An exploration of generalist and specialist approaches in the psychotherapy profession
The maga zine of the UK Council for Psychother apy
Sex and relationship therapy
Issue 60 â€˘ Summer 2015
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contents Feature articles Sex and relationship psychotherapy 4 Introducing the UKCP College for Sexual and Relationship Psychotherapy (CSRP) 5 How sex therapy has changed from the 1970s to the present 6 The ethical considerations of sexual surrogacy 9 Working with people who commit sexual offences and their families 11 QUIZ Know your law 13 The power of touch 14 Gender and sexuality diversity (GSD): respecting difference 16 Understanding and handling sexual desire in therapy 18 ‘I need you – except when I don’t’: healing co-dependence 20 What’s wrong with porn? 23 BOOK REVIEW Sexual Attraction in Therapy 25 Reflections from the psychosexual psychotherapy classroom 26 Discussion Peer-supported open dialogue UKCP news Raising the profile of the Accredited Registers programme Conversion therapy: what are we doing now? UKCP members Learning from complaints: confidentiality Why does psychotherapy research matter to UKCP? ‘I think it can help to improve my work as a therapist’ The Shape review: update Books about psychotherapy: write a review? Welcome to our new UKCP members
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 psychotherapy and psychotherapeutic 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 issues of prejudice and discrimination in relation to the mental wellbeing, political belief, gender and gender identity, sexual preference or
How well do you know the law? 13
Attraction in therapy
28 30 31 33 34 36 38 40 41
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. UKCP seeks to ensure that 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.
Benefits and risks of pornography23 The Psychotherapist is now available online. See page 32
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
Sex, relationships and creativity It is with great pleasure that I welcome you to the latest edition of The Psychotherapist.
he theme of this issue is sex and relationship therapy. I would like to thank Julie Sale, the guest editor, and the College of Sex and Relationship Psychotherapy (CSRP) for producing the exciting articles that are in this featured edition of The Psychotherapist. I would also like to take this opportunity to thank those involved, under Charmian Beer’s chair-ship of CSRP, for their hard work in developing the College. We all know about relationships and sex. When the two come together it can be powerful and creative – we don’t tend to see those in the therapy room. But
Janet Weisz UKCP Chair
sometimes it goes wrong with long-lasting consequences. We see the results in our consulting rooms weekly. Juliet Grayson writes eloquently about this. For a relationship to be creative, it needs creative intercourse: two people or more coming together, meeting, and creating something new. Later on in this issue, Katrin Maier writes about work emerging from the Research Faculty and Practice Research Networks. The ‘Moments of Meeting’ project seeks to examine the impact of the alliance between therapist and client in the therapy process and identify special ‘moments’ where two come together and create something new, transforming the client . Nor is creative transformation exclusive to the therapy relationship. As I write this, I think about the relationships that happen in other professional settings. Many of you will know that our Chief Executive, David Pink, left UKCP at the beginning of the month to pursue other opportunities. David and I had a creative relationship
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.
Consulting Editors: Mary MacCallum Sullivan, Rachel Pollard, Karen Demsey
Advertising policy Advertisements are the responsibility of the advertiser and do not constitute UKCP’s endorsement of the advertiser, its products or services. The Editor reserves the right to reject or cancel advertisements without notice. Display ads: For a current advertising pack and rate card, please contact UKCP on 020 7014 9490 or email firstname.lastname@example.org
Editorial board: Sandra Scott, Janet Weisz, Mary MacCallum Sullivan, Richard Casebow, Rachel Pollard, Karen Demsey
which I hope UKCP, psychotherapy and psychotherapeutic counselling benefited from. There will be more space in the next issue to feature David so let me just say that, after six years in post, he leaves UKCP professionalised, more modern and streamlined. I thank him both personally and on behalf of UKCP for what we have learnt from him and wish him well in his new direction. On a different but related matter, we have a report on page 38 from Judith Lask, who is a member of the ‘Shape working group’. The consultation document on the future ‘Shape’ of UKCP is out – please have a look at it and respond. You can find all the information you need here: www.ukcp.org.uk/news/consultation-onukcps-future-shape. The deadline for your thoughts and feedback is 31 July. Finally, I hope you read and enjoy all the articles in this current issue.
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Sex and relationship psychotherapy: common themes within a specialism Our guest editor, Julie Sale, introduces this special issue, which aims to bridge generalist and specialist approaches in the psychotherapy profession to sex and relationship therapy Julie Sale is Director of Local Counselling Centre, a counselling service with clinics in Hertfordshire, Bedfordshire and North London. Julie is a UKCP-registered psychotherapist and a College of Sex and Relationship Therapists (COSRT)-accredited sex and relationship psychotherapist. She is a member of the teaching faculties of BeeLeaf, the London Diploma in Psychosexual and Relationship Therapy and NAOS. Julie is Vice Chair of COSRT’s Ethics Committee. Email firstname.lastname@example.org www.localcounsellingcentre.co.uk
lthough sex and relationship psychotherapy is a specialism within the broader profession of psychotherapy, represented in UKCP by the College for Sexual and Relationship Psychotherapy (CSRP) and in the UK by the College of Sexual and Relationship Therapists (COSRT), the themes of sex and relationships enter the work of every psychotherapist. Specialists might well be working with the psychology behind so-called specific ‘sexual dysfunctions’, but every psychotherapist will, at some point, encounter a client with a history of childhood sexual abuse or difficulties with a relationship.
Increased public interest The timing for a special edition on these themes seems particularly apposite. In recent years, there has been increased public interest in sex and relationship therapy, with films such as The Sessions and Hope Springs and the TV programme Masters of Sex featuring the work of sex therapy pioneers Masters and Johnson. Exploration and representation of wider sexual preferences and gender identities is now evident on mainstream television, led by Channel 4, although still notably absent in many psychotherapy trainings.
Complex ethical questions Operation Yewtree and the UN Committee on the Rights of the Child have placed childhood sexual abuse firmly in the public consciousness, raising for our profession the controversial question of appropriate therapeutic treatment for both victim and perpetrator. Concerns currently exercising the sex therapy world, such as whether or not sex and porn addiction exist as mental health conditions and the appropriateness of referring to sexual surrogates, have relevance for the wider psychotherapy community in the complex ethical questions they raise. And, of course, the eternally thorny question of sexual attraction in the therapy room applies to us all, as does the risk of co-dependent relationship patterns, either in our clients’ lives or in our therapy dyads. The personal and professional development that grows from cross-modality training and discourse provides valuable insights for effective client work, reading across, beyond and between specific philosophies of therapy. This issue of The Psychotherapist aims to bridge the worlds of specialist and generalist in articles that inform and reflect on aspects of sex and relationships that apply to both.
Every psychotherapist will encounter a client with a history of childhood sexual abuse or difficulties with a relationship 4
The College for Sexual and Relationship Psychotherapy (CSRP) CSRP Chair, Charmian Beer, introduces the College for Sexual Relationship Psychotherapy Charmian Beer is Chair of the College of Sexual and Relationship Psychotherapy (CSRP). She is a UKCP-registered sexual and relationship psychotherapist and supervisor with a private practice in Birmingham.
he College for Sexual and Relationship Psychotherapy came into being in July 2013. It is one of UKCP’s smaller modality colleges, with fewer than 200 members, all accredited through our only organisational member, the College of Sexual and Relationship Therapists (COSRT). Any UKCP registrant who is accredited by COSRT is automatically a member of CSRP.
Integrating knowledge I guess that all psychotherapists would say they work with ‘the relationship’, whether between therapist and client or therapist and ‘other’, but CSRP is the only UKCP college with the word ‘sexual’ in its description. We specifically integrate knowledge of the physiology of human sexual functioning with psychodynamic, systemic, mindfulness-based and sociological theories of relationship, both in human partnerships and in the therapeutic space. Using the framework of CBT, we set carefully graduated tasks (completed in the privacy of the client’s home), with the goal of a comfortable sexual relationship, whatever that might mean for the client or clients/individual or couple, and, hopefully, a healing of the trauma (attachment, sexual, accidental, illness, physiological) that brought about the disruption to the relationship or the sexual functioning.
Practical, observable difference The directive and goal-oriented nature of this CBT-framed psychosexual psychotherapy would be anathema to many psychotherapists, but our specialism hopes to bring about practical, observable difference. Anyone who has learned to ride a bike or play a musical instrument didn’t do it by reading or talking about it – practice is essential! Members of CSRP offer a guided programme of learning, helping people to understand their own sexual responses better, to communicate better with partners, and to understand the anxieties which have maintained the unwanted sexual and relationship patterns.
Discovering peace and comfort Because we work with such detailed, highly intimate material, the College has very high standards of ethics and practice, which include never touching clients (unless medically trained and qualified), never asking people to undertake sexual ‘tasks’ in the therapy room, and never having a sexual relationship with clients, even after the therapy has finished. These standards recognise the highly complex, power-imbalanced and transferentially loaded nature of working with sex and sexual relationships and the care needed to work alongside people as they discover peace and comfort with their sexual relationship, perhaps for the first time.
How sex therapy has changed from the 1970s to the present: a personal view Dr Michael Perring traces the evolution of sex therapy over the decades and celebrates a new interdisciplinarity in the field
n the 1970s I remember uncertainty about how we, as sex therapists, should identify ourselves and the clinics we ran. The label over my clinic door said ‘Sexual Dysfunction Clinic’ and only much later ‘Psychosexual Counselling’. As service providers, the staff might be, by training, a psychologist, psychiatrist, urologist, gynaecologist, marriage guidance counsellor or even a sexologist.
Kinsey reports I have selected three sex surveys, not entirely at random, done approximately 25 years apart, which show the attitudes and context in which sex therapy has evolved. The Kinsey reports (1948, 1953) came out in
Dr Michael Perring Michael read Medicine at Cambridge, Bart’s and Capetown University, graduating as a Fellow of the S.A. College of Physicians in 1970. In the UK he worked as a GP, psychiatrist and Lecturer in Sexual Medicine at the University of Southampton and the Gender Clinic at Charing Cross Hospital. UKCP registration as a humanistic psychotherapist and ongoing practice has led to his eclectic approach bridging medicine and psychodynamic therapy in independent practice and in the NHS.
the late 1940s and 50s. Controversially, they asserted that sexuality is diverse and prone to change over time. In place of the three categories of homosexual, heterosexual and bisexual, Kinsey developed the seven-point Kinsey Scale, also called the Heterosexual– Homosexual Rating Scale, using a scale from 0, meaning exclusively heterosexual, to 6, meaning exclusively homosexual, with an additional grade, ‘X’, which meant ‘no socio-sexual contacts or reactions’, currently referred to as asexuality.
The books still on my shelf show the enthusiasms of the time: sexual variance, conducting multiple relationships and, of course, Alex Comfort’s (1972) book with line drawings of possible positions for sex. What more can I write about the enthusiasm of the people I met during those times? I remember the founder of the Institute, the Reverend Ted McIlvenna, charismatic and constantly challenging the social norms of sexual behaviour.
Kinsey’s findings were controversial and they have been criticised as unscientific. For example, he used data that were not randomised and he included an insufficient number of older people in the survey to enable statistical conclusions to be made.
My summer in San Francisco in the late 70s was informative and eye opening: the spectacle of the Gay Parade, conversations with members of the transgendered community, immersion in ‘desensitisation’ to erotic videos, a video presentation on the ‘G’ spot, sadomasochistic practices by someone who brought their whips and handcuffs. I remember having to take my clothes off and talk about my body for five minutes while being watched by 100 people. Afterwards, in other people’s descriptions of themselves, I realised the extent that feelings distort the reality of appearance. It was one experience in an immersive fortnight leading me to the conclusion that sex therapy in theory benefits from field experience.
Freedom and experimentation For the second survey I recall Professor Brecker (1984) on the staff at the Institute for the Advanced Study of Human Sexuality – no modesty in that title – in San Francisco, where I was an extramural student. In the late 70s, he surveyed the marital relations of older couples in the permissive period following the arrival of the contraceptive pill and before anxiety about HIV led to caution in sexual exploration. In the gap between the two, there was a sense of freedom in sexuality and pleasure in its experimentation. Becker showed that continuance of sexual activity into later life was a matter of choice and the level of activity for couples related less to age than to the duration of the relationship.
Benefiting from field experience
The third survey is the 1994 NatSal Survey of UK Sexual Attitudes and Behaviour (Johnson et al, 1994) by an academic team funded owing to concern about HIV. One conclusion of the survey, I recall, was that the most common reason for sexual activity to end in a heterosexual relationship is the
feature article death of a partner, obvious but important when women live longer than men, and accounting for the preponderance of women looking for a partner in later life.
Important things have not changed Let me say this about the surveys: if you take each of them, about a generation apart, you might rightly think that much has changed about attitudes to sexual behaviour. But equally, some important things have not changed: companionship in a couple’s relationship has continued to be rated more highly than the level of sexual activity in it, and the security and trust a relationship offers are highly rated in all three surveys. Perhaps unsurprisingly, in general, sexual activity is rated more highly by men than women. Returning to the mid 70s, I was working in a psychiatric unit at Knowle Hospital between Portsmouth and Southampton. The hospital was run as a community, with extensive grounds, a hospital football team and an occupational health department offering work in the kitchen garden and the craft skills of basket-making and painting. In the long-stay wards, some inmates had not left the hospital for decades and were institutionalised – there was little clarity among any of us why they were there. New medications for psychosis, including long-acting phenothiazines, led to patients’ easier management and fitted the prevailing economic policy to discharge patients from long-stay wards into the community. In the psychology department, the influence of Skinner’s behaviourism was still evident. In that setting, the use of aversion therapy for dystonic homosexuality was practised using erotic images and apomorphine, while bilateral ECT was regularly given for depression.
