clients and will contract with them about the terms on which our services will be provided. Attention will be given to: a. reaching an agreement or contract that takes account of each client’s expressed needs and choices so far as possible b. communicating terms and conditions of the agreement or contract in ways easily understood by the client and appropriate to their context c. stating clearly how a client’s confidentiality and privacy will be protected and any circumstances in which confidential or private information will be communicated to others.’

If your agreement with the EAP does not specify how client data are used, how anonymised the information is and who sees it, you will need to establish this with them so that you can be transparent with your client and make sure that she understands the limitations of confidentiality.

As it says in Good Practice, point 55: ‘We will protect the confidentiality and privacy of clients by: a. actively protecting information about clients from unauthorised access or disclosure b. informing clients about how the use of personal data and information that they share with us will be used and who is within the circle of confidentiality, particularly with access to personally identifiable information… d. informing clients about any reasonably foreseeable limitations of privacy or confidentiality in advance of our work together…’

Once the contract has been discussed and agreed with your client, the work itself could be focused on the issues of her own choosing, rather than whatever the employer might be expecting her to work on, provided your agreement with the EAP does not dictate otherwise (under the ethical principle of ‘Autonomy’ – the client’s right to be self-governing). The employer might be recommending counselling in order to discharge its duty of welfare, but you might invite her to bring whatever she chooses, bearing in mind that the work will be timelimited. She could, for example, explore what she describes as her ‘real reasons’ for feeling stressed at work.

You are concerned about ‘colluding with a flawed system’, but such EAP referrals might present opportunities for employees to access counselling that they might not otherwise have.

Dilemmas, 1

Admittedly, there may be practices within their workplace or in their EAP’s ways of working that you may not be altogether happy with, and which are largely beyond your control.

But within the boundaries of the therapeutic relationship, your work with your client might be about building her resilience and supporting her to find a way to work within, or perhaps even to challenge, the system in which she finds herself. That could be the real assistance that she is seeking.

Which one’s the client?

I have had one online session so far with a new client. Initially it was the client’s spouse who contacted me by telephone, to enquire about my availability and whether I could help her husband. She gave me her own email address as the FRQWDFW $W WKH EHJLQQLQJ RI WKH ƓUVW session, I was aware that it was the client’s wife who was setting up their laptop, adjusting the video and microphone settings, and I think she was hovering in the background (off camera) because the client kept looking up throughout the session, as if seeking her reassurance.

I also noticed that the online payment was made in her name, not his. I don’t know whether to address these things next time, as I can see that the client might be unable to access the counselling without her support.

IT’S ALWAYS A GOOD IDEA to communicate directly with the client before commencing counselling, to establish that they are coming of their own free will rather than from a desire to please someone else, however well-meaning that other person may be. You might find it helpful in situations such as this to keep asking yourself, ‘Who is my client here?’ and, if you can,

‘You might find it helpful in situations such as this to keep asking yourself, “Who is my client here?” and, if you can, avoid using the go-between’ avoid using the go-between in order to keep the therapeutic relationship as straightforward and uncontaminated as possible.

However, this client might be unable, for some reason, to operate totally independently.

Perhaps a disability or lack of technical knowhow means that he has to rely on his wife to set up the online sessions, send emails and make payments. To insist on your client doing these things for himself might be unfairly discriminating against him (see Good Practice, point 22b), whereas to accept them might be an example of making ‘adjustments to overcome barriers to accessibility, so far as is reasonably possible, for clients of any ability wishing to engage with a service’ (point 22f ).

While accepting that a degree of third-party assistance might be necessary, you could stress the need for privacy and explain that, for the therapy to be most effective, the client would need to be alone in the room, and the session should proceed without interruption.

Once the laptop is set up and the online connection made, you could politely ask the spouse to leave. If she is ‘hovering in the background’, it will be difficult for both you and your client not to be distracted, as you will be only too aware of the ‘third person’ in the room. It could be the case that the relationship with the spouse is the very issue that the client wants to discuss with you.

