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Issue 57 • Summer 2014

Psychotherapy, imagination and health

The maga zine of the UK Council for Psychother apy

ISSN 2049-4912

Balancing rationalist and intuitive approaches to wellness

Follow us @UKCP_Updates


contents Feature articles Psychotherapy, imagination and health 4 Reviving forgotten foundations of western medicine 5 The medical humanities: necessary knots in the crooked timber of medicine 7 Reimagining our relationship with the microbial world: infection, antibiotic resistance and peaceful coexistence 10 Perceptions of mental health 13 Healing fiction: spirituality and psychotherapy 15 Beauty, God, death, evil: re-imagining real psychotherapy 18 Contemporary psychosomatics and non-verbal techniques 20 The shirt of Nessus 23 Illness is a part of health 25 Discussion The Face(book) of psychotherapy is changing The BodyMind Approach Values-based commissioning Review: Far from the Tree by Andrew Solomon

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UKCP news Valuing Mental Health UKCP’s new website Childhoods never last but everyone deserves one Our work to combat gay conversion therapy

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UKCP members Low-cost and free therapy provision in private practice Welcome to our new UKCP members

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Our relationship with the microbial world p10

Contribute to The Psychotherapist We welcome readers’ comments, letters and suggestions for one-off articles or themed issues. Could you commission a themed feature section? If you have a theme you’d like to explore in depth and share with our readers, why not consider sending us a proposal for a feature section? Our feature sections offer a variety of perspectives and encourage fresh thinking in the profession of psychotherapy. In addition to your introduction, you can commission around seven articles of 1,500-2,500 words each. One-off articles and letters are also welcome. For articles, we recommend that you send a summary of what you would like to submit before you begin writing. For more information, contact communications@ukcp.org.uk

Diversity and equalities statement The UK Council for Psychotherapy (UKCP) promotes an active engagement with difference and therefore seeks to provide a framework for the professions of psychotherapyandpsychotherapeutic counselling which allows competing and diverse ideas and perspectives on what it means to be human to be considered, respected and valued. UKCP is committed to addressing issuesofprejudiceanddiscrimination in relation to the mental wellbeing, political belief, gender and gender identity, sexual preference or

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orientation, disability, marital or partnership status, race, nationality, ethnic origin, heritage identity, religious or spiritual identity, age or socioeconomic class of individuals and groups. UKCP keeps its policies and procedures under review in order to ensure that the realities of discrimination, exclusion, oppression and alienation that may form part of the experience of its members as well as of their clients are addressed appropriately.UKCPseekstoensurethat the practice of psychotherapy is utilised in the service of the celebration of human difference and diversity, and that at no time is psychotherapy used as a means of coercion or oppression of any group or individual.

Editorial policy The Psychotherapist is published for UKCP members, to keep them informed of developments likely to impact on their practice and to provide an opportunity to share information and views on professional practice and topical issues. The contents of The Psychotherapist are provided for general information purposes and do not constitute professional advice of any nature. While every effort is made to ensure the content in The Psychotherapist is accurate and true, on occasion there may be mistakes and readers are advised not to rely on its content. The Editor and UKCP accept no responsibility or liability for any loss which may arise from

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welcome

Reviewing the way we work Avid readers may remember that in the last issue’s editorial David Pink wrote about new beginnings. This issue continues that theme.

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he Professional Standards Authority’s affirmation of our identity as a regulator of highly trained professionals working to the highest standards of practice is a new beginning. But we are more than just a regulator; we are also innovators, as articles in this edition show. For example, we commissioned research showing for the first time just how much valuing mental health matters (see page 36) and we took a leadership role in coordinating public information on gay conversion therapy which is available via NHS Choices (see page 42).

Janet Weisz UKCP Chair

Our members, too, are innovators. On page 30, Helen Payne explains her awardwinning work with patients with medically unexplained symptoms. All these point to an organisation and members leading the way in promoting and affirming psychotherapeutic therapies as a treatment of choice. In order to keep our work fresh and relevant we are constantly reviewing the way we work. In keeping with this, your Board is reviewing its governance and looking at whether our structure supports the functions it performs. You will find a letter enclosed with this issue which explains this review. The last time UKCP underwent a momentous change was 2009. In my view the organisation bravely voted for a different UKCP, and over these five years it has grown into a more professional place. Much of our work throughout the organisation relies on volunteers, from the UKCP Chair through to chairs of

reliance on the information contained in The Psychotherapist.

Managing editor: Sandra Scott

From time to time The Psychotherapist may publish articles of a controversial nature. The views expressed are those of the author and not of the Editor or of UKCP.

Editorial board: Sandra Scott, Janet Weisz, Mary MacCallum Sullivan, Philippa Whittick, Richard Casebow, Sapna Shah

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committees, colleges and faculties, and college delegates. Under the guidance of our Chief Executive, we have an increasingly professional office. But we depend on those who give up their time to individual projects, or who take time out of their precious weekends to participate or input into UKCP work. And we must ensure that these various contributions complement and support each other. Something that was lost in the 2009 restructure which is missed by many was the infamous AGMs. These were important annual gatherings of delegates from our organisational members. They were arenas for energetic debate where members held the Board to account and heard about the work of the various parts of the organisation. Somehow we need to find a way to recapture the enormous energy and passion that was generated in those AGM weekends. Please read the enclosed letter and get involved in our governance review. That is the spirit of UKCP.

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The Psychotherapist

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feature editorial

Psychotherapy, imagination and health Guy Dargert introduces this special issue of The Psychotherapist, which focuses on the balance and tension between rationalist and intuitive approaches to health and wellness.

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odern, rational, evidence-based medicine can trace its origins back 2,500 years to ancient Greece and to the physician Hippocrates who lived on the Island of Kos. Even today some physicians swear his oath and, like him, pledge their service to the Greek gods of healing. This was a time when rational and intuitive approaches to healing worked harmoniously side by side. On the one hand, the healing sanctuaries offered surgical, dietary, herbal and physiological treatments. On the other, the sanctuaries of ancient Greece healed through the power of inspiration and imagination.

The healing dream

The sanctuaries were built to the plans of the most respected architects and situated near springs in places of outstanding natural beauty. They were filled with the finest works of art. As a part of their treatment, patients were expected to witness and to participate in theatre, poetry, art, music, philosophical debate, prayer and, crucially and most importantly of all, in sacred dreaming. When we speak of a ‘clinical’ approach today, we are in fact referring to the klinai or the ancient Greek couch of the healing dream on which supplicants would sleep and hope to commune with Asclepius, the god of medicine. Asclepius today is remembered by the medical emblem of the rod and serpent. The serpent represents Asclepius in his totem animal form as he

coils up the staff, bringing with him healing energies from the dark invisible realms of the underworld or unconscious. It has now been well over a century since Freud first reclaimed both couch and dream for modern medicine. Yet psychotherapy and medicine still have far to go in order to fully re-enlist the healing power of the imagination.

Remarkable responses

It is my pleasure and privilege to present to you in this edition of The Psychotherapist a selection of writers who have given thought and attention to these issues and have come up with some remarkable and innovative responses. Robert Bosnak will tell you of his work to recreate the atmosphere of the ancient healing sanctuaries in modern-day California and Mexico. Alan Bleakley shares something of his innovative work at Plymouth University Peninsula School of Medicine in the UK, where he aims to educate medical students in the role of the arts in healing. Biologist Mary Murray challenges us to reconsider the sometimes hostile way we think of the microbial world and to appreciate its essential importance to our very survival. Paul Farmer of the mental health charity Mind questions the way both professionals and the public think about mental health. In keeping with the spirit of the ancient Asclepia or healing sanctuaries, Jungian academic David Tacey stresses

Guy Dargert is a UKCP-registered psychotherapist with over

30 years’ experience of practice. A former Head of Counsellor Training at Chichester University, he is an honorary fellow of the universities of Plymouth and Exeter and a consultant lecturer at the Peninsula College of Medicine, where he has been teaching medical humanities, including special study units on the ‘Healing Dream’ and ‘Metaphors of the Body’.

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the importance of spiritualty as an aspect of psychotherapeutic healing, while Stephen Diamond emphasises the need to appreciate the roles of ‘beauty, God and death’ in the practice of our work. Denise Ramos shares something of her Jungian approach to working non-verbally with psychosomatic issues. Anglo-Irish esoteric writer and student of alchemy Patrick Harpur looks to mythology and points out the limitations of ‘reason’ as our principal guide to an understanding of the world. In my own contribution, I argue that illness is not an enemy to be defeated but is instead an essential part of health.

The meaning of health

Psychotherapy is widely but not universally regarded as a health profession. But what exactly do we mean by ‘health’? Do we share a common vision with that of the medical profession? What is the relationship between psychological and physical health? Do we psychotherapists agree among ourselves about the nature of that to which we refer when we use this word? Do we even agree a precise definition of ‘psychotherapy’? Do we for example share a common belief that health can be quantified and measured? If so, how do we imagine this might be done? Are we agreed that evidence-based practice is the ‘gold standard’ to which we must aspire or are there other more psychological ways that health can be imagined? Perhaps the very ideas of ‘health’ and ‘objective measurement’ are themselves psychological fantasies in need of exploration. Does psychotherapy share a common goal with that of many of our funders, namely the delivery of fast, effective, low-cost symptom removal and the restoration of normal functioning? Or is there something more? That ‘something more’ is, I suggest, no less than the very heart and soul of the profession.

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feature article

Reviving forgotten foundations of western medicine Robert Bosnak explains the work of his clinics in California and Mexico. Emulating the healing sanctuaries of the ancient world, dream-based Asclepian medicine enables clients to make profound changes in their lives.

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radition tells us that western medicine began in the person of a legendary physician called Asclepius, who later came to be considered divine, the mythical founder of a bloodline of physicians called the Asclepiads. The most famous Asclepiad was Hippocrates, who considered himself a descendant of Asclepius 18 generations down. Most western physicians still swear by him.

Healing through dreaming

While Hippocrates rationalised classical medicine by stating that diseases were not caused by the gods but by nature, he left intact the notion that the physician god Asclepius could bring healing by way of dreaming. Like all Asclepian sanctuaries, Hippocrates’ medical school on the Greek island of Kos was arranged around an Abaton, a place for dreaming. These were rooms near the altar of the healing gods furnished with klinai, stone couches, on which dreamers could recline, from which we derive the word ‘clinic’. The word Abaton can be translated from the Greek as meaning ‘the inaccessible place’ or ‘the untrodden place’. In this place, dedicated to the sacred mystery of medicine, the dreamers would have otherwise inaccessible encounters with those powerful dominants of the healing creative imagination called gods. Asclepian medicine is based on the premise that dreaming can respond to crucial life issues in a meaningful manner. When a

particular problem is effectively posed to the dreaming imagination, characters are drawn in (like the gods of yore,) who may inspire healing.

The physical and the subjective Since 2011, at the Santa Barbara Healing Sanctuary in the USA and the Malinalco Healing Sanctuary in Mexico, we have been involved in the revival of dream-based Asclepian medicine. At these sanctuaries we work subjectively and with conventional medicine. We subscribe to the premise that physical illness needs to be treated on both

Robert Bosnak is a Dutch Jungian psychoanalyst with 40

years’ clinical experience. He is a founding director of the Santa Barbara Healing Sanctuary in California, a past president of the International Association for the Study of Dreams, and has been a visiting professor of clinical psychology at Kyoto University, Japan. Robert has developed a method of working with dreams that is said to profoundly affect physical health and is used around the world.

The Psychotherapist

the physical and subjective levels. We are researching whether a combined object/ subject approach that includes elements such as dreams (usually overlooked by the person with a physical illness) works better than an exclusively objective approach. Anecdotal evidence indicates that it does and points towards directions for possible scientific pilot studies. It suggests that dream-based Asclepian medicine sets upward spirals of positive feedback in motion. These facilitate the effectiveness of conventional and integrative medical procedures, leading to significantly enhanced objective and subjective healing. Dream-based medicine may lead to a strengthening of a sense of direction in the often-confusing world of health options. It may significantly reduce the detrimental feelings of helplessness suffered when faced with the overwhelming prospects of illness or our need for its prevention.

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feature article Embodied imagination

In the sanctuary programmes we treat people for physical illness and for stressful situations that may lead to health problems if left untreated. The following detailed example comes from preventive care. It explains the embodied imagination method, which we combine with writing based on dreaming, dream-based theatre and fine arts and is accompanied by integrative approaches such as therapeutic yoga, meditation, aquatic therapy and a review of nutrition choices. A woman brings in a problem. She is at a stressful crossroads in her life. Her children are about to leave home. She feels she can’t continue her old life as a teacher. Her job has great responsibilities. She fears that a change of direction may badly disrupt the lives of many others. Under our guidance, she focuses on a moment that is paradigmatic of her current dilemma. Her new interests are guided by her dread arising from the calamitous ecological changes going on in Mexico. She is overwhelmed with distress that she feels painfully in her body.

Dream incubation

In a process called ‘dream incubation’, she intentionally experiences this fully embodied stress in her body for half a minute before going to sleep. She then dreams that she meets her teacher. He looks completely different from his usual self. He is a man who has been fully identified with his teaching. In the dream he has stopped work. She is completely taken aback. Then she is in an auditorium with a friend. On stage it is announced that a girl child is being auctioned off. Does anyone want to see her? Only the dreamer’s friend says yes. Everyone around is upset with the friend, including the dreamer. The little girl is brought on stage. She looks like a rag doll with long limbs and a Chinese face. A jet engine appears in the back of the audience. The girl leaves the stage. She walks up to the engine and jumps into it. She disappears, though a sense of her presence remains. Instantly the dreamer finds herself in outer space looking at an entirely unknown universe. In embodied imagination we help the person flash back into the dreaming environment. We use the natural ability of memory to remember events in flashback, familiar to us from encounters with trauma.

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She will experience events with all her senses as if they were taking place here and now. We elicit this capacity of memory to remember by way of a fully embodied sensate flashback by slowing down the narrative of the dream and asking questions oriented towards the senses, such as: What is the light like? What is the distance between you and the teacher? How are you walking? Are you hearing sounds? Are there smells? What do you notice? In this way, the dreamer gets pulled back into the environment of the dream. The more we slow down the pace of recall, the more environmental details arise and the more it begins to involve physical and emotional responses until she is fully immersed in a flashback.

Hope and curiosity

When the dreamer is immersed in the environment where she meets her teacher her spine straightens automatically and she has a feeling of hope and curiosity. After staying with this embodied sensation for some time, she realises that he has quit teaching. She begins to lose her sense of gravity. She experiences a feeling of being afloat as if she has been unhinged from her moorings. She can’t believe that a man who has been so completely identified with his teaching has just stopped and changed direction. As we help her focus on the posture of the teacher and on his voice, she notices the deep relaxation within him. Through extended focus on him – while her body with subtle, barely perceptible movements imitates those of the dream figure – she begins to participate in his experience, a slow process of instinctive mimicking which leads to a sudden experience of identification. As she partakes of his experience through identification, she physically senses his feelings of profound peace with his decision and his openness to new directions. She can sense this in his relaxed muscles. His throat opens and more air enters his body. Through a prolonged focus on the opening throat sensed through identification, the entire embodied state is anchored as a sense memory in the throat. Precisely located sense memories can be triggered later to release the psychophysical state they embody.

A moment of affirmation

We then forward the action to the moment of sitting next to her friend. As her friend says, ‘Yes, I want to see the girl’, there is a palpable feeling of danger surrounding

the girl. Sensing the subtle motions in the body of the friend by way of identification, she observes how the friend turns from her pelvis to the right towards the stage in a gesture of a strong ‘yes!’ It feels in the friend’s body as a moment of affirmation of whatever is to come her way. She wants to see rather than avert her eyes from the truth. The dreamer’s body unconsciously follows the graceful movement of the friend in a spiralling motion up from her pelvis, folding out to the right. I direct her to keep her focus on this spiralling movement so she can recall it at will in the way a dancer can sense rehearsed choreography in her body. Subsequently, we focus on the girl. She looks deeply dejected. Her arms hang around her body like a cloth doll. She participates in the floppy body of the girl and recognises her complete dejection as a sense of rejection felt in her belly. The girl loathes the people in the audience, who avert their gaze from her, frightened that seeing her will change their lives. She experiences it as the umpteenth rejection. She can take it no longer. As she walks off the stage to the back of the auditorium longing for liberation, she throws herself into the turbine jet engine as the gate to her freedom. She disappears as a simple exhale. The dreamer makes a soft whistling sound marking the liberating moment. The exhale remains as a presence in space. The next moment the dreamer inhales with the onomatopoeic sound ‘awe!’ as she finds herself in a completely new universe, as if she has passed through to a different dimension.

Dimensional shift

Finally, the dreamer holds all the worked states in one single body, a composite of embodied states. We simultaneously trigger the sense memories of feeling hope and curiosity in the straight spine, which turns into a floating sense of disorientation; the relaxed muscles and ample air coming in through the open throat of the teacher at peace with his decision for complete change; the turn to ‘yes!’ spiralling up in the spine of the friend; the dejection and rejection in the heavy belly of the rag doll girl; her exhale of liberation as she throws herself into the turbine jet; the inhale of awe in the completely new cosmos, accompanied by the sense of a dimensional shift. After staying in this body for some time, the dreamer is very emotional. She feels as if she has received a lot of new information

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feature article she could never have accessed, however long she might have thought about this present crucial moment in her life. This new information is physically experienced as the various locations in her body lighting up and clicking into place, giving a sense of vital verticality. It makes her body feel alive and ready, as though she is standing up straight within the profound changes her life demands in an upwards spiral of affirmation and lightness like breath. While being intensely curious about the next dimensions of her life as the old disappears in a profound sense of liberation, there is peace in her muscles. She is able to hold previously rejected ominous conditions – which remain heavy, painful and alarming – against a completely new background. Later she wrote to me: When I wrote it down and went through the images I thought they were quite horrifying but I found a whole different perspective through the work of embodied imagination, a depth I could never have imagined and much less felt … For me, after having that experience anchored in the body, it is easier to believe and manifest that possibility in my life ... because I’ve ‘been there’ somehow. My current conclusions are that the results of dream-based Asclepian medicine improve conditions over time in the upwardly spiralling manner of positive feedback loops, making new treatment modalities accessible. I believe that participants become inspired by the images they encounter and are moved to change their lives dramatically. This can mean making space for themselves in a life cluttered with the care for others, gaining the energy to make their way through the medical maze, or creating a sanctuary in their daily lives to give access to the inspiration of the healing imagination. They may open up from a life encased in illness and form new relationships, resulting in unexpected salutary marriages and long hoped-for babies. Asclepian medicine understands illness not only as a source of suffering. With the eyes of classical antiquity, it dignifies medical conditions with that sense of the great mysteries that leads to spontaneous conversions towards healing.

The Psychotherapist

The medical humanities: necessary knots in the crooked timber of medicine Alan Bleakley asserts that application of medical humanities and a psychotherapeutic imagination is required to shift the dominant discourse of medicine to the lyrical and tender-minded orientation necessary for collaborative, person-centred care.

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he practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. William Osler

Cultural shifts

As somebody who came to medical education from a background in psychology and psychotherapy, I have a strong interest in how medical students become humane and psychologically savvy doctors – technically proficient clinicians who can communicate effectively with patients and colleagues, work well in clinical teams and look after their own health. More, I am interested in how we can lift medical students to become connoisseurs in the social and emotional side of their work, developing artistry and acute sensitivity. This is a tough call, and medical education has so far not been up to the task, relying as it does on functional approaches that fail to frame professional communication as a sophisticated psychotherapeutic art. In short, medical education needs the medical humanities.1

Use of arts and humanities in medical education is fairly recent. It is only over the past decade that more innovative medical schools in the UK have developed an interest in visual art, music, performance/ drama and literature as media to educate for empathy, trust, imagination, tolerance of ambiguity, and a moral imagination through tuning the senses (necessary for clinical acumen) and narrative intelligence (necessary for listening to and making sense of patients’ stories).

Patriarchy, individualism and heroism

Medical culture is steeped in tough-minded patriarchy, individualism and heroism, where good bedside manner has been optional. Today, medicine is transforming, with more women than men now entering the profession, patient-centredness established as the default position, and collaborative clinical teamwork the norm.2 Medicine has been shaped by militaristic codes and metaphors – initiations such as dissecting the human body; rituals such as teaching by humiliation; dress codes such

Alan Bleakley is Professor of Medical Education and Medical Humanities at Plymouth University Peninsula School of Medicine, where he was instrumental in setting up the innovative medical humanities curriculum, and is President of the Association for Medical Humanities. He has published eight books with two more in preparation and many academic articles and book chapters. His passion is surfing.

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feature article a realistic professionalism, and tolerance of ambiguity is precisely what the arts and humanities cultivate. The UK NHS mostly does a brilliant job, with over 1 million patients admitted every 36 hours in the fourth largest institution in the world behind the Chinese People’s Liberation Army, the Indian Railways and the Wal-Mart supermarket chain, and employing 1.7 million people. Yet deaths from medical error in the UK are estimated at 40,000 a year, around half of which are avoidable. Seventy per cent are grounded in poor communication in team settings.2 It is not doctors’ technical ability that produces error, but poor communication. Yet doctors are supposed to follow the Hippocratic injunction: ‘First, do no harm’.

Not listening to the patient’s story

as the white coat; and the maintenance of strict, authoritarian hierarchies. The main metaphors guiding practice have been martial. 3 Thomas Sydenham, in the midseventeenth century, first framed medicine as warfare: ‘A murderous array of disease has to be fought against, and the battle is not a battle for the sluggard … I steadily investigate the disease … and I proceed straight ahead, and in full confidence, towards its annihilation.’

Equality and collaboration

All of this is rapidly changing to a more pacific, tender-minded practice, where patients and their symptoms must be listened to (just as a psychotherapist works) in order to diagnose well. Medicine and healthcare are also democratising – introducing equality and collaborative methods into teamwork.2 There is not enough space here to track a history of the medical humanities or to rehearse the rationale for why the medical humanities work best when they are core and integrated in the curriculum (achieved only in one UK medical school: Peninsula from 20024); or indeed to explain why the medical humanities educate for empathy better than standard communication skills input. All these arguments have been made elsewhere.5 Rather, I will focus on two interrelated issues. First, we need the medical humanities to prevent medicine from slipping back into undemocratic,

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authoritarian habits; and, second, we need to shift the dominant genre or discourse of medicine from its traditional (and destructive), tough-minded, epic and heroic orientation to the lyrical and tender-minded orientation necessary for collaborative, person-centred care. These issues are primarily political, moral and aesthetic. At the core of this shift is the employment of a psychotherapeutic imagination.