Masters and Johnson and cotherapy As for sex therapy, Masters and Johnson (1970), and their model of co-therapy for couples, was published in the States and I, with a multidisciplinary team of volunteers, started a ‘sexual dysfunction’ clinic. Working in a Southampton family planning clinic, the team consisted of a marriage guidance counsellor, a health visitor, a social worker and my co-worker Dr Margaret White, a psychologist. Within two years, the clinic had a long waiting list of referrals from GPs responding to the highly publicised new
therapy. Recognition of sexual medicine as a specialty at this time led to my appointment by Professor John Dennis as a Lecturer in Sexual Medicine in the Department of Human Reproduction at the University of Southampton. I remained in post there for six busy years. In the sexual dysfunction clinic, we worked in co-therapy with two therapists and the dyadic couple along lines described by Masters and Johnson. Our training was a shoestring operation, which grew from the work, co-therapist support and weekly lunch break discussions. Typically we saw a couple every two weeks for between three to six months. We followed the M&J description of ‘sensate focus’ therapy and used their model of homework assignments.
Companionship has continued to be rated more highly than the level of sexual activity We had the enthusiasm of novices, engaged with our couples, and enjoyed what we were doing. With hindsight, the relational style of therapy we adopted and the genuineness of our concern for clients may well have accounted for our ‘substantial improvement’ rating of 75 per cent reported by the evaluating psychologist, Dr John Sketchley. We celebrated our success in the new Journal of Sexual Medicine edited by Dr Alan Riley who was later to become the Professor of Sexual Medicine at York. In parallel to our clinic, Dr Liz Stanley was appointed to a post in Sexual Medicine at St George’s Hospital and started the first of a dozen training programmes in psychosexual counselling available in the UK by the 1990s.
Desensitisation Both Liz Stanley and I had exposure at Ted McIlvenna’s Institute in San Francisco to the videotaped erotic material used there by trainees to ‘desensitise’ them to explicit sexual behaviour. The tapes were made by the Institute’s students and portrayed explicitly their sexual preferences. Liz, after delays at UK customs, succeeded in importing some of the material for educational purposes in the newly established psychosexual
training programmes. I used them with medical students to explore with them their feelings and attitudes to the different sexual lifestyles they would encounter in medical practice. For three or four years, these videos were a focus of discussion on subjects such as ‘what language is appropriate when talking about sex?’ and ‘how to remain impartial to sexual preferences which are different from our own’. Of course, the erotic content of the tapes was not without its effect and a straw poll of participating medical students showed an increase in sexual activity over the weekends the programme was run. But over time the novelty of the tapes wore off and, in truth, I think those of us who had worked with them ‘immersively’ became thoroughly sick of their repeated use. I have not heard these novel erotic desensitisation tapes discussed for the past 20 years. A briefer approach to sex therapy at this time, advocated by the psychologist Dr Jack Anonn (1974), was succinctly described as the PLISSIT model. The letters stood for permission, limited information, specific suggestions, and intensive therapy, and the model provided a good novitiate’s guide to the territory!
Diverging options for managing problems In the UK in the 1980s the different traditions of medicine and psychotherapy became evident in the diverging options for managing sexual problems. Health workers and doctors in particular had permission to touch and physically examine their patients. For me, as a part-time GP, physical examination was accepted as normal practice and, in a tradition that was ritualised and structured, it assisted as a proper means to establish a diagnosis. I was also aware of the importance it had in creating trust in the relationship between patient and doctor. By contrast, in the ‘talking’ therapies, physical contact with patients was taboo. Psychotherapists by tradition listened and promoted catharsis and ‘insight’ as the basis for change, while for an analyst working with transference, the intimacy of physical contact was seen as a boundary violation that would be countertherapeutic to the process of therapy. Bridging the divide between these two traditions were family planning doctors who routinely examined patients when advising on contraception. The intimacy
feature article Psychological factors, including relationship dynamics, require consideration alongside exploration of physical disease of examination was leading women to talk more easily about their sexual difficulties. Discussion in training seminars led to the formation of the Institute of Psychosexual Medicine and the psychiatrist, Dr Tom Main, became its founding president. I attended a seminar Tom Main held at the Brompton Hospital in 1987. He was a charismatic figure and a pioneer in an organisation mostly composed of women. A key understanding of the help offered was the recognition that vaginal examination was a moment when truth might be spoken. A study of the treatment of vaginismus, with an attentive ear to what it represented for the patient while the examination was being made, could be constructively interpreted. As I saw it, here was further evidence of the importance of touch to the patient–doctor relationship.
Better means of investigation Meanwhile, amongst those of us working in several sexual dysfunction clinics around the UK there was a need to share our understanding of the work we were doing. It led to the formation of the Association of Sexual and Relationship Therapists. The majority of our members were either doctors or counsellors and Dr Elizabeth Stanley became our first president. Over the next decade, medicalisation of treatment led to the separate formation of the British Institute of Sexual Medicine, which could accommodate those members who preferred the primacy of diagnostic formulation and prescription. A medical approach was boosted by the discovery of a group of drugs of which the best known was Viagra. The striking benefits it provided to male function and to male confidence led GPs, whom patients often first approached, to prescribe for erectile dysfunction (ED). A generation before, it was thought that about three-quarters of ED had a psychological basis. With better means
of investigation available, the presence of physical – and for the most part vascular – factors were recognised as underlying the problem in three-quarters of the cases seen. It also highlighted the fact that not all men benefited from a ‘one size’ solution and that psychological factors, including relationship dynamics, required consideration alongside exploration of physical disease. A further point about the medicalisation of sexual problems has been the tendency to add to the diagnostic categories of sexual dysfunction. Historically, I recall that, before the 1950s, female anorgasmia was not described as a problem and until the 1980s the American DSM classification of disease did not distinguish dystonic homosexuality. In the late 70s Dr Helen Kaplan (1979) drew attention to complex factors in the disorders of sexual desire and from early this century a distinction has increasingly been made between disorders of female arousal.
A seminal book Published in 1983, John Bancroft’s Problems of Human Sexuality provided a seminal book for those of us working in the sexual dysfunction field. He brought together, as a scientist and a practitioner, the provable with the practical, the scientifically valid with what could be understood and justified pragmatically as treatment.
The books still on my shelf show the enthusiasms of the time Over two decades there has been maturation of the organisations providing services for sexual dysfunction and the sexual minorities. There is a UK College of Sexual and Relationship Therapists, the British Society for Sexual Medicine and the UK Institute of Psychosexual Medicine. There is also a psychosexual service provided by Relate and services offered by other voluntary bodies for the sexual minorities and LGBT community. Pressure for regulation of psychosexual counselling has come from the United Kingdom Standing Conference for Psychotherapy and from doctors from the General Medical Council. These in turn have responded to expectations in the wider community for improved access to healthcare and less
autocracy in its delivery. The outcome has been regulation from without and selfgovernance from within the healthcare field. Alongside this, there have been stringent economic considerations affecting the provision of services in the NHS. Inevitably, services are more structured, and more attention is being paid to training practitioners and the qualifications and standards of their practice. The demands of regulation on our time are the new norm for doctors and psychotherapists alike.
A buzz of excitement Finally, on a more upbeat note, I think the enthusiasm that led to my entering the field of sex therapy is still evident in the work of my colleagues. There is a new recognition of plasticity in the brain and possibilities for change in our behaviour. New investigative techniques may show that neural networks, once established, are resistant to change, but we have a capacity to overlay their patterns with the sprouting of new connections and behaviours. The theories on which psychotherapy has been predicated are compatible with neurobiology. It is possible to integrate models and there is a buzz and excitement in the fields of attachment, psychoanalytic and relational theory as, together with our understanding of neurobiology, we find new ways of thinking about and working with our clients. As for myself, I am validated in a way of being with my patients, which encourages empathy, realness and constructive enactment between us. It is an approach that should continue to encourage all of us in our enquiries into sex, relationships and life itself.
References Annon JS (1974). The behavioral treatment of sexual problems. Honolulu: Kapiolani Health Services. Bancroft J (1983). Human sexuality and its problems. USA: Longman Group Limited. Brecker E (1984). Love, sex and aging. Consumer’s Union. Comfort A (1972). The joy of sex. A gourmet guide to lovemaking. UK: Mitchell Beasley. Johnson AM, Wadsworth J, Wellings K and Field J (1994). Sexual attitudes & lifestyles. Oxford: Blackwell Scientific Publications. Kaplan HS (1979). Disorders of sexual desire. New York: Brunner/Mazel. Kinsey A, Pomeroy WB and Martin CE (1948). Sexual behavior in the human male. Philadelphia: Saunders. Kinsey A, Pomeroy WB, Martin CE and Gebhard P (1953). Sexual behavior in the human female. Philadelphia: Saunders. Masters WH and Johnson VE (1970). Human sexual inadequacy. Toronto; New York: Bantam Books.
The ethical considerations of sexual surrogacy Jo Coker and our guest editor Julie Sale highlight some of the ethical and legal issues related to sexual surrogacy and COSRT’s current position as expressed in its code of practice
n psychosexual psychotherapy, disabled clients and those without partners who suffer from sexual problems may find it difficult to complete the exercise programmes on their own that are part of their treatment, or they may want a full sexual experience and wish to consider sexual surrogacy as a treatment option. In this article, we attempt to illustrate the complex ethical, moral and legal perspectives involved in sexual surrogacy. These perspectives do not always align, presenting difficulties and conflicts for those of us navigating this complicated area for the benefit of the client.
Joanna Coker is the national Professional Standards Manager for COSRT and is responsible for its clinical standards, as well as being part of the media consultancy team. She is a counselling psychologist registered with HCPC, a BPS member, a BACP-accredited psychotherapist, a COSRT-accredited sex and relationship therapist, an accredited clinical supervisor and a qualified mediator, with over 30 years’ experience of working in the NHS. With special thanks to Barry Gower, Chair of Ethics, for his contribution to the content and structure of this article.
Key questions The July 2013 conference of the College of Sexual and Relationship Therapists (COSRT), What’s going on in the world of sexual healing?, raised the ethical and legal considerations of sexual surrogacy in the context of psychosexual psychotherapy. One key question that emerged was whether the time was right for COSRT to reconsider its statement regarding sexual surrogacy: ‘COSRT does not support/ endorse/recommend surrogate therapy’ (Code of Ethics and Practice for General and Accredited Members, 3.3.10). A further question arose around whether COSRT members were permitted to work in conjunction with, refer to or inform clients about sexual surrogacy. COSRT’s Board of Trustees commissioned the organisation’s Ethics Committee and Professional Standards Board to thoroughly investigate the relevant legal, insurance and ethical positions in order to offer clearer guidelines to members. This was not intended as a judgment on the role of sexual surrogacy, rather a desire to understand the present position. In undertaking this review, COSRT identified seven main ethical considerations:
different levels of intimate touch they agree to undertake, and the differences between touch therapy described as sex coaching and that described as sexual surrogacy are not always clear. Masters and Johnson (1970) established sexual surrogacy in the context of a threeperson therapeutic sex therapy team, consisting of sexual surrogate, client and supervising psychosexual psychotherapist. Although the International Professional Surrogates Association continues to define sexual surrogate partner therapy in the same way, sexual surrogacy is now also practised independently of a qualified psychosexual psychotherapist.
2. Law and insurance The criminal law in England and Wales contains various offences relating to the provision of sexual services for payment. However, it is unlikely that an offence would be committed by a therapist discussing a particular sexual surrogate with a client, or with them recommending or even introducing a surrogate. An exception to this would be where the therapist causes or encourages someone not already acting as a sexual surrogate to become one, even if only on one occasion. In this case,
1. Definitions There is currently a distinct lack of clarity in the use and meaning of descriptors in the UK sex therapy field (Zur, 2013). This has the potential to create confusion and vulnerability to risk for clients and to challenge the professional integrity of appropriately trained mental health professionals working in this area. Many descriptors are used interchangeably between talk and touch therapists, with both using the terms ‘sex coach’ and ‘sexologist’, for instance. To further cloud the issue, touch therapists have
The term ‘psychosexual psychotherapist’ is used to denote talk-based therapists who are specifically qualified to work with sexual issues. The term ‘sexual surrogacy’ is used to describe the practice of working as a professional sexual substitute at an intimate touch level (which may include sexual intercourse) with clients. Legal advice cited is based on English law, which covers England and Wales.
feature article an offence might be committed under section 52 of the Sexual Offences Act 2003. It should, however, be noted that this area does not appear to have been tested directly in case law; until it is, it cannot be guaranteed that an offence would have been committed. Psychotherapists should be aware of this and use their professional judgment in any decisions they make. A survey of the main professional indemnity insurers used by COSRT members found that they do not presently differentiate between sex workers and sexual surrogates, meaning that psychosexual psychotherapists referring to sexual surrogacy may possibly be in contravention of their insurance policy. Psychotherapists who have any involvement with sexual surrogacy services are therefore advised to seek their own legal guidance, particularly where they think the person who is to provide the services may not already be providing such services. It is also advisable that they carefully review the terms of their insurance cover and contact their insurer to ensure that they are not risking breaching those terms.
3. Professional standards for surrogacy Although there are well-established professional bodies for the practice of sexual surrogacy in the USA, the UK equivalent, the Association of Somatic and Integrative Sexology (ASIS), was formed relatively recently. ASIS has in place stated ethical principles, an ethics committee, code of conduct and complaints procedure for its members but it will take time to fully know how these structures are used and reported to the wider profession.
4. Contra-indicators Although COSRT’s code of ethics and practice and use of supervision already offer a robust structure for assessing client and therapist safety, further detailed guidance on the contra-indicators for sexual surrogacy need to be developed, including consideration of the implications of psychiatric diagnosis, mental and physical vulnerability, the ability to give informed consent and challenges with attachment (for both surrogate and client), which could lead to higher clinical risk to the client and/ or legal or ethical liability to the referring psychosexual psychotherapist.
5. Sexual health and conception Clearly, a major ethical implication of referral to sexual surrogacy is risk to sexual
COSRT has concluded that the practice of sexual surrogacy is not currently well enough developed to be supported by its code of ethics and practice health and/or the risk of conception, for both the surrogate and the client (Zur, 2013). ASIS addresses this in its code of conduct but consideration of the ethical responsibility of a referring psychosexual psychotherapist would also be required.