Maybe he has been made to feel powerless and

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inadequate, and he wants help to reclaim some measure of independence or assertiveness.

Hopefully the second and subsequent sessions will be easier to manage, as trust is being established and the client grows in confidence, including, perhaps, in the ability to handle the technology unaided. He may have genuinely needed his spouse to be around initially, but later he might be willing to go it alone and only invite his wife in if there is an IT problem.

For those therapists who have had to adjust to alternative ways of working as a result of the pandemic restrictions, these are typical of many issues having to be addressed for the first time. They point to the importance of clear contracting, which might include specific reference to the need for privacy.

Lost in translation , DP ZRUNLQJ ZLWK D FOLHQW ZKRVH ƓUVW language is not English and we are using the services of an interpreter. However, I am noticing that the client looks at the interpreter when responding, rather than at me and, judging by the look on their faces, I am not sure that the interpreter always conveys the intended meaning of my words. They sometimes exchange what looks like a knowing smile and the interpreter might mutter little ‘asides’, as if adding his own commentary to what I am saying. Is this just me feeling left out, or should I challenge the interpreter?

WHEN WORKING WITH an interpreter, it is important to meet separately before the therapy commences, to agree on how to work together and to have a shared understanding of how to proceed. You would need to make it clear that your interpreter’s role is to translate

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Dilemmas, 2

Dilemmas VERSION REPRO OP SUBS ART PRODUCTION CLIENT

your words, not to add their own commentary or express their own empathy towards the client, however strong the temptation might be.

As the therapist, it is you, not the interpreter, who holds responsibility for the work. If the interpretation is simultaneous, rather than consecutive, perhaps the communication between you and the client would seem more direct and less prone to interruption.

It would also be useful to find out if the interpreter and the client have any connection outside the therapy. Do they share the same cultural background, or meet each other socially? If so, it needs to be acknowledged and the need for confidentiality and boundaries made explicit.

You should also check with your client that they are happy with the choice of interpreter and that they feel comfortable sharing personal and sensitive information with them. You might explain to your client that you will be expecting them to look at you rather than the interpreter when you are speaking or they are responding.

If you are unsure that the interpreter has conveyed your intended meaning, you could take time to check this out with the client. Could they tell you in their own words what they have understood you to say?

If you are feeling like a passive bystander, this would need to be addressed in your own supervision. Working with an interpreter calls for trust on the part of all three of you in the room, but the therapeutic relationship is between you and your client, so it is vital that neither of you feels persistently left out.

Genuine interest I have a private practice, and one of my clients is a girl aged 15 years. At various times, my client and her siblings have been taken into temporary foster care.

They are currently living at home with their birth parents and Social Services are aware that my client is having counselling. I have just received an email from the social worker inviting me to a multi-agency safeguarding meeting to discuss their concerns about my client and her family.

I am not sure how to reply.

A FOUNDATIONAL COMMITMENT is to make clients ‘our primary concern while we are working with them’ (Commitment to Clients, 1a).

Therefore, in a situation like this, we need to be asking ‘What is in my client’s best interest here?’

It’s a question of balancing those core principles

SUPPORT AND RESOURCES You can find more information and guidance in these BACP resources, which are all available online at www.bacp.co.uk/gpia:  0DQDJLQJ FRQƓGHQWLDOLW\ ZLWKLQ WKH FRXQVHOOLQJ SURIHVVLRQV (GPiA 014)  6DIHJXDUGLQJ FKLOGUHQ DQG \RXQJ SHRSOH ZLWKLQ WKH FRXQVHOOLQJ SURIHVVLRQV LQ (QJODQG DQG :DOHV (GPiA 031)  8QGHUVWDQGLQJ FKLOG SURWHFWLRQ LQ 6FRWODQG (GPiA 053)  0DNLQJ WKH FRQWUDFW ZLWKLQ WKH FRXQVHOOLQJ SURIHVVLRQV (GPiA 039 and 055)  :RUNLQJ ZLWK FKLOGUHQ DQG \RXQJ SHRSOH ZLWKLQ WKH FRXQVHOOLQJ SURIHVVLRQV (GPiA 046)  'XDO UROHV ZLWKLQ WKH FRXQVHOOLQJ SURIHVVLRQV (GPiA 077) of ‘Being trustworthy’ (honouring the client’s trust in the practitioner), client ‘Autonomy’ (respecting their right to be self-governing) and ‘Non-maleficence’ (avoiding harm to the client), and deciding which one takes priority in these circumstances, at this point in time.