Necessary knots and the democratising of medical culture Immanuel Kant said that ‘out of the crooked timber of humanity, no straight thing was ever made’. Ideals meet the reality of a complex and messy world. Isaiah Berlin, after Kant, said that ‘no perfect solution is, not merely in practice, but in principle, possible in human affairs, and any determined attempt to produce it is likely to lead to suffering, disillusionment and failure’. Medicine is a crooked timber, driven by idealism but knotted with uncertainty, the main outcome of which is iatrogenesis – medically caused injury and death. Yet these knots in the timber are necessary, where they alert us to how we might best work with or against the grain educationally: how we might fashion the best possible education for medical students knowing that this will always be less than perfect. Medicine is risky, but need not be quite so risky. Owning up to the high levels of ambiguity in medicine is a first step towards

Second, 10 to 15 per cent of medical errors are due to misdiagnosis by doctors in consultations and this is grounded in not listening closely to the patient’s story. Third, ‘empathy decline’ sets in, as medical students’ initial idealism disappears into a crooked timber by year three of their study (entry into clinical placements), so that they harden towards their patients and become more cynical. Fourth, doctors show poor self-care, having the highest rates of suicide, suicide ideation, and drug and alcohol abuse among the professions. Fifth, medical culture may be said to suffer from what the psychoanalyst Alfred Adler called the ‘masculine protest’, discussed earlier: medicine sits within a male, heroic tradition shaped by the epic genre and martial metaphors.2 The psychoanalyst Alfred Adler (18701937), founder of community psychology, described the ‘masculine protest’ as an irritable striving for control and superiority, denying the human capacity for collaboration or ‘fellow feeling’. Theodor Adorno and colleagues, after the Holocaust, described the authoritarian ‘fascist’ type as intolerant of ambiguity. Hitler’s most hated music was jazz, not just because it was associated with blacks, gypsies and Jews, but because it was syncopated and improvised. Hitler preferred marching to the beat: militaristic music in which everyone knows his or her place.

Democracy and uncertainty Freud described regression to an ‘anal’ stage of development – either hanging

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feature article on tight (retention) in meanness and excessive control, or shitting on everybody (expulsive). Wilhelm Reich described ‘body armouring’: that authoritarians freeze up and hold on, denying the fluidity of eros or life force. Donald Winnicott, after Freud, showed how adults might regress to infantile forms of control and then fail to develop empathy or concern for others. French feminists such as Hélène Cixous have described how the masculine protest can only be softened through a dose of ‘mother’s milk’, in fully subscribing to social practices (and languages) that are genuinely caring, inscribed with tenderness and succour. All of this is important for medicine as doctors transform their ‘high-control’ styles in favour of collaborative, caring patient- and team-centredness through the democratisation of a previously authorityand hierarchy-led medicine, where tolerance of ambiguity is a central attribute. As Claude Lefort says, ‘Democracy is a form of society in which persons consent to live under the stress of uncertainty’. Living democratically is an art informed by a moral imagination.

The dominance of the epic genre and repression of lyricism

The medical humanities in medical education then serve a political purpose: to democratise medicine, flattening unproductive authority structures to create the conditions for better communication and then improved patient care and safety. But this aim for democratisation is linked with an aesthetic issue – the need to transform medical practice from domination by tough-mindedness from within an epic mode to release what is repressed by that mode – lyricism, a more tender-minded, sensitive medicine. Medicine’s ‘frontstage’ has historically involved the epic, heroic dragon-slaying doctor; the tragic, which is given with the territory of illness and death; and the dark comic. Black humour develops in hospital subcultures, such as intensive care, as a way of blowing off steam (out of families’ earshot). What is missing (and repressed) however is lyricism in medicine. Repressed lyricism returns as cynicism, hostility, arrogance, sarcasm and bullying, felt as disillusion and burnout, dry cinders and bitter ash. Lyricism can be characterised as tending the garden, vocation, devotion, tenderness, joy, fecundity, abundance, generative, songlike, rhythmic, poetic, rhapsodic, erotic,

The Psychotherapist

celebrating the beauty of the mundane (the extraordinary in the ordinary) and providing genuine hospitality (which has the same root as ‘hospital’). Doing lyrical work fashions a sensitive self. Lyrical medicine is a no-brainer: elegant, inspiring, beautiful, imaginative, animated, dignified, graceful, sensitive, distinctive, passionate and expressive, or ‘aesthetic’. Non-lyrical medicine serves as an anaesthetic – blunting, souring and dulling, leading to uninspired, flat, ungracious, insensitive and restrictive practice. Which doctor would you rather have?

Lyricism meets tragedy

The lyricism I am calling for is not ‘lite’, but intense. One full of passion that the poet StJohn Perse described as ‘passionate action’, which ‘does not raise cultured pearls (but) is intimately related to beauty’. In other words, an ‘everyday’ beauty, seeing the mundane in a new light. In medicine, the lyrical often meets the tragic. A radiologist describing an ‘apple core’ shape on an X-ray of the colon indicating colonic cancer does so with the elegance of a minimalist poet in the style of William Carlos Williams. Here is the appearance of a bitter fruit: There is an area of narrowing in the sigmoid. The under cut edges give an apple core appearance. This is colonic carcinoma. The doctor and writer Abraham Verghese writes about diagnostic acumen: ‘There are many distinct smells in medicine: the mousy, ammoniacal odour of liver failure … the urine-like odour of renal failure; the fecal odour of a lung abscess; the fruity odour of a diabetic coma’, using literary devices such as repetition (‘odour’), and sonorous devices including alliteration (‘failure’, ‘fecal’, ‘fruity’). This carries through to incantation, as if setting up a spell: ‘Smells registered in a primitive part of the brain, the ancient limbic system. I liked to think that from there they echoed and led me to think “typhoid” or “rheumatic fever” without ever being able to explain why. I taught students to avoid the “blink-of-an-eye” diagnosis, the snap judgment. But secretly, I trusted my primitive brain, trusted the animal snout.’

The lyrical mode

The switch in genre from the epic to the lyric again suggests a switch in metaphor and style: from the lecture to the song; from the individual to collaboration; from martial metaphors (curing) to pastoral metaphors

(caring); and from intolerance of ambiguity (dragon slaying) to tolerance of ambiguity (dialogue). Within the lyrical mode, we might find doctors seeing their work as Ballads, where the response to the patient is not blunt but tender and sensitive; or as Georgics, traditionally an ode to agriculture and the pastoral life, but in medicine perhaps a celebration and recognition of the fruits of hard labour. Eclogues (Bucolics), championed by Virgil, celebrate the mundane in work – finding the extraordinary in the ordinary. The everyday round of medical work is like this. Not the crash and bang of ‘boys’ medicine’ (accident and emergency or the operating theatre), but the slow pulse of the ward at night, the everyday symptoms brought to the general practitioner: colds and flu, sprains and knocks, a persistent pain, light anxiety and depression. Pindaric odes celebrate the feats of athletes, where attention shifts from heroic individualism and competition to collaboration, team games, echoing the need for doctors to sing the praises of the interprofessional clinical team. Epithalamia are songs in praise of the bride or bridegroom – the junior doctor loses her work virginity as she gradually gains expertise, undergoing a series of rites of passage. She learns ‘professional intimacy’ – typical of psychotherapy – with a range of patients whom she must accommodate, regardless of her personal feelings, managing disgust through counterresistance or erotic feelings through counter-transference. Finally, Epitaphs honour the deceased, where the doctor does not sing the praises of the dead white males of medicine, but rather, through her lyrical work, remembers patients who die, in a liturgy of clinical stories.

References 1 Bates V, Bleakley A and Goodman S (2014). Medicine, health and the arts: approaches to the medical humanities. Routledge: London. 2 Bleakley A (2014). The heart of the matter: patient-centered medicine in transition. Springer: Dordrecht. 3 Bleakley A, Marshall R and Levine D (2014: in press). ‘He drove forward with a yell: anger in medicine and Homer’. Medical Humanities. 4 Bleakley A, Marshall R and Broemer R (2006). ‘Toward an aesthetic medicine: developing a core medical humanities undergraduate curriculum’. Journal of Medical Humanities, 27, pp197–213. 5 Bleakley A and Marshall RJ (2012). ‘Can the science of communication inform the art of the medical humanities?’ Medical Education, 47, pp126–33.

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Reimagining our relationship with the microbial world: infection, antibiotic resistance and peaceful coexistence Mary Murray observes increasing anxiety about the threat of microbes. Embodied imagination, she says, can be used to encompass personal and collective fear of a real and specific bacterial threat, together with joy of connection with the invisible, holistic and health-giving eco-world.

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et me fascinate you with the resilience, sheer scale and beauty of the microbial world! Why? Because it is fundamental to the existence, survival and health of our species, and of the planet as a whole. I argue that we need a more conscious relationship with the invisible health-giving and illnessproducing nature of the world and we need to challenge the dominant war metaphor which describes and structures much of our collective relationship to microbes. The phenomenon of growing antibiotic resistance sharpens the urgency of transforming this relationship. Psychotherapy can contribute much to uncovering personal and collective

Mary Murray is a

pharmacist involved internationally in improving the use of medicines and developing national drug policies. In Australia, she was instrumental in developing the Quality Use of Medicines policy. She holds a PhD in cultural psychology and is the Global Network Coordinator of ReAct – Action on Antibiotic Resistance. Using ‘embodied imagination’, she works with scientists and artists, challenging the war metaphor in defining our relation to the microbial world.

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fear and anxiety about microbes, infection and associated symptoms, and perhaps to inducing a process of transformation of these states, particularly through using embodied imagination.

The value of microbes

Microorganisms make up over 80 per cent of the earth’s biomass – by weight. They are the major component of the biosphere and the oldest of all living species. Microbes are at the heart of the ecological systems critical to the functioning of the Earth’s life-support system. In 1997, these free eco-services were estimated to be worth US $33 trillion, three times that year’s global gross domestic product.1 Yet we know very little about them. Only 5,000 bacterial species have been named. One teaspoon of soil alone contains 4,000 to 10,000 species, 99 per cent of which remain undescribed.2 It is now thought that anywhere between five and 100 million species may exist. Over 99 per cent of microbes are not only harmless but positively needed for health. The human body is home to many indigenous microorganisms, with distinct communities found at different anatomical sites. 3 By the time we are a few years old, mature complex microbial communities have established themselves in our bowels and we carry these more or less our entire lives. Working as communities, evidence is emerging that they promote proper development of host organs, new capillary blood vessels, stimulate the development

of the immune system, provide nutrients, regulate fat storage and exclude potential pathogens.4 Jeremy Nicholson has shown how bodily fluids are filled with metabolites of intestinal bacteria and proposes that these gut microbes influence processes ranging from the metabolising of drugs and food to the subtle workings of brain chemistry. They are not random squatters but organised communities that evolve with us and are passed down from generation to generation.5

Who are we?

Bacteria in and on the body outnumber human cells by ten to one. So, who are we? We know that genomes capture only a part of who we are, but that part may have to take account of the genes of the collective communities of bacteria in the body, known as the microbiome. These are estimated to contribute 360 times more than the 22,000 genes each of us ‘owns’ from egg and sperm.6 The microbiome is now regarded as an organ of the body, weighing at least as much as other organs – about a kilogram. Bacteria have fascinating means of communicating with each other, within and across species, and across biological kingdoms – including with us. Bacteria can sense their population density using a stimulus-response system, called quorum sensing, allowing a coordinated collective response. The interaction of communities of microbes is probably much more important than the behavior of single bacterial species in health and disease. Certain body functions could be the result of negotiations between several partners, and diseases the

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result of small changes in group dynamics or of a breakdown in communication between symbiotic partners.7

A delicate system

Many of the organisms that cause illness in humans live quite happily within us in balance with a myriad of other organisms. Stanley Falkow calls these ‘commensal pathogens’. Something in this balance and/or in our immune system changes and disease results. Relatively few ‘foreign’ organisms literally jump across our defences and overwhelm us, plague being an example. The evolution of the immune system needs the ongoing stimulus of microbes to enable us to respond to those microbial species that cause infection. This delicate system works both by directly activating the means of destroying invading pathogens – those able to penetrate, survive and replicate in parts of the human body where others cannot – and by enhancing and promoting a complementary host-protective effect. So it is becoming clear that bacterial diversity and interaction is key for human and environmental health … it is not the one pathogen that we meet when we get sick that is the microbe we [should] worry about, it is our entire microbiome that determines health and disease, productivity

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of our crops, and all the different aspects of life that microbes manage … it is a sort of microbial blanket of the earth … there is no aspect of our planet that is separate from or unaffected by microbial life.8

The war metaphor

Compare the insights into microbes above with the predominant negative way in which microbes are perceived and portrayed. What drives the immense commercial success of antibacterial sprays, wipes and even antimicrobial wall paint available to sanitise our homes? Preventive measures such as public sanitation and hygiene, along with changed economic and social conditions in the 1800s, reduced death from infection. However, now, we seem vulnerable to undoing this achievement through the image of a completely sterile home. A war metaphor shapes our lives – bacteria the enemy and antibiotics the weapons. The war metaphor evolved in parallel with the development of the microscope and germ theory. Medicine succeeded in identifying individual pathogens involved in life-threatening infection and produced life-saving treatments. Penicillin increased the chance of survival of those with blood infections or pneumonia from 10 to 90 per cent. A steady stream of new antibiotics

kept coming, with the US Surgeon General predicting in 1967 that we would soon close the door on infectious disease. Massive human and animal use of antibiotics over the past 70 years has driven bacteria to create many ways to resist antibiotics. New genetic material is shared between and across species, including with the normal flora in the bowel. Thus, not only do bacteria spread but also resistance genes, accelerated by the global movement of people, food and animals. Some patients now have multi-resistant infections for which there are no effective antibiotics. No new antibiotic classes have been developed since 1987, making existing antibiotics a non-renewable resource. We need to release our imaginative capacities to invent approaches that do less collateral damage to health-giving bacteria.

What has this to do with psychotherapy?

It is as if our socialisation into living the war metaphor over the past 70 years and an associated sense of human power over microbes through antibiotics has masked a pre-existing deep fear of contagion, resulting in a collective contagious anxiety to get rid of bacteria altogether. We are over-concerned at home, paradoxically inattentive where we should be alert, such

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feature article as in hospitals, with no deep knowledge about how to act regarding the bacteria we should fear, nor appreciation of our essential dependence on microbes. We need more radical imagination to be able to encompass both personal and collective fear of a real and specific bacterial threat, together with joy of connection with the invisible, holistic and health-giving eco-world. Embodied imagination provides such a therapeutic tool, which may help uncover images of new paradigms of relationship with microbes.

Fear of germs

G, a 12-year-old boy, had had a two-year history of stomach ache following possible threadworm infection. Following sudden weight loss, nausea and anxiety, he stopped sucking his fingers for fear of germs, started washing his hands frequently and used a tissue to pick up food to avoid germs. Homeopathy treatment stopped the excessive hand washing and use of the tissue. However, the anxiety returned a year later, with abdominal pain when he focused on germs, and use of a tissue to handle food.

Courage and fear

Then G did a number of sandtrays. In week six, during a war between two armies, G identified one soldier holding a grenade. The soldier was feeling both courage and pride that he might win a medal – but also afraid that he might die. He felt pride in his chest and fear brought butterflies to the stomach. After ten sessions, G was eating with his fingers frequently and had a tiny bit of fear. The therapist suggested that he should be like a scientist exploring the germs, observing them closely. They are green and yellow dots of medium brightness. When I am frightened they are jumping around and they are shaky. At other times when I am calm they are still. When the therapist suggested bringing an attitude of friendliness to them, he said they are jumping up and down like they are happy. Subsequently, G could lick his fingers, his own sense of power and strength developed. He became more confidently interactive with his friends, more comfortable with angry feelings and able to say what he thought, even if not

“When I am happy, [the germs] are happy, when I am sad, they are sad. If I could speak to them I would tell them to go away” Keen to work on his ‘sensitive stomach’, G began seeing a therapist who used a combination of mindfulness, sand-play and embodied imagination. In the first session, she asked him to draw the germs. When I am happy, they are happy, when I am sad, they are sad. If I could speak to them I would tell them to go away. She asked him to think of a safe place. Using embodied imagination she established that he felt safe and happy in his bed at night and sensed that in his stomach. Asked what else he could see around the room, G noticed on the wall his drawing of a shark eating fish. The therapist guided him to ‘transit’ in to the shark. Transit is a term for allowing one’s full concentration to focus on the shark – its detail, its posture – until, through mimesis, the presence of the shark grows and the person is able to participate in the phenomenon of the shark, sense its intelligence and nature, while staying in dual consciousness. Shark is the king of the sea – ‘I am the best’ – powerful. I am eating fish. The following week he tried being brave and twice ate with his hands.

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positive. Anxiety about germs was re-rooted in a real fear – of dying – while G’s ability to tolerate dual feelings of courage and fear of dying (just) developed, with perhaps a hint of joy in germs. Other experiences with embodied imagination illustrate possibilities. One person developed the capacity to ‘companion’ his immune system, changing his embodied emotional relationship to his bowel and the path of his severe colitis. He became able to allow emotions to generate and find expression. He realised their power when ‘pushed down’ to his gut and on its resident microorganisms. A cutting-edge microbiologist explored image and the feeling of ‘being transported’ into the unknown world of a microorganism under study. Images in a subsequent dream awakened realisation that he had never viewed microorganisms without a strong sense that life and death mattered. Now able to sense the dance of microbes, what descriptions might emerge from research if he moves out of the perspective of the

physician and enters the embodied world of microbes?

Conclusion

Atrophy of the capacity to imagine is the breeding ground for self-inflicted misery. When old mythologies are corrupt and dysfunctional, one solution is to replace the ideas they symbolised by demonstrating their falseness, using the rationality of science. But for the psyche, the weakening of imagination is a trauma because what is lost in the imaginal realm can only be replaced by images, not by abstract concepts. Joy is a better teacher than pain – always.9 So might we say about infection, microbes and our immune system. We are living without images, trying to turn the concepts of science into something to live by. Without a new paradigm, a new mythology – without the capacity to imagine – a generalised anxiety about the threat of invisible microbes, symptoms and death robs us of our capacity to act, to adapt, to be an integral part of an ever-changing inventive ecosystem. Embodied imagination can help uncover images symbolising our intimate relationship, personal and collective, to the microbial world.

References 1 Constanza et al: www.nature.com/nature/ journal/v387/n6630/abs/387253a0.html 2 Michael Gillings: interview in Microbes and Metaphors report, 2011 3 Dethlefsen L, McFall-Ngai M and Relman DA (2007). ‘An ecological and evolutionary perspective on human-microbe mutualism and disease’. Nature, 18, 449 (7164), pp811-818. 4 Flint et al (2007). ‘Interactions and competition within the microbial community of the human colon: links between diet and health’. Environ Microbiol, 9(5), pp1101-1111; Tappenden and Deutsch (2007). ‘The physiological relevance of the intestinal microbiota--contributions to human health’. J Am Coll Nutr, 26(6), pp679S-83S; Cogen et al (2008). ‘Skin microbiota: a source of disease or defence?’ Br J Dermatol, 158(3), pp442-455. 5 Humphries C (2009). The Body Politic, feature, 14 April. Available at: http://seedmagazine.com/content/article/ the_body_politic/) 6 ‘NIH Human Microbiome Project defines normal bacterial makeup of the body’, June 2012. Available at: www.nih.gov/news/health/jun2012/ nhgri-13.htm 6 Humphries C: ibid. 8 Interview with Jo Handelsman, Yale University, by Satya Sivaraman and Mary Murray. To be published at www.microbiana.org 9 Paris G (2007). Wisdom of the psyche, p197.

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Perceptions of mental health Paul Farmer celebrates a positive shift in public attitudes to mental health.

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recently took part in the 25th anniversary of BBC Radio 4’s series All in the Mind, on a programme that looked back on perceptions of mental health over the past quarter century. It was a good opportunity to take stock and reflect on where we are really up to.

Discussed like never before

It’s an exciting time for the public profile of mental health, with lots of positive things to point to showing the progress we are making. MPs have spoken out in parliament, we are seeing increased and more accurate use of mental health as a subject for documentaries and soap storylines, and Mind recently took part in the launch of the City Mental Health Alliance in London to improve mental wellbeing and ‘mental health literacy’ in the banking, legal and accountancy sectors. Mental health is being discussed like never before, among people who typically might not have spoken up or thought much about it in the past. Yet, around the same time as the launch of the City Mental Health Alliance and World Mental Health Day in October, we saw inaccurate and stigmatising reporting in

Paul Farmer is

Chief Executive of Mind, the leading mental health charity working in England and Wales, and Chair of the Disability Charities Consortium. He is also Chair of the Equalities and Diversity Forum panel on human rights, Chair of the NHS England Mental Health Safety Board and a trustee of the Mental Health Providers Forum, an umbrella body for voluntary organisations supporting people with mental distress.

The Psychotherapist

The Sun about mental health and violence, while Asda and Tesco came under fire for selling a ‘mental patient’ Halloween costume. These incidents brought home to us how much we still have to do.

A turning tide

On a positive note, both cases led to productive discussions with The Sun and the supermarkets. In times gone by, I doubt we would have seen the same willingness to hold hands up and accept blame, and such readiness to make things right and engage with charities like Mind. The tide is most certainly turning. The reason any of this matters is because the way mental health is perceived publicly has a profound effect on how individual people with mental health problems perceive themselves and their mental health. As with physical health, early intervention is key, but stigma about mental health problems can make people reluctant to seek help, which makes recovery slower and more difficult and increases the risk that problems will reach crisis point.

Discrimination from GPs

Curiously, stigma around mental health also affects physical health. People with mental health problems tend to have poorer than average physical health but stigma means that these concerns are not always taken seriously. Almost half of people with mental health problems report discrimination from GPs who think physical problems are being imagined or made up. The impact of stigma is perhaps most damaging around the issue of violence and mental health. Violent acts by people with mental health problems are comparatively rare, yet media reporting of homicides by people with mental health problems creates the impression that people are being randomly attacked every other day. The idea that being mentally unwell makes people likely to attack strangers is so ingrained in

the national psyche that people believe themselves to be violent as a result. Mind, together with Rethink Mental Illness, runs the anti-stigma campaign Time to Change. A woman who attended one of these events last year said that when she was diagnosed with schizo-affective disorder one of her early thoughts was that she shouldn’t have children because she ‘must be violent’, although she hadn’t had any violent thoughts or done anything to hurt anyone. This kind of self-stigma can have a profound impact on a person’s life and the way they view and manage their condition.

Challenging attitudes; challenging behaviour

That’s why Time to Change is so important. Scotland and New Zealand have led the way with similar campaigns, but this is the first time England has benefited from a major, country-wide initiative. Launched publicly in 2009, the aim is to challenge attitudes and change behaviour around mental health problems. The campaign is aimed at people who know someone with a mental health problem – family, friends, colleagues or neighbours – but who don’t realise the impact their attitudes and behaviours can have or who don’t know what to say and do. Time to Change is built on the principle of ‘social contact’, so a lot of the campaign’s work is about creating opportunities for more members of the public to come into contact with people who are open about their mental health problems.

Improving attitudes

Attitudes towards mental health have been measured since 1994. Measurement takes the form of a survey in which people are asked to say how far they agree or disagree with a set of statements. The most recent data show that attitudes towards integrating people with mental illness into the community have improved since 1994. For example, agreement with ‘the best therapy for many people with mental illness is to be part of a normal community’ has increased from 76 to 81 per cent, and agreement with ‘no one has the right to exclude people with mental illness from their neighbourhood’ has increased from 76 to 83 per cent. There are specific challenges for some groups of course. In some communities, western ideas around mental health are

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feature article fairly meaningless and belief in possession and other spiritual forces prevail. This was highlighted by the winner of the 2013 Mind Media Award for Journalist of the Year, Catrin Nye. Her work for Newsnight and the BBC Asian Network highlighted the use of spiritual exorcisms in some south Asian communities in the UK, exposing how the use of spiritual practices can mean that mental health disorders are left untreated.

It can be hard enough to come to terms with the idea that your personality, which is core to who you are, is somehow ‘disordered’ but many of the diagnostic labels used are words with negative connotations that we use in everyday language to offend or hurt others. To be described as fundamentally ‘paranoid’, ‘antisocial’ or ‘dependent’, for example, can be difficult to bear and impacts on how you perceive yourself, your illness and how much you embrace and interact with services.