6. Lack of research evidence Unsurprisingly, given its controversial status, the efficacy of sexual surrogacy is not extensively evidenced in research, although a few studies do exist (Aloni et al, 2012; BenZion et al, 2007). With insufficient objective data for use of a referral to sexual surrogacy, the basis on which a psychosexual psychotherapist would make a referral could be unclear and subject to question. Is the desire to refer linked to a lack of comfort or professional confidence in addressing sexual performance issues through talking, a fear of sexual arousal in the therapy room, a vicarious enactment of sexual attraction, a drive towards rescuing the client, or wellconsidered professional judgment based purely on client need? As psychosexual psychotherapists, we are called to examine these questions in private reflection and with our supervisors.
7. Client autonomy Clearly, clients have a right to exercise autonomy in the choice of therapies they engage in to resolve a sexual issue. This could create the situation of a client working concurrently and independently with a psychosexual psychotherapist and a sexual surrogate, creating the ethical dilemma for the psychosexual psychotherapist of how to support client choice and/or to follow stated COSRT professional standards. For some this will be very problematic.
Conclusion Sexual surrogacy and its relevance to the work of psychosexual psychotherapy remain ethically problematic (Zur, 2013). From COSRT’s position, based on the legal advice it has received, the legal and insurance implications at this time complicate the ethical considerations. COSRT has therefore concluded that the practice of sexual surrogacy is currently not well enough developed to be supported. As
such, COSRT has amended its code of ethics and practice to read: 3.3.10 COSRT’s understanding is that currently in England and Wales making a direct referral to a sexual surrogate is very unlikely to constitute a criminal act. However, an offence may be committed where a member causes or encourages someone who is not already working as a sexual surrogate to become one (see Practice Guideline 11 and Surrogacy Paper). COSRT’s position is that members may discuss sexual surrogacy with clients, but may not help secure these services for clients nor make specific recommendations. While COSRT sees this as the current position, it is open to change and will continue discussing the matter as an organisation, canvassing views from members and the public, as well as continuing to engage with other major psychotherapy organisations following its lead.
References Aloni R, Keren O and Katz S (2012). ‘Sex therapy surrogate partners for individuals with very limited functional ability following traumatic brain injury’. Sexuality and Disability, 25(3): 125134. Ben‐Zion I, Rothschild S, Chudakov B and Aloni R (2007). ‘Surrogate versus couple therapy in vaginismus’. Journal of Sexual Medicine, 4(3): 728-733. Masters WH and Johnson VE (1970). Human sexual inadequacy. USA: Ishi Press International. Zur O (2013). To refer or not to refer – surrogate partner therapy: definitions, debates, questions, ethical-legal considerations & resources. Accessed 25/08/13 at www.zurinstitute.com/surrogate_ partner_therapy.html
Websites www.cosrt.org.uk www.surrogatetherapy.org http://sexologicalbodyworkers.org http://worldassociationofsexcoaches.org www.aasect.org http://the-asis.org
If you would like to comment on this issue, or learn more about sex and relationship psychotherapy, please contact Jo Coker via email only on email@example.com or go to www.cosrt.org.uk.
Working with people who commit sexual offences and their families Juliet Grayson chooses to work with perpetrators of sexual abuse. Working with one person who is determined to change their behaviour has the potential to protect many others from becoming victims
hen I tell colleagues that I work with sex offenders, I receive one of two reactions. Either they look at me with fresh eyes and a new kind of respect, or they step back away from me as if just by being near sex offenders I might be contagious. It reminds me of ancient biblical stories about leper colonies. Whereas, in fact, these clients rarely have the ‘dark energy’ that we might imagine. They are just normal human beings and usually very likeable.
Ignorance among therapists When considering working as a psychotherapist with this client group, I think we have a responsibility to be very clear about the law with regard to reporting a sexual offence. I am astonished at the ignorance amongst therapists about this. At a conference where I gave a keynote talk last year, I asked about the law in relation to reporting a client who had been looking at child abuse imagery. Almost half the psychotherapists and counsellors in the audience thought they had a legal requirement to report, but there is no law that requires someone in private practice to disclose that they are seeing a client who is looking at underage images. One colleague wanted to clarify this, so contacted the Home Office about it. The Criminal Law
Policy Unit replied: ‘With regards to your question: If a client confides in you during the course of therapy that they had been viewing child pornography on the Internet, whether you would be obliged to disclose this to the authorities. There is no specific requirement in The Protection of Children Act 1978.’
Exploring ethical choices As therapists, we need to explore our ethical choices and think about how to respond to different situations. Imagine David, a quiet, slim, 48-year-old man who has been attending therapy with you for three months. He is working on his anxiety and depression, and you have formed a good therapeutic alliance with him. You like him a lot: he is an engaged and willing client. Then, one session, he arrives late and unshaven. You wonder what is happening. He looks embarrassed and blurts out that from his bedroom window he can see a woman who gets undressed every night at the same time. He has been watching her for more than six months and regularly masturbates as he watches her. He is sure that she doesn’t know that he is there. Recently, he has found himself going for night-time walks, with binoculars in his pocket, hoping to see other women undressing. Last week, he took a video camera out for the first time. What do you
Juliet Grayson is a UKCP registered NLPtCA, PBSP and COSRT accredited sex and relationship therapist. She is the co-founder of StopSO, the Specialist Treatment Organisation for the Prevention of Sexual Offending, and she runs a group working with sex offenders using Pesso Boyden System Psychomotor (PBSP). Juliet offers training courses to teach therapists about how to work with couples and sexual problems and PBSP personal development groups across the UK. www.therapyancounselling.co.uk/diary.htm
do, now that you know that he is crossing the line into illegal behaviour? Do you stop seeing him? Do you like him less than you did before you knew this? Would you report him? Who to? Again, there is no legal obligation to report a man who has done this if you work in private practice (it is different if you work in the NHS or social services). Many therapists do not want to work with someone whose behaviour is escalating in this way, but if he is absolutely clear that he is very motivated to change and wants to stop, would you keep working with him?
No law requires someone in private practice to disclose that they are seeing a client who is looking at underage images We all run the risk that a client suddenly tells us about their ‘dark secret’. The whole issue of paedophilia and sex offending is increasingly in the news. People are talking about it. I think that we, as therapists and supervisors, need to think this through beforehand, and be prepared in case one of our clients surprises us like this. Will we work with him or her? If we prefer not to, then where can we refer them?
StopSO: connecting clients and therapists It was for precisely this reason that colleagues and I set up StopSO, the Specialist Treatment Organisation for the Prevention
feature article These clients rarely have the ‘dark energy’ that we might imagine
The importance of accuracy
of Sexual Offending. StopSO (www.stopso. org.uk) is a not-for-profit organisation with a UK register of psychotherapists, counsellors and psychologists who will work with sex offenders and their families. By acting as an introduction agency, StopSO can match clients who are actively seeking help with therapists who are trained to work with them. Some StopSO therapists are willing to work with people who have worrying thoughts about sexual offending, and, because UK law allows therapists in private practice to do this, we have therapists who will see people who are offending but have not yet been caught. StopSO provides training to all these therapists, covering the law, ethical issues, risk assessment, treatment interventions and working with the partners of those who have committed a sexual offence. This is especially important because sexual offending has such a devastating effect, not only on the person who has been sexually abused but also on all those who are connected to the perpetrator. Imagine the stigma that a husband or wife (or parent) feels when their partner (or child) is questioned by the police about sexually inappropriate behaviour. Imagine losing your job as a teacher in an infant school because your husband has been convicted of viewing child pornography. It can often take months or years for the case to go to court, so the whole family may need support during that time.
The term ‘paedophile’ is constantly misused by the media. The psychopathological definition of a paedophile is a person who has a persistent sexual preference for prepubescent children. It is generally acknowledged that 1 per cent of the population are paedophiles. And having a preference does not mean they are acting on it. In Germany, they handle issues of paedophilia differently. Their initiative Prevention Project Dunkelfeld (www.dontoffend.org) offers confidential therapy to any self-identified paedophile. It is supported by German law, where it is considered a breach of confidentiality for the treating therapist to report either a committed or a planned child sex abuse offence. Their slogan sums it up: ‘You are not guilty because of your sexual desire, but you are responsible for your sexual behaviour. There is help! Don’t become an offender!’ Some therapists say to me, ‘I cannot work with sex offenders because I work with people who have been sexually abused.’ This one always floors me. I don’t understand what the problem is with working with both sides of the coin. One 50-year-old client, who had been coming to me for several years, had been used by a paedophile ring when he was a child. He said, ‘Thank God you are working with the abusers. It is only when they get help that this will stop.’ He is not a saint and in our sessions he is capable of showing huge anger and outrage at what happened, as well as fear and heartbreak at the cost to him and his wife (he avoids affection and sexual contact with his wife – sex has been too contaminated for him). But he has never once suggested that I should not be working with the people who have committed similar unspeakable acts.
Historical trauma I run a group using the method Pesso Boyden System Psychomotor (Grayson, 2014). I have noticed that, without exception, all the sex offenders – and this matches the research – have had a trauma in their history, often at around the age of eight or nine, a vulnerable time for boys when the sexual template comes online (it is about six
or seven years old for girls) (Hudson Allez, 2011). Typical historical issues we work on include severe neglect, violent parents, the unexpected death of a beloved grandfather, and, in just one case, sexual abuse as a child. By processing the trauma and re-integrating lost parts of themselves, clients say they feel calmer, more peaceful, more tolerant, and more able to manage difficult feelings without feeling overwhelmed. Their desire to act out is reduced and they seem more able to live by society’s rules. This group comprises members of the general public working on general therapeutic issues alongside those working on their sexually inappropriate behaviour. Everyone knows there are sex offenders in the group, but all are welcomed and treated the same, which itself is therapeutic for those who have offended. As the dynamic of the group is to work on history, unless the client mentions it, the group do not know who the sex offenders are. The sobering truth is that you cannot tell by looks and they don’t usually have a ‘creepy’ energy. I love working with people who really want to change, and I have found that most of the clients I see who have engaged in sexually inappropriate behaviour are hungry to find tools that work. They want to grow, develop and live good lives. I have made a choice. I can work with one person who has been sexually abused and do good and important work for that one person. Or, by working with one perpetrator who is motivated to change, and breaking the cycle of abuse, there is a chance that I may help to prevent many people from becoming a victim.
References Grayson J (2014). ‘Back to the root: healing potential sexual offenders’ childhood trauma with Pesso Boyden System Psychomotor’. In G Hudson Allez (ed) Sexual diversity and sexual offending (1st edn). London: Karnac: 251-273. Hudson-Allez G (2011). Infant losses, adult searches: a neural and developmental perspective on psychopathology and sexual offending (2nd edn). London: Karnac: 63.
feature article QUIZ
Know your law Juliet Grayson
You are a therapist in private practice… QUESTIONS
3 Yes. Sarah is guilty of distributing child pornography (Protection of Children Act 1978).
10 According to Ministry of Justice statistics for England and Wales, July 2010 and June 2011, domestic burglary had the highest proven re-offending rate at 49.8% and sexual (child) offences the lowest at 8.9%. 9 It is an offence under section 53 of the Drug Trafficking Act 1994 to inform the client that the authorities have been notified. 8 Yes. Under the Drug Trafficking Act 1994, it is an offence not to disclose information about drug money laundering received in the course of a trade. for ethical reasons. If you work in the NHS, it is usually part of your contract of employment that you will report cases such as those above.
4 Yes. James is guilty of possession of child pornography (Criminal Justice and Immigration Act 1988).
James (age 15) loves the photo of his girlfriend Sarah’s genitals. He looks at it once a day at least. Has he broken the law?
If you are interested in a one-day workshop exploring the law and ethical choices, look out for Crossing the line: what to do when a client presents who may be straying into illegal territory and is at risk of sexual offending or re-offending on www.stopso.org.uk/training.htm
1 No. The Protection of Children Act 1978 and related statutory guidance from Her Majesty’s Government have not imposed a mandatory reporting of child abuse.
photograph of her genitals on her phone and sends it to her boyfriend James, who is 15. Has Sarah broken the law?
If the reconviction rate for domestic burglary is approx 50%, what do you think the re-offending rate for sexual (child) offences is? 70% or above; 30–70%; 10–30%; below 10%?
A client arrives and seems excited. He says, ‘I was worried I would have to cancel owing to lack of funds, but I didn’t. I can afford to pay you this week because I sold some marijuana to a friend this morning.’ Would you have a legal duty to report him?
5 Yes. Anal and vaginal penetration of or by an animal is illegal, and carries a sentence of up to two years’ imprisonment (Sexual Offences Act 2003).
3 Sarah is 14 years old and takes a
If you were a therapist in private practice, would you have a legal duty to report any of the cases above (questions 1–5)?
6 It is a criminal offence for a person in a position of trust to engage in sexual activity with a person under 18 (Sexual Offences Act 2003).
of adult women’s bodies, and puts the head of a child on to these and he masturbates to these images. Is this an illegal act?
A teacher has sex with his 17-year-oldstudent. As she is over 16, is this against the law?
You are concerned about the drug dealing, and it violates your ethics. You ask him to go to the police. You tell him that you are planning to report him. Have you broken the law?
7 If you work in private practice, there is no legal duty to report any of the above, although many would choose to report
2 Another client says he makes images
Is it illegal for a man to have penetrative sex with his four-year-old Labrador dog?
2 Yes. In the Criminal Justice and Immigration Act 2008 pseudo-photographs are put on the same footing as actual photographs. If the dominant impression conveyed is that the person shown is a child, notwithstanding that some of the physical characteristics shown are those of an adult person, there can be a conviction. Pseudo photographs include derivatives of photographs, such as tracings or other forms of data.
A therapy client you have been seeing for a month admits they have looked at child abuse images involving four- and five-year-old girls. As a psychotherapist or counsellor in private practice, would you have a legal duty to report them?
The power of touch: how the coupling of sensate focus and psychoanalysis brings so much to the surface In this article, Susan Pacey illuminates the connection between sensate focus and psychoanalysis, and the insights that each may offer the other
he history of the relationship between sex therapy (including sensate focus) and psychoanalysis has been like a dance of separations and reunions through the decades since Freud. Arguably, when it comes to improving unhappy sexual relationships, a combination of both approaches is needed.
a Freudian psychoanalyst and psychiatrist with a keen interest in behavioural science, pioneered an integrated psychoanalyticbehavioural ‘new’ sex therapy and led the field. Ironically, Kaplan’s rising star coincided with psychoanalysis’s declining interest in sex, as object relations and the mother–infant relationship replaced Freudian drive theory and libido as the principal paradigm.