Unless you have received a court order, it is unlikely that you would be legally obliged to attend a meeting such as this. It would involve disclosing information that your client has given you in confidence (unless you were to attend but say nothing). But how does your client feel about the request? If she has been assessed to be Gillick competent, having the capacity to understand the therapeutic contract and decide whether to enter into it, she has a right to be involved in this decision, without needing to consult her parents or whoever has parental responsibility. Does she welcome or resent the third-party involvement? It could actually be in her best interests that you attend and represent her, to give her a voice and make a positive contribution to her welfare. Is she aware of what

‘Working with an interpreter calls for trust on the part of all three of you, but the therapeutic relationship is between you and your client’ THERAPY TODAY

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 :RUNLQJ ZLWK LQWHUSUHWHUV LQ WKH FRXQVHOOLQJ SURIHVVLRQV (GPiA 091)  %RXQGDULHV ZLWKLQ WKH FRXQVHOOLQJ SURIHVVLRQV (GPiA 110)  :RUNLQJ ZLWK GRPHVWLF DEXVH ZLWKLQ WKH FRXQVHOOLQJ SURIHVVLRQV (GPiA 116, in press)  &KDUJLQJ IRU VHUYLFHV ZLWKLQ WKH FRXQVHOOLQJ SURIHVVLRQV (GPiA 118) Costa B. Multilingualism in the counselling room. 7KHUDS\ 7RGD\ 2020; 31(10). www.bacp.co.uk/bacpjournals/therapy-today/2020/ december-2020/articles/the-biginterview might be discussed in the meeting and what you might be asked? Do you have her explicit consent and, if so, have you discussed together what you might say?

It’s always worth remembering that ‘all communications between colleagues about clients should be on a professional basis and thus purposeful, respectful and consistent with the management of confidences agreed with clients’ (Good Practice, point 59) and ‘we will do everything we can to develop and protect our clients’ trust’ (Good Practice, point 12).

ABOUT THE AUTHOR Stephen Hitchcock is BACP’s ethics consultant. He is a senior accredited counsellor and supervisor with 20 years’ experience, and he has a private practice in the Lake District. Stephen previously worked with BACP’s Professional Standards department as an accreditation assessor and moderator. This column is reviewed by an ethics panel of experienced practitioners.

The dilemmas and responses reported here are typical of those worked with by BACP’s Ethics Services. BACP members are entitled to access this consultation service free of charge. Appointments can be booked via the Ethics hub on the BACP website.

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How do I find a supervisor and does modality matter?

SUBS ART PRODUCTION CLIENT

A supervisor’s primary task is to support you and help you reflect on all aspects of your practice. For this, it is essential to have a good working relationship in which both parties respect each other. To identify the type of supervisor who is right for you, it is helpful to spend some time reflecting about what you would like from supervision and then think about what kind of supervisor would make that possible. What skills, qualities and style of relating would they need to have?

This is not going to be the same for everyone.

For example, one supervisee may feel very insecure and may therefore want someone who is, above all, kind and empathic as well as very experienced. Another may have been practising for a few years and may prefer someone who is fairly straightforward and not afraid to challenge when necessary.