Moving to a better place

Engaging with communities that approach mental health in different ways can be a challenge for traditional services in the UK, but some of our local Minds are well placed to take a lead. Mind in Harrow, for example, serves a large Somali community, where high levels of stigma and low levels of understanding prevent people from seeking help. With funding from the Social Action Fund, Mind in Harrow has developed a peersupport service called ‘Hayaan’, which is a nomadic term in Somali meaning ‘moving to a better place’. The Hayaan project aims to reduce the isolation experienced by Somalis with mental health difficulties, increase the self-confidence of service users and provide advocacy and interpreting support to improve access to services. It’s been a huge success, reaching many more people than originally anticipated, recruiting more volunteers and delivering more hours of support to the local community than planned. In one feedback survey, 86 per cent of volunteers said they would be willing to continue offering support to their peers as a result of participation in the Hayaan project, a very positive response from a community in which mental health is highly stigmatised. As one ‘service user’ put it: ‘I thought all mentally ill Somalis were ‘crazy’ for life and now I see through Mind’s project that people can have depression or other conditions and can get better.’

A lifeline or a life sentence

Even in western medicine, opinion about the best approach to mental health is divided, highlighted in last year’s debate about the fifth edition of the Diagnostic and Statistical Manual. The range of views at a professional level is reflected too among those the manual seeks to diagnose – for some, diagnosis is a lifeline, for others a life sentence. Receiving a diagnosis can be extremely helpful, opening the door to appropriate

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Giving people a voice

One of the key things that came out of the All in the Mind special and, for me, the single biggest factor in the progress we have made in the past 25 years, is the importance of giving people a voice. We no longer hear only from professionals speaking on behalf of the people they treat.

Stephen Fry, President of Mind

treatment and aiding access to support and services, including benefits. Many report a sense of relief at finally being able to give a name to something they have been struggling with. However, with diagnosis comes the risk of misdiagnosis. Incorrect diagnosis has physical health implications, including side-effects from the wrong medication, and it can weaken a person’s faith in the professionals who are there to support them, causing many to give up on pursuing effective treatment that may help them recover.

Written off

For some, being labelled at all is problematic because of stigma. High-profile people such as our President, Stephen Fry, Ruby Wax and Frank Bruno may have helped to bring mental health out of the shadows and made some diagnoses easier to bear, but some mental health conditions remain misunderstood and attract ignorance and fear. Some diagnoses, such as personality disorders, are seen as especially unhelpful by some. We hear from people who, misdiagnosed with other conditions for many years, notice a significant shift from professionals when they are diagnosed with a personality disorder. It can be seen as a ‘last resort’ diagnosis, and the person can be written off as beyond help.

We are also seeing a reclaiming of the ‘mental patient’ label and a change in public perception. Thorpe Park recently came under fire for its Halloween-themed Asylum attraction in which visitors are chased through a maze by actors dressed as stereotypical ‘mental patients’. Thousands signed a petition calling for it to close, while the Royal College of Psychiatrists, the Lancet, Mind and others wrote an open letter to Thorpe Park’s management outlining why some might find it offensive. Part of their response was that the attraction had been running for a number of years without complaint. This misses the point – attitudes are changing and people with mental health problems are increasingly willing to speak out and challenge stigma in all areas of life.

A counter-narrative

What we see, read, watch and consume influences us deeply. For a long and sustained period, the only images of mental health were the fictionalised and the demonised. It’s interesting to note that attitudes to mental health didn’t get worse when the asylums closed, they got worse around the time of the Mental Health Act when politicians were pushing a narrative about violence in the popular press. It was a conscious choice, predominantly by the survivor movement, to provide a counternarrative and show the true face of mental health. I feel we are now at a point where the counter-narrative is starting to take over. The impact of this shift on people’s mental and physical health, wellbeing and quality of life cannot be overestimated.

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Healing fiction: spirituality and psychotherapy Therapists need to listen to their clients’ assertions of the spiritual with a new openness and an awareness of how this might lead to health rather than to madness asserts David Tacey.

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n important yet surprising generator of spirituality in today’s society is psychotherapy. The burgeoning field of ‘spirituality and health’1 is not, it seems, inspired primarily by therapists and clinicians but by suffering patients who bring the question of spirituality to the clinical setting. 2 The person suffering from a neurosis, mental illness, addiction or compulsive disorder tentatively expresses the view that a lack of ‘spiritual meaning’ might have something to do with their malady or despair. In our non-religious age, people often have inadequate language to express this sense of spiritual absence, but they grope toward it, using intuition, experience and whatever resources they can find, whether these are drawn from religion, popular music, movies or conversations with therapists and friends. Today we can speak of a clientled or grassroots recovery of the spiritual dimension in health and healing. 3 It is a sign that civilisation is in transition, that we have moved beyond the high watermark of secularism and perhaps live in a post-secular age.4

Bracketing out the spiritual

Clinicians are often sceptical of spirituality as they sense it is an attempt to escape from personal difficulties and emotional trauma. If one of the aims of therapy is to ground the patient in the real, and to work through

the emotional landscape, spirituality can be seen as an obstacle to the therapeutic process rather than a source of healing. Most of our healthcare professions and the discourses that support them have been shaped by a secular and humanist paradigm and a biopsychosocial model that has ignored or bracketed out the spiritual. Many therapists and clinicians have therefore had to do their spiritual training by themselves, or with small groups of like-minded people. Often it is a matter of individual discretion and self-tuition rather than formal training as such. But try as some might to get up to speed with the clientled demand for spiritual input in therapy, there is a ‘spirituality gap’ between patients and clinicians, which I have explored in The Spirituality Revolution and, most recently, Gods and Diseases.5 Psychiatrist Andrew Powell concedes: Patients’ attempts to talk about their spiritual beliefs and concerns are often met with incomprehension and mistrust. Sometimes the chaplain will be called in but frequently the patient will be advised not to dwell on such matters, or else will find those experiences dismissed as delusions or hallucinations.6 Such attitudes, designed to protect the client from delusion, might rather express a desire to protect the professions from the trespass of spirituality on their terrain. The challenge of the spiritual might be too hard to cope with, especially if the

David Tacey is Professor of Literature at La Trobe University in

PHOTO: SANTI FOX

The Psychotherapist

Melbourne, Australia. His books on Jung include: How to Read Jung (2006), The Idea of the Numinous (2006), Jung and the New Age (2001), The Jung Reader (2012) and The Darkening Spirit: Jung, Spirituality, Religion (2013). Other works include: Gods and Diseases: Making Sense of Our Physical and Mental Wellbeing (2012) and The Spirituality Revolution (2004).

therapist lacks training in this area and no longer feels competent or in control. Despite an absence of appropriate training in spirituality for therapists, some organisations are turning their backs on the negative views of the past and espousing an affirmative attitude towards spirituality. For instance, the Royal College of Psychiatry makes this statement on its official website: Spirituality involves a dimension of human experience that psychiatrists are increasingly interested in, because of its potential benefits to mental health.7

A renewed relationship with reality

Although I am prepared to admit that some spiritualities are pathological, there are forms of spirituality that bring people into fuller health and renewed relationship with reality.8 Spirituality is an umbrella term, designating a vast range of activities which have to do with the life of the mind and spirit. The clientcentred therapist has to ascertain what spirituality means for the individual client, and whether it might connect him or her with sources of power or renewal, or whether it beckons the client away from reality towards a world of illusion. There has to be receptivity to the particular case, a sensitivity that reaches out to the suffering patient and empathises with their condition and search.9 The clientcentred therapist has to learn to go along with this drift into spiritual discourse, even if he or she does not fully comprehend its meaning. If the spiritual has been raised as part of the healing process, there should be some acknowledgement that this element has crept into the clinical setting, even if it makes both parties embarrassed owing to the prevailing secular paradigm. Therapists are forced to

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feature article “It is far more the urgent psychic problems of patients, rather than the curiosity of research workers, that have given effective impetus to the recent developments in medical psychology and psychotherapy.”  CG JUNG10 listen to the stories about the spiritual with a new openness about how they might lead to health rather than to madness.

Experiencing deeper meaning

Spirituality seems to be the new, favoured term for ‘meaning’ and, in asking for spirituality, patients are not always referring to anything supernatural but to an experience of deeper meaning. This kind of meaning has something to do with making contact with forces in the psyche that promote growth and healing. The prevailing idea, which is a return to the ‘perennial philosophy’, is that there is an authentic place where our personal lives meet and interact with transpersonal forces. These are popular analogues to Jung’s idea of ‘archetypes’, and the hope or expectation is that therapy will open a doorway to this hidden citadel and expedite healing and recovery. Even if the therapist does not ‘believe’ in such forces, or in the idea of an ‘inner self’, attending to this encounter with sensitivity and care can be salutary. How is this contact achieved? Primarily through imagination and the creative process as expressed in visualisations, dreams, images, metaphors and symbols. These are the conduits to what Bion calls the ‘memoirs of the future’. A pragmatic therapist might be too sceptical to tolerate much of this, but if he or she is trained in psychodynamic theory, he or she will recognise that imagination is a powerful ally in the therapeutic process.

A deeper layer

What we do not yet understand in the west is that ‘deep subjectivity’ is not entirely subjective. We do not yet comprehend what the east means by ‘universal mind’. We see the mind as shaped by individual experience, which of course it is, but there is a deeper layer which allows access to the realm in earlier times referred to as the realm of gods, spirits or daimonia. The depths of self may contain, as western mystical theology attests, objective powers or forces, which the therapist’s worldview will not allow. This is why ‘negative capability’ can be useful. Jung was one of the first psychiatrists to appreciate

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the role of spirituality in healing, and to accept that ‘spirituality’ does not mean an internalisation of religious dogma but a receptive attitude to the presence of mystery in the psyche. He was aware that imagination was crucial in the establishment of what he called a ‘symbolic attitude’. Jung defined the symbolic attitude as that which ‘assigns meaning to events, whether great or small, and attaches to this meaning a greater value than to bare facts’.11 Lack of meaning can make us physically sick and mentally disturbed. ‘Meaning’ may seem inconsequential and may be discounted as ‘only imagination’. But Jung is convinced that meaning has been underestimated in the approach to disease: But ‘meaning’ is something mental or spiritual. Call it a fiction if you like. Nevertheless this fiction enables us to influence the course of the disease far more effectively than we could with chemical preparations. Indeed, we can even influence the biochemical processes of the body. Whether the fiction forms itself in me spontaneously or reaches me from outside via human speech, it can make me ill or cure me. Fictions, illusions, opinions are perhaps the most intangible and unreal things we can think of, yet they are the most effective of all in the psychic and even the psychophysical realm.12 Jung goes on to describe this ‘fiction’ as ‘healing fiction’ and as ‘the meaning that quickens’. It quickens the body, mind and spirit because the person feels connected to the world and no longer sealed off inside an alienated ego. The meaning that quickens is the bread by which the psyche is nourished and the state of alienation overcome. Such meanings seem like illusions to the rational intellect but act as a balm to the soul and a cure to our search for justification and purpose.

Nature, others, cosmos and spirit

The symbolic attitude, developed through a cultivated imagination, admits the possibility that universal forces impact on our lives and shape our experience. While such forces are subjectively experienced,

they are not reducible to subjectivity. But taking these forces literally as occult powers or supernatural beings may be the prelude to schizophrenia. Imagination plays an important role in keeping them metaphorical rather than literal. The forces may be real, but our conceptualisation of their reality is always provisional. Metaphorical awareness of these forces can lead to a life-enhancing mysticism that brings wholeness and vitality. To a secular mind, the forces are merely anthropomorphic projections of the human mind, but to the patient in search of healing, they can form the basis of a new self that is connected to nature, others, cosmos and spirit. This is often referred to as ‘rebirth’, an experience that has become debased and vulgarised by fundamentalism but is an incredibly real possibility for a person in search of healing. Spirituality struggles for credibility in our world, and its proximity to schizophrenia and mental disturbance has to be acknowledged. When I was a boy, a common saying in the schoolyard ran: ‘A person who talks to God is spiritual, but a person to whom God talks back is schizophrenic’. Spirituality and schizophrenia are both limit-experiences, where ‘normality’ is dissolved in the experience of another dimension. But the difference is determined by the kind of consciousness that experiences the other dimension. If the ego can remain intact, and not be blasted to pieces or overwhelmed by inflation, the encounter can be positive. How we relate to archetypal forces determines whether we achieve authentic selfhood, or whether we succumb to psychosis and madness.

Spirit and body in dynamic relationship

My book Gods and Diseases represents an attempt to bring Jung’s work into the twenty-first century. It tries to connect his theory of archetypes with what is going on now in the field of spirituality and health. Some remain unaware that Jung was the first healer in modern times to bring spirit and body into dynamic relationship. In 1929,

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he announced, to an uncomprehending public, that ‘the gods have become diseases’: We are still as much possessed by autonomous psychic contents as if they were Olympians. Today they are called phobias, obsessions, and so forth; in a word, neurotic symptoms. The gods have become diseases; Zeus no longer rules Olympus but rather the solar plexus, and produces curious specimens for the doctor’s consulting room, or disorders the brains of politicians and journalists who unwittingly let loose psychic epidemics on the world.13 The archetypal forces or ‘gods’ are not acknowledged today, and seem to have no other option than to become disturbances. They are shunned by our intellects and by scientific reason. The only way they can express themselves is through our bodies, sufferings, symptoms and sexual disturbances. This is why the clinical setting is a likely place for the ‘rebirth of the gods’

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in a secular time. Few of us want to be beset by gods, or deal with forces that move beyond our subjectivity. But those who want to manage suffering are often aware that a rapprochement with sacred forces can bring healing, even if our present model of reality will not allow it. This is why ‘spirituality’ is emerging at the grassroots level and urging the healing professions to take note.

References 1 The extent and growth of this field is discussed in Mark Cobb, Christina Puchalski and Bruce Rumbold (eds) (2012). Oxford textbook of spirituality in healthcare. Oxford: Oxford University Press. 2 Roach SM (1997) Caring from the heart: the convergence of caring and spirituality. New York: Paulist Press. 3 Swinton J (2001). Spirituality and mental health care: rediscovering a ‘forgotten’ dimension. London and Philadelphia: Jessica Kingsley. 4 The post-secular condition is explored in Caputo J (2001). ‘How the secular world

became post-secular’. In On religion. London: Routledge, 2001. 5 Tacey D (2003/2004). The spirituality revolution: the emergence of contemporary spirituality. Sydney: Harper Collins; London & New York: Routledge; and Tacey D (2011/2012). Gods and diseases: making sense of our physical and mental wellbeing. Sydney: Harper Collins; London & New York: Routledge. 6 Powell A (2005). ‘Spirituality, healing and the mind’, Spirituality and Health International, 6:3,p167. 7 Royal College of Psychiatry (2009).‘Spirituality and mental health’. Available at: www.rcpsych.ac.uk/ mentalhealthinfo/treatments/spirituality.aspx 8 Koenig HG (2002). Spirituality in patient care. Philadelphia and London: Templeton Foundation Press. 9 Orchard H (ed) (2001). Spirituality in health care contexts. Philadelphia: Jessica Kingsley. 10 Jung CG (1932/1969).‘Psychotherapists or the clergy’. In The collected works of CG Jung, 11. London: Routledge, p488. 11 Jung CG (1921/1971). ‘Definitions: symbol’, Psychological types. The collected works of CG Jung, 6. Princeton University Press, p819. 12 Jung CG ‘Psychotherapists or the clergy’, p494. 13 Jung, CG (1929).‘Commentary on “The secret of the golden flower”’, CW, 13, p54.

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Beauty, God, death, evil:

resources of the doctor’s personality and not technical tricks’.

CBT and psychopharma­cology are reductive and inadequate approaches to sets of symptoms, asserts Stephen Diamond. We should honour and acknowledge the liberating roles of beauty, God, death and evil in a ‘real’ psychotherapy.

Clearly, psychotherapy of any sort depends partly on specific techniques, methods and interventions. But, from the perspective of existential therapy, the use of such techniques must always be secondary to the ‘working alliance’ between patient and therapist, which is the common healing factor in all forms of psychotherapy. Typically, the specific symptoms presented by patients are not the real problem but rather represent, symbolise, express or mask a more fundamental underlying intrapsychic, interpersonal, sexual, existential or spiritual conflict or conundrum.

re-imagining real psychotherapy

T

ake a moment to try this mental exercise: when you think about psychotherapy today, how do you imagine it? For clinicians, this will depend in part on your particular therapeutic orientation. Or perhaps on your own personal experience in therapy. Most psychotherapists today are trained to take a technical approach to treatment. CBT is a prime example of this standardised, technique-driven type of therapy designed to reduce or suppress a patient’s symptoms and suffering as quickly and economically as possible. Psychopharmacology – the mainstay of contemporary psychiatric treatment – is another symptomcentred, suppressive approach to treatment. For many, including insurance companies and national mental health programmes, this sterile, mechanistic postmodern mix of CBT and medication is how psychotherapy is imagined today.

Is there any room left?

Outcome studies support the efficacy of this two-pronged biocognitive-behavioural, ‘evidence-based’ approach, though other research shows that all forms of psychotherapy are equally effective. And that some, like psychodynamic therapy, can provide more enduring benefits than

either CBT or medication. But does either of these images accurately convey what psychotherapy is really about? To be sure, timely pharmaceutical relief of intolerable and crippling psychiatric symptoms is practical, precious and sometimes lifesaving. Problematic behaviours, irrational thought processes and distorted beliefs about ourselves and the world must be directly challenged. But should that be the end goal or merely the starting point of psychotherapy? Is there any room or reason left in the therapy process to even imagine musing about esoteric subjects such as beauty, God, death or evil? One of my former mentors, existential analyst Rollo May, passionately argued that real psychotherapy should be less about technique, or what he pejoratively called ‘gimmicks’ designed to superficially subdue symptoms, than about enhancing and liberating the patient’s capacity to feel, experience, imagine, create, make meaning, and to become more receptive, accepting and appreciative of life and love, in their positive and negative aspects. These days, this is a radically different way of imagining the very nature, significance and purpose of psychotherapy. In this sense, May’s existential analytic orientation towards therapy is closely related to that of Jung, who quipped that psychotherapy ‘demands all the

Stephen Diamond PhD is a clinical and forensic

psychologist, a former pupil and protégé of Rollo May, and author of Anger, Madness, and the Daimonic. He practises psychotherapy in the Beverly Hills area of California and is a resident faculty member in the Department of Psychology at both Argosy University and Ryokan College in Los Angeles. He serves on the board of editors of the Journal of Humanistic Psychology.

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The working alliance

Freud was the first to formally recognise this fact and developed his own still controversial theory and practice (psychoanalysis) to explain the intrapsychic source (at first sexual, later including aggression) of these symptoms. One of Freud’s most ingenious methods devised to disclose such ‘unconscious’ conflicts was ‘free association’. For Freud, the whole point of free association was to tap into imagination and fantasy in order to access and help make what was unconscious more conscious. Jung made even more creative use of imagination in his approach (analytical psychology), especially with his technique called ‘active imagination’, where patients were encouraged to imagine themselves actually engaging in dialogue with various aspects of their own dissociated or underdeveloped psyche.

‘Real’ psychotherapy

Consider the following scenario: the patient starts spontaneously ‘free associating’, speaking not of implicit or explicit conflict or trauma, nor of specific symptoms, or interpersonal problems, but of ‘big’ topics like beauty, God, death and evil. Is this still considered psychotherapy? Some might say such subjects are inappropriate and superfluous – perhaps even taboo – in today’s highly medicalised, symptomdriven, efficiency-minded mental health marketplace, and must be discouraged. But I wonder whether any treatment that devalues and excludes such archetypal spiritual or existential issues can be considered ‘real’ psychotherapy. Imagine what real psychotherapy might look like. Would you be comfortable listening to and even encouraging your client to speak freely of such concerns? Might you consciously or

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unconsciously change the subject, steering the conversation into some more rational, pragmatic, ‘clinical’ direction? In his semi-autobiographical book My Quest for Beauty, Rollo May relates his own rediscovery of beauty and its therapeutic power. Finding himself as a young man alone in a foreign culture for the first time and in the throes of a debilitating depression or ‘nervous breakdown’, really an existential crisis, May stumbles upon a gorgeous sea of wild poppies. He suddenly experiences a life-altering epiphany: ‘I realised that I had not listened to my inner voice, which had tried to talk to me about beauty. I had been too hard-working, too ‘principled’ to spend time merely looking at flowers! It seems it had taken a collapse of my whole former way of life for this voice to make itself heard.’ This momentous reawakening to the wonder, awe and majesty of beauty helped free him from his funk and propel him toward a new, less regimented and more meaningful creative life. It transformed his destiny.

Losing touch with beauty

This is sometimes a problem in seekers of psychotherapy: they have lost touch with their transcendent sense of mystery, wonder and beauty. May (1985) shares the following excerpt from a psychotherapy session with a woman who, until this point, had been exclusively focused on her painful marital problems: ‘I stopped my car on the way here to look at the twilight. It was just beautiful, the purple hues with green hills behind them … it is the most beautiful time of day … I don’t believe in a God, at least in a personal God, there is so much evil in the world, it makes it so pointless. But when I see such beauty, I can’t believe it is by accident … This time of day would be a good time to die, a

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good time to be alone … I would like to die at this time … It is so peaceful here in your office … I keep noticing the beauty outside the window.’ Beauty, writes May, ‘is serene and at the same time exhilarating; it increases one’s sense of being alive’. The beauty of nature, for example, can inspire a profound sense of inner peace, joy, wonder and awe, helping to place our petty daily problems or even catastrophic life crises into cosmic perspective. Of course, this holds equally true for our capacity to imagine beauty, even in the midst of misery, suffering, ugliness and despair. Some might find this patient’s talk of beauty, God, death and evil evasive, possibly a manifestation of what Freud referred to as ‘resistance’. Indeed, the patient herself, recounts May, ‘expressed her fear that she had said nothing today, maybe it was all superficial talk. I assured her that no topics could be more important than beauty, God, death.’

The existential significance of symptoms

Psychotherapy is really about helping people to understand the psychological, existential or spiritual significance of their symptoms, and what these symptoms or behaviours say about them, their choices, values, self-esteem, motivations and way of life. Symptoms commonly abate as their root causes and psychological significance are understood, worked through and resolved. We will always have problems. Psychotherapy, therefore, is not just about solving problems. It is about accompanying patients through and, whenever practically possible, beyond their personal demon-filled hell toward finding and fulfilling their destiny, or, at least, getting them back on that path.

The goal of real psychotherapy is to help the patient learn to stand on his or her own feet, to face and accept the stark existential facts of life – difficulties, struggles, suffering, disease, meaninglessness, loss, loneliness, frustration, disappointment, evil, illness, death – with dignity and courage, while being fully present to the sublime pleasures, wonders and beauty of existence. It is about becoming more authentic and embracing, both in imagination and outer reality, the hideous and beauteous, divine and diabolic, destructive and creative polarities of life. The kind of real therapy I am describing has less to do with the duration, frequency or cost of treatment than with how the psychotherapist and patient imagine the nature and purpose of therapy itself.