In the late 1990s, a disenchantment with the limitations of behavioural techniques within the field of sex therapy co-existed with an increasing awareness of the complex aetiology of sexual problems. Interestingly, sex therapy did not go on to develop its own couple theories and, with the advent of Viagra and many pharmacological treatments, became incorporated into the field of sexual medicine, concentrating on individual, genitally focused symptoms rather than the dynamics of sexual relationships. By contrast, psychoanalysis enjoyed a resurgence of interest in sex and a modernisation of classic concepts (including the Oedipus complex), which post-Kleinian theorists applied convincingly to the understanding of
Sensate focus, a cognitive-behavioural programme of mutual touching and caressing exercises, given as ‘homework’ to couples in treatment, has been the cornerstone of sex therapy for over 40 years. It was William Masters and Virginia Johnson who developed and properly named sensate focus in their 1970 landmark book, Human Sexual Inadequacy, following their 11-year study of human sexual dysfunction. The authors’ behavioural techniques were highly influential in the field of sexuality, displacing psychoanalysis as the predominant treatment model for sexual problems and launching sex therapy as a discipline in its own right. Just four years later, Helen Singer Kaplan,
Susan Pacey has been a sex and relationship psychotherapist for over 20 years in central London. She is currently undertaking original research in couple psychotherapy and sensate focus as a doctoral candidate at the Tavistock Centre for Couple Relationships, London. Susan has authored numerous papers on sexual relationships and is an editor and manuscript reviewer for two academic journals. She has organised and presented at many international and national conferences on the topic of sexuality. 14
adult couples and their shared defences and anxieties about intimacy.
The debate On a simple, perhaps over-simple level, the fundamental difference between psychoanalysis and sex therapy is that, in addressing couples’ sexual problems, the first treats the mind and the second the body. There are other important differences, however. Psychoanalysis is a non-directive, no-touch therapy, whereas sex therapy is often directive and brings the sense of touch explicitly into the work in a number of ways. In sensate focus, the sex therapist invites (instructs) the couple to make time for tactile experience, to engage with their bodies, and to make physical contact preferably without words. To the mind of the psychoanalyst, sensate focus creates an affect-laden context of prescribed intimacy, arguably even before the couple have left the therapy session, and represents concrete thinking about relational problems (Benioff, 2012). It is tantamount, as Donald Meltzer once said, to ‘managing the mating’ (Clulow, 2013). Moreover, it changes the couple’s transference relationship to the therapist. In my view, however, it is questionable whether either type of therapy is enough on its own to address couples’ sexual problems satisfactorily. After sex therapy, couples may have improved sexual pleasure, but if the repeated, unconscious patterns of relating are not worked through, can sexual satisfaction be sustained? On the other hand, psychoanalytic treatments may improve couples’ emotional relationships but do they leave sexual problems untouched and unchanged?
Universal importance of touch The human need for touch and its meaning in the human psyche permeate both sex therapy and psychoanalysis. In sensate focus, and indeed in sensuality and sex, the predominant language is touch and it is non-verbal. The sense of touch is the first to develop in the embryo and is acknowledged as crucial to human development and health. So much of early life is about being touched or not touched, and in countless ways. Care of neonates is necessarily focused on their bodily wellbeing; the baby is held and cared for by his mother, and all his daily experiences and emotional responses at her hands and in her arms become embodied, stored in his implicit memory, and are potentially recalled in touching and being touched later in life.
feature article The study of these early relationship experiences gave rise to attachment theory (Bowlby, 1982), which holds that the most significant and enduring learning about self and relationships takes place in the first years of life. This implicit relational knowing is manifested in adulthood in how partners behave together, how they feel about each other, and their expectations of their relationship (Wallin, 2007). I might add that it is also present in their responses to behavioural tasks in therapy. Sensate focus may evoke responses of attachment, including proximity-seeking or distancing behaviour, exploration of each other’s body, and anxieties about separations and reunions as partners begin and end each exercise. Over time, it may also help build couples’ trust and felt security (Caruso, 2011).
Connecting with sensations An early task in sensate focus is concerned with encouraging couples to make time for shared sensual experience for its own sake, along with developing their capacity to recognise first their own and later their partner’s sensations. In sex therapy, this is named ‘permission-giving’: permission to have sensual enjoyment. According to American psychoanalyst Joseph Lichtenberg (2008), sensate focus is a kind of reparenting in this respect, encouraging clients to allow, discover and enjoy their sensuality and pleasurable bodily sensations. This is perhaps the most challenging phase of the programme, when couples may need sensitive support to allow and stay with these bodily experiences. However, a couple’s sensations may be unpleasant, particularly if the quality of the partners’ touch conveys hostility and relational conflict. Unpleasant experiences need to be worked through and changed. Lichtenberg asserts, as did Masters and Johnson, that pleasurable sensuality is the platform for healthy sexuality. Lichtenberg distinguishes between sensuality and sexuality – both developmentally in the child and in clinical work – suggesting that they are separate motivational systems. Sensuality is observable from birth, claims the author, and caregivers may either validate or inhibit the baby’s bodily pleasures. Every parent tends to cultivate or discourage her infant’s sensual pleasures according to her own particular sociocultural attitudes. Pleasurable experiences that are inhibited elicit shame in the child. For Lichtenberg (2008: 19), sexual goals in adults ‘represent a struggle between
body pleasure-seeking arousal and the inhibiting force of shame’. Sensuality, on the other hand, can be a conflict-free part of the self. The infant’s experience of his parents’ caregiving during the preverbal period, claims the author, creates in the child an internal affirmation-shame balance, which affects his expression of sensuality and sexuality in adult life.
Inhibited sensuality As discussed earlier, the caressing exercises of sensate focus tend to evoke powerful responses in adult partners, who may be grappling with emergent shared anxieties, for which they cannot find words and which they may not understand. Their reports of their ‘homework’ (done or not done), both verbal and non-verbal, in facial expression, gaze and body movements, may be re-enactments of primitive experience. The diversity of both positive and negative responses is remarkable: clients’ reports range from intense, sensuous, first-time-in-their-lives experiences, which are intimate, tender and safe, through to wandering minds, absence of feeling, resentment, inability to focus, boredom and a sense of wasting time. The latter may be defences against emergent sensual and sexual feelings. In one case study of a couple presenting with loss of desire, Green and Seymour (2009) use sensate focus to help the partners work through many anxieties and defences: from ‘spectatoring’, as defined by Kaplan (1974), the yearning for ‘magical’ symbiosis, connecting with and fearing vulnerability and neediness, having a safe haven, managing a rush of primitive feelings, through to separation anxieties and fears of disintegration. Couples’ anxieties, conscious and unconscious, are not evoked in linear fashion during the sensate focus programme, which itself is no more linear than psychotherapy; there is movement, often rapid and fleeting, between many kinds of anxieties and defences arising from partners’ impairments to development at different life stages. That said, few couples can do sensate focus in the early stages of therapy, and some couples not at all, particularly those with a history of abuse and extreme neglect. This is the case in Berg’s (2012) description of a couple whose responses to sensual contact
indicated early sensory deprivation and inadequate maternal holding, manifested in hypersensitivity to touch and a craving for, or a repudiation of, the sensation of touch. For this couple, skin-to-skin contact mobilised primitive anxieties about the shared psychic threat of annihilation. In abused couples, sensate focus and intimate contact are too threatening to their sense of self, a self that needs to be preserved and protected by retreating from the task and the partner.
Conclusion Sex therapy and psychoanalysis have distinctive methods in facilitating sexual change in couples, the one focusing on a ‘bottom up’ approach, addressing the mind through the body (ie sensory somatic awareness through sensate focus), the other a ‘top down’ approach, reaching the mind-body through cortical processing. In my view, both therapies are potent and reparative in their way: sensate focus is used widely and creatively, and is respected by practitioners; it is a concept that has endured. Equally, psychoanalysis has a richness and depth to its couple theories, which draw on a range of identified early existential anxieties about disintegration, dissolution and annihilation, emerging from birth onwards. All of these are universally in the human psyche and contribute much to therapists’ understanding of couples’ sexual unhappiness.
References Benioff L (2012). ‘A discussion of Christopher Clulow’s “How was it for you?” Is sex always too much?’ fort da, 18(2): 29-37. Berg J (2012). ‘A bad moment with the light. No-sex couples: the role of autistic-contiguous anxieties’. Couple and Family Psychoanalysis, 2(1): 33-48. Bowlby J (1982). Attachment and loss (vol 3) (2nd edn). London: The Hogarth Press. Caruso N. (2011). ‘The entangled nature of attachment and sexuality in the couple relationship’. Couple and Family Psychoanalysis, 1(1): 117-135. Clulow C (2013). Discussion with Susan Pacey, 23 May. Green L and Seymour J (2009). ‘Loss of desire: a psycho-sexual case study’. In C Clulow (ed) Sex, attachment and couple psychotherapy. London: Karnac: 141-163. Kaplan HS (1974). The new sex therapy. New York: Times Books. Lichtenberg JD (2008). Sensuality and sexuality across the divide of shame. Hove: The Analytic Press. Masters WH and Johnson VE (1970). Human sexual inadequacy. Boston: Little, Brown and Company. Wallin D (2007). Attachment in psychotherapy. New York: Guilford Press.
Gender and sexuality diversity (GSD): respecting difference Dominic Davies and Meg John Barker emphasise how a broad understanding and respect for gender and sexual diversity is immensely valuable to all psychotherapists working with sex and relationships Conversion therapy and normativity The recent publication of the memorandum of understanding on gay to straight conversion therapy1 brought many key psychology, health, counselling, and psychotherapy organisations together for the first time to collaborate on a subject on which they had no disagreement. The memorandum clearly states that efforts to try to change sexual orientation through psychological therapies are unethical and potentially harmful. Clearly, therapy has come a long way since the declassification of homosexuality as a mental disorder in the American Psychiatric Association Diagnostic and Statistical Manual (DSM, 1973) and the World Health Organization’s International Classification of Diseases (ICD, 1992).
1 www.psychotherapy.org.uk/UKCP_ Documents/policy/MoU-conversiontherapy.pdf
What the document left out was conversion therapy as it applies to gender and sexual diversity (GSD) identities and practices beyond gay identities and same sex attractions. For example, in relation to trans, some therapists still deem it acceptable to try to eliminate behaviour in children that doesn’t conform to cultural gender norms, or private ‘cross-dressing’ practices by husbands in a heterosexual marriage. In the case of bisexuality, some still encourage clients to ‘pick’ homosexuality or heterosexuality, rather than respecting the person holding a bisexual identity.
A heteronormative lens The problem, as we see it, is that many therapists view human sexuality and relationships through a heteronormative lens. Heteronormativity is a set of social norms about sexuality, gender and relationships, which includes the following assumptions:
Dominic Davies founded Pink Therapy 16 years ago and it is now the lead body for training therapists in working with gender and sexual diversities (www.pinktherapy.com). He is a Fellow of BACP and is a senior accredited counsellor psychotherapist with BACP and the National Council of Psychotherapists. He is acknowledged as one of the ‘founding fathers’ of non-pathologising approaches to therapy with gender and sexual diversities. Email: firstname.lastname@example.org Dr Meg John Barker is a writer, academic, counsellor and activist specialising in sex and relationships. Meg John is a senior lecturer in psychology at the Open University and a UKCP-accredited therapist, and has over a decade of experience researching and publishing on these topics, including the popular book Rewriting the Rules. Website: www.rewriting-the-rules.com Twitter: @megbarkerpsych
• There are two opposite sexes – male and female – with different associated gender roles – masculinity and femininity • Normal sexuality is attraction to the ‘opposite sex’; attraction to the ‘same sex’ is possible but not normal, and it is not possible to be attracted to more than one sex • Normal relationships are monogamous – or at least dyadic – and sex should only take place in the context of that dyad • Relationships must be sexual, and the normal sexual script consists of foreplay, penis-in-vagina penetration, and orgasm. People who experience no sexual attraction are thus pathologised by many therapists as having ‘hypoactive sexual desire disorder’ rather than potentially having an asexual orientation.2 Also, people who recognise that one partner cannot meet all their sexual – or relationship – needs often find it impossible to access relationship therapy. Mainstream services generally use the term ‘couple therapy’ rather than ‘relationship therapy’ and are simply not accessible to people in polyamorous or otherwise openly nonmonogamous relationships.
Specialist therapy Often the only option available to those who fall outside heteronormativity in such ways is to access specialist independent therapy (via the Directory of Pink Therapists). This makes therapy for GSD people only available to those who can afford it, and even this is likely to be restricted to certain urban areas. This lacuna has lead to Pink Therapy setting up the world’s first postgraduate training in relationship therapy for GSD people. We could frame the therapeutic task through a pair of 3D glasses. Typically, because of being socialised in a heteronormative world, therapists have been trained to view sex and relationships through the heteronormative lens (the blue lens of the glasses). This often results in the assumption that a client’s difficulties are necessarily related to their gender or sexual identity, and in clients getting the message that their sexual or relationship practices are somehow questionable. Alternatively, some GSD therapists may know to eschew that lens and only view their clients through an entirely affirmative 2 Thanks to the work of Lori Brotto and others, DSM-5 clearly states that asexual people should not be diagnosed with HSDD.
feature article queer lens (the red lens of the glasses), which could lead to making collusive alliances and assuming that they know all about the client’s experience because they live within similar communities themselves. Viewing the client through both lenses of the 3D glasses allows a three-dimensional perspective: where we recognise the client’s lived experience within a heteronormative cultural context and we can remain curious about what is similar and different for each individual client.