Once you are clear about what you are looking for in a supervisor, ask around – what do people say about their supervisors? Who sounds like they might fit the bill for you? It can be helpful to then check their website, to give you more of an idea of the kind of person they are and provide information about location, area, theoretical orientation, cost and so on. It is a good idea to book an initial meeting first, so that the two of you can decide whether or not you might like to work together. After a few sessions, you and your new supervisor may like to evaluate how it is going and what perhaps might need changing.

During training, supervision is part of the learning process and your supervisor should therefore have knowledge and experience of your modality. With increasing experience, however, this may become less important and you may value the different point of view that another orientation can bring. It may also be helpful if you want to integrate different ways of working into your practice and, as such, be part of your continuing professional development.

Dr Els van Ooijen BACP accredited psychotherapist, counsellor and supervisor, and author of Clinical Supervision Made Easy (PCCS Books)

When looking for a supervisor I would recommend thinking about the following: 1. What qualification and experience does the supervisor have?

2. Will the supervisor encourage and support you to engage and grapple with defensible ethical decision making?

3. Do you need a supervisor with specialist knowledge, such as working with gender, sexual or relationship-diverse clients/supervisees, racial/cultural differences, or children and young people?

4. Is the supervisor willing to do their own learning (in their own time) about areas of difference or marginalisation that impact you and/or your clients? Do you expect to have to educate the supervisor before you can discuss what you need to?

5. Is the (experienced) supervisee working in an environment where their own material might be evoked and so they may themselves need some additional supervision?

6. What is their modality? It may be necessary in training and early in your career to be working with a supervisor of the same modality. As experience is gained this may matter less but it can be helpful to know what you are looking for alongside a willingness to try something a little different.

7. Do you envisage they will offer a helpful mix of containment, exploration and knowledge for you?

8. What is the style of the supervisor? Do they work more in a collaborative, informative, passive or integrative way?

9. Do you have a preference regarding frequency of sessions? You may have to work around the supervisor’s availability should you wish to work with a particular person.

10. If the arrangement doesn’t feel helpful, what would it need to look like to make it more helpful? What would it need to look like for you to know it’s time to change supervisors?

Luan Baines-Ball (they/them) BACP senior accredited counsellor, psychotherapist and supervisor in private practice

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Finding the right supervisor is about intentionally deciding what is right for you. This means identifying what support you need in your current clinical and professional practice, as well as what may be coming up in your practice over the next year or so, and finding a supervisor who matches these needs. Do you need supervision and a supervisor who has expertise in working with your client groups or specific presenting issues?

One who can support you in your professional development such as private practice, applying for accreditation or working in a specific clinical setting? Or perhaps it’s a combination of various needs. The right supervisor will be different for each of us, as we each have our own bespoke supervision needs.

The therapeutic modality of your supervisor does matter. A supervisor with training, understanding and clinical experience of working in the same modality as you brings a shared understanding and reflective process of how and why you are working with clients in the way you do, and help you to process your approach and work through ethical issues.

A shared modality also offers a supervision process that is complementary to your clinical work so supervision itself can help teach or model your modality practice, by perhaps helping you understand parallel processes taking place within supervision, or how the client is impacting on you and what you bring to supervision. Your client groups, presenting issues and mode of counselling also shape your practice, so being able to explore how they impact on your work through your shared modality may also offer an effective way of supporting your work.

Identifying who is the right fit as a supervisor might take initial time and effort, but it means you are more likely to find a supervisor who best meets your needs and can offer you the most appropriate and suitable support.

Myira Khan BACP accredited counsellor, supervisor in private practice and founder of the Muslim Counsellor and Psychotherapist Network

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Supervision, 1

Supervision

Analyse Me, 1

The questionnaire VERSION REPRO OP SUBS

me Analyse

:KDW GR \RX GR IRU VHOI FDUH"

I move my body and I read. My relationship with the rest of nature is very important to me, so I always invest in my alone time outside to speak with the world. I adventure. I cycle. I run.

But my inner imaginal world is of equal comfort, and I love being immersed in speculative or foreign fiction.