Inner strength, resilience and stability

People have an innate need to ponder life’s awesome mysteries, to play creatively and with close attention to their fertile imagination. Imagination is also where our innate potentiality for evil and destructiveness, what May (1969) called the ‘daimonic’, is played out, consciously or unconsciously. If patients are permitted to consciously explore their destructive cognitions, affects and impulsions in their fantasies, dreams and imaginations, there is less danger of them feeling driven to unconsciously act out these evil deeds in outer reality. Real psychotherapy gives patients the opportunity to grapple with these thorny issues – which are often closely, though unconsciously, connected to their presenting problems, complaints and symptoms. The aim of real therapy is to assist patients in finding their own philosophical or spiritual perspective, so as to deal with present and future problems from a position of inner strength, resilience and stability. This is a far cry from what passes for therapy today. If psychotherapy persists in being perceived as a prescribed, predetermined, mechanistic cookbook of techniques designed solely to rapidly reduce, suppress or eliminate troublesome symptoms or behaviours, such vital and animating subjects as God, death, beauty and evil will increasingly seem moot. Patients receiving such severely limited and unimaginative treatment are deprived of a much-needed opportunity to grapple imaginatively with what philosopher Paul Tillich called ‘ultimate concerns’. The collective consequence of this denigrated need to exercise the imagination

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feature article in confronting life’s existential mysteries can be found in our fascination with UFOs, spirits, ghosts, demons, Satanism, ancient astronauts, alien abduction, reincarnation, psychics, mediums and magic, as well as in our dreams and the fantastically imaginative delusions and hallucinations of psychosis.

Existential depth psychology

Curiously, over the years, my own approach to therapy, which I dub ‘existential depth psychology’, has been described by more than one critic as ‘cognitive’. I take no offence. Any effective psychotherapy must deal with cognitions, thoughts, ideas. The crucial question is which cognitive phenomena are worthy to work with, and what exactly is done with them in therapy. And which kinds of cognitions are devalued, avoided or rejected out of hand. The greatest weakness of CBT may be its hyper-rationalistic refusal to recognise the human necessity and clinical importance of consciously contemplating these ‘irrational’ mysteries; its pseudoscientific insistence on discounting or excluding such philosophical or spiritual cognitions from the consulting room; and its obsession with technical tricks intended to alter and suppress rather than honour and encourage pondering these spiritual and existential questions. We exist today in a therapeutic culture that subtly discourages speaking about these soulful matters, to the sad detriment of patients, psychotherapy and society. If we can start to recognise, respect and appreciate the pragmatic clinical value, power and relevance of engaging in subjects that spark the meaning-making imagination as they arise in treatment then maybe psychotherapy – real psychotherapy – has some chance of surviving. The prognosis seems poor but is not hopeless. For this recovery to happen, we must be ready to re-imagine moving toward a renewed and reinvigorated real psychotherapy. Imagination is always the first and crucial step toward creating the future.

References Diamond SA (1996). Anger, madness, and the daimonic: The psychological genesis of violence, evil, and creativity. Foreword by Rollo May. Albany, NY: State University of New York Press. Jung CG (1970). ‘Civilization in transition’. In The collected works of CG Jung, vol 10. Princeton, NJ: Princeton University Press. May R (1985). My quest for beauty. San Francisco: Saybrook. May R (1969). Love and will. New York: WW Norton. Tillich P (1952). The courage to be. New Haven: Yale University Press.

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Contemporary psychosomatics and non-verbaltechniques A sensitive and flexible understanding of the psyche–body phenomenon is the basis for effective clinical work, asserts Denise Ramos, permitting the development of interdisciplinary holistic practice.

W

e have crossed into the twenty-first century with the intriguing question of how psyche and body relate to one another still largely unanswered. Many attempts have been made, including by Freud. He tried in 1895 to construct a neuroscientific model of the mind but was obliged to give up when he realised that most of the fundamental concepts on which he based his ideas amounted to mere speculation (Solms 1998).

Functioning of the organism

Today, the advance of neurosciences and the development of sophisticated measurements enable us to observe with greater technical precision how stress and psychic disorders affect the functioning of the organism and vice versa, and a new approach to the relationship between psychology and biology is beginning to appear. As early as 1936, Jung stated in a lecture given at Harvard University that ‘although psychology claims for its own rights in its special field of research, it has to admit that there is a close

correspondence between its data and ‘the data presented by biology’ (Jung, CW 8, para 232). Nonetheless, difficulties in observation and the lack of a holistic theory enabling a unified reasoning for the various levels of our being have been the major obstacles in this area. The hope that neurology and the cognitive sciences would resolve the situation unquestionably was a new reductionist way of facing the problem. Without disregarding the importance of the new discoveries in the area, reducing the psyche to a chain of physiological reactions is quite unsatisfactory. It is like saying that music and the piano are of the same order of grandeur.

A holistic model

A brief reflection is sufficient to observe that analytical psychology presents us with a full description of the bases for the new paradigm. Although Jung did not contribute in a direct manner to this controversy, the principles of the holistic model are already to be found in the psychotherapeutic theory and method that he proposed. The earliest tests of

Denise Ramos PhD is a Jungian analyst and a professor at Pontifícia Universidade Católica de São Paulo, where she coordinates the graduation programme in clinical psychology. She has been the Vice-President of the International Association for Analytical Psychology, is the author of several articles and books on psychosomatics and has lectured in Europe and USA. She is currently involved in research on non-verbal psychotherapeutic techniques, psychoneuroimmunology and trauma.

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feature article word association, developed by Jung in 1902, demonstrated that the emotions and psychic phenomena have a physiological correlate. He showed that the constellation of a complex provokes a simultaneous alteration on both the physiological and psychological level, irrespective of whether the individual notices these alterations. Complexes are mostly responsible for the formation of symptoms. Jung defined them as ‘a collection of imaginings, which, in consequence of this autonomy, is relatively independent of the central control of the consciousness and at any moment liable to bend or cross the intentions of the individual’ (Jung, CW 2, para 1352). The core of the complex is a painful or traumatic conflict that upsets the nervous system and disturbs the systems that are not under the control of the superior brain structures. According to Kolk, ‘traumatic memories come back as emotional and sensory states with little verbal representations’ (Kolk 2007: 296).

Muscular contraction

It is noticeable that profound existential or traumatic situations can provoke unconscious emotional and organic excitability, which cannot be expressed on the verbal, abstract level. This excitation, a reaction either to freeze or ‘fight or flight’ from some threatening stimulus or strong emotional charge, stays fixed in the organism as a muscular contraction. It provokes a hormonal alteration or lowering of the efficacy of the immunological system, which, for example, makes the system more vulnerable and prone to illness. The different individual reactions to adverse stimuli, however, are important and depend partly on the structure and dynamic of the personality. External or internal events can stir incoherent reactions when they stimulate or touch a complex. They can trigger intense physiological reactions when they ‘reproduce’ the central dynamics of the complex. Accordingly, a seemingly harmless stimulus can be transduced by the organism as adverse and menacing, thereby producing a rupture of the organism’s homeostasis. By transduction we mean the conversion or transformation of information from one form to another. We know that the basic function of the sensorial systems is to perform the transduction of the information contained in the external or internal environment to the language of the nervous system. This

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enables the individual to use this codified information in the perceptual or functional control operations called for at each and every moment. Different mechanisms of synaptic integration engage in action throughout this chain of transmission to enable an analysis of the various attributes of the stimuli. Subsequently, they can be used in other physiological processes or to mentally reconstruct the objects (Alberts 1994; Rossi 1986).

Codify, process and transmit

If we envisage the human body as a network of informative, genetic, immunological, hormonal and other systems, we see that each one of them has its own code. Transmitting information among the various systems requires some type of transducer to allow the code of a system to be transposed to the code of another system. The capacity to symbolise in linguistic or extra-linguistic fashion can also be considered as a way to codify, process and transmit information related to the organism from the psyche to the soma and vice versa (Rossi 1986). The sight or smell of a positive stimulus, for instance, will set off a chain reaction of transductions that will possibly lead to a sensation of pleasure and homeostasis, whereas a negative stimulus is transduced into physiological alterations that are responded to with alarm and stress. Once the danger is over, normally the organism returns to its homeostatic state. Often this psychophysiological excitation, which is initially protective, is not registered in consciousness. It can occur dissociated from any perceiving subject, who may feel discomfort or a vague physiological sensation of pain without relating this to the triggering event. In the case where there is an overexcited or aggressive reaction incompatible with the reality, it is likely that the dynamism of a complex is at play.

Working at the physiological and corporal level The dilemma for us psychotherapists is how to reach these organic, unconscious levels where words have no effect because the excitation is registered on primitive regions of the cerebral structure. If the disorder is psychophysiological, the language is that of sensation and motor functions, which obliges us to work on the physiological and corporal level, as well as with non-verbal expressive symbolism. Once the lesion is fixed in preverbal structures, we will

hardly be able to provoke alterations using psychoanalytical techniques. Pierre Marty himself, founder of the Psychosomatic School of Paris, proposes to psychoanalysts a therapeutic non-psychoanalytical form of work. According to him, somatisation does not have a symbolic significance and is but a signal of a dysfunction (Ramos 2004). However, unlike the psychoanalytical school, Jungian understanding of the symbol allows for a new approach to the psychosomatic phenomenon. Here the word ‘symbol’ is understood in its etymological sense, derived from the Greek synballein (syn, together + ballein, throw), meaning a joining of opposites, throwing together the known and the unknown; the unconscious. Insofar as symbol implies the union of something conscious with something unconscious, it always provokes emotion, that is to say, a ‘movement outwards’ (e+motion), a movement of the vegetative, sympathetic and parasympathetic nervous system. Working on the non-verbal symbolic level, we can transduce the organic polarity of the symptom to the verbal, conscious level.

Defensive mechanisms built around a complex

The following clinical case illustrates this approach. A 46-year-old patient suffering from gastritis, and already operated on for a duodenal ulcer, sought out an analyst on account of uncontrolled anxiety. He underwent fits of rage that he justified citing the improper behaviour of others. His difficulty in tolerating anything that caused him annoyance involved him in many conflicts. These at times ended up with him in hospital with stomach pains. His extremely violent parents had abandoned him. They caused constant psychological abuse that led to defensive mechanisms being built around a complex. This traumatic complex made apparently inoffensive episodes take on enormous dimensions since they touched an unconscious conflict and provoked an excitation that could not be verbalised. This evoked a generalised commotion transduced by the autonomous nervous system as a threat to life. In this case, verbal arguments or interpretations were innocuous, failing to reach the lower layers of his organism, which reacted with alarm. While working with the sand-play technique, the patient broke into tears on sinking his hands into the sand. Regressive behaviour made him want to ‘get inside’

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feature article “Drinking milk was an unconscious way to ‘calm down with his good mother’ the rage and terror he felt.”

the sand because, in his childhood, the beach was a warm place where he could hide from the family squabbles. The patient also liked to use a straw to drink chocolate from a little bottle: a clear allusion to the lack of maternal milk. He said that this calmed him down, despite the doctor’s recommendation that milk could worsen his symptoms. He drew his stomach as a place that bled and hurt. In one exercise of imagination he asked it why it hurt and the answer was ‘fear, anger and impotence’. It bled because he was afraid of his violent father. He then remembered the beating that his little sister took: watching this scene without moving while thinking that he would be next made him freeze. He could neither flee nor fight. Drinking milk was an unconscious way to ‘calm down with his good mother’ the rage and terror he felt.

Holding in consciousness

In therapy, the psychophysiological excitation had to be transduced from the organic to the conscious level, from the right hemisphere to the left, using non-verbal techniques. Little by little, the patient managed first of all to identify the excitation and the triggering stimuli in his body. Subsequently he transduced his suffering into images and then into words so as to hold it in his consciousness. The excitation that had remained stagnant in one of his somatic systems, being repeated compulsively, gradually subsided. The gastritis was a symbol that expressed his consternation: he could not ‘swallow’ the offences and rejections. His digestive system reacted angrily to the ‘intruders who wanted to destroy him’. Here we hold the key to psychosomatics: by observing the symptom as the best expression that his organism produced to defend itself from suffering – a non-verbal symbol – we reached the profound organic layers that were inaccessible to consciousness. Sick or healthy creative productions are symbolic productions, for they bring to the surface unknown material that provokes emotions not controlled by consciousness. Although we lack the space here to delve further into the psychoneurological bases of this approach, it is crucial to observe that

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‘therapeutic interventions that enhance neural integration and collaborative interhemisphere function may be especially helpful in moving unresolved traumatic states toward resolution’ (Solomon and Siegel 2003:15).

Transduction between different systems By promoting holistic reasoning, compatible with theories from other fields of knowledge, Jungian psychosomatics enables deep psychodynamic reflection on the phenomena related to the healthy functioning of human beings. So we may say that all illnesses are psychosomatic, regardless of their physical, organic or emotional causality. When poorly adapted psychophysiological mechanisms cause an individual to suffer, he/she can fall ill. In this way he/she may express his/her suffering more emphatically, either in organic or psychic polarity. Techniques that facilitate transduction between the different systems can intervene in the process of sickness and health, even when the cause is explicitly external. Skin cancer as a result of exposure to the sun, for example, lies inside an organism with a psyche that reacts to it. Among the techniques that have been most useful in the process of transduction are expressive modalities such as painting and pottery, active imagination and sand-play therapy.

In conclusion, understanding the psyche– body phenomenon and the use of expressive and imaginative techniques are the bases of efficacious clinical work. They promote and permit the work of interdisciplinary teams that develop holistic health practices derived from different spheres of scientific knowledge.

References Albertz B (1994). Molecular biology of the cell. New York: Garland Science. Jung CG. The collected works of Carl G Jung. London: Routledge & Kegan Paul. Jung CG (1972). The structure and dynamics of the psyche. CW, 8. Jung CG (1973). Experimental researches. CW: 2. Ramos DG (2004). The psyche of the body. Hover: Brunner-Routledge. Rossi EL (1986). The psychobiology of mind–body relationship. New York: WW Norton. Solms M (1998). ‘Before and after Freud’s project’. Annals of the New York Academy of Sciences, 843, pp1–10. Solomon M and Siegel D (2003). Healing trauma. New York: WW Norton.

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The shirt of Nessus Using mythology to point out the limitations of ‘reason’ as a way of understanding the world, Patrick Harpur asserts that psychotherapy sees through the eye, not simply with the eye, to the points where we are blocked and the path to soul health.

S

ince the Enlightenment, we have been held up by the belief that our chief faculty is reason. It was not long before this belief congealed into an ideology, rationalism, which, together with the rise of the nineteenth century ideology, materialism, forms the prevailing orthodoxy of scientism. But there is another tradition, which asserts that the chief faculty of the soul is imagination. During much of the past 2,000 years this tradition has run underground, kept alive by odd poets and errant alchemists. But whenever it has broken the surface, it has always been accompanied by an efflorescence of imaginative life: among the Hermetic philosophers, Gnostics and Neoplatonists of second and third century Alexandria, for example; among the great renaissance magi from Marsilio Ficino

to Jacob Boehme (to say nothing of Shakespeare); among the German Romantic thinkers and their poetic English counterparts, from William Blake and ST Coleridge to WB Yeats, TS Eliot and Ted Hughes. It even found its way, via CG Jung and James Hillman, into depth psychology.

The living power of human perception

It ought not to be necessary to add that imagination has come to mean almost the opposite of its traditional sense. We tend to think of it as the ability to ‘make things up’ – what Blake and Coleridge called mere fantasy – or the ability to picture things which are not present to the senses. But imagination in the true sense is an autonomous self-generating realm, an Otherworld, ‘an alien country outside the ego’, as Jung called it; or, as Coleridge more thunderously put it, ‘the living power

Patrick Harpur is the author of an alchemical treatise,

PHOTO: CAROLINE FORBES

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Mercurius; or, the Marriage of Heaven and Earth. Other publications include: Daimonic Reality, a study of visions, apparitions and otherworld journeys; The Philosophers’ Secret Fire, a history of the imagination; and the rather ambitiously titled A Complete Guide to the Soul. His latest book is The Savoy Truffle, a highly autobiographical, darkly comic novel set in the home counties of the early 1960s.

and prime agent of all human perception, and … a repetition in the finite mind of the eternal I AM’. It is quite separate from what we think of as ourselves, and peopled by those archetypal personages we used to call gods and daimons, who interact in those archetypal, unauthored narratives we call myths. Myths are the true stories of the soul and, as such – pace the genetic fantasy – the blueprints of our lives. As Sallust sublimely said of them: ‘These things never happened; they are always.’ The intellectual model, or root metaphor, for this description of imagination is Plato’s Soul of the World which, elaborated by such Neoplatonists as Plotinus, was pictured as the very ground of all reality. It is the macrocosm in relation to which we humans are microcosms: our souls, that is, are individual expressions of a collective world-soul which contains us but which, paradoxically and at our deepest level, is also contained by us. It need hardly be said that the Soul of the World is also the model for Jung’s collective unconscious. Imagination, soul and unconscious are, if not synonymous, then analogous terms. They each stand for another world from which we are born into this world and for which, whether we are aware of it or not, we are filled all our lives with what Iamblichus calls a ‘deep eros’ – an infinite longing – to return.

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feature article Loss of soul

Pre-literate, tribal cultures – traditional cultures – inhabit, without exception, an ensouled cosmos, just as we did before the scientific revolution of the seventeenth century. We were all animists once – a pejorative term which tends to dismiss what it describes, namely an imaginative participation in the world where there is no strict separation of outer and inner life. The rise of Cartesian dualism drained soul from the world and located it within us. Yet even here it was exiled because the Cartesian subject was hardening into what has been called ‘the heroic rational ego’ whose brilliant, focused consciousness allowed no place for soul’s twilit imaginings and banished them into the shadow it cast – banished them into the unconscious. But the outcast daimons of soul did not so much fill the unconscious as form it (the unconscious as we know it did not exist before the seventeenth century) and there they stayed, as the nightmares that troubled the sleep of reason, until their alien voices were heard once again crying out from the couches of the psychoanalysts. The gods, as Jung was fond of saying, had become diseases. In other words, the central issue for psychotherapy is what traditional cultures call ‘loss of soul’ – a loss of which the invention of psychotherapy is itself a symptom.

Repression of images

We blame the indomitable heroic ego for this loss; but we might also remember the remarkable fact that this kind of ego is itself adumbrated in myth, and is therefore part of our imaginative life. As James Hillman has pointed out in The Dream and the Underworld, Heracles’ intimidation of the shades in Hades during his 12th labour is the model for the rational ego’s repression of images. I think that the model for this ego is Sigurd, the great hero of Norse myth, who betrays his soul-image Brynhild twice: first, he forgets her and second – decisively – he wilfully rejects her by refusing to give up his allegiance to his earthly wife. He asserts the priority of the ethical over the erotic; and this, too, I suppose, is characteristic of the northern Protestant ego he underpins. Both heroes pay the price. Although Sigurd is invulnerable, he has (like Achilles) a weak spot where he is stabbed and killed. Every heavily armoured heroic ego has such a spot through which soul can penetrate and lead it down to death. Weakness and sickness therefore are not necessarily things that have

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“Psychotherapy … reads the timeless metaphors behind our rigid chronological and literal version of events – sees the myth behind the case history” to be done away with at all costs – this is the ego’s point of view. They might be the points at which soul is manifesting itself. Heracles’s death is even more cautionary. His neglected but still-loving wife, his soul-image, tries to win him back with the gift of a shirt. But the shirt-maker is Nessus, a vengeful centaur who, like all daimons, has been assailed by Heracles in the past. He secretly poisons the shirt so that, when Heracles puts it on, he is driven mad by pain and, in an attempt to tear off the shirt, tears himself to pieces. Thus can soul’s gift of love appear as a caustic and destructive force to the ego which neglects or denies it.

Souls do not change

Our error, perhaps, has been to allow this kind of overweening ego to step out of myth where it belongs and to embody itself literally within us. Perhaps this was inevitable; for its drive to literalism is the key characteristic of the heroic rational ego. It disdains soul’s images, metaphors and myths. It accounts nothing real which isn’t ‘fact’. It wishes to break free from its own grounding in soul (its pre-eminence in scientism is precisely the delusion that it has succeeded). Unluckily, while soul can indeed be ignored, neglected and suppressed, it is immortal and can therefore no more be done away with than, say, the unconscious. On the contrary, it gathers power, and darkens, in exact proportion to the force with which it is repressed. The daimons are notorious shapeshifters. Just as Freud noticed, we no sooner suppress them than they return in another – possibly demonic – guise. The neoplatonic tradition, to say nothing of oriental religion, reminds us that our souls do not change. They are complete at the beginning. It is just that, like Sleeping Beauty, they have to be woken by life’s kiss – woken into John Keats’s ‘vale of soul-making’, where what is latent is allowed, through imagination, to unfold. We commonly think of our life’s task as being the need to progress or to grow. It is legitimate to think like this, providing we recognise that these are metaphors: progress is the Apollonian fantasy, which has gripped us since the Enlightenment, while the notion of growth is

a mother goddess-like fantasy which would cast the psyche in an organic, natural mould. But we are not, or not only, natural beings. Psychic transformation is, as the alchemists insisted, a ‘work against nature’. So there is soul-making – a realising of potential – but not necessarily progress or growth. There is transformation, that is, but not necessarily change.

Initiation and transformation

Central to all transformation is death and rebirth. We have to die to ourselves in order that the Self might be reborn. (It is axiomatic that the more ego we have, the less Self). We have to dismantle the ego’s armour in order that the soul can find itself in a more expansive Self. The continual readjustment of the ego’s relation to soul through metaphorical death leading to rebirth is traditionally expressed through rites of passage. Transformation is initiation. Unluckily, our culture has all but lost formal rites of initiation. (It is telling that Heracles was refused initiation into the Mysteries before his assault on the Underworld.) Too often psychotherapy is called upon to fill this want. Still, at least psychotherapy understands that initiation cannot be achieved without suffering, that we should not medicalise suffering, seeking only to relieve it (especially with drugs), but that we should, on the contrary, try (to paraphrase Simone Weil) not so much to seek a natural cure for suffering as a supernatural use for it. For, if the gruelling puberty rites of tribal cultures are anything to go by, only fear and physical pain (scarring, male circumcision, fasting, interment in symbolic graves etc) can release the enormous energies required for psychic transformation – the candidates released into the deep imaginative life of the tribe as, at the finale, all its myths are unrolled before them like a vast tapestry, filling their lives with meaning. We are reminded of CG Jung’s midlife crisis, when he was beset by uncontrollable fantasies surging up from the unconscious and threatening to overwhelm him. As a psychiatrist, he would have feared the madness of psychosis more than death. But when he was forced to give in, sitting at his desk (as he describes in Memories, Dreams, Reflections) and letting himself as if physically

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feature article drop into the underworld, he found not the madness he feared, but myth – the central myth of his life: the need to kill the brilliant but rigid Siegfried-like ego in himself as in all of us. All initiation feels, to begin with, like breakdown and regression; but if the ego surrenders, it is not plunged into madness and chaos but into the clarity and precision of a myth. And if initiation is not performed voluntarily, it occurs spontaneously and forcefully, as Jung discovered, by the innate drive of the unconscious – of the soul – to realise itself, to make itself heard despite the ego’s gag. The soul’s garment of love warms and enlightens us unless we deny it; and then, like the shirt of Nessus, it burns like hell.