Implicit message The heteronormative lens does not mean that most therapists are overtly homophobic, biphobic or transphobic towards their clients, or even that they give them an explicit message that they are not acceptable as they are (King, Semylen, Killaspy, Nazareth and Osborn, 2007). Rather, research suggests that the impact is much more implicit. For example, Moon (2008) found that heterosexual therapists tended to use more negative and loaded emotion words when describing LGBT clients in comparison to heterosexual clients. And Grove (2014) found that LGBT clients with heterosexual relationship therapists felt that they had to give the impression that they were ‘good gays’ and that they couldn’t talk openly – for example about kinky or casual sexual encounters. The uncritical acceptance of the concept and treatment of ‘sex addiction’ by many in the therapy profession also causes us grave concern when there is a lack of evidence to support it and a lack of agreement over what constitutes it. For example, some of the criteria considered indicative of sex addiction are entirely normative practices among many gay and bisexual men, people with kink identities, swingers, and others.
GSD experiences It is our experience that three core issues run as threads through most GSD identities and practices which therapists should be aware of. These are hypervigilance, shame and resilience. Hypervigilance is where clients constantly monitor everything they say and do because of an assumption that the therapist may view them as ‘mad, bad or dangerous to know’. And this – as we’ve seen – is often the case. It is impossible to live in a world which privileges heteronormativity without introjecting negative ideas about oneself that lead to shame. Sex, in particular, is a subject that probably everyone feels some degree of shame about – given the wider sex-negative
culture we live in. Within GSD populations, people often feel this more acutely and deeply, given that their sexual experiences are likely to deviate from the normative sexual script. There is also a strong cultural sexual imperative, which can mean that asexual people feel shame and stigma, and indeed may struggle to find relationships in which they aren’t expected – or pressured – to be sexual. However, of course, not everything to do with GSD identities and practices is problematic. Many GSD people are extraordinarily resilient, as found by the recent Risk and Resilience Explained (RaRE) study by the LGBT charity PACE.3 Moreover, there is much that can be learnt from GSD experience that is valuable for all clients.
Learning from GSD So far we have been referring to GSD as if we may be talking about a minority of people in comparison to a heteronormative majority. However, it is worth questioning this common assumption. Consider the proportion of the population who are non-monogamous (whether openly or secretly – at least 50 per cent); who have experienced attraction to more than one gender (around 30 per cent); who do not experience their own gender as simply stereotypically masculine or feminine (around 30 per cent); who have periods of no sexual attraction, or who have kinky sex of some kind (up to 50 per cent and perhaps more given the popularity of Fifty Shades of Grey). Adding all this together, it would be the heterosexual, monogamous, non-kinky, cisgender4 folk who would be in the minority. Along with the need to add a queer lens to the heteronormative one, this is another reason to include GSD throughout all therapeutic training, and it is heartening that the memorandum of understanding emphasises the need for such training so that therapists gain cultural competency in working with gender and sexually diverse clients. Beyond this, there is much of value that can be learnt from GSD people for sex and relationship therapy with all clients. For example, people involved in consensual BDSM (bondage and discipline, dominance and submission, and sadomasochism) communities have had to develop extremely good communication skills and a high degree of self-reflexivity to be able to articulate their desires and communicate 3 www.pacehealth.org.uk/interact/rare-study/ 4 Cisgender people are those who remain in the gender they were assigned at birth
these to their partner(s), and they have often had to step outside shame-filled narratives around normative sexual behaviour. Equally, people conducting polyamorous relationships often have highly developed communication skills because they have to negotiate their relationship dynamics and creatively engage with jealousy. One example of this is the development of new language for relationships and emotional states: for example, metamour for a partner’s partner and compersion for a positive feeling on seeing a partner happy with another partner. This radically challenges the assumption of possession in romantic relationships (Ritchie and Barker, 2006).
Summary In summary, in this article, we have considered how three different understandings of respect might relate to our work as therapists, with a particular focus on sex and relationship therapy. These three understandings are: • respecting who a person is rather than trying to change them • respecting what their identities and practices will mean for their experience in a world which positions them as outside the norm • respecting what we might learn from them.
Further resources You can find out about the training and CPD on GSD issues on the Pink Therapy website: www.pinktherapy.com/en-gb/training.aspx Meg John and colleagues provide GSD training for general counselling and psychotherapy courses and organisations: www. londonsexrelationshiptherapy.com/training For therapists looking for an accessible overview of the main gender and sexual identities and practices, see Richards C and Barker M (2013). Sexuality and gender for mental health professionals: a practical guide. London: Sage.
References Grove J (2014). Same-sex couple counselling: a qualitative study of client perspectives. PhD thesis, University of Leicester. King M, Semylen J, Killaspy H, Nazareth I and Osborn D (2007). A systematic review of the research on counselling and psychotherapy for lesbian, gay, bisexual & transgender people. Leicester: BACP. Moon L (ed) (2008). Feeling queer or queer feelings. London: Routledge. Ritchie A and Barker M (2006). ‘“There aren’t words for what we do or how we feel so we have to make them up”: Constructing polyamorous languages in a culture of compulsory monogamy’. Sexualities, 9(5): 584-601.
Understanding and handling sexual desire in therapy Dr Maria Luca asks us to give sexual attraction as a therapeutic experience the attention it deserves It does not take particularly great powers of observation to see that sexual matters are everywhere, that sexual meanings infiltrate and imbue our daily interactions, that sexual glances are forever being made, that sexual fantasies quietly attend our dealings with numerous people, that a person’s gender and sexual attractiveness fundamentally determine how we react to him or her. (Giles, 2008: 2) I have been interested in the topic of sexual attraction in the therapy room for several years, culminating in my recent book (Luca, 2014). This article invites the profession to give the subject consideration in order to create a fertile ground for discussions and more rigorous investigations into the subject. This could positively enhance both our understanding and handling of sexual attraction in therapy.
Therapist subjectivity Historically, the literature speaks more readily of platonic love for our clients, of empathy and understanding, of attunement and containment, holding, challenging and affirming, as key to a facilitative process for successful therapy. However, little is known of therapists’ sexual feelings towards their clients and how these are handled. There are a few exceptions (Fischer, 2004; Giovazolias and Davis, 2001) showing
that a substantial number of therapists experience sexual feelings towards a client at some point in their career. Sexual arousal is present from infancy, evident from masturbatory behaviour in boys and girls (Fonagy, 2008: 20). This begs the question of how therapists handle their own and their clients’ sexuality and desire in therapy. In psychoanalytic thinking much has been written on erotic transference and countertransference, but with little emphasis on the therapist’s subjectivity playing a crucial part in their therapeutic response. Searles, as early as 1959, was an exception. He felt there was a connection between the analyst’s erotic and loving feelings and the patient’s psychological growth, a perspective giving significance to such feelings and challenging the maxim (see Wolf, 1992) that a therapist’s sexual arousal or attraction is indicative of psychopathology. It has taken decades for the field (Mann, 1994; Schaverien, 2006) to recognise that, like the client, erotic feelings also stem from the therapist’s own subjectivity and not purely as a direct reaction to the client’s erotic transference. The handling through transference interpretations of this dynamic reflects the dominant psychoanalytic conceptualisations of erotic, erotised and sexualised transference.
Dr Maria Luca is Senior Research Fellow in the School of Psychotherapy & Psychology, Regent’s University London, and Head of the Reflections Research Centre. Past roles include Head of School and NHS therapist. Research interests include sexual attraction and the erotic in therapy, migrants and working with MUS. Her most recent publication is Sexual Attraction in Therapy: Clinical Perspectives on Moving Beyond the Taboo: A Guide for Training and Practice (London: Wiley, 2014).
Understanding sexual attraction Eros is an issue of boundaries. He exists because certain boundaries do. In the interval between reach and grasp, between glance and counterglance, between ‘I love you’ and ‘I love you too’, the absent presence of desire comes alive. But the boundaries of time and glance and I love you are only aftershocks of the main, inevitable boundary that creates Eros: the boundary of flesh and self between you and me. And it is only, suddenly, at the moment when I would dissolve that boundary, I realise I never can. (Carson, 1998) Interpersonal relationships in everyday life include, among other relational states, sexual attraction – a notion that is intricately intertwined with love, erotic desire, longing, the wish for sensual pleasure and exciting imaginings in relation to another person. It is an affective state that encapsulates an expectation for emotional and/or bodily connection with the other. This otherness can, through desire, graduate to bodily union in the act of sex. Eros in the Greek meaning was a uniting force. Therefore the human desire for union is intertwined with awareness of otherness and difference. Union temporarily removes the experience of otherness, difference and existential aloneness, providing relief and pleasure. Agape (platonic love) is a Greek term used to capture emotional, intimate closeness and friendship without elements of erotic desire, a therapeutic quality more legitimised in the field through the use of terms such as empathy, attunement, care and loving, even though the latter is still much of a taboo in the field.
Sexual desire in therapy The therapeutic space lends itself to both eros and agape. As discussed elsewhere (Luca, 2014: xvii), ‘it is within this space that erotic desire appears demanding a response’. Therapists and clients are not immune to sexual feelings towards each other. The therapy relationship rests on an alliance, trust and understanding; therefore it is probable that interest and desire can develop into sexual attraction. In some therapy dyads, sexual attraction (client, therapist or mutual) presents itself at the first meeting, especially in the presence of complex factors, for example chemistry, disclosure of intimate self. If it is not understood and handled appropriately by the therapist, it could hinder the
feature article penetrate through us in their attempt to know us and be special to us. If we conceive of the therapy relationship as one of reciprocal mutual influence, we become aware that intersubjectively clients and therapists have mutual insights. Our clients have intuitive perceptions about us; just as we tune into them, they sense us. This interplay creates mutual transformation. We know that boundary maintenance is essential for progress in therapy and that our profession holds us accountable for this. The question is: what are we attempting to achieve and how do we facilitate this process? How humane do we allow ourselves to be so that our clients can push through our professional defences and feel they can access us emotionally?
Erotic feelings also stem from the therapist’s own subjectivity and not purely as a direct reaction to the client’s erotic transference development of a therapy of trust, respect and emotional intimacy and pose an obstacle to helpful therapeutic work. If acknowledged and understood, sexual attraction, as an anticipated desire, not an actuality, has the potential to positively transform a client’s psychic space. As a clinician and supervisor for many years, I have witnessed the fears, anxieties and sense of shame associated with clinicians who experience sexual attraction towards a client. I have often wondered how such a normal experience, located at the heart of the human condition, destabilises psychotherapists, to the extent that some would end the therapy as they consider no other means of dealing with the potential risk of acting out or being viewed as unethical by supervisors. Is the force of sexual feelings so powerful that therapists struggle to contain it in both themselves and in their clients? Is it possible that the topic is neglected by psychotherapy trainings? Could ethical guidelines by professional bodies, apart from the conceptual ambiguity about boundary interventions contributing to ‘stultifying defensive therapeutic rigidity’ (Glass, 2003: 429), generate overwhelming anxiety for therapists? The literature of the past 20 years, with its focus on sexual boundary
violations and their damaging effects on both clients and clinicians, has certainly not helped ease clinicians’ fears of enactment or being unethical, often purely by association. Gabbard, in his introduction to Sexual Exploitation in Professional Relationships, draws attention to the harmful effects of professional exploitation on patients. He asserts: ‘The problem of sexual exploitation is one with which every clinician must be familiar’ (pxii). Knowledge and maintenance of boundaries is recognised by the majority of therapists as essential for effective therapeutic outcomes. The importance of understanding the permutations of sexual attraction that lead a small percentage of clinicians to exploitative enactments therefore becomes more urgent. As practitioners we are confronted with tension that arises from erotic desire towards clients or vice versa. In the context of a boundaried professional relationship, navigating through tension could nurture the potential growth and depth of therapy.
The reciprocity of transformation As Searles (1959) argued, the analyst’s erotic, loving feelings are potentially transformational for the client. Many of our clients harbour the desire to have an impact on us: to influence us, to challenge us and
In my own clinical experience, a mutual emotional opening can nurture sexual desire between therapist and client. We may become phobic to these moments and resist being known by our clients, something that could create an impasse and a phony response rather than a constructive communication of what is going on between us here and now. Therefore how we communicate this internal emotional landscape is what will make a difference in reaching the depths of understanding and ultimately transformation.
Handling sexual attraction Forms of avoidance promoted by fearful ignorance, shame or guilt are unhelpful. Fearful ignorance, like feeling that attraction is synonymous with a boundary violation or that it should not be happening if one is a good therapist, can produce shame and attempts ‘not to know’ that desire is present. (McIlwain, 2014: 53) In the course of our work we encounter an emotional landscape of monumental proportions, whose every corner offers unlimited opportunities for exploration and discovery. We choose a promising avenue only to realise that it quickly leads to narrowing spaces and in the end to an impasse. We turn back and seek alternative paths. In the midst of our keenness to see through the fog, we forget how important it is to navigate through before we can clearly see what’s on the other side. I have used this analogy to make a point about how essential it is for therapists to navigate through confusing feelings in ourselves and in our clients before we reach clarity. This quality becomes more pertinent in the face
feature article Sexual attraction – as an anticipated desire, not an actuality – has the potential to positively transform a client’s psychic space of fears that sexual attraction would pose a threat to ethical practice. In my view, the threat of inappropriate enactment is more pertinent if therapists ignore erotic feelings in their clients and in themselves. Although some literature may argue persuasively that neutrality, an uninvolved stance and non-surrender to the client’s power are fundamental to transformation, it seems more humane to me that to break through defences and facilitate emotional integration we need to be relationally involved. Moments of emotional meeting are memorable to clients. A therapist’s tear, smile, sadness, love or erotic desire can be the mirror of empathy, validation of desirability and understanding that a client needs for growth. Clients vary in their wish to know their therapist. Some fear it and feel safer with snippets of mutuality, while others would bathe in it. Our own fears of being at the mercy of feelings of anger, love, sexual desire or hate in relation to our clients can lead to avoidance and an impasse in our work.