Ruth Allen speaks for herself ART

What motivated you to become a therapist? Without realising it,

PRODUCTION CLIENT

I had been moving towards therapy for some time, having volunteered with Samaritans for several years, when I developed a growing passion for helping people in crisis. But I didn’t take it further until years later, when my sister-in-law became very unwell and took her life and I thought, ‘The services available to her are completely inadequate.’ I wanted to play a part in a system that does better.

'R \RX KDYH D VSHFLDOLVW ƓHOG RI practice? My specialism is outdoor

practice, where I work with nature, body and movement as part of the therapeutic process. This, for me, is a very natural way of working and speaks to my own relationship with the rest of nature. I am also passionate about public outreach beyond the privacy of the therapeutic space and do a lot of communication work around nature connectedness. To this end, my first book, Grounded, has just been published on the benefits of nature for our mental and emotional wellbeing. It is not a therapy book but something for everyone – a lyrical encouragement to make a meaningful relationship with the living planet.

What have you learned about \RXUVHOI VLQFH EHFRPLQJ D therapist? I’ve learned that I am

best suited to this way of being in

dialogue with people. I have learned that I am capable of offering a certain quality of steady attention over time that is valuable. That said, I have also realised how difficult I find it to be in a relationship at times. Being a therapist has helped me work out how to ‘stay in’ things, and attend to my own experience of life in different ways. :KDW GR \RX ƓQG FKDOOHQJLQJ DERXW EHLQJ D WKHUDSLVW" I will never

be easy with other people’s despair and suffering. It makes me very achy. +RZ GR FOLHQWV ƓQG \RX" A lot

through social media, where I maintain an active, open presence, and then by word of mouth and via things I have written, or radio.

Sometimes people contact me who have heard me give a talk a year or two previously. I am always interested in how we find people in this world – people who challenge us, inspire us, provoke us into new ways of being.

It’s a big magic!

Where would you like to be in ƓYH \HDUVō WLPH" I would like to go

further with my specialism, really honing the work and perhaps returning to research. I also keep joking that, within a few years, I will be a body psychotherapist, and that might well come to pass. I would also hope to have written another book or two. I tend to work quite intuitively

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and follow my nose where curiosity and learning take me – the main thing is I am doing right by my clients and offering something to the field. :KDW ERRN EORJ RU SRGFDVW GR \RX UHFRPPHQG PRVW RIWHQ" Oh, I am

not very good at recommendations.

I panic when people ask. I am much more interested in hearing what speaks to other people and why it has meaning. You can learn a lot through people’s preferences and I am not keen to impose mine. :KDW LV \RXU IDYRXULWH SLHFH RI music and why? I have different

pieces for different occasions. If I need to cry, then ‘Brothers In Arms’

by Dire Straits, which reminds me of my dad. If I want to feel competent, then Taylor Swift. I listen to a lot of classical, too, because I find it hugely regulating. Nothing gets to me like a cello. $UH \RX D ODUN RU D QLJKW RZO"

More of a pigeon, I think. Make of that what you will. :KDW JLYHV \RXU OLIH PHDQLQJ"

Taking every chance to connect with a sense of vitality and purposefulness.

I try to be as intentional with my time as possible. I take relaxation seriously these days. Learning, loving, cultivating, moving – all of these things help me make meaning.

About Ruth Now: A humanistic, body-informed counselling psychotherapist with philosophical underpinnings in ecopsychology. My first book, Grounded: how connection with nature can improve our mental and physical wellbeing, is published by Welbeck Publishing.

Once was: A PhDqualified geologist researching Himalayan geology. I left because I wanted to focus on people, not rocks!

First paid job: My own business, aged 11, cleaning wheelie bins in my street. I wanted money to buy sweets and wildlife magazines.

Who would you like to answer the questionnaire?

Email your suggestions to the Editor at therapytoday@ thinkpublishing.co.uk

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