Seeing through

In short, initiation opens us into the otherworld of imagination. Without it, we run the risk of remaining trapped in the ego’s single-minded view of the world. Like Ixion endlessly revolving on his wheel of fire, or Sisyphus crushed by the rolling-back of the boulder he can never push to the peak, we return over and over again to the literal person, event or pattern of behaviour we can get no perspective on – where ‘perspective’ aptly means ‘seeing through’. Psychotherapy helps us see through the points at which we are blocked. It recognises the deep eros for the infinite behind our narrow and twisted fixations on finite objects of desire. It sees behind the obsessive repetitions that shadow the decorous rituals they would become; behind our vicious circles to the alchemists’ endless refluxing, which, suddenly, transforms matter into the miraculous stone. It reads the timeless metaphors behind our rigid chronological and literal version of events – sees the myth behind the case history. It unearths the soul’s longing for depth and its affinity with ‘death’s dream kingdom’ behind our melancholy and depression. It sees the symptom as an Achilles’ heel through which imagination can draw us down into the underworld of Hades or Plouton, the ‘rich one’, whose riches are not of this world but of that other limitless world of imagination. This ‘double vision’, as William Blake called it – seeing as if through the eye instead of merely with the eye – is what untangles the fouled net of the psyche and restores, regardless of what monsters of the deep are drawn up in the process, that free play of images, that self-delighting imagination, so essential to the soul’s health.

The Psychotherapist

Illness is a part of health For Guy Dargert health is less about feeling good and more about being whole. We must learn to accept the inevitability of illness and to value it as a part of health.

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he UK Health Professions Council (HPC) was set up by a piece of legislation called the Health Professions Order in 2001. The Council is presently in negotiation with representatives of the psychotherapy profession over the way our occupation is best managed and regulated. One point of agreement does not seem to be contested. Along with paramedics, podiatrists, hearing aid dispensers and 12 other health professions, psychotherapists are in agreement that they are indeed healthcare professionals. If this can be said to be the case, it begs the question, what exactly do we all understand by the term ‘health’?

A sense of wellbeing

Health professionals can have an idealised, even utopian, view of what constitutes health. This existing definition

was formulated by the World Health Organization (WHO) back in 1948, and was an attempt to move away from a prevailing negative definition of health as being simply the absence of disease and infirmity. To be completely healthy, they decided, we must have a sense of wellbeing that extends beyond the physical into the mental and the social/ societal realms. Like all idealised and perfectionist aspirations, the net effect of this is that it reminds the aspirant of his or her shortcomings and insufficiencies. For this reason, there is presently some debate among medical professionals as to whether the definition should be modified.2 Many medics today think that health might be better thought of as the ability to ‘adapt and self-manage’ in order to retain our sense of ‘wellbeing’. In other words, those living with less than complete physical, psychological and social wellbeing might still consider

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feature article themselves to be healthy so long as they can self-manage and find a sense of adequate wellbeing despite their imperfections. Patients or clients might in turn settle for the much more achievable end of having a state of health that Donald Winnicott might have called ‘good enough’. Obviously this possible new definition would take considerable stress off healthcare providers, allowing them to be less heroic.

Living with less than ideal health

As health professionals, we may continue to reject illness as the enemy as we do in the present definition of health. Alternatively, we might learn to live relatively contentedly with a certain degree of less than ideal health while enjoying a satisfactory sense of wellbeing. Illness according to both of these views remains something to be overcome and ideally avoided. This apparently attractive objective is spoiled only by the fact that it impossible. Not one of us will leave this life in a ‘state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity’. Death and disease are a part of living a whole life. So what is ‘health’? Etymologically health means ‘wholeness’. To ‘heal’ is to ‘make whole or healthy’. As healing professionals we must learn to accept illness (and indeed death) in the interests of wholeness. Health accordingly cannot be an ‘absence of illness or infirmity’. On the contrary, health must allow for the presence of illness and infirmity.

Wellbeing is not the same as health

Curiously, WHO defines health (wholeness) in terms of ‘wellbeing’. Whatever can be meant by wellbeing? The English word ‘well’ can be traced back to its Latin root ‘velle’, which means ‘to wish strongly’. It is related to the word ‘volition’, which means ‘the act of exercising the will’. In effect, the medical definition of health refers to a state in which we feel as we want to feel or would wish to feel. Those psychotherapists and others with an awareness of unconscious and subliminal psychological processes will immediately have a problem with this. What part of the psyche is doing the wishing and the wanting? We are aware that the psyche is made of many parts. Many therapies hypothesise that the psyche is made of conscious, semi-conscious and unconscious aspects. According to theory, these different

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“Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” WORLD HEALTH ORGANIZATION1 aspects can have very different wishes and desires. Are we saying then that health is a kind of ego gratification? What gratifies one part of the psyche may create problems for another part. What if we want both security and freedom for instance? What if a client enjoys the longed-for success of a career breakthrough and suddenly becomes inexplicably depressed on achieving this. The depth psychological work might be to explore the losses of freedom that accompany the new responsibilities and the emotional repercussions of this.

Unconscious processes

Some therapies address symptoms but do not recognise the significance of unconscious processes. In cases of depression, for example, therapies and medical prescriptions for antidepressants might lead to a greater sense of wellbeing. The patient or client may feel more as he or she wishes to feel or believes he or she should feel but it does not lead to greater wholeness. The depression might in fact be a positive and purposive sign that something is missing from consciousness that needs to be included in order to gain ‘wholeness’ (or health). If conscious awareness is not complete or whole, it cannot be described as ‘healthy’. The feeling of improved wellbeing gained by such medical or psychological interventions may further the wishes of the conscious ego but can only be described as ‘unhealthy’ in as far as it blocks the unconscious concerns that would ‘heal’ the psyche and make it more whole.

Holism

Apart from the fact that there is no mention of soul or spirit, WHO’s definition of health cannot be faulted with regard to its holism and ambition. Physical, psychological and social aspects are given equal status. It follows from this that HPC is justified in bringing together counsellors and psychotherapists who deal mainly with the psychological facets of health with paramedics, podiatrists, hearing aid dispensers and others who are in the main concerned with the more physical aspects. In accord with this line of thinking, HPC may at some point wish to consider achieving an

even more holistic approach. It could also be monitoring and regulating professions that deal with the social dimensions of health. Among others, these professions might include social workers, teachers, police and politicians. It is interesting to consider how politicians might respond to being monitored by regulators that include counsellors and psychotherapists. When we consider health from this holistic perspective of the physical, psychological and social, we can see that what happens to us in one of these three domains may have its roots in another. The patient who presents to the doctor with a physical illness such as diabetes may perhaps trace its origins to a weight problem. This in turn may have emotional, familial, social or political roots. Perhaps a habit of comfort eating developed as a strategy for dealing with unmet emotional needs. These in turn might be the by-product of social and financial disadvantages suffered by the parents of the patient, or by social pressures that result in poor diet.

Emotional underpinnings of disease

In our fragmented healthcare system, and with a fragmented view of health, there is likelihood that a medical practitioner will be unaware of the emotional underpinnings of a physical disease. A physician may not be able to imagine more deeply into a condition like diabetes other than considering its biochemical and dietary implications. Psychotherapists may be equally unaware of the implications of medical treatments. GPs and psychotherapists alike share the experience of most often working one-onone with their patients or clients. All are unlikely to know their patient or client in a social context. It is difficult for all of these practitioners to see illness and symptoms in their wider contexts. Marital, family, group and systemic therapists will have a broader outlook but none will come near to addressing health as ‘complete social wellbeing’.

Health is paradoxical

Given that illness and death cannot be eliminated or avoided, we must accept

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feature article them as inescapable realities of life. We could consider that there are healthy and unhealthy responses to these realities. Examples of unhealthy responses might include denial, nihilism or despair. Passive and resigned acceptance of ill health could also be considered as another way of refusing to engage with the energies of illness. So also could be clinging to the symptoms and sufferings of illness to gain practical or psychological advantages. All of these responses amount to unawareness, inability or refusal to see meaning and significance in the challenges that illness present. We cannot see the bigger picture and so respond in an unhealthy way. That is to say in a way that does not consider the whole of the situation. A more holistic approach and, in terms of this discussion, a more ‘healthy’ approach might involve receptivity, acceptance, interest and a willingness to engage in a dynamic interaction with the energy behind illness. We would do this knowing that the illness may contain the potential to make us more whole. This brings us to another nuance in our exploration of the words ‘health’ and ‘wholeness’. We now meet the missing spiritual and soul element in WHO’s definition. ‘Wholeness’ is closely related to ‘holiness’. The western medical tradition has spiritual roots. It is descended from the times of Hippocrates and the ancient Greek healing temples sacred to the god Asclepius. Healing was

then regarded as a spiritual act facilitated by doctors who were also priests. Our nursing profession retains something of this tradition with its ecclesiastical history. The eleventh century Sufi mystic and intellectual Abu Hamid al-Ghazali said: ‘Illness is one of the forms of experience by which humans arrive at a knowledge of God; as He says, “Illnesses are my servants which I attach to my chosen friends”.’3 In the modern era, CG Jung made a similar remark when he said that in today’s world the gods have become diseases.

A divine privilege

The notion that afflictions are a divine privilege is not an easy one for patient, client, doctor or therapist. Yet it is widely recognised. In the Sri Lankan healing tradition, for example, the spirits of illness are recognised as being ultimately in the service of the Buddha, while in the Christian tradition we can relate to the frustration of St Theresa of Avila. This devout sixteenth century Carmelite nun was afflicted by bouts of malaria. Once, when travelling, her cart broke and tipped her into a muddy stream. She is reputed to have cried out to God: ‘If this is the way you treat your friends it is no wonder you have so few of them!’ Illness can be seen as a way of putting us in touch with disassociated or emerging aspects of our being. These may originate primarily in the body, the mind, the social being or in matters of spirit. A ‘healthy’ response would

be to bring the new experience into association with other aspects of our being. Illness is physical but not just physical; psychological but not just psychological; social but not just social; and spiritual but not just spiritual. To make and to see these connections is to step toward a more holistic view. To facilitate such connecting is an act of ‘making whole’ or healing. It is a step towards health. Illness is a part of the human experience. Life is ever evolving. Balances shift. Dis-ease is an inevitable part of this process. Constant adaptations are necessary in order to function successfully and live fully in a fluctuating world. Illness stops us in our tracks, disrupts habitual behaviours and forces new behaviours and adaptations. It can also expand our capacity to feel and invite us to adopt new ways of thinking. Health is more than a sense of wellbeing. Health is less about feeling good and more about being whole and responsible (able to respond) to life. To do this we must not only accept the inevitability of illness but learn to value it as a part of health.

References 1 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, 2: 100) and entered into force on 7 April 1948. 2 Huber M (2011). ‘Health – How should we define it?’ BMJ, 30 July 2011, 343. 3 Al-Ghazzali. The alchemy of happiness, chap 2: 42. Available at: www.sacred-texts.com/isl/tah/ tah04.htm

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discussion

The Face(book) of psychotherapy is changing: how to reconsider the extended self Aaron Balick encourages psychotherapists to put their worries about social networking in context and to view online relating as an increasingly important part of life.

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f you’re reading these words, it is highly likely that you are in a transient generation of psychotherapists who are on the way out. Most therapists today are what we call ‘digital immigrants’ – individuals who did not grow up online and only came to understand the digital world later in life. It’s likely that many therapists in training today are ‘digital natives’: that is, they grew up in the digital age, connected online from the time they gained full control of their extremities.

A minor appendage

As new therapists replace old, more digital natives than immigrants will populate the field, and this new generation will be asking what the fuss was all about. Today however, most trainings do not cover the ubiquitous issue of social networking – and how could they? In this respect, the trainees (in general) are far ahead of the trainers. Today, the practice of psychotherapy is either being taught for a world where social media doesn’t really exist or at best in a world where it’s seen a minor appendage to everyday life. Digital natives will tell you that social media is far from being a minor appendage, but rather an important representation of self. The field of psychotherapy is unusual because, for many, it is a profession that is often chosen in midlife or beyond. For these reasons, it has been especially slow to adapt to the digital environment that surrounds us. As a rule of thumb, those born

Aaron Balick (PhD) is a UKCP registered

psycho­therapist and supervisor working in London. He is also an honorary senior lecturer at the Centre for Psychoanalytic Studies at the University of Essex. He has a special interest in relational psychoanalysis and psychotherapy and is chair of The Relational School, UK.  In addition to his academic and clinical work, Aaron is a media spokesperson for UKCP and a mental health writer, consultant and media contributor for the BBC. He has written two books, The Psychodynamics of Social Networking: connected up instantaneous culture and the self (2014, Karnac) and the children’s book Keep your Cool: how to deal with life’s worries and stress (2013, Hachette).

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around 1980 and after tend to be designated digital natives; those born before are the digital immigrants. Think about it: the oldest digital natives are already approaching their midthirties.

Telephone vs Google

When I was in training at the turn of the century (the most recent one), none of us had a social networking profile. In those days, advertising for psychotherapy services in general was seen as relatively uncouth – and if you did advertise, having your photograph alongside your ad was seen to be especially gauche. It used to be said that the psychotherapy relationship starts ‘at that first phone call’. Today it’s with the first Google search, and it’s unusual if you are approached by phone in the first instance. Not only have the goalposts moved, the lawns have been replaced with astroturf! Today, unless already well established, a therapist without a presence on one of the many online registers or their own website adorned with a sparkling headshot is seen to be committing marketing suicide. While many in the field have come to accept this, it is not wholly embraced; engaging in social networking is a step further for many. Having run social media trainings for a variety of groups, I have found that psychotherapists are hands down the least savvy and the most nervous about the digital world – and the least likely to have experimented with social media themselves.

Digital exposure

This anxiety is not surprising. There are lots of reasons for it, not least concern about how individuals relate across social networks (with many therapists thinking that this sort of relating simply isn’t good enough), and the fear of being exposed to clients through a digital profile (often enhanced because therapists are not aware of how to set their privacy settings). It was indeed through my being unwittingly exposed when one of my clients performed a Google search that I realised what a ubiquitous problem this was; it was partly this event that inspired me to write The Psychodynamics of Social Networking: Connected-up Instantaneous Culture and the Self. I came to learn first of all that there are two different identities that the digital world brings to life:

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discussion “Technology becomes the architecture of our intimacies” The architecture of a technology

1. Passive online identities – These are representations of ourselves online over which we have little or no control, like the information that comes in a Google search, or when others have posted something about you on their social media pages (eg a friend’s photo of you on their page). 2. Active online identities – These are representations of yourself that you do control by way of your own website or social networking profile. I also learned that the presence of these digital identities often promote ‘virtual impingements’ – that is, an event where you are psychologically affected by somebody else’s online presence. This can happen in a variety of ways, from someone purposefully attacking you online (as in trolling), or simply by witnessing something online that hurts your feelings (eg seeing a photo of a former partner with someone else). It also happens in the most banal ways: for example, if you happen to be on Skype, which randomly alerts you that Soandso is online. This Soandso may be your client, your therapist, or indeed your mother: their unbidden presence on your computer screen may feel impinging.

Authentic intimate relating

These elements are unnerving, and it is these very things, alongside the everyday way in which individuals maintain their relational lives online, that can be disturbing to therapists, who as a rule prize privacy and authentic intimate relating. Further, for many in this profession, there is a long and honoured tradition of being separate or opaque to our clients – a position that makes this digital world of exposure particularly unnerving. We are as vulnerable to anxiety as anyone else – and we know what anxiety does – it prevents thinking. I fear that this anxious response is preventing us as a general profession from responding well to the needs of our clients and to our culture as a whole. Historian of technology Melvin Kranzberg famously said: ‘Technology is neither good nor bad: nor is it neutral.’ Sherry Turkle, author of Alone Together, pithily states: ‘Technology proposes itself as the architect of our intimacies.’ Both these statements are right on. But what do they mean, and what are we supposed to do about it?

The Psychotherapist

In a sense, they are both talking about the architecture of a given technology. A railroad can be used to deliver arms for war, or food to the hungry. All it really does is bring linked cars back and forth over rails. It is essentially neither good nor bad, but nor is it neutral because what is designed to do constrains its consequences in particular ways. Similarly, the architecture of the internet quite simply allows the rapid transmission of almost any kind of information from A to B. Online social networking operates by way of the internet to enable human beings to create a representation of themselves online and conduct an aspect of their social and relational lives there. This is where technology becomes the architecture of our intimacies. In many ways, Facebook for one, truly is. It’s not good, it’s not bad, but nor is it neutral. In brief (see more in my book), what our most popular online social networks do is they allow individuals to extend certain aspects of themselves into an online environment which then mediates their self-representations and their relationships. Because the architecture of these sites is set up in a particular way, they create an environment that’s amenable to the outward-facing parts of the ego (the persona or the false self) while disabling the activation of more inward facing aspects of the self. Hence their ‘non-neutrality’ can enable an inflation of the outward-facing ego at the expense of more private inner experience (where our shame and vulnerability lurk).

A partial self

It is perhaps these elements that make the average therapist nervous because it presents a self that is only partial – omitting those very parts that we encourage our clients to recognise in psychotherapy. However, when we see our socially networked selves as participating in what might simply be understood as another public environment, it is no mystery why we behave in particular ways there. We do not generally bare our vulnerabilities at dinner parties, so it’s no surprise we don’t when exposed online (though we do, in fact, across more private social networks like Facebook). In short, if we trade our anxiety for curiosity we will see that our online existences are extensions of our partial selves online and need to be taken seriously. If we apply our established values of non-judgment, curiosity, and respect to online relating and to those whose relations across online social networks are an important part of life, we can also deploy our skills as witnesses of the human condition to think wisely about these interactions. In this way, we can provide feedback to individuals and society about the potential consequences – positive, negative, and not neutral – that our new age of online relating brings.

References Balick A (2014). The psychodynamics of social networking: connected-up instantaneous culture and the self. London: Karnac. Kranzberg M (1987). ‘Technology and history: Kranzberg’s laws’. Technology and Culture, 27(3), pp544–560. Turkle S (2011). Alone together: why we expect more from technology and less from each other. New York: Basic Books.

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discussion

The BodyMind Approach™: the treatment of people with medically unexplained symptoms UKCP member Professor Helen Payne explains how a new primary care clinic, run by a university spinout company with grants from government, is offering a lifeline to patients with medically unexplained symptoms and relieving pressure on GP surgeries.

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he University of Hertfordshire’s spinout social enterprise company, Pathways2Wellbeing (P2W), recently won a Department of Health (DH) Quality, Innovation, Productivity and Prevention (QIPP) award to deliver a new treatment pathway for people with physical symptoms with no medical explanation. Patients with medically unexplained symptoms (MUS) are common (Morriss et al, 2007) and heavy users of the health system, with costs escalating for the NHS and society as a whole. In the UK, the cost to the NHS of MUS is around £3bn per year, rising to £18bn if quality of life, benefits and absence from work are included (Bermingham et al 2010). The BodyMind Approach™ (TBMA) has been specifically designed to integrate the body and mind in people with chronic MUS. It has the potential to dramatically reduce these costs. CBT is advocated for some medically unexplained symptoms, but patients often find this unacceptable owing to the stigma of being labelled mentally ill (Sartorius 2007). Moreover, they often do not have

a psychological explanation for their symptoms and, apart from medication and pain management, are offered little support.

Drivers

Drivers for the TBMA framework were derived from a pilot research study (Payne and Stott 2010) and the QIPP process. In the UK, a DH directive encourages mental and physical health integration. Furthermore, within the target population of longterm conditions, in which MUS sits, there is a move towards supporting patients’ mental and physical health and wellbeing. TBMA fits this directive as it is based on the interrelationship between body and mind. As well as being effective in its own right, TBMA can also act as a gateway to psychological therapies.

The BodyMind Approach™

TBMA uses a mindful, kinetic practice, derived from person-centred/humanistic dance movement psychotherapy, mindfulness, experiential learning through experimentation/exploration, group

Professor Helen Payne, PhD is a UKCP accredited

psychotherapist; Fellow ADMP.UK and Senior Registered dance movement psychotherapist who helped to pioneer DMP in the UK leading the professional association, post graduate accredited training, research and publications. She conducts research, supervises PhDs, teaches and examines nationally and internationally. She is a Director of The University of Hertfordshire spin-out social enterprise company ‘Pathways2Wellbeing’ which trains facilitators in The BodyMind Approach (TBMA)™ for patients with persistent, physical symptoms which have no medical explanation.

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analysis and authentic movement1. Using the recovery model for mental health and incorporating research from attachment theory and neuroscience, group work is central to the approach. It addresses the isolation patients often experience, while other members of the group act as a secure base and support. TBMA is bio-psychosocial, focusing on the person holistically, and honours and engages with their relationship to, and perception of, their bodily symptoms. TBMA differs from CBT, psychotherapy or counselling in that it focuses on physical symptoms (and their sensory experience) whereby the body speaks the mind. Verbal communication emerges from bodily responses to the approach. There is no explicit discussion of psychological, biographical or any other causal relationship to symptoms, unless a patient makes such connections, and psychodynamic or psycho-educative components are not explicitly involved. TBMA can address a range of symptoms for a number of patients in the same group. Benefits for the patient include improved wellbeing and activity levels, decreased symptom distress/anxiety/depression, improved self-management of symptoms and lower or stabilised levels of medication. For GPs, benefits include increased capacity due to reduced attendance at primary and/ or secondary care referrals and reduced medication. An economic analysis of TBMA

1 Authentic movement is an aspect of dance movement psychotherapy which employs the inter-relationship between body and mind.

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discussion compared with CBT showed that cost savings would be large in primary care and in secondary care even greater.

Referrals

The MUS Clinic

• MUS has been present/diagnosed for at least six months • The patient has been a frequent attendee (more than five GP visits for the particular symptom in the past 12 months) • Co-occurrence of depression/anxiety • The patient is a fluent English speaker

Following extensive consultation with GPs, a need was identified for the treatment and support of patients with MUS. P2W set up a clinic, which runs in Hertfordshire primary care, with two names. For GPs it is called The MUS Clinic; for patients, The Symptoms Group. Our research revealed that patients with MUS are often resistant to psychological therapies, so it made sense for them to attend a group where their physical symptoms were honoured. TBMA is complementary to CBT/psychotherapy and cross-referrals are encouraged during and post-delivery of the service. In the MUS Clinic, the patient becomes engaged in a state of inner mindfulness as they move in the presence of a witness/ facilitator, who guides them from everyday consciousness into mindfulness or ‘bodyfulness’ while constantly attending to their sense of wellbeing. The patient directs their attention to embodied inner experiences of self, actively reflecting and commenting on bodily sensations. Gradually, participants become more connected to their experience of self and may then be able to act as their own witness and as a witness for others. Embodied, experiential learning exercises, such as different movement patterns and/or breathing methods, which the patient can practise between sessions, form an integral part of the intervention. The clinic offers an experiential learning framework for up to ten patients per group. Groups run locally in a suitable community setting, with 12 two-hour sessions taking place over eight weeks in the first phase (the first two weeks have two sessions per week). Phase two, over the following nine months, maintains contact with the patient through other methods. Assessments are conducted before and after the sessions and at six-month follow-up, with GP surgery case reports requested in months three and six to gather further information. Attendance rates for the groups have been extremely high, with only 5 to 10 per cent of those entering not completing the treatment.