Boundary violations So what are the risks for boundary violations? In Maroda’s words (1998: 57): ‘While I realise that we are only human and boundary violations cannot be eliminated, I do believe that more boundary violations result from the analyst’s emotional dishonesty than anything else.’ It is our responsibility to negotiate within each unique encounter what is appropriate therapist verbal/non-verbal disclosure and the way it is best communicated. Acknowledging sexual feelings when present in therapy and finding the appropriate language and timing to openly explore these feelings can be a useful tool for deepening understanding. For therapists to feel safe and honest about their erotic feelings, both trainings and professional bodies need to encourage open discussion and give the message that to feel erotic desire is not the same as to act on it. In sum, my hope is that my presentation of this material will contribute towards more dialogue about a therapy phenomenon that has been in the shadows. If we avoid sexual desire, or succumb to
temptation, we may fail in our quest to help our clients reach illumination and growth. Our approach must be one of acknowledgement, exploration and disentangling what is happening between us. In therapy, consciousness is a mindbody consciousness. It emerges through a rhythm of negotiating separateness and togetherness and impacts on self-discovery, if indeed our reflections are honest.
‘I need you – except when I don’t’: healing codependence
References Carson A (1998). Eros the bittersweet. Guildford: Princeton University Press. Fisher CD (2004). ‘Ethical issues in therapy: therapist self-disclosure of sexual feelings’. Ethics & Behavior, 14: 105-121. Fonagy P (2008). ‘A genuinely developmental theory of sexual enjoyment and its implications for psychoanalytic technique’. Journal of American Psychoanalytic Association, 56: 11-36. Gabbard GO (1994). ‘Psychotherapists who transgress sexual boundaries’. Bull Menn Clin, 58: 124-135. Giovazolias T and Davis P (2001). ‘How common is sexual attraction towards clients? The experiences of sexual attraction of counselling psychologists toward their clients and its impact on the therapeutic process’. Counselling Psychology Quarterly, 14: 281-286.
Pamela Gawler-Wright examines the potentially unhealthy pattern of relating known as codependence. Ironically, she says, it seems to be particularly common in psychotherapists!
Giles J (2008). The nature of sexual desire. Plymouth: UPA. Glass LL (2003). ‘The gray areas of boundary crossings and violations American Journal of Psychotherapy, 57(4): 429-44. Luca M (2014). Sexual attraction in therapy: clinical perspectives on moving beyond the taboo – a guide for training and practice. London: Wiley. Mann D (1994). ‘The psychotherapist’s erotic subjectivity’. British Journal of Psychotherapy, 1: 244-254. Maroda KJ (1998). Seduction, surrender, and transformation. London: Psychology Press. McIllwain D (2014). ‘Knowing but not showing: achieving reflective encounter with desire – a relational psychoanalytic perspective’. In M Luca (ed) Sexual attraction in therapy: clinical perspectives on moving beyond the taboo – a guide for training and practice. London: Wiley. Searles H (1959). ‘Oedipal love in the countertransference’. In Collected papers on schizophrenia and related subjects. New York: International Universities Press, 1965. Schaverien J (2006). Gender, countertransference and the erotic transference: perspectives from analytical psychology and psychoanalysis. London: Karnac Books. Wolf E (1992). ‘On being a scientist or a healer: reflections on abstinence, neutrality, and gratification’. The annual of psychoanalysis, 20: 115-144. Hillsdale, NJ: The Analytic Press.
Pamela GawlerWright is Training Director for BeeLeaf Institute for Contemporary Psychotherapy, Clinical Associate of Pink Therapy and External Moderator for the United Kingdom Association for Transactional Analysis. Her busy practice focuses especially on the deeper connections between trauma, addiction and relationship. A frequent commentator in print and broadcast media, Pamela’s greatest passion is offering in-depth training that supports each psychotherapist to meet their unique potential as healer-through-relational-presence.
feature article Co-dependence – it’s only human There is a wonderful thing about being human. We cannot live without making deep connections with others.
INDEPENDENT I have choice Just affects me
There is a terrible thing about being human. We cannot live without making deep connections with others.
Under own control
I have some power
ur connecting instinct propels us to acts of kindness, intimacy, strong bonds of commitment and even self-sacrifice in giving care and contributing to the social whole. The same instinct can also drive seemingly unstoppable compulsions to cling, control, hurt and deny.
Feelings of connection and belonging As a species, we are biologically programmed, socially constructed and behaviourally conditioned to make adaptations to keep us safely in relationship dynamics that maintain a feeling of connection and belonging. Most psychotherapy models offer some description of these processes and dynamics in their healthy, and destructive, manifestations. When we work with individuals, couples, families or organisations who have become trapped in patterns of self-harm, violence, abuse and obstruction, we are often encountering the underlying templates of independence, interdependence and co-dependence that run through all human life. As the contributions of attachment theory (Subby, 1984) and family systems (Smith, 1986) to the understanding of codependence are well covered elsewhere, this article focuses on addressing the impact of these patterns as they occur in all personal and social relationships. By the end, you might recognise why many self-aware psychotherapists increasingly recognise co-dependence as a potential pattern of unhealthy relating that is especially common in people attracted to working in the psychotherapy profession. The diagnostic criteria of co-dependence almost read like a psychotherapist’s job description (Schaef, 1991).
Not just about ‘addiction’ Much has been written about ‘codependence’ or ‘co-dependency’ in the past five decades. Like many human relating patterns, it was first named when
Figure 1: Dependent states, Gawler-Wright (2010)
Can change at will
CO-DEPENDENT INTERDEPENDENT I have choices You have choices Relationship affects us We affect relationship Shared control Cannot not change We are more powerful together
You choose or I choose • I have no choice • Can’t accept your choices Affected by relationship • You affect me • I can’t affect you Out of control • You take my control • I have to control you • It’s out of control ‘Nothing changes’ • You won’t change • I can’t change • Change will be bad • The same, only worse Powerless • You disempower me • I have no power over you
working with couples and families who were compromised by alcohol or substance misuse. In this context, it describes people within the system of the identified addict inadvertently enabling the addiction through repeatedly rescuing, covering up and averting crisis, with a martyr-like attitude of ‘We’re fine here. I’m taking care of it.’ So entrenched is the co-dependent person in their role of misplaced ‘caregiving’, ‘crisismanaging’ and avoidance of their own feelings and needs that change, whether ‘positive’ or ‘negative’, in the identified addict can threaten the co-dependent’s sense of fundamental security and identity. The co-dependent has become drilled in denying signals of pain to the point where challenge to their habituated states of protecting, denying and repairing can be felt as a terrifying and catastrophic loss of control, and ultimately failure in their role.
Anyone who has worked in the field of addiction will have witnessed the cruel irony for the co-dependent that, while their behaviours within the dependence system are ostensibly those of loyalty, kindness, protection and self-sacrifice, they become dynamics of constant power struggle, shame, disabling and self-justification. However, addiction is not the only field in which co-dependence has been recognised as an apparently immutable compulsion in people to repeat destructive patterns in the name of ‘caring’. As with most issues addressed in recovery from addiction, drugs don’t cause these human patterns, they just reveal them in exaggerated technicolour, so we can finally see them as prevalent tendencies in all of us. So, although codependence was originally understood as concomitant with a status of adult child of alcoholic (ACOA), it is a revelatory model, helping us to understand and address patterns of self-soothing developed by the
feature article A person with co-dependent tendencies is a person with a higher than average ability to empathise and mentalise child whose way of experiencing worth and intimacy was in their perceived ability to sooth the feelings and meet the needs of others.
Healing and recovery Co-dependence has made its way into the diagnostic literature as a disordered ‘personality’. However, retaining a nonpathologising understanding of codependent patterns, while recognising them in some cases as life-threatening, is considered to be at the heart of models of psychotherapy that promote healing and recovery. This clinical optimism is important to keep hold of, as working with a codependent person can be frustrating and baffling, and a common feature of working with those cases where individuals and couples are identified as being at high risk of harm to self or to other. Co-dependence can poison the interactions of couples, siblings, neighbours, organisations, even a government and its people (Shaef, 1987). A co-dependent relationship is identified when all parties feel their needs are not being met and where each member believes it is the other members who hold the ‘real’ control.
Co-dependence is not for wimps At the heart of the co-dependent’s sense of self is a belief that goes something like ‘I can make people feel better. I know I can because sometimes I make everything OK for others. If there’s something wrong I have to try harder to make others feel better. To accept that I cannot fix things for people is to admit that I have deeply failed and am unlovable.’ It takes a lot of heart and mind to sustain such a belief system. A person with codependent tendencies is a person with a higher than average ability to empathise and mentalise, so that it is possible to read the emotional signals of those around them, and to sometimes get it right. And these sensitivities rely on sustaining an unbreakable optimism that the principles of loving and kindness will be enough, one day, to make the world turn around and be ready to return such attention and commitment to the needs of the faithful co-dependent.
Co-dependent people provoke an impulse in others to shake and discard them, but deep down, you’ve got to admire them for how they (we) keep trying! Appreciating these strengths, values and intentions is an important part of identifying and recovering from co-dependent states.
are revealed in our emotional body, in our language and behaviour. Knowing these tendencies better can equip us with skills and self-awareness to move on more smoothly and constructively to the ebb and flow of connection and differentiation between ‘I’ and ‘you’ and ‘us’.
Principles of cultural schismogenesis
Dependence as changing states – NOT personality status
Gregory Bateson’s contribution to our understanding of co-dependence and how to work with it came from his observations of the underlying principles of Alcoholics Anonymous and the emphasis on inner relationship cultivated by people in recovery (Bateson, 1971). Extending the principles of cultural ‘schismogenesis’ developed in anthropology, Bateson described the psychic split between felt experience (ontology, somatic intelligence) and label (epistemology, cognitive description) as the point where denial is born. A child learns to distrust and condemn their subjective experience of affect or need when the interpretations and labels offered to them by the external world conflict with, or negate the validity of, these somatic signals. When experience of need becomes associated with shame and loss of connection, the child enters a negative trance of denying internal signals and seeks comfort in creating better feelings in those around them.
From government officials to probationers with a history of abuse, I have never yet met a client who was not able, when asked, to identify specific emotive experiences of the intermerging states that I define as independence–interdependence–codependence.
Even if our background has not overly predisposed us to marked co-dependent imbalances, just being the primary person in the life of another person who has extraordinary need, over a length of time, naturally biases attention away from our own needs as those immediate distresses of the other take priority. In and of itself, there is no pathology in this. It is how we humans create co-operation, security, love, intimacy and joy in our lives. Reducing these highly complex processes to a static label of ‘personality’ can further rigidify people into positions of defence, blame and conflict. For many of us, these human tendencies towards co-dependence will be passing states experienced in some relationships sometimes. We can usefully learn the distinctions between interdependence when it tips into co-dependence as they
This reveals something important. We all move between these states to a greater or lesser degree. Co-dependence requires the converse matching of two or more units in a system and is co-created. If I tip into a codependent state more regularly or for longer periods, you will find it difficult to resist balancing the system through adjusting your own state and making compensatory efforts. No wonder being in the presence of a person in a co-dependent state can result in making us feel stifled and trapped. No question why a co-dependent person experiences rejection when at their most needy… and no mystery why client and therapist sometimes move in intimate, creative flow and sometimes get stuck. In fact, it is argued by some that most therapists are expert at denying their own intimate needs and are vulnerable to entering a co-dependent denial of their client’s strengths and ability to grow (Schaef, 1992).
References Bateson G (1971). The cybernetics of ‘self’: a theory of alcoholism. Gawler-Wright P (1997). Working successfully with addiction. Gawler-Wright P (2010). Healing codependence. Schaef AW (1987). When society becomes an addict. Schaef AW (1991). Beyond therapy, beyond science: a new model for healing the whole person. Smith A (1986). Grandchildren of alcoholics: another generation of co-dependence. Subby R (1984). Inside the chemically dependent marriage: denial and manipulation.
What’s wrong with porn? Paula Hall believes that psychotherapists have an important role to play in helping people with excessive or negative use of porn and in educating others about the potential benefits and risks
ornography is nothing new, but our ability to create and distribute porn has changed considerably from early caveman drawings. Controversy around pornography is also not new, from Victorian times when the first prohibitions were put in place to the recent wranglings with The Sun by the No More Page 3 campaigners. But there’s little doubt that society is more concerned about pornography now than perhaps at any other time in history, as the increased, unfettered access afforded by the internet fuels fears of the impact on young people’s sexual attitudes and risks of addiction.
Conflicting feelings Pornography can illicit many powerful and conflicting feelings, not just sexual ones: feelings of shame, disgust and
empowerment. For some, the ability to view the sexual images of their choice is seen as a basic human right and an expression of sexual freedom, while for others the production of porn is viewed as a crime against humanity. Meanwhile, some feminists proclaim it a sign of equality and sexual liberation, while others view it as the cause of the continued oppression of women.
which equates to approximately 25 per cent of all searches. Mobile adult content and services are estimated to generate $2.8 billion per year and one in five mobile searches are for pornography. But despite these staggering financial figures, nine out of ten internet users only access free material. There’s no doubt that porn is widely used and contributes to the world’s economy.
Views on pornography vary around the world and change over time as societies evolve, as indeed does the definition of what is sexually explicit and what is sexually exploitative. But whatever your view, pornography is almost certainly here to stay. The worldwide pornography industry is estimated to be worth $97 billion and search engines deal with around 68 million requests daily for pornographic material,
So the question is, how do these conflicting views affect our clients? And how might we as therapists help those who struggle with their porn use?
Paula Hall is a UKCP-registered and COSRT-accredited sex and relationship psychotherapist. She is a leading UK specialist in treating sex and porn addiction and founder member of the Association for the Treatment of Sexual Addiction and Compulsivity (ATSAC). She works in private practice, providing individual and group therapy for people with addiction and their partners (info@ paulahall.co.uk) and is author of Understanding & Treating Sex Addiction (Routledge 2013) and Sex Addiction – The Partners’ Perspective (Routledge, Autumn 2015).
The benefits of pornography The benefits of viewing pornography can be broken down into two categories – education and entertainment. Our current sex education system continues to focus on procreation and health. There is little or no discussion about sexual pleasure and the techniques required for achieving it. And until sex education becomes statutory, there are still many young people who receive no education at all. For many, pornography fills this gap. Pornography can also benefit adults who want to enhance their sex lives, alone or partnered, and can provide access to communities for those who fear their tastes are not the norm. But not all learning is beneficial. According
feature article Where the couple relationship is affected, attempts to rebuild trust may be impossible until underlying causes are identified and addressed to the Papadopulous report written for the Home Office in 2010, consumption of pornography is linked with sexual behaviour, including violent and offending behaviours (Papadopulous, 2010). In terms of entertainment, porn is much like any other form. It can provide an opportunity to escape the pressures and strains of every day life and lose oneself in a flow experience. Some consider their porn tastes akin to art, while others enjoy it as a physical expression of their sexual self and yet others enjoy the dramatic performance. The world of porn has many, many genres. From the fly-on-the-wall style documentary revealing everyday sex lives to the aspirational ‘you too can be like this’ films to the escapist fantasies of science fiction or cartoons. Advances in technology allow anyone to star in their own show or interact with other performers. Or you can create your own personalised characters, or indeed your own sexual persona and interact with anyone, anywhere who shares your predilections. Those who complain that internet pornography does not represent ‘real’ sex are missing the point when the goal is entertainment.
The risks of addiction Whether or not pornography can become ‘addictive’ in the same way as chemical addiction is still debated. Sex and porn addiction did not get into DSM-V, but gambling addiction did and internet addiction is the appendix, thus opening the door for behavioural addictions. Many professionals believe it’s just a matter of time before porn addiction and sex addiction do become recognised classifications. Advances in neuroscience and brain imaging technology are revealing increasing similarities between other addictions and porn addiction with regard to the role of dopamine, cue responses and hypofrontality (Voon et al, 2014; Hilton, 2013). Additionally, research is demonstrating psychological correlates with gambling addiction (Farre et al, 2015). A common argument against the existence of pornography addiction is that, while porn has been around forever, the notion
of it being addictive is new. It’s important to understand that availability and opportunity are key in the development of any addiction. Internet pornography is not the same as other types of porn and has been described as the crack cocaine of sex addiction. It is a ‘supernormal stimuli’, a term first coined in the 1930s to describe the many different substances and situations that trigger our instinctive impulses beyond their original evolutionary purpose. Seeking sexual stimuli and variety is innate; the internet exploits that instinctive drive with endless novelty and uninhibited opportunity. Our appetite is often not the best judge of what is best for us, as the growing obesity epidemic, driven by easy accessibility to fast, cheap fatty and sugary foods, bears testament. Some fear that the term ‘addiction’ pathologises sexual freedom and variety, or detracts from exploring underlying issues (Ley, 2012). But this demonstrates a misunderstanding of addiction and modern treatment approaches. An alcoholic seeking therapy should not have to fear that their penchant for tequila will be pathologised, nor that their lifelong struggle with depression will be ignored. The same should be true for clients struggling with porn or sex addiction.
Assessing pornography addiction It may be some years before a formal diagnosis and appropriate assessment tools are available, but in the meantime, a few simple questions can help therapists ascertain if a client needs help to stop: Does your pornography use have negative consequences on your life? Such as your relationships with others, your ability to form or maintain a relationship, your sexual functioning, finances or work? Have you tried to stop or limit your porn use, but repeatedly failed? Have you noticed that your porn habits are escalating, either in terms of time or in the type of material you’re viewing? If the answer is yes to each of these questions, then there’s a problem –
whatever you want to call it. But further questions can help to highlight the severity of the problem and detect underlying issues. For example: Are you more likely to view pornography when you’re feeling stressed, anxious or depressed? Do you find it difficult to turn to people for support or comfort in times of need? Did your behaviours start or escalate after experiencing any kind of trauma? There has been significant research showing that addictions are frequently a response to disrupted attachments and/or unresolved trauma (Carruth, 2011; Fisher, 2007; Flores, 2004) and may become a primary method for regulating difficult emotions. While this will not be the case for all, identifying these drivers is essential for establishing the best therapeutic approach.
Therapeutic approaches One of the biggest blocks to getting help for problems with pornography is shame. Not necessarily shame about viewing porn, but perhaps shame about the type of porn and the amount of porn. Moreover, many people struggle with acute shame about the lengths they will go to in order to create the opportunity to view porn, the responsibilities they fail to meet and the people they hurt when doing so. Group work has been the bedrock of addiction recovery for many years, primarily because of its ability to break through shame through identification with others (Yalom, 1985). Furthermore, group work can provide long-term support that can continue to repair attachment wounds and provide a place for accountability, long after individual work has been completed.
One of the biggest blocks to getting help for problems with pornography is shame The route to recovery will be different for each individual, but will require understanding and development of relapse prevention strategies in addition to work on underlying issues. One of the challenges of working with addiction is that, until a period of abstinence is achieved, it may be impossible to identify and access the deeper unconscious causes. Addiction is often referred to as an emotional anaesthetic; hence,
feature article until the anaesthesia has worn off, there may be little or no awareness of emotional pain. And where the couple relationship is affected, attempts to rebuild trust may be impossible until underlying causes are both identified and addressed. Addiction is complex and multi-faceted, which means a range of therapeutic interventions is often required. Specialist addiction treatment and group therapy to secure recovery, individual psychotherapy to treat attachment and/or trauma wounds, couple counselling and psychosexual therapy to repair the couple relationship or facilitate healthy separation.
Conclusion While professional and public opinions continue to conflict about the benefits and pitfalls of pornography, there is at least one area of common ground – and that is the importance of public information and education. Internet pornography is almost certainly here to stay as a form of sexual expression. And, like alcohol, some will enjoy it alone, others in company, and occasionally some may use it to excess. Furthermore, some will find themselves unable to stop, in spite of the damaging consequences it has on their lives. It is my belief that we as therapeutic professionals have a role to play, not only in helping those who already experience problems with their porn use, but educating others about the potential risks and supporting the positive use of porn.
References Carruth B (2011). Psychological trauma and addiction treatment. Routledge. Farre et al (2015). ‘Sex addiction and gambling disorder: similarities and differences’. Comprehensive Psychiatry, 56: 59-68. Fisher J (2007). Addictions and trauma recovery. New York: Basic Books. Flores JP (2004). Addiction as an attachment disorder. New York: Jason Aronson. Hilton DL (2013). ‘Pornography addiction – a supranormal stimulus considered in the context of neuroplasticity’. Socioaffective Neuroscience and Psychology, 3: 20767. Ley DL (2012). The myth of sex addiction. Roman & Littlefield. Papadopulous L (2010). Sexualisation of young people review. UK Home Office: www. homeoffice.gov.uk Voon V et al (2014). ‘Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours’. PLoS ONE, 9(7). Yalom ID (1985). The theory and practice of group psychotherapy (3rd edn). New York: Basic Books.
Sexual Attraction in Therapy: Clinical Perspectives on Moving Beyond the Taboo. A Guide for Training and Practice Edited by Maria Luca (2014) · Wiley Blackwell
review of current literature reveals that relatively little is written on the subject of sexual attraction between counsellors and their clients, which perhaps reflects the taboo, fear and misunderstanding that still surrounds this experience in therapeutic practice.
It is this gap that Sexual Attraction in Therapy attempts to address. The book is edited by Dr Maria Luca, a researcher, clinician, teacher and supervisor of psychotherapy, who has ‘witnessed the unsettling journeys of clinicians in their attempts to grapple with their own sexual attraction to a client or know how to handle a client’s sexual desire’ and felt the need to ‘give it the unique place it deserves’ (pxvii). Bringing together contributors from a range of modalities, the book is divided into two sections. Part 1, ‘Relational perspectives on sexual attraction in therapy’, features modality-specific considerations of the experience of sexual attraction in the therapy room. The wide range of views allows a multifocal perspective on the subject, highlighting the fact that sexual attraction in therapy applies to all clinicians regardless of theoretical approach. An engaging aspect of this section is the use of case studies to illustrate various manifestations of sexual attraction for both client and therapist, supported by structured guidance from the different theoretical approaches on how to manage these. The contributors are unanimous in their view that sexual attraction in the therapy room is unavoidable, normal and to be expected (in contrast to sexual behaviour, which is widely agreed and established to be unethical), arguing that it is this confusion between the experience of sexual attraction and the fear of sexual behaviour
that has hindered open exploration of this subject in trainings and supervision. Part 2 explores recent research on the subject, balancing the theoretical and experiential content of part 1 with muchneeded evidence of the impact of sexual attraction in practice. It also broadens the reader’s awareness of the significant number of variables to be considered when managing what can be a very difficult issue. A criticism of the book would be that, surprisingly, there is no contribution from a psychosexual psychotherapist. This strikes me as a significant omission given that a psychosexual therapist specifically discusses sexual issues with clients, meaning that erotic transference and countertransference is often unavoidable for this therapist group. Overall, however, this book is a valuable contribution to the bookshelves of psychotherapists, counsellors and supervisors, and has particular relevance for counsellors in training, who could learn to skillfully manage sexual attraction in therapy from the outset.
Reflections from the psychosexual psychotherapy classroom Two perspectives on sex and relationship psychotherapy training the trainer
hen I was asked to reflect on training sex and relationship therapists over many years, I cast my mind back to my own training. In my working life I have journeyed from being an art therapist to social worker to joint investigation trainer (police/ social services) to psychotherapist and group therapist. I then arrived at St George’s Hospital for an interview to become a sex and relationship psychotherapist. I had many years’ experience of running women’s groups, single sex and mixed survivor groups, and working in the field of sexual abuse and molestation.
Learning another language One of the questions I was asked at interview was quite simply why I wanted to do more training – my answer was to learn another language, to understand the complexities and nuances of working within a dedicated psychosexual domain. I wanted to learn more, not only about couple/relationship psychotherapy per se but about the convolutions and intricacies when working with relationships and individuals with the focus on sex, sensuality and intimacy. I wanted to gain an enhanced understanding of anatomy, physiology, the impact of prescribed and non-prescribed drugs, and to attend to all aspects of both organic and non-organic issues that are brought into the therapy room. That awareness back then has formed the basis of the teaching we provide today, together with the requirements of COSRT.
Being naïve and shy My role is to facilitate and teach psychotherapists and counsellors to become dedicated and specialist sex and relationship therapists, and this job has changed over the years. As an integrative training, we need to be inclusive of all modalities of psychotherapy while also embracing psychiatry, medicine and the larger social, cultural, religious and environmental world of the clients. For students who may have studied in one particular therapeutic style or belief system, this is a challenge: not only do we ask them to be students again but in effect to allow themselves to be naïve and shy. To be in the place of ‘not knowing’ and encourage openness to explicit and revealing language and material, to be part of a diverse training group and to be confronted by sex in its rawest and sometimes darkest form, and its pleasures and sensuality, and then to be asked to deliver this to the clients in a knowledgeable, coherent and meaningful way for their benefit. Student populations have changed over the years. More recently, we have at least one-third male students, and in each cohort there are medics and nurses who add something quite unique and special to the training. We have welcomed students from as far afield as the Lebanon, Nigeria, Russia and all parts of mainland Europe, together with several Irish students. Sexual diversity and preference is well represented in each cohort of students. Some arrive in the training with a very wide experience of sexuality and some with less. However, I would suggest that none of them at the point of starting the course have any real
None of them at the point of starting the course have any real understanding of what it really means to train and do this work 26
understanding of what it really means to train and do this work.
The core of therapeutic work Students also come from different theoretical orientations or perhaps from other aligned professions. Thus the training groups, usually now 24 to 26 students, are representative of a diverse population, with differing levels of experience in the field. In my experience, what students share at the commencement of their clinical placements irrespective of experience is anxiety – working psychosexually with couples and attending to the couple dynamics takes them to the very core of their therapeutic work. In my life as an established course director and educator of many students, I remain excited, challenged, tested and enthusiastic about the work. I have to rely on my history, my knowledge and my capacity to be in their world as well as my own. I seek to step into my authority while remaining openly dialogic; at times, as a gatekeeper, the task of calling a halt to a student’s training remains one of the most difficult aspects of the job. Equally, supporting and assisting
Judi KeshetOrr is a consultant psychosexual and relationship psychotherapist and a Fellow of COSRT. She has over 35 years of clinical, teaching, mentoring and supervisory experience. Judi has cofounded several successful organisations and training programmes including the London Diploma in Psychosexual and Relationship Therapy ten years ago. Judi contributes to academic journals, speaks at conferences, has published a number of articles, and has appeared on radio and television.
them to flourish and immerse themselves into the work of a sex therapist with intelligence and creativity is a joy. My view from the classroom is one of encountering and watching students grapple and grow, finding their place of challenge and humility, weeping, laughing, being part of a perceptible internal developmental process, and emerging with a unique skill set and an enhanced body of knowledge and therapeutic ability to work in the field.
chose to train in psychosexual and relationship therapy after completing my master’s degree in psychotherapy and counselling psychology at Regent’s University instead of an advanced diploma. With a good grounding from my many hours of clinical practice in a placement, I felt I was ready to specialise.
The dual nature of the relational and the psychosexual appealed to my notion of sexually embodied experience. Coming from an existential background, this emphasises the uniqueness of everyone’s experience. But this meant a lot of new and detailed material, especially in relation to physiology, and I did wonder how would
There was a real sense of support from a multidisciplinary approach
I retain it all. But the more I did, the more comfortable I became with this new side to my practice. Additionally, there was a real sense of support from a multidisciplinary approach: GPs, urologists, sexual health advisors, and more.
Challenging assumptions Viewing psychosexual and relationship therapy as a holism, I now work in a far more directive way with clients, and am far more forensic about the issues they bring. This is distinctly at odds with the phenomenological approach of an existential approach, and initially I felt somewhat ‘inauthentic’ from a philosophical standpoint. ‘Bracketing’ took a back seat, as we were actively encouraged by our course leaders to embrace this stance in an empathetic and congruent way. But then I realised as an existential psychosexual therapist I can still ask difficult questions, I still challenge assumptions, I still draw out polarities. I also take sexual and relational histories, ask couples about the finer details of their intimate lives and anatomy as well as instruct them in ways that they might make their sex lives richer, fuller
and even a little wilder. In this sense, I am far more ‘interventionist’, while convinced that working with both the personal and sexual relationship acknowledges the whole person. For this reason, the work can sometimes be challenging but also incredibly rewarding for clients. And that’s what really counts.