The Psychotherapist

GPs refer to the clinic on the following grounds:

Exclusion criteria: • No current relevant diagnosed physical health problems • Fewer than four GP consultations in previous 12 months • No trauma in previous six months • No current relevant physical disability • No complex bereavement in previous six months • No primary diagnosis of any psychiatric condition in previous 12 months (including chronic anxiety/depression) and/or the patient currently based in secondary (hospital) care • No current substance misuse, nor in past six months • No diagnosis of eating disorder

Challenges addressed IAPT The service encountered difficulties liaising with IAPT, which takes GP referrals for anxiety and depression. Some of these patients will also have MUS; however, IAPT does not address MUS but concentrates on the anxiety/depression associated with the symptoms. With this in mind, the importance of cross-referrals has also been discussed and avenues opened with providers such as the London-based clinic, the Tavistock Institute. GP (un)awareness Other obstacles included GPs’ lack of knowledge about MUS. There is no category for collecting data on these patients in GP practices; they are filed under conditions such as IBS, etc. The overall picture remains hidden, with GPs unaware of the scale of the problem and many having difficulties in identifying patients with MUS and making relevant referrals. As a social enterprise company offering a new MUS service based on an unknown approach, there was also suspicion to overcome. Various strategies were adopted:

• Invitations were sought from GPs to present at surgeries • GPs and patients were requested to give verbal feedback on service design and delivery • Referrals were encouraged through letters from commissioner and an identified ‘GP champion’, where it was clearly stated that this was a ‘both-and’ intervention rather than ‘either/or’ and that other referrals could be made at the same time • Case report forms and attendance record/patient outcomes were distributed to referring GP practices • Information and support materials were provided to support referral by GPs (including a patient consultation brief) • Two five-minute videos on TBMA/referral process were added to P2W website • On-going training for GPs and trainee GPs in MUS was instigated through local postgraduate medical centre The online referral system, set up through P2W’s management information system was designed to take GP referrals directly. It has NHS security level 2. However, the reticence of GPs to use the system resulted in deferring to the GP culture of paperbased referrals.

Case study: Lyn

Lyn2 was a middle-aged woman in fulltime employment who visited her GP for consultations lasting approximately 36 minutes each time. These visits, 13+ times a year, took place over two years in a surgery of four GPs in southeast England. Lyn presented as a ‘bundle of nerves’, complaining of muscular cramps, insomnia, headaches and feeling low and tired. She often visited A&E with headaches and muscular cramps. Lyn’s symptoms began after a traumatic event. When stressful situations arose in everyday life, she had panic attacks and could not function nor self-manage. She was unable to sleep and found it hard to go to work because she felt tired and could not concentrate. She had frequent absences from work. Lyn’s GP was unsure whether she needed investigations but sent her for two scans

2 The name and identifying features have been changed to protect the anonymity of the patient.

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discussion and for blood tests on four occasions, emphasising that the investigations would probably come back negative. The patient was reluctant to attend CBT, insisting on a physical explanation for her symptoms and not wanting to consider a psychological one. The frequent referrals for tests and scans increased her belief that there would be a medical explanation, which had not yet been discovered, and her reluctance to engage with psychological therapies came from the fear that she would be given a mental health label. She said her depression was a reaction to the lack of medical explanation. Discussions about the possibility that psychosocial causes and stress at work were exacerbating symptoms did not appear to help her to make the link. When she visited other GPs in the practice, she had similar experiences. This was understandable because her GP ensured colleagues had an appreciation of her condition and copied letters to the clinicians involved to ensure a shared view that the patient may have MUS. Lyn’s GP documented all contacts with Lyn and actions/inactions agreed and continued to discuss the case with fellow GPs and specialist colleagues. There was also peer collaboration in formal clinical meetings and informal discussions to support the difficult decision of not referring for any more tests and investigations. The GP shared the decision with Lyn about why referrals were no longer going to be made and discussed with her the idea of attending a supportive group treatment focusing on her symptoms and quality of life. The GP used the P2W consultation document to give Lyn the relevant information and answer queries, so she was able to participate in shared decisionmaking to attend the group. He also put in place a safety net – a contingency plan informing colleagues about triggers for a further referral and the patient about when they should re-present. With Lyn’s buy-in, her GP referred her to a group at the MUS Clinic, which she attended

Pathways2Wellbeing

twitter.com/p2w_Ltd info@pathways2wellbeing.com Tel: 0844 358 2143 www.pathways2wellbeing.com

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on ten out of the 12 occasions. Exploring her breathing patterns through various exercises, she discovered the right way of breathing, which she practised frequently. In the group, she looked happier and seemed more energised. She reported to the facilitator and group that she was sleeping better and enjoying work, and said the new breathing pattern had become second nature to her. She appeared to increase in confidence at every session. Through the bodywork practices, she found she was well coordinated and gracious in movement, had a good sense of rhythm and could dance! She reported that now she enjoys dancing around in her kitchen pain-free. Six months later Lyn recounted that the group experience had changed her life. She has not needed to return to her GP or A&E for the symptoms and enjoys a better quality of life. When her symptoms return, which they do from time to time, the bad days are not so bad and she can selfmanage so she feels far more in control. Her medication for depression and pain relief has reduced to almost nil. Lyn’s GP and colleagues have increased capacity as a result. They have been freed up from her frequent visits to see other patients whom they can help. The costs for tests, scans and medication have significantly reduced. A&E visits have stopped altogether, reducing costs to the surgery. The frustration felt by the GP in being unable to help this ‘heart-sink’ patient has disappeared, improving his job satisfaction. Lyn now only visits the surgery occasionally for different conditions with organic explanations.

Summary

Setting up a new service is a process of building on firm foundations, one stone at a time. It necessitates a balancing act, finely tuning delivery from each stakeholder’s perspective. Patients, GPs/ referrers, commissioners, the university, assessors, trainers and facilitators all had to be considered, their needs and agendas clarified each step of the way. Adaptations and refinements inevitably take place that could not have been envisaged when conducting the research. Real-world intervention is quite different from that undertaken in a research bubble where patients are often aspirational, wanting to help others like them, motivated to

support the research team and interested in outcomes. Sometimes people involved in research roles act differently when engaged in everyday activity. Research cannot reflect the context of everyday practice just as everyday practice cannot fully represent research. The obstacles and challenges of transferring research knowledge into real-world, practice-based service delivery can lead to positive developments for future research, reductions in the parameters of practice and/ or restrictions in delivery. In practice-based evidence, patients are not participating in the service for research purposes but for themselves, which gives a different context to delivery. For the health service, the MUS Clinic using TBMA provides immediate support for the patient, leading to increased time for GPs, more patient and GP choice, and help for practices to meet their quality outcomes targets. Once awareness has been raised, GPs appear to be more willing to refer patients and receive presentations. Eighteen psychotherapists and arts therapists with a body orientation have been trained in TBMA so far, with a view to them facilitating groups privately under licence, in the NHS and in private healthcare. 3

References Bermingham S; Cohen A; Hague J & Parsonage M (2010) The cost of somatisation among the working-age population in England for the year 2008-09. Mental Health in Family Medicine, 7, 71-84. Morriss R; Dowrick C; Salmon P (2007). Cluster randomised controlled trial of training practices in reattribution for MUS. British Journal of Psychiatry; 191:536–42. Payne &Stott (2010) Change in the moving bodymind: Quantitative results from a pilot study on the BodyMind Approach (BMA) to group work for patients with medically unexplained symptoms (MUS). Counselling and Psychotherapy Research, 10, 4, 295-307. Payne H; Fordham R (2008) Group BodyMind Approach to Medically Unexplained Symptoms: Proof of Concept & Potential Cost Savings. Unpublished Report, Funded by The East of England Development Agency/University of Hertfordshire. Sartorius, N (2007) Stigma and mental health. The Lancet, 370, 9590, 810 - 811, 8 doi:10.1016/S0140-6736(07)6124

3 Details of training CPD courses for experienced psychotherapists interested to become group facilitators can be found at www.pathways2wellbeing.com Or email info@pathways2wellbeing.com twitter @p2w_ltd

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discussion

Values-based commissioning Carmen Joanne Ablack asks Professor Chris Heginbotham about the contribution that service-users and psychotherapists can make to commissioning.

Carmen Joanne Ablack: You’ve been involved in mental health policymaking in the UK for over 40 years. What was it about commissioning that called you? Professor Chris Heginbotham: Commissioners have to understand the real mental health needs of service users and communities and I was very interested in that challenge. We’ve been trying to find a way of procuring services effectively to meet service user or patient needs. There are interesting ethical and organisational economic issues involved in doing so. Over the past ten years we’ve seen a significant development of service user involvement. It’s only really since 2000 that we’ve seen that develop. Coproduction is very important in our thinking about health and social care. CJA: I’ve heard you speak about valuesbased commissioning. Could you say something about that?

CH: We have had an important emphasis on evidence and evidence-based practice over the past ten to 15 years. But evidence itself incorporates inherent values and we haven’t had the concomitant values made real. For example, if you talk about quality adjusted life years (QALY), you’re making a values-based statement. You can’t use those QALY calculations as if they’re purely evidence based. They’re based, in fact, on surveys of individuals who helped to provide points on a quality life expectancy matrix. We know that when QALYs were first designed, 30 to 40 years ago, the first people surveyed were a group of students at York University. They had certain values and views about life expectancy, and so on, which were not typical of the whole of society. So my view is that if we don’t have an emphasis on values then we’re missing a whole halffield, if you like, of human experience.

Chris Heginbotham OBE

FRSPH is Emeritus Professor of Mental Health Policy and Management at the University of Central Lancashire and a Non-Executive Director of Lancashire Care NHS Foundation Trust. Until March 2008, he was also Chief Executive of the Mental Health Act Commission in England and Wales. Chris has worked at senior level in the public and third sectors for over 40 years including a period as National Director of Mind (the National Association for Mental Health) and as Chief Executive of two health authorities and two NHS trusts.

The Psychotherapist

CJA: It’s like leaving out parts of the dialogue. And you can’t do that if you want to cocreate. CH: Yes. By engaging the service user, we not only understand which of those services they would use and find valuable and helpful, we may find that there are new services they would like to have which we haven’t thought about. And the service user will bring an evaluative process to bear that will help you shape the response you make to those service users’ needs. CJA: How can individual psychotherapists engage in the debate? How can they get more involved with the commissioners? CH: Either through other providers, such as NHS trusts that may employ some of your people, or through local organisations, with which psychotherapists are engaged. They need to be part of a process that brings together those various organisations

Carmen Joanne Ablack is joint chair of

UKCP’s Professional Occupational Practice Committee, where she specialises in external relations. She has authored a book chapter and various articles on psychotherapy theory, contemporary practice and regulation and contributed to radio, newspapers and magazines covering subjects on psychotherapy and society. She serves on several UKCP committees, including the Psychotherapy Council, International and Diversity, Equalities and Social Responsibility committees and is a UKCP Honorary Fellow and a Trustee. As an integrative and body psychotherapist, she supervises and teaches in the UK and Europe, and works with individuals, groups, couples and organisations.

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discussion that have an impact on service delivery. Psychotherapists might be their own worst enemies in the sense that a lot of them practise individually and effectively but are not necessarily well located within an organisational structure that could fight for them. CJA: Some will be based as therapists in voluntary sector provision, as employees and/or as volunteers, and some will be private practitioners. CH: They need to find a way to be part of some sort of group that can speak about the importance of psychotherapeutic delivery to GPs and their colleagues who do the commissioning. GPs aren’t actually going to ‘do’ the commissioning. We’re told that CCGs will commission but, within the CCG, GPs will set out a strategy and say that within this overall strategy we think psychotherapy is important. Then it will be for the commissioning support unit (CSU) and its staff and commissioning managers to turn that into reality. CJA: You’re saying that organisations could approach local commissioners, and that it’s not the GPs who will actually be doing the commissioning, it’s the support units. CH: By and large, yes. GPs will create the strategy; commissioning support staff will implement it. I’ve seen quite a lot of interest in developing neighbourhood models of 30,000 to 50,000 populations, commissioning for an integrated neighbourhood service for both physical and mental health. The thing to do would be to talk to an individual GP who, in his or her CCG, may not be the mental health commissioning lead but may have a real interest in his or her neighbourhood. Find out who those people are, talk to them and persuade them that, as part of a neighbourhood response, you need more talking therapies. CJA: What you’re saying is that it’s really important that we continue to encourage our members to educate themselves about the structures that exist. CH: Well, I think it’s very important that you know how the NHS works. CCGs cover different sizes of community, but there are some CCGs that cover a 300,000 population. Within that, the chances are that you will have five or six neighbourhoods, and if we’re to get

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a good-quality local service, which is supportive to people in that community and supports GPs in their practices, then that’s an obvious route for you to gain some traction with the GPs. The whole system has not yet settled down and it’s very variable. So some places you will find a GP taking much more interest than in other places. Some places you will find there’s nobody who’s really taking much of an interest at all. There are parts of the country where I am told CSUs have simply collapsed. Then there are others, such as Manchester, in which the CSU has a very clear view of how it wants to go forward in commissioning services. CJA: Getting help to people who need it, as a profession and a professional body, is something we have some expertise in. How can we contribute that expertise to this mix and to this structure? CH: I think there are probably three ways. You can work through existing organisations such as foundation trusts and NHS trusts. You can link to them in some way, perhaps as employees or paid on a sessional basis. Second, you could form some sort of third sector organisation, which will provide a structure for negotiation on contracting and so forth. Or third, individuals can put themselves forward to the CSU and say that they have a particular therapy which they would like to see made available. Now, I think the third of those is less likely to achieve very much because when you’re on your own you don’t have much clout. You won’t have time to do all that work. Even if you’re in a small partnership of two or three, it’s very difficult. The second of them, I think, is probably your way forward. And it may be that you need to help some of your colleagues create small third sector organisations as a vehicle for their own activity. CJA: Such as clinics in local neighbourhoods? CH: Or chambers, like lawyers and barristers. Form a chamber, which you can then use as a vehicle for selling your services to GPs but within which you are essentially self-employed. There are obviously different possibilities and a variety of different mechanisms. One mechanism may be relevant for Lancaster and another may

be relevant for London, depending on what else is being provided. It could be that a local Mind group is the place to go. In Lancashire for example, there are 2,700 third sector organisations. CJA: Wow! CH: Yes. And that’s just Lancashire. There is a forum which brings together all of those bodies. Some of them, such as Richmond Fellowship, Making Space or Mind are relatively big, and could be a very good vehicle for some of your folks to work with. A local Mind group may be quite well locked in with discussions with commissioners. It knows who the commissioners are and it’s working with the CCGs. You don’t then have to start from scratch. You don’t then have to make all of those connections yourself. CJA: This is the point. It’s about the practitioners getting to know, and making sure they are making links with them and learning who the local third sector bodies are that are engaging with commissioning groups. CH: Yes. CJA: One of the things we’re very committed to is ensuring greater access to high-quality psychotherapy across different approaches. The key for us is high-quality, well-trained, well-regulated psychotherapists, which is what our practitioners are. CH: You need to make that clear to the commissioners. That your people are properly accredited, properly trained professional people who go through a reaccreditation and validation process, just like GPs and psychiatrists. They need to understand that you have that degree of professionalism, borne of the training, the proper supervision, and so on. Because a lot of GPs will throw evidence-based medicine back at you and will say, ‘We’re only interested in evidence, we only want to buy things which are well evidenced.’ We need a very powerful statement that ‘Yes, we need the evidence, but we also need values.’ We need to have robust debate about the interface between evidence and values. You can’t be certain of what will work with an individual because of the nature of coproduction. But you have broad evidence of what works and you integrate values into that.

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discussion Review

Far from the Tree: A Dozen Kinds of Love by Andrew Solomon 976 pages, Chatto & Windus, 2013, £30 Adele Pile, personal construct psychotherapist We have all been children and many of us are parents, but for each one of us the experience and the sense that we make of it is unique. This book is the result of ten years of academic research and extended discussions and observations with some 300 families whose children are out of the ordinary. Andrew Solomon reminds us that ‘parenting is no sport for perfectionists’. In his introductory chapter, titled ‘Son’, Solomon differentiates between ‘horizontal’ as opposed to ‘vertical’ identity. Vertical identities bear attributes that are passed down through our genes and our shared cultural norms: for example, ethnicity, language and religion. By contrast, horizontal identity is acquired through a peer group and is often a result of random

mutations, prenatal and environmental influences: for example, autism, disability, criminal behaviour. Solomon challenges us to reconsider ‘illness’ and ‘identity’ – ‘fixing is the illness model, acceptance is the identity model’ – and urges the reader to reconstruct their understanding of difference. Later chapters focus on families coping with deafness, dwarfism, Down’s syndrome, autism, schizophrenia, disability, child prodigies, crime, children born of rape and transgender issues. Solomon presents deeply moving life stories of families who, despite the unending emotional and practical demands, express their love for their child through a determination to do what they feel is right regardless of the opinion of others.

In the final chapter, titled ‘Father’, Solomon reflects on his gay identity and his very slow realisation that he wanted to become a father. He summarises his book as ‘a description of how to tolerate what cannot be cured, and an argument that cures are not always appropriate even when they are feasible’. This book is essential reading for all professionals who think they know best.

News

EAP Honorary Award On 15 February, the European Association for Psychotherapy Board awarded honorary EAP membership to Heward Wilkinson in recognition of his many contributions to EAP. In 1994, Heward became the first editor of EAP’s International Journal for Psychotherapy.

The Psychotherapist

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ukcp news

Valuing Mental Health In January at the House of Commons, UKCP launched its breakthrough report on mental health, revealing for the first time that the detrimental impact of mental ill‐health on our quality of life is ten times worse than the impact of any other health condition. A subjective wellbeing approach The report, Valuing Mental Health: How A Subjective Wellbeing Approach Can Show Just How Much It Matters, is authored by Daniel Fujiwara and Paul Dolan from the London School of Economics. In it, they strongly recommend that the current cost benefit analysis of assessing healthcare costs (by quality of life years or QALYs) used by bodies such as the National Institute for Health and Care Excellence (NICE) should be replaced by a more accurate method known as the subjective wellbeing approach).

It is notable that Paul Dolan himself was an original architect of the QALYs system. In this latest report he argues that this approach serves to reinforce the stigma concerning mental health and is therefore responsible for a systematic undervaluation of its seriousness in the health service.

The launch was hosted by Paul Burstow MP

The stigma of mental health

The report was launched at a parliamentary event hosted by Paul Burstow MP, who said: ‘There’s an element in the way that [NICE’s system of using QALYs] works which I, as a lay person, would describe as an attempt to capture the wisdom of the crowd, despite the fact that most people in the crowd have no lived experience of the thing they’re being asked to give a judgement as to whether it would make a difference to the life. ‘And because of that the things that people know about (and because of the stigma in our society they know less about mental health) are the things they prioritise. So, cancer, dementia; not mental health. What we need to see is a shift, a change of emphasis, so that we actually engage and get the insight of lived experience into this process to enable us to move the goalposts in a way that it ensures that wellbeing really is at the heart of the way in which NICE operates.’

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Therapy changed my life

Also speaking at the event was Jacqui Dyer, a community worker, advisor to the Time To Change anti-stigma campaign and a member of the ministerial advisory Group for mental health. Jacqui spoke movingly about her experiences as a user of mental health services and carer, and about the value of psychotherapy in changing lives. She said: ‘It was the access I got to psychoanalytical therapy that really saved my life which enabled me to be here today to speak my story. I never used to be able to talk. And now I can talk, not just about my own needs, my own aspirations, I can speak on behalf of the communities that I work with, my siblings and other vulnerable groups. A key part [of the mental health services portfolio] must be access to psychological therapies, access to psychotherapy because that is what is needed.

Impressive impact

The Valuing Mental Health report is already beginning to have an impact. It was referred to extensively in a recent Centre for Mental Health review of the City and Hackney psychotherapy service, and UKCP will be meeting with Norman Lamb, the mental health minister, to discuss the policy implications of the report. If the subjective wellbeing approach to health valuation is embraced by policymakers, it could lead to a substantial shift in resources towards treating mental ill health and psychological distress. This would be good news for all concerned: patients and their families, the many thousands who cannot currently access support and, of course, those such as UKCP members who provide valuable support and treatment for those affected by psychological distress.

www.ukcp.org.uk


ukcp news The report in summary by Daniel Fujiwara

A

big challenge for policymakers is assessing the worth and benefit of an intervention. The consensus approach is that the quality of an intervention is judged in terms of human wellbeing. Traditionally, this is done through cost benefit analysis, where we look at the benefits of an intervention and its costs, and monetise it. The monetary element is a measure of changes in people’s welfare. For example, if we were to provide parks and green spaces in a neighbourhood and we wanted to know the value of that in cost benefit analysis, what we’re trying to find is the equivalent amount of money we’d have to provide to that neighbourhood to make people just as well in their lives had they not had the parks.

Cost utility analysis

In the UK, health quality uses something called the cost utility analysis. This method doesn’t try to monetise benefits but looks at them in terms of quality adjusted life years (QALYs). The QALY is based on the number of years of life that would be added by the intervention. It considers welfare in a similar way to cost benefit analysis but doesn’t go as far as monetising it. The way that NICE does this is to survey thousands of people in the UK population and ask them about their preferences about different health conditions. This is based on the assumption that what people want is generally good for them. Their preferences are used to derive a QALY.

Self-reporting

Under the preference model, we might ask people which they prefer between health state A and health state B. And, of course, these people may not have any lived experience of these conditions. In the UK and other countries, policy is now moving much more towards subjective measures of wellbeing. With the subjective wellbeing we’d look at people’s self-reports of their wellbeing and whether A or B had the biggest effect.

The Psychotherapist

“Mental health conditions are the biggest impact factor on the experience of our lives”

What is really exciting is that, using the subjective wellbeing measure, we can recalculate the QALY rates that we’re given by NICE, or we can forget about the QALY entirely and simply monetise the health benefits.

Underrating of mental health What we’ve done in the paper is to look at all the data and attempt the QALY re-rating with subjective wellbeing figures. And what we find is that when we compare mental health against a group of physical health conditions, mental health conditions are the biggest impact factor on the experience of our lives. This is in stark contrast to the results that you get when people are asked to hypothesise about difference health conditions.

There are several reasons, we think, for this underrating of mental health. One is that we’re notoriously bad at projecting our preferences. People don’t take into account the extent to which they will adapt to the conditions, and the ability to adapt is greater with physical health states. So, if you walk with a cane or you’re in a wheelchair, that doesn’t, over time, make a huge difference when you’re watching TV or having a meal in a restaurant. But schizophrenia or clinical depression is there all the time regardless of what you do.

A focusing illusion

The second reason is what is known as a focusing illusion. If I ask you to think about walking with a cane and how that will impact on your life, you tend to forget about all of the other things that vie for your attention. You think solely about walking with a cane. In the experience of your life, walking with a cane is an issue but, a bit like the adaptation, it subsides after a while. And the third factor is that when we measure QALYS in the UK we look at the impact of different health states in five dimensions: mobility, self-care, impact on daily activities, mood and pain. Issues such as stigmatisation don’t come up, which means that, again, mental health conditions will be underrated.

Valuing mental health: how a subjective wellbeing approach can show just how much it matters

Daniel Fujiwara Paul Dolan

January 2014

Cost benefit analysis

The other thing we can do, explained in the latter part of the report, is to forget about the QALY and use cost benefit analysis to attach values to interventions. What we’re trying to find is the equivalent amount of money we’d have to provide to a person living with depression to make them just as well in their lives as someone without depression. This shows that people living with depression and anxiety are £45,000 per year worse off. The worst physical health condition that we found in the data was kidney, liver and digestive problems. That experience of wellbeing was only a cost of around £6,000. We’ve shown that whether you reweight QALYs using people’s experiences rather than their preferences, or whether you leave QALYs alone and go for a full cost benefit analysis, the impact of mental health conditions is much larger than we once thought. More resources must go to mental health. See the report at www.ukcp.org.uk/value

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ukcp news

UKCP’s new website

When we launched our new website at the beginning of the year, we had clear aims for what we wanted the new site to achieve. We're working hard to improve the way we present what our members do and get our messages out to the world.

Improved Find a Therapist

Visitor journeys The design of our new site was based on an analysis of the way people used our old site. This enabled us to identify three main visitor journeys. These were therapists looking for information on renewing their membership, members of the public looking for information about psychotherapy and students looking for information on training.

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Our new design was based on the concept of user journeys. Taking the colours from our new logo, we created sections with content specifically aimed at members of the public, therapists and students (both members and non-members), and organisations – an area of the site we want to grow.

We needed to improve Find a Therapist for potential clients. The old website was not effective, with members telling us that it didn't generate many referrals. As a result, many therapists didn't fill in all their profile fields. We need all our members to complete their Find a Therapist entry. The richer the information available when people search for therapists, the more Find a Therapist will be useful for those searching for help.

www.ukcp.org.uk


New website

In order to make these improvement we needed the new site to: • work more effectively for our various audiences • encourage people to use our Find a Therapist directory • be visually more modern and reflect the bold identity of the new logo.

Old website

When we looked at the way people were using our website, we realised that the old site was not working effectively. While we were attracting almost 40,000 visitors a month, people weren't staying. Just under 45 per cent of visitors left the website after only viewing one page rather than continuing to view other parts of the site.

Clearly we needed to make our site more 'sticky'. We needed a site with content which would entice people in and encourage them to continue to explore.

Work in progress

The new website is a work in progress. We will be adding functions and improving the way the website works for visitors over the coming months.

Members’ area In order to present UKCP therapists as the best, we need Find a Therapist’s results to reflect this. A major change for the new website is the separation of the register from the Find a Therapist directory. This means that if you don't want to accept new clients through Find a Therapist at the moment, you can specify this in your profile when you log on to the website.

The Psychotherapist

We wanted to improve the members’ area of the website, making it easier for you to update your details. The first page you see when you log in has four tabs. Clicking each tab reveals a different address option for you to edit. The address options are: Private details – these are your confidential contact details for UKCP use; they are not published, so are not available to the public. Find a Therapist contact details 1, 2 and 3 – you can enter up to three different addresses

if you work from multiple locations. These addresses will bring up your profile in the Find a Therapist section of the website. All these addresses are published and are publicly available. We also wanted to include content specifically for members such as the archive of email bulletins or downloadable versions of the UKCP logo for your own website or publicity materials.

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ukcp news

Childhoods never last but everyone deserves one Michèle Bartlett reports on the UKCP conference held in March at the Barbican in London on the theme of how to help children reclaim their lost childhoods and how to prevent others from losing theirs.

T

Phillips, another care leaver, offered powerful insights to practitioners.

The keynote

Rotimi Akinsete presented a video, Exposure, created by gang-affected youth in Haringey. He spoke about the specific issues affecting young people in gangs: issues of trust and betrayal and the difficulties of leaving the gang. His message was that therapy cannot be successful in a vacuum, and that the problem needs to be tackled at a community level with the involvement of other service providers. Rotimi challenged us to think about whether a therapeutic intervention always needs to be one-to-one for an hour or 50 minutes.

he aim of this conference was to reflect on the many children who do not experience anything remotely like the idyllic childhood portrayed in some fictional accounts. To this end, the conference started by contrasting excerpts from Enid Blyton's Famous Five books with modern-day, gritty scenarios. Our first speaker, Luke Rodgers, described his experience of childhood in the care system and spoke about how he uses this to inform his work as a social entrepreneur, empowering young care leavers to deliver effective presentations to professionals. Luke was able to illuminate powerfully the ambivalence felt by children in care, and how difficult it can be to constantly move placement and adapt to a different family culture, norms and attitudes. He emphasised the importance for young people in care to have clear boundaries and to feel empowered to make mistakes they can learn from in the context of a supportive foster family. Luke said that being able to reflect had helped him understand by making the internal conflict a more conscious process. His experience of therapy has been fundamentally important, enabling him to learn strength, resilience and to understand who he really is. Both this keynote and Luke's workshop, delivered with Karylle

Exposure

Studio Youth Theatre drew on the story of Oliver Twist to present their take on lost childhood in a Dickensian setting. As at our previous conference, the young people proved to be highly engaged participants, sharing their thoughts on the video in a lively Q&A session.

Michèle Bartlett is a UKCP registered integrative arts psychotherapist and child psychotherapist. She is Chair of the Faculty for the Psychological Health of Children. Michèle works with both adults and children using creative arts, storytelling, and imagery. She has extensive experience of working with young people in educational settings, and in foster care. Michèle supervises child psychotherapists in training.

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“Does a therapeutic intervention always need to be one-to-one for an hour or 50 minutes?” Re-traumantisation

Our final speaker, Michelle Knorr, is a human rights barrister who represents children and young people in immigration and asylum proceedings. Michelle spoke of the particular difficulties of highly vulnerable refugees and trafficked children. These can include threats of harm, fear of debt bondage and juju rituals by traffickers, as well as risk of arrest by the authorities for forced prostitution or criminality. Children may struggle to know whom to trust and may run away from care. Michelle spoke movingly about how refugees and trafficked children, who may already be traumatised by experiences of violence in their home country, are often re-traumatised by immigration officials who refuse to believe their stories. She emphasised the important role of mental health professionals in helping decision-makers understand the child's vulnerability and the potential impact of return to their home country. Michelle works with the charity Room to Heal, which offers therapeutic support to this client group.

Workshops Lost kidulthood: what part can psychotherapy play? Rotimi Akinsete Rotimi's workshop built on his earlier presentation by asking participants to brainstorm what might be possible if we had complete financial and artistic control over services for young people at risk of being caught up in youth violence. This brought

www.ukcp.org.uk


Workshop review

Working with children in care – advocating to empower young people forward many ideas for grassroots partnerships involving arts, music, sports and dance. It was clear that initiatives should involve former gang members acting as mentors and advocates and that practitioners would need help and support in surviving the chaos of working with this client group. When disability becomes the child’s identity Gemma Mason Gemma Mason’s workshop considered common responses to illness and disability. The group discussed the impact on parents and other family members when a child is living with a disability. The group also considered how the emotional impact of living with disability can affect the child's sense of ‘who I am and how others see me’. Holding the hope. Separated children/young people, trauma and resilience Anne Salter Anne invited each member of the group to reflect on their own childhood experience and how the narrative of their family was impacted by intergenerational experiences. An insight from this process was that we come to understand the full impact of influences within the family only in retrospect and with an adult perspective. The question that arose was what happens to refugee children who are separated from their family and have no opportunity to revisit their early childhood experience and no one they can ask for clarification. Through considering a case example of a separated refugee child, the group was able to reflect on the experience of multiple losses for any child in this situation. Working with children in care: advocating to empower young people Luke Rodgers and Karylle Phillips

Run by Karylle Phillips and Luke Rodgers

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his was a workshop with a difference, full of energy from the start. It kicked off with warm-up games, which not only broke the ice but were deeply probing, challenging participants to examine their presumptions and beliefs about the rights of children in general and foster children in particular. In a game of ‘true or false’, each of us positioned ourselves in the room in response to the question asked, depending on whether we believed the answer to be true or false. There was no place to hide. We then had the opportunity to defend our positions and beliefs. The facilitators, Karylle and Luke, communicated with youthful passion and gave us a touching insight into the life of a foster child: the separation from a loved parent and the logic behind the challenging behaviours inflicted on the foster family. Karylle spoke of her strategic attack on each foster placement, hoping that by dismantling them she would be eventually returned to her mother. Her use of tongue-in-cheek humour made the painful aspects of her communication bearable. It was only when it was finally explained to her that she would not be going back home that she finally settled down. As a long-term foster carer inspired to train as a psychotherapist in order to feel equipped to survive the challenges of fostering, I felt a strong bond with both facilitators. They brought a refreshing and genuine experience to the workshop as they shared how they struggled to feel part of a family yet, regardless of the efforts of the foster carer to treat them impartially, still felt on the outside. Participants were able to design the ideal foster carer who would create a fun-filled environment that enabled the child to develop the capacity to play and to form secure attachments. There was a buzz of animated discussion from start to finish, with content that could easily fill more than a whole day’s training. A thoroughly enjoyable and believable experience. Luke and Karylle demonstrated that they are indeed worthy advocates in their aim to empower young people.

Yvonne Osafo

See the review on the right.

The Psychotherapist

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ukcp news

Our work to combat gay conversion therapy Tim Swain reiterates UKCP’s position on ‘conversion’ or ‘reparative’ therapy and outlines activities on the issue to date.

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Ps across political parties have become very concerned to hear of fringe practitioners continuing to offer ‘cures’ for homosexuality, as if it were an illness. This practice, with its roots in the nineteenth century, has no place in the twenty-first. On 20 November last year, parliament held a debate about the issue of gay conversion therapy.

Working in partnership

The government minister responsible, Norman Lamb, rose to speak of his personal ‘abhorrence’ at the practice: ‘We want to minimise the risk that lesbians, gay men and bisexual people who seek counselling about their sexuality will face therapists attempting to change their sexual orientation because the therapist considers that being gay is wrong.’ He went on to say that this is why the UK government will ‘work in partnership with UKCP …’ This recognition of UKCP is important. As a national professional body, we represent high standards of ethical practice in psychotherapy. Our role as a standards-setting body is at the core of what we do. And issues such as gay cure therapy are opportunities for us to demonstrate that the modern psychotherapy workforce is ethical, professional and equipped to work with others to confront complex social and cultural issues.

A leadership position

UKCP has taken a national leadership position on gay conversion therapy (sometimes called ‘reparative’ therapy) for over five years now. We

Tim Swain UKCP Public Affairs Manager

issued ethical guidance to members in 2011, and we have worked with partners at Pink Therapy and across the psychotherapy and counselling professions to develop a robust response. Since the government has been alerted to the issues, UKCP has been there, able to offer professional leadership and advice in formulating policy. And since the debate last November, this agenda has moved forward. First, UKCP led seven professional psychological associations plus Stonewall in issuing public information about gay conversion therapy. This was released in February 2014 and is available on the NHS Choices website as well as the UKCP website. This easy-to-read information is vital to ensure that people concerned about this practice know where responsible professionals stand. Special thanks here go to Pam GawlerWright from our Diversity, Equalities and Social Responsibility Committee (DESR) whose expertise and wisdom were crucial in getting the tone and content of this document right. Producing public information was also an important exercise in building cross-profession unity on key diversity and equalities issues, which we know still need much work to fully address.

Work to be done

Second, in April, UKCP helped the Department of Health host a roundtable looking at further actions regulators and government could take to ensure that people are protected from ‘gay cures’. Norman Lamb hosted the discussion and leaders from statutory and voluntary regulators, as well as representatives from NHS England, were present. While the

meeting agreed that a government ban on a particular therapy (currently taking place in many US states) was unlikely to work and therefore inappropriate, it did acknowledge that there is still work to be done. Agreement was reached on developing a memorandum of understanding to establish the responsibilities of the different parties involved to tackle this issue. Particular attention was given to issues of training, accreditation and continuing professional development for practitioners. It is clear that, within the profession, we need to ensure that people are supported and well advised about working with vulnerable people who are struggling with issues around sexuality.

Clear opposition

While UKCP’s ethical guidelines are very clearly opposed to conversion therapy, it is important to ensure such messages do not have the unintended consequence of frightening practitioners away from working with people who need help. Through the memorandum of understanding and cross-organisation work, there is potential to develop a much-improved training offer to current and prospective therapists around issues of sexuality. Such work will help address the alarming shortfall in current trainings on diversity and equality issues. It is clear to me that Norman Lamb is personally committed to ensuring that gay cure therapy has no place in modern society. The Department of Health has, until now, played an important role in ensuring that psychotherapists, counsellors, psychiatrists and psychologists come together to recognise a collective responsibility to act. We have every reason to believe this departmental support will continue.

Raising our sights

UKCP has raised its sights and is striving to live up to its charitable ideals. It is through this model of mutual respect and collaborative exchange that we can achieve so much more. I am pleased to report that, in recent months, UKCP has been a national leader on this vital issue of public safety. See more on this issue at www.ukcp.org.uk/conversion

“It is important to ensure that such messages do not frighten practitioners away from working with people who need help” 42

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ukcp members

Low-cost and free therapy provision in private practice: a snapshot Riva Joffe, Eugene Ellis and Pam Gawler-Wright summarise the results of a survey of UKCP members on free and low-cost therapy for those in need. The context

Research evidence shows that poor mental health is linked to poverty and marginalisation. However, many socioeconomically disadvantaged people cannot access the psychological therapies they need. Free psychotherapy and psychotherapeutic counselling in the NHS is limited, waiting lists are long and only a limited number of approaches are NICEapproved.

Honour our commitment

One of UKCP’s main aims is to identify ways to overcome the difficulties in accessing therapy and so honour its commitment to the public. We certainly need to press for improvement in choice and quality of public psychological services. But there are also thousands of skilled and experienced UKCP members working in private practice who can offer an invaluable resource in addressing mental wellbeing in wider society. Last year, we conducted a small study of a random sample of full individual members to find out what UKCP therapists think and do about low-cost and free therapy provision in private practice. Many participants felt it was an important issue and were pleased it had been raised.

Below is a summary of results and issues emerging from the survey. The full report can be accessed on the UKCP website.

Setting session charges

The survey responses show that many therapists are flexible in what they charge for a session. Almost 80 per cent of respondents offered reduced-cost therapy on the basis of a pre-set sliding scale of session fees. When setting their rates, therapists took the specific circumstances of clients into consideration. Two-thirds of participants reported that fees were negotiated and agreed with the client in a conversation: I explain my usual fee and advise that some reduced fees are available. In session we discuss what is affordable and agree. Almost 68 per cent of all respondents indicated that they sometimes reduced fees below their usual rates. Around 14 per cent of respondents occasionally waived session fees altogether – usually as a temporary measure in response to a client’s financial situation.

Ethical considerations

In the absence of a standard assessment procedure, therapists seemed to develop their own ways of taking the individual

circumstances of each client into account. Participating therapists invested much thought into the ethical, moral and sociopolitical considerations involved. At the forefront was the aim to make therapy available to clients of any socio-economic background. The income of a client (whether waged or on benefits) was the most frequent criterion used when considering reducing session fees. Others reduced fees for specific groups such as refugees and asylum-seekers, children and teenagers, elderly people, as well as students and trainee therapists. We asked the survey participants to describe in their own words why they offered reduced-cost, low-cost or free therapy. Here is a selection of their responses: I believe in sharing with those less fortunate than myself. Social conscience: in order to see a slightly wider range of clients, class-wise. I want to reward personal responsibility, so keen to support those proactive and highly motivated who want change ... Will also support students who are trying to improve selves. To enable psychotherapy to be accessible without long NHS waiting lists.

Riva Joffe

The Psychotherapist

Eugene Ellis

Pam GawlerWright

Members of UKCP’s Diversity, Equalities and Social Responsibility Committee (DESRC)

I offer lower fees because I come from a working class background and know how difficult it is, in all sorts of ways, to access psychotherapeutic help outside what is offered in GP surgeries.

Concerns

But it also became apparent that providing low-cost and free therapy was

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ukcp members sometimes at odds with respondents’ own financial needs: covering living expenses, rent for therapy rooms, cost of supervision, professional insurance, membership of professional bodies, advertising, professional development, pension/sick pay, to name just a few. There was recognition that reducing fees could help to build a client base and might enhance professional experience, for example by attracting or keeping clients with specific and severe disorders. Overall, though, moral and socio-political concerns had to be considered alongside the need to build a viable small business. Some respondents therefore offered only a certain number of low-cost places at any time. A few respondents raised issues related to the therapeutic process itself: would the therapist feel resentful when a client paid a low fee? Would the client take advantage of the therapist’s flexibility or take their therapy process less seriously?

A complicated matter

Most therapists who responded to the survey were passionate about their work. They were also committed to improving access to psychotherapy – both for the sake of people who might benefit and as a way of increasing their experience and building their practice. In practice, however, low-cost therapy

“Poor mental health is linked to poverty and marginalisation” provision is a complicated matter with controversial implications. Despite therapists’ good intentions, numbers of clients receiving therapy at low rates were small. This apparent contradiction reflects the tensions in psychotherapy provision more generally. • The NHS aims to provide appropriate access to psychotherapy for those who need it. However, economic constraints limit the frequency and duration of NHS therapy so some much-needed therapy can currently only be provided by therapists in private practice. Some private practitioners try to bridge this shortfall by offering lower-cost therapy to clients who could otherwise not afford psychotherapy. • NHS therapy provision has increased in recent years but choice is increasingly limited to short-term and manualised approaches. The range of approaches that UKCP registrants offer has the potential to improve this situation. • UKCP members in private practice often struggle to make a living out of what they do. They need to balance making therapy affordable for the client while providing an adequate

income for themselves. Not everyone can reduce the cost of their sessions or offer free therapy as much as they would like. • As a result, therapists’ flexibility about session fees existed but was usually concealed from public knowledge. Respondents expressed a desire (and economic need!) to retain the freedom to leave price information vague and to negotiate session fees afresh with each individual client. This is understandable but raises two points. If the availability of lower-cost therapy continues to depend on individual initiatives by therapists, it may continue to be provided only to a very small number of clients. And unclear pricing could perpetuate the popular opinion that private therapy is expensive.

Join the debate

This article is a snapshot and does not present ready-made solutions. But we believe that it does provide a point of departure for a timely debate about the public’s access to the wide range of therapies currently only available in private practice. You can join this debate! Tell us what you think about the social responsibility of individual psychotherapists, the role of UKCP, training institutions and service-providing charities by visiting our website: www.ukcp.org.uk/therapysurvey

Offering therapy at lower rates Offering therapy at lower rates is one way in which UKCP therapists can show commitment to improving access to therapy for all members of the public – particularly for people on restricted incomes, those with special needs and hardto-reach groups. Public services and access to therapy could and should be improved. However, in the meantime, highly qualified UKCP members in private practice offering a wide range of modalities can play a special role in making therapy more widely available. The low-cost therapy report provides a baseline for action on UKCP’s aim to improve access to and the quality of therapy. It is an important step towards a deeper exploration of the many

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other ways we can promote equality and social responsibility, and integrate diversity-related issues into all levels of the organisation and the profession as a whole. It is encouraging that so many of the survey participants located their practice in a wider social context and felt motivated, for political or moral reasons, to reduce their fees despite the financial challenges this posed. A debate about working as socially responsible therapists is timely and imperative. In the light of the Equality Act 2010, and its emphasis on advancing equality of opportunity, it is an inextricable part of ethical practice.

www.ukcp.org.uk


ukcp members

WelcometoournewUKCPmembers Psychotherapists

Vanessa Peter Shirley Dean Micol Peter Rosanne Jane Julie Louise Martina Nerma Jane Andrea Susan Susan Rebecca Nicola Sarah Carolann Kay Jennifer Sally Valerie Magdalena Michael Penelope Anca John David Stephanie Gillian Peter Jessica Carolyn Victoria Jenny Angela Jerilee Jennifer Emma Irene Jane Elizabeth Deborah Stuart Catherine Ron Natasha Bay Giulietta Heather Anna Katharine Joanna Nancy Tessa Julia Roy Mark Christopher Jane Melanie Titos Antoinette Charlotte Lucy Patricia Robert

Allen AFT Ammann RSPOP Amshalom LSBP Andrews SEA Ascoli RFT Aston GASW Awadalla IATE Bacon IGAP Baerwolf IATE Beard UPCA Bilmayer FPC Biscevic RFT Blackhurst PET Blair IATE Blair IGA Blundell GP Booth CF Boss AFT Bowen BCPC Brown AFT Buchan IATE Bucksey CCPE Burns UPCA Butkiewicz AFT Cahalan AFT Campling AOMP Carrington FIP Cavanagh AFT Cawthorn BCPC Chapman FPC Chidwick WMIP Chown IATE Choy MI Clancy IATE Clark MC Clark NGPC Claydon RSPP Clegg FPC Clews CABP Corimba AFT Cramp IATE Creed AFT Crosbie RV Daga-Jeanperrin FPC Davis SPTI De Meric  FPC Deane BCPC Del Signore-Dean  IATE Dentoom TER Dias AFT Dufton AOMP Ede IATE Elliott FPC Ettedgui MC Evans AFT Farquharson AFT Farrall BPA Faulkner IATE Featherstone IGA Florides SEA Fox CSP Fox Weber  RSPP Frank NGPC Frankish RSPP French GCL

Maria Fernanda Mark Rosemary Bernice Sarah Catherine Joanna Rebecca Yodit Maria Cristalle Anthony Sue Tony Grace Mark Simon Emma Razwana Pam Oliver Victoria Christine David David Adamantia Melissa Georgina Sophie Jill Michaela Karin Shinobu Timothy Catherine David Daniel Sharon Mehran Helena Joanne Nyasha Dave Brendan Colin Luke Susannah Sue Adrian Nick Susan Edith Luiza Susan Nicholas Emma Judith Margaret Yvonne Margaret Alistair Sarah Alanah Adam Laura Jane

Garcia-Costas AFT Gilson* BCPC Goodall ScPTI Gorringe RSPP Graham SPTI Green MI Green RSPP Greenslade SEA Haile Abebe  RSPP Harding RSPP Hayes SEA Hill MC Hinds ScPTI Hodder BCPC Hopkins MC Howkins SPTI Hudson CCPE Innes FPC Jabbin FIP Jaganath IGA James BC Jones AFT Jude UKAHPP Kenny AFT Kraft NCHP Kriezi MI Laurie FPC Lenon FPC Livingstone MC Lubienski AFT Luckett CF Mathews FPC Matsuo FPC Matthews AFT McCoy RSPP McCrindle AOMP McQueen AOMP McWilliam AFT Mesbahi ACAT Michaels IATE Morgan IATE Mutavayi ScPTI Naylor IGA Nee MI Ollerenshaw RSPP Palmer CF Penk CF Pepper MC Perkins AFT Peters MC Poach* BCPC Ponce Machado Smith FPC Pontin* BCPC Ratcliff SPTI Rich RSPP Roberts GP Rose AFT Ross IATE Ross UPCA Rutter FPC Salter SEA Saltiel AA Sandelson RSPP Saunderson* BCPC

John Johanna Julia Mary Leslie Nigel Monique Sara Noy Rita Louise Christa Mark Deborah Eugenia Maria Denise Mona-Karina Ginny Fadime Ian Athanasios Helen Vladimir Sally Rossella Chiara Olwen Lynne Hilary Anna Katharina Sarah Helen Barbara Hélène Linda Louise Nicole Douglas Debbie

Seex BCPC Shapira FPC Shaw CF Sheinman RSPP Smaller UPCA Spevock RSPP Squarza UKATA Squires PET Stadtler RSPP Stroud AFT Tee ACAT Teixeira de Oliveira  PET Terzi IATE Theodosius AFT Thomas GP Tiskaya AFT Tomlinson UKATA Tsapas AOMP Turner AFT Urban SEA Urquhart RSPP Vaccaro SEA Vincenti SEA Wade-Jones FPC Walker ScPTI Waters GASW Watkins AFT Watt MC Wheeler SPTI Williams ACAT Williams IATE Wisheart WMIP Witney UKATA Worrica IATE Youngson SPTI Zimmerman BC

Psychotherapeutic counsellors Denise Sharon Sharon Rosalind Viviane Stephanie Melanie Annette Dayna Catherine Toni Carole Lesley John Jacqueline Kathryn Hilary Anne Claire Eva Liane Danielle Andy Philip Paul Maurice Richard Randy Moira

Askew MCCP Birch MCCP Calver MCCP Carman UPCA Carneiro IP Carter IP Charnock NGPC Cook MCCP Edmunds NGPC Edwards IP Goodwin CPPC Hall MCCP Hayton NGPC Hill CPPC Mendus UPCA Naish UPCA Pancott IP Pierce IP Preston MCCP Quirke IP Rushton UKAHPP Slaney IP Stevens IP Tomkinson IP Towers CPPC Ulland IP Wilson IP

* Apologies to these psychotherapists who were omitted from previous issues of The Psychotherapist AA Arbours Association · ACAT Association for Cognitive Analytic Therapy · AFT Association for Family Therapy and Systemic Practice · AOMP Accrediting Organisation for Medical Psychotherapy · BC The Bowlby Centre · BCPC Bath Centre for Psychotherapy and Counselling · BI The Berne Institute · BICP Beeleaf Institute for Contemporary Psychotherapy · BPA British Psychodrama Association · CABP Chiron Association for Body Psychotherapists · CAP Confederation for Analytical Psychology · CCOPPP Canterbury Consortium of Psychoanalytic & Psychodynamic Psychotherapists · CCPE Centre for Counselling and Psychotherapy Education · CF Caspari Foundation · CFAP Centre for Freudian Analysis and Research · COSRT College of Sexual and Relationship Therapists · CPPC Counsellors and Psychotherapists in Primary Care · CSP Cambridge Society for Psychotherapy · FIP Forum for Independent Psychotherapists · FPC Foundation for Psychotherapy and Counselling · GAP Guild of Analytical Psychologists · GASW Group Analysis South West · GCL Gestalt Centre London · GP Guild of Psychotherapists · GUILD Guild of Psychotherapists · HIP Hallam Institute of Psychotherapy · HIPC Humanistic and Integrative Psychotherapy College · IATE Institute for Arts in Therapy and Education · IFT Institute of Family Therapy · IGA Institute of Group Analysis · IGAP Independent Group Analytical Psychologists · IP Institute of Psychosynthesis · IPD Institute for Psychotherapy and Disability · IPSS Institute of Psychotherapy and Social Studies · KI Karuna Institute · LSBP London School of Biodynamic Psychotherapy · MC Minster Centre · MCCP Matrix College of Counselling and Psychotherapy · MI Metanoia Institute · NCHP National College of Hypnosis and Psychotherapy · NGPC Northern Guild for Psychotherapy and Counselling · NLPtCA Neuro Linguistic Psychotherapy Counselling Association · PET Psychosynthesis and Education Trust · RSPOP Research Society for Process Oriented Psychology · RSPP The Regent’s School of Psychotherapy and Psychology · RTC Refugee Therapy Centre · RV Re-Vision · ScPTI Scarborough Counselling and Psychotherapy Training Institute · SEA Society for Existential Analysis · SPTI Sherwood Psychotherapy Training Institute · TER Terapia · UKAHPP UK Association of Humanistic Psychology Practitioners · UKATA United Kingdom Association for Transactional Analysis · UPCA Universities Psychotherapy and Counselling Association · WMIP West Midlands Institute of Psychotherapy

The Psychotherapist

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continuingprofessionaldevelopment UK Council for Psychotherapy Book Editorial Board

Call for Book Proposal Assessors Are you interested in the world of publishing? Do you have the skills to assess potentially successful publications? Would you consider giving a few hours a year to the Book Editorial Board to help us with assessing proposals? It is enormously helpful for the Book Editorial Board to be able to call on UKCP members to help them with assessments. The book series began in 2007 and we already have over 30 books published, with more in the pipeline. If you would like to be involved please send an email to Pippa Weitz at Philippa.Weitz@ukcp.org.uk with a short summary of your interests and experience in the field.

Complaints

Recent outcomes of UKCP’s complaints and conduct process

Rob Waygood, Oxfordshire – 22 January 2014 The Appeal Panel imposed a suspension order of six months following the Adjudication Panel’s determination to find seven breaches of the UKCP Ethical Principles and Code of Professional Conduct proved. Sue Holden Smith, Kent – 7 April 2014 The Preliminary Enquiry Committee determined to uphold the complaint and found one breach of the UKCP Ethical Principles and Code of Professional Conduct proved and imposed a sanction by way of further supervision and personal therapy for a period of 12 months.

I’m a psychotherapist everyday – but on Mondays, Tuesdays and Fridays I’m also a Registered Mindfulness Teacher To find out more about pathways for student and qualified psychotherapists to become Registered Mindfulness Teachers Registered Mindfulness-based Therapists and Registered Mindfulness-based Psychotherapists

www.integration2014.com/ukcp All courses to become Registered Mindfulness-based Therapists or Registered Mindfulness Teachers are now accreditable towards joining the UKCP National Registers

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continuingprofessionaldevelopment

Come and discuss a new future for UKCP Members’ Assembly and General Meeting Saturday 19 July 2014 Central London (venue to be confirmed) At this meeting we will consider important proposed key changes to the way UKCP is governed and managed. This is your chance to have a say about how UKCP is structured and governed at present and in the future. It’s free to attend and lunch/refreshments will be provided. Please complete the online booking form which can be found on the events page on our website. Further information: telephone 020 7014 9966 or email events@ukcp.org.uk

The Psychotherapist

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continuingprofessionaldevelopment THE GESTALT CENTRE EST. 1980 LONDON Our CPD programme includes Advanced Group Facilitation

Personal Development

3 & 4 July 2014

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Certificate in Groupwork

5 & 6 July

Workshops include: Developing Effective Group Facilitation

10-Week Group 2 October - 4 December plus

12 September

1 & 2 November

Conflict Challenge and Confrontation in Groups 18 & 19 September

Psychotherapy and Counselling Training Autumn 2014

Group Facilitation Training Intensive Friday mornings (26 Sep - 5 Dec) Gestalt in Organisational Development Gestalt in OD Core Concepts 10 & 11 October Gestalt in OD In Practice 16,17 & 18 October 11,12 & 13 December

www.gestaltcentre.co.uk enquire@gestaltcentre.co.uk Call 020 7247 6501

Counselling  Certificate in Humanistic Counselling Skills (one year)  BACP Accredited Diploma in Counselling (two years) Psychotherapy  Advanced Diploma in Professional Development (one year)  MA in Gestalt Therapy Theory Studies (three years)

- 

  -   - -   - --            

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continuingprofessionaldevelopment CCPE

Accredited and Validated Psychotherapy Training

Centre for Counselling and Psychotherapy Education

Weekend Seminars 2014 20 + 21 September, Life Crisis 18 + 19 October, Facilitating Spiritual Growth

Autumn Conference

Same Sex, But Different? Exploring Intimacy and Separateness in Lesbian and Gay Couple Relationships Saturday, 11 October 2014. Course fee: £130 (early bird £115 if booked and paid for by 29 August)

CPD & Short Courses

1 + 2 November, Alchemy of Relationships

Exploring the Relationship Between Individual & Couple Therapy Speaker - Stanley Ruszczynski and Discussant - Francis Grier Saturday, 28 June 2014. Course fee: £85

Cost: £180 (non-refundable deposit £90)

Love across the Life Cycle: Neuroscience, Attachment & the Couple. Presenters Dr Sue Gerhardt, Dr Christopher Clulow & Julie Friend. Friday, 11 July 2014. Course fee: £125

Times: Sat / Sun 10am – 5pm

M.A. in Transpersonal Counselling and Psychotherapy This two-year part-time Research Masters is validated by University of Northampton and commences in January 2015.

CCPE Beauchamp Lodge 2 Warwick Crescent London, W2 6NE

Summer Schools: 15-18 July 2014

Developing Skills in Couple Work (for those new to couple thinking) Course fee: £650 Advancing Skills: When a Twosome Becomes a Threesome (for experienced couple practitioners) Course fee: £650

www.tccr.ac.uk

info@ccpe.org.uk www.ccpe.org.uk Tel: 020 7266 3006

70 Warren Street London W1T 5PB

Registered Charity No. 211058

The Society of Analytical Psychology Dedicated to Deeper Understanding

Post-Qualification Programme (starting Autumn 2014) The SAP brings modern post-Jungian insights for clinicians to develop their professional practice in:  Working with Adolescents  Clinical Assessment  Training in Supervision  Infant Observation These courses all run for one year, with 10 monthly sessions on a Saturday. They are designed for those who want to enhance their skills. For further information: training@thesap.org.uk

Public Events

2014 - Quarter page – CPD and RMA starting 2015 – The Psychotherapist Issue June

The Society runs a number of thought-provoking events in London, Oxford and Cambridge for professionals interested in Jungian psychotherapy. For further information: publicevents@thesap.org.uk

Open Evening Explore the SAP’s courses at our Open Evening (11 July 2014; 4:30 pm onward). Book by emailing training@thesap.org.uk 1 Daleham Gardens, London NW3 5BY; 020 74357696

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continuingprofessionaldevelopment The British Psychotherapy Foundation provides access to treatment for the public, comprehensive support to members and education and training to the next generation.

CPD Courses for Counsellors & Psychotherapists 2014/2015 The Work of DW Winnicott

Ref.CPD/9 A series of six seminars and discussion on the work of Donald Winnicott. Commencing September 2014. Fee: £230

Bion’s Clinical Relevance

Ref.CPD/32 Saturday morning workshops commencing June 2014. Fee: £230

Weekend course on Assessment Skills 18th & 19th October 2014 For psychodynamically trained mental health professionals.

Ref.CPD/7

Fee: £280

Jungian Dream Workshops

Ref.CPD/5 6 Saturday morning workshops will take place between November 2014 and March 2015. Fee: £420

Developing Supervision Skills

Ref.CPD/16 10 Saturday mornings held monthly between January to December 2015. Fee: £595

Psyche’s Awakening in the Body 14th & 15th February 2015

Ref.CPD/25 This course engages in the dialogue between body and psyche, listening to the images that arise from the body and from dreams. Fee: £200

Introductory & Pre-Training Courses 2014/2015 MSc in the Psychodynamics of Human Development A two-year, part-time evening course, which combines the knowledge of BPF clinicians with the research expertise of Birkbeck College. Starting September 2014.

One-Year Weekly Introduction to Psychoanalytic Ref.INT/31 and Jungian Theory and Practice 30 seminars over 3 Terms from October 2014 to July 2015, Wednesday evenings 7pm–10pm. Fee: £900

Weekend Course: Introduction to Psychoanalytic Ref.INT/4 and Jungian Theory & Practice Suitable for anyone interested in exploring psychoanalytic ideas or considering further training. 5 Weekends: March, April, May, June & July 2015. Fee: £900 Psychoanalysis Today Ref.INT/2 10 Introductory lectures, Mondays 8.00pm – 10.00pm commencing in September 2014. Fee: £300

Pre-training in Adult Psychoanalytic Psychotherapy Ref.INT/15 Work Discussion Group 8 seminars per term held over 3 terms. Commencing in Autumn 2014. Fee: £590

Developing a Psychoanalytic Approach to Working Ref.INT/10 with Children & Adolescents 2014 Weekly Work Discussions seminars over 3 terms on Monday evenings. Commencing September 2014. Fee: £630 Infant Observation – A Jungian Approach Ref.INT/12 Joining the course is possible at the beginning of any term. Seminars are held in South and West London. Fee: £720 pa

Infant Observation – A Psychoanalytic Approach

Ref.INT/13

Certificate in CBT Skills 3 weekends, intakes in October 2014 and March 2015 with Dr Michael Worrell.

Diploma in Integrative Supervision of individuals and groups, starts March 2015 led by Glenn Nicholls.

PG Diploma in Trauma & PTSD

A systematic approach to trauma therapy, from January 2015 with Lucia Hall.

Cultivating ‘presence’

1-day workshop with Manu Bazzano, on attunement, creativity, spontaneity, 18 October 2015.

Who is the Other?

1-day workshop with Manu Bazzano, the art of genuine encounter and rapport, 22 November 2014.

Introduction to Psychosexual Therapy

2-day workshop with Cabby Laffy, on common sex and sexuality issues, 25 & 26 October 2014.

Working with Shame

2-day workshop with Cabby Laffy, tackling compulsivity led by shame, 15 & 16 November 2014.

Certificate in Working with Couples 4 weekends, starting 13 March 2015 with Cabby Laffy.

Creativity in Therapy

2-day workshop 7 & 8 February 2015 with Simon Jacobs on dreams, imagery, creative intervention.

All venues in central London W1. Details in the Courses section of our website.

A one or two year course to gain an understanding of the earliest stages of human development. Fee: £720 pa

For further information and application forms, please contact: Sandra Pereira on 020 8452 9823 or E-mail: sandrap@bpf-psychotherapy.org.uk www.britishpsychotherapyfoundation.org.uk BPF Courses qualify for CPD. The BPF welcomes applications from all sections of society

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continuingprofessionaldevelopment CONVERGING STREAMS

Integrating Energy Psychology methods into Psychotherapy

21st Annual Conference

In this 13 day course Jan-Dec 2015

10th to 12th July 2014

Liverpool

“Celebrating 30 years of Cognitive Analytic Therapy: Culture, Identity and Pride”

• •

The practice of Cognitive Analytic Therapy (CAT) is being used in many different ways, within different settings and with a variety of client groups. CAT recognises the relational and social origins of distress and offers a framework that both recognises and values identity and culture. The Association for Cognitive Analytic Therapy warmly invites you to Liverpool - a city with a richly diverse culture and an unmistakable identity and human personality - to celebrate 30 years of CAT.

• •

practitioners will learn to:

Understand meridian and chakra systems Use energy/muscle testing mindfully

Work with conflicts/resistances to change

Use a variety of EP methods to clear problems/trauma from the energy field Integrate into existing practice

Work ethically with a new modality

All welcome

Online booking fee – whole event: ACAT Member £350 / Non-member £400

Individual items may be booked where it is not possible to stay for the duration of the conference

Course organisers: Ruthie Smith, Heather Redington,

For full details of the event, with information on how to book and a provisional programme to include inspirational speakers and workshops, please visit the ACAT website: www.acat.me.uk/event/743/ Email enquiries may be sent to maria.cross@acat.me.uk Telephone 0844 800 9496

James Barrett, Judith Anderson

see website for details and dates of Course and Introductory Days

www.energypsychotherapyworks.co.uk

For further information visit

www.acat.me.uk/event/743/

 

Counselling Training and CPD MA in Psychodynamic Counselling and Psychotherapy (BACP Accredited) Leicester Campus

Foundation Degree in Integrative Counselling Leicester Campus

Foundation Degree in Drug and Alcohol Counselling and Treatment Leicester Campus or via Distance Learning

Applications are now being taken for Autumn 2014 For further details and to make an application: w: www.le.ac.uk/lifelonglearning/counselling e: lifelonglearning@le.ac.uk t: 0116 252 5919

Vaughan Centre for Lifelong Learning

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continuingprofessionaldevelopment Parent Infant Psychotherapy: OXPIP Training 2015

Introducing Cognitive Analytic Therapy (CAT)

This highly-rated, hands-on two day course, offered by ACAT, is an introduction to the ideas, methods and skills of CAT for those new to the CAT way of working Online booking fee: £220 th th 19 and 20 September 2014 - Manchester th th 6 and 7 November 2014 – London www.acat.me.uk/course/745/ www.acat.me.uk/course/763/ maria.cross@acat.me.uk |Telephone 0844 800 9496

Applications are invited for our parent infant psychotherapy programme from qualified and appropriately registered mental health professionals. Time commitment: 25 Fridays in 2015 plus supervised clinical work. Further details are available online. web: www.oxpip.org.uk tel: 01865 778034

Apply now for September INSTITUTE

FOR CONTEMPORARY PSYCHOTHERAPY

Healing Codependency

2-Day Training, 12th June & 10th July

Working Successfully with Addiction & Recovery 5-Day Training, starts 28th July

Working Creatively with Trauma 5-Day Training, starts 4th August

Working Effectively with Anxiety & Depression

5-Day Training, starts 11th August

Experiential Training CPD Certificates Discounts Bright spacious venue close to public transport Contemporary Psychotherapy is an Integrative Outcome Oriented approach that organically facilitates recovery, growth and healing.

ENQUIRIES & BOOKINGS CALL

020 8983 9699

DProf in Existential Psychotherapy & Counselling

A joint course with Middlesex University, leading to eligibility for UKCP accreditation

MSc in Psychotherapy Studies

Online Programme validated by Middlesex University

New: Intensive Summer Professional Certificate in Existential Supervision and Group Leadership Module: 14 July – 1 August

Professional training in supervision, groups and clinical leadership To apply please contact: 0207 624 0471 0845 557 7752 admissions@nspc.org.uk

New School of Psychotherapy & Counselling 254-256 Belsize Road South Hampstead London NW6 4BT

BOOK ONLINE

www.beeleaf.com

www.nspc.org.uk

Qualified Accountant available to assist fellow counsellors and psychotherapists with tax returns, accounts and other financial needs. Please contact Paul Silver-Myer FCCA, UKCP [Reg.] 020 7486 0541 or psm@simonsilvermyer.com

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continuingprofessionaldevelopment

F_UOD_0312 UDOL UKCP June advert v3_Layout 1 16/04/2014 11:09 Page 1

READY TO ADVANCE YOUR CAREER? Gain the qualifications you need through online learning Our online degree courses offer you a flexible and affordable way to gain the qualifications required to take the next step in your career. Courses starting in September include: n n n

PG Cert Clinical Supervision MSc Health Psychology (BPS accredited) MSc/PG Dip Psychology (BPS accredited)

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MSc Integrative Health and Social Care University Advanced Diploma Cognitive Behavioural Studies and Skills

Call today on 01332 594279 or visit our website for further information. Whether you’re starting out, moving up or starting again

WE’RE READY WHEN YOU ARE 54

www.derby.ac.uk/ukcp www.ukcp.org.uk


Training and CPD for the modern professional The Manchester Institute provides a range of certificates and training to enhance your personal development portfolio. With over 20 years of bringing you trusted and challenging training techniques - that will enrich your understanding of the world of psychotherapy & counselling - we will enable you to work effectively and safely within your chosen environment.

Psychotherapy Training in Transactional Analysis - 4 Year Diploma Course This is a 4 year part-time course which leads to a professional accredited qualification in Transactional Analysis. (ITA, EATA & UKCP). For a detailed prospectus please contact the Manchester Institute for Psychotherapy. (Start Date:Weekend course from October 2014)

Certificate in Supervision This is a 5 day course spread over a period of 5 modules. We will look at the meaning of supervision as it applies in your field of work, whether you work individually or in a group setting, in psychotherapy, counselling or in the areas of social work, nursing, clinical psychology or indeed any of the caring professions.

NEW

NEW

4 Year Child Diploma This four year diploma is for people who wish to gain a qualification that upon completion will lead to accreditation by the European Interdisciplinary Association for Therapy With Children and Young People. Course Tutor - Karen F. Burke (M.Sc. Gestalt Psychotherapy) is Registered and Accredited by the UKCP

Tutor: Bob Cooke T.S.T.A (p) UKCP

Oher Trainers are Stephanie Cooke UKCP Registered and Amanda Phillips UKCP Registered

Sep to Dec 2014 & Jan to Apr 2015

Course Starts Oct 2014

2 Year Child Conversion Diploma Course This two year diploma is for experienced accredited and registered Psychotherapists who wish to gain a qualification that upon completion will lead to accreditation by the European Interdisciplinary Association for Therapy with Children and Young People. Course Tutor - Karen F. Burke (M.Sc. Gestalt Psychotherapy) is Registered and Accredited by the UKCP Oher Trainers are Stephanie Cooke UKCP Registered and Amanda Phillips UKCP Registered

PSYCHOTHERAPY IN INTEGRATIVE RELATIONAL PSYCHOTHERAPY This is a 4 Year Part-Time Psychotherapy Training Course, which is taught over 10 weekends per year. This Course leads to being a Professionally Accredited Intergrative Relational Psychotherapist, recognised by MIP and EAIP. Course Tutor: Bob Cooke T.S.T.A - CTA (P) and UKCP Registered.

Course Starts Oct 2014 Manchester Institute for Psychotherapy 454 Barlow Moor Rd Chorlton Manchester M21 0BQ

Course starts Jan 2015

For all the above courses and to see our CPD programme (2014) contact us on: 0161-862-9456 or bob@mcpt.co.uk or visit our website www.mcpt.co.uk Please check out our new website for support for those in the child and adolescent Psychotherapy/Supervision field: www.childtherapyworld.com

TAtherapy


UKCP Supervision Conference

Physical, mental and emotional health: interdependence and integration through supervision Saturday 18 October 2014 London (venue to be confirmed)

O

ur physical, emotional and psychological states are core matters for the supervisory experience and the work of therapists with clients. Understanding and working with the interdependent relationship between these states can influence the quality of life clients experience in wider society. In supervision, capacity is fostered and enhanced, through a diversity of approaches and special interests, to help therapists and other psychological facilitators integrate this understanding into their work with others. This conference is an opportunity for a multiplicity of supervisory voices to engage with each other in a conversation that works towards an improved addressing of the emotional and relational aspects of better wellbeing through our work.

Who might benefit from attending?

Confirmed keynote address Expanding the field of awareness integrating somatic, emotional and mental processes in supervision Margaret Landale is a psychotherapist and supervisor with over 25 years of experience. She has been a training director at the Chiron Centre and delivers workshops and talks nationwide on subjects such as somatization, complex trauma and the integration of mindfulness in psychotherapy. Recently she co-facilitated the ‘mindfulness in individual psychotherapy’ module at CMRP, Bangor University. Publications include: ‘Working with psychosomatic distress and developmental trauma’ in: Contemporary Body Psychotherapy – The Chiron Approach, Linda Hartley ed., Routledge 2009. ‘The use of imagery in body oriented psychotherapy’ in Body Psychotherapy, Tree Staunton ed., Brunner-Routledge, 2002.

If you take your own work with clients to another professional to critically enquire and reflect upon it; or if you offer a space to which others come to critically enquire and reflect upon their work, this conference is for you.

Confirmed workshop

Conference fees incl. admin fees

To book your place please visit: www.ukcp.org.uk/ukcpsupervision2014 For assistance and further information please email: events@ukcp.org.uk or telephone: 020 7014 9966. Follow the event on: #ukcpsupervision

UKCP member UKCP student or trainee member Non UKCP student Non member

Early bird Standard 3 Sept £82.92 £98.43 £39.49

£46.75

£47.46

£57.07

£133.60 £155.30

I’m beyond your peripheral vision… so you might want to turn your head Pam Gawler-Wright and Cynthia Mitchell In this experiential workshop we will play together to generate some guidelines for uncovering, naming, managing and

utilising difference and diversity as it is revealed in the client-therapist-supervisor system. We will look at holding and healing from positions of hurt, shame and power.

Call for workshops We are calling for proposals for an experiential workshop using a large group process. The content and title of the workshop would need to address supervision practice and to clearly pick up on the theme or an aspect of the theme of the conference. This parallel workshop will have an emphasis on experiential learning in a large group and could be for approximately 35-40 people, lasting 1.5 hours in the afternoon of the conference. Please send your proposal to events@ukcp.org.uk by 22 August 2014, including the following: - Your name, email address and telephone number - Title for the workshop and abstract (up to 200 words) for inclusion on the UKCP website and programme - Brief biography for inclusion on the UKCP website and programme (3-4 lines) Notice of acceptance of workshops will be sent by 12 September 2014.

UK Council for Psychotherapy, 2nd Floor, Edward House, 2 Wakley Street, London EC1V 7LT · 020 7014 9966 · www.ukcp.org.uk · Registered Charity No 1058545 · Company No 3258939 · Registered in England

The Psychotherapist issue 57: Summer 2014  
The Psychotherapist issue 57: Summer 2014  
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