Murray Blacket is an existential psychotherapist with an MA from Regent’s University and a London Diploma in Psychosexual and Relationship Therapy. He has a private practice in North London and also works at the Grove and Ealing Abbey dealing with relationship and psychosexual issues. He hopes to start a PhD this year looking at the phenomenology of male sexuality and how it affects sexual performance and embodied perception.
Peer-supported open dialogue: a new paradigm for therapeutic treatment in mental health services in the UK A dialogic, family therapy-based model working with the family network Jane Hetherington explains how a pilot study could radically alter NHS provision for patients with psychosis
Current situation Psychosis In the UK, about 1 per cent of the population will develop psychosis or schizophrenia over the course of their lifetime and there is still considerable ignorance, stigma and public lack of understanding of this condition. Psychosis and the more specific diagnosis of schizophrenia represent a major psychiatric disorder or group of disorders where the individual’s comprehension, thoughts, feelings and behaviour are substantially affected. The service user will have a unique combination of ‘positive’ symptoms, comprising hallucinations and delusions, and ‘negative’ symptoms including emotional/ social withdrawal, poverty of speech and self-neglect.
Early intervention in psychosis (EIP) services EIP services have evolved for patients aged between 14 and 35 experiencing their first episode of psychosis. Psychosis first tends to emerge during the teenage years and early twenties, an important developmental stage for a young person. EIP teams provide a range of services and adopt a proactive and optimistic view of the individual’s ability to recover, eschewing the traditional preoccupations with symptom management, diagnosis and medication. Services promote a variety of treatments, including antipsychotic medications, but there is now greater emphasis on psychosocial interventions, care coordination and a growing range of psychological approaches. Psychological interventions advocated by the NICE guidelines include cognitive behavioural therapy and behavioural family
therapy but there is a growing body of evidence supporting psychodynamic work, among other approaches. Individuals with psychosis or schizophrenia are likely to have been impacted by the adverse effects of trauma occurring at an earlier developmental stage. They may also experience trauma resulting from the development of the psychosis or as a result of the psychosis itself. The individual will also be assessed for pre-existing conditions including depression, anxiety and substance misuse because these factors will impact treatment.
Developing open dialogue in the NHS Pilot project and family therapy training I work for the EIP service in Kent, which is currently part of a NHS pilot project using the open dialogue model. The pilot, running over the next three years, involves teams from the North East London Foundation Trust (NELFT), North Essex, Nottingham, and the Kent and Medway Partnership Trust (KMPT). A national conference in 2014, organised by NELFT and attended by 150 professionals and service users from across the UK,
engineered a forward strategy incorporating a multicentre randomised control trial (RCT). As part of the programme, staff in each trust managing the more severe presentations, predominantly psychosis, are given peersupported open dialogue (POD) training. The care provided by these POD-trained teams will be compared to treatment as usual (TAU). The project is being examined through both quantitative and qualitative research methods and is attracting interest politically, in addition to considerable excitement in the mental health field. Our team in Kent comprises 17 practitioners, predominantly working in EIP but also including staff managing severe presentations in other services. The POD team is multidisciplinary, comprising peer support workers, managers, psychiatrists, psychotherapists, psychologists, social workers, community psychiatric nurses, occupational therapists and the medical director.
Foundation year The initial stage of the pilot requires the team to undertake a foundation year of intensive part-time training in POD. Designed by NELFT in conjunction with Gjovik University College in Norway, this is completed before the pilot begins. The course emphasises the
Jane Hetherington is a UKCP-registered integrative psychotherapist working in the NHS in Kent as a senior specialist psychotherapist and supervisor in the Early Intervention in Psychosis (EIP) service. She has a long-term interest in working with substance misuse and currently supervises staff at Turning Point in East Kent. She runs a small private practice and is a member of UKCP’s Professional Conduct Committee.
discussion importance of the therapeutic relationship and the need for dialogue to foster personal recovery, and encourages professionals to develop these skills. It also encourages participants to reflect on the philosophy and values of a peer-supported, client-focused, person-centred approach. Considerable attention is paid to the work of Carl Rogers and humanising psychiatry and mental healthcare. The programme hopes to receive accreditation at foundation level from the Association of Family Therapists, which will be applied for retrospectively. We have commenced the training, which consists of residential weeks with long days of concentrated study, based initially around the principles of family therapy. Later modules explore trauma-informed and recovery-based approaches. The teaching is interspersed with experiential exercises, role play, self-reflection, mindfulness practice, group project work and discussions. The first week proved a psychologically and physically taxing time. For many of us, historic emotional issues arose and there was a high level of somatic presentation within our teams. Many in our extended group had no experience of personal therapy; emotions and thoughts occurred that required reflection, exploration and processing. Between modules, we are required to interact with one another through postings on a net-based virtual learning environment (VLE), submit self-reflective pieces and read voraciously the recommended literature. The training and pilot are being filmed for a three-part documentary to be aired at the end of the pilot’s first year.
Open dialogue Background Open dialogue (OD) is an ethos – and a theoretical and philosophical concept. The approach originated in the 1980s in Finland, where it is now standard psychiatric care (not an alternative to treatment). Western Lapland 30 years ago experienced some of the worst incidences of ‘schizophrenia’ in Europe. They now have the best recorded outcomes in western health services. The data are striking: in non-randomised trials, currently 75 per cent of those experiencing psychosis return to work or studies within two years and only 20 per cent of those diagnosed continue to take antipsychotic medicine at two-year follow-up compared
OD assists those in a crisis situation to work with the emotions of the crisis and to tolerate the uncertainty
to TAU. OD has since developed and evolved in the Scandinavian countries, and more recently, many European nations have developed services using variations of this model. The variant we are piloting is based on New York’s Parachute project, which pioneers the involvement of peer support workers in trainings and process. Workers are included in each team who are trained in intentional peer support, incorporating crisis care and holistic models of social intervention. These workers are seen as experts in their own right through their lived experience. The New York model requires professionals and peer workers to be trained jointly in POD. Peer workers are eventually encouraged to disseminate the training to a supportive peer community.
Fostering involvement The OD approach involves psychologically consistent family and social network meetings. Members of the service user’s family or peer group meet with a team of professionals in their own home and engage in dialogue, including the service user in the discussion. Members of the professional team remain consistently involved in the treatment where possible. OD assists those in a crisis situation to work with the emotions of the crisis and to tolerate the uncertainty. Over time, working in a dialogic manner results in understanding the meaning of the crisis and in healing and reparation. These network meetings are the only forum in which the patient is discussed. POD training enables professionals to utilise this space therapeutically, so the individual is empowered to involve themselves in their own treatment and recovery. The network meeting places the individual, their family and peer group at the heart of the provision of care, empowering them to make decisions pertaining to treatment. Fostering this involvement provides the individual and their network with a better experience of the system and will ultimately lead to a future reduction in chronicity and less long-term dependence on mental health services.
Lack of hierarchy A unique feature of OD is the lack of hierarchy involved in network meetings: the opinions of all the professionals involved are considered equally relevant to those of the family or peer support group. There is more emphasis on the meaning of the psychotic episode and the dialogue that occurs and less focus on medication, resulting in a more therapeutic provision of service. Often, when working professionally in the NHS, we become involved in a way of operating that we think is rational and subsequently we become disengaged. We imagine issues existing in a vacuum, removed from other connections, but this is not the case – and not how dialogicality works. In ‘Becoming Dialogical: Psychotherapy or a Way of Life?’, Seikkula (2011) talks of dialogism as a way of life that originates from birth, an inherent biological phenomenon that develops with us as we grow and respond to our environment. It is an attunement and response to the other, and a seeking of meaning and possibility. We, the participants in this scheme, have invested psychologically and emotionally in the OD approach and feel almost evangelical in our belief that it will result in reshaping mental health service provision. I will write at greater length at the end of our training and update UKCP members on the completion of the pilot, which will almost certainly involve considerable adaptation for the NHS in the UK.
References Freeth R (2007). Humanising psychiatry and mental health care: the challenge of the person-centred approach. London: Radcliffe Publishing. NICE (2014). Guidelines psychosis and schizophrenia in adults: treatment and management. Sainsbury Centre for Mental Health (2003). A window of opportunity: a practical guide for developing early intervention in psychosis services. Seikkula J (2011), ‘Becoming dialogical: psychotherapy or a way of life?’ Australian and New Zealand Journal of Family Therapy, 32(3): 179-193. Shotter J (2008). ‘Dialogism and polyphony in organisational theorizing: action guiding anticipations and the continuous creation of novelty.’ Organisational Studies, 29(4): 501-524.
Raising the profile of the Accredited Registers programme The Professional Standards Authority for Health and Social Care (PSA) has undertaken two initiatives to help raise the programme’s profile
KCP’s register was accredited by the PSA under its Accredited Registers programme in 2013. The programme was set up to provide assurance on the standard of registers for health and care occupations not covered by statutory regulation. The PSA aims eventually to cover all health and care services registers.
The first initiative was to ‘rebrand’ the programme in an effort to make its purpose more clearly understood. The PSA decided to omit the word ‘voluntary’ from the name and logo of its accredited registers programme. After consultation with accredited registers, including UKCP, and its public network, the PSA found that the word voluntary was thought to be confusing. The other change was that the Professional Standards Authority name was incorporated into the existing quality mark.
Ensuring that health and care practitioners are competent and safe March 2015
Members using the old logo should change to the new one before the end of the year for printed materials and as soon as possible for websites and emails. Please contact UKCP’s communications team if you would like a copy of the new logo to add to your website or promotional materials (email@example.com).
Could you commission a themed feature section for The Psychotherapist? If you have a theme you’d like to explore in depth and share with our readers, please consider sending 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.
confidence choice protection quality
The second initiative was the publication of a report setting out how patients, service users and the public have benefited from accredited registers in the two years since the programme launched. The report, which was sent to policymakers, the media and commissioners, highlights some of the achievements of the programme including: • increasing confidence in health and care practitioners • improving the standards expected of registrants on individual registers, and crucially • helping the public to make safer choices about the practitioners they use. A copy of the PSA report is available on the UKCP website: www.ukcp.org.uk/news/accredited-registers
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 and a copy of our guidelines for editors and contributors, contact firstname.lastname@example.org.
Conversion therapy: what are we doing now? Keith Carlton of UKCP’s Education, Training and Practice Committee working group explains how the organisation is implementing the Memorandum of Understanding on Conversion Therapy
The then Health Minister Norman Lamb met representatives from UKCP in January this year
t a meeting at the Department of Health in January of this year, in the presence of Health Minister Norman Lamb, UKCP was one of 14 signatories to launch the Memorandum of Understanding on Conversion Therapy, along with NHS England, the Royal College of Psychiatrists and other leading psychotherapy and counselling organisations. In March, we heard that NHS Scotland had also agreed to sign up to the memorandum.
Keith Carlton is a psychoanalytic psychotherapist working in private practice in the Canterbury area, after training at the University of Kent. His previous career was in marketing, communications and research. He is an accredited sexual diversity therapist and works extensively with clients from gender and sexual diversity backgrounds. Since January 2014 he has been a member of the UKCP Board of Trustees.
The memorandum follows an earlier consensus statement on gay conversion therapy, and starts from the position that therapeutic attempts to change or alter sexual orientation are unethical and potentially harmful. It recognises at the same time that when people present with conflicted feelings around their sexuality they should have access to therapeutic options that can help them live more comfortably with their sexual orientation. It also contains the expectation that signatories will ensure that their members have access to the latest information regarding conversion therapy, and that members have the appropriate
understanding and cultural competence when working with lesbian, gay and bisexual (LGB) clients, both through training curricula and through CPD. This is particularly important given that, for many psychotherapists and counsellors, their training did not contain relevant content relating to the specific understanding of LGB and trans life experience and issues.
Standards for education and training As a result, UKCP has begun working to implement the memorandum with the organisation. We have a working group from the Education, Training and Practice Committee (ETPC) looking at the adult standards for education and training (SETs) to ensure that qualifying training programmes address the necessary cultural competence for working with LGB clients. The EPTC working group is also looking at supporting guidance to help training leaders and therapists develop this understanding and learn how to deal with clients who come seeking to change sexual orientation or expressing unhappiness with their orientation. Once the adult SETs and supporting guidance are complete, the EPTC working group will look at the child and adolescent SETs.
We aim to demonstrate that UKCP continues to be a leader in working appropriately with LGB and trans people 31
ukcp news Once the amendments to the SETs are in place, we will look at amending the accreditation and re-accreditation processes, to ensure that therapists and therapeutic counsellors working with LGB clients have and maintain the appropriate levels of knowledge and cultural competence. We are also considering a major UKCP event or conference to raise awareness of the subject area.
Gender dysphoria and transgender The Memorandum of Understanding did not cover gender dysphoria or transgender in its brief, and there was much discussion of this both before and after the launch. This was in part driven post-launch by the suicide of Leelah Alcorn, a young American transgender woman who committed suicide in December 2014 at the age of 17 as a result of being forced by her parents to attempt conversion therapy in order to ‘accept’ her birth gender identity. In the light of all the discussions, UKCP took the decision, with the support of the Diversity, Equality and Social Responsibility Committee, to include gender dysphoria and transgender in its work to implement the memorandum, and the ETPC working group will include gender dysphoria and transgender in its work on the adult SETs. A separate working group has been set up to develop guidelines to support members working with gender dysphoria and with transgender adults, and this group has reached out to key individuals and groups in the wider transgender community for their expertise. We will also ensure that accreditation and re-accreditation processes address this and include this area in the proposed conference.
Ethical guidelines In addition, the Ethics Committee has been asked to look at developing an ethical guidelines statement on transgender conversion therapy (attempts to change clients’ identity from transgender to their birth gender identity), in a similar format to their recent ‘Guidance on the Practice of Psychological Therapies that Pathologise and/or Seek to Eliminate or Reduce Same Sex Attraction’. Through this work, we aim to demonstrate that UKCP continues to be a leader in working appropriately with LGB and trans people, and ensuring that LGB and trans clients feel that they can access psychotherapy and psychotherapeutic counselling which will be supportive, non-pathologising, and informed and understanding of their needs.
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The Psychotherapist is available online You can now read a digital version of The Psychotherapist online. This issue that you are holding in your hands, plus many other back issues, can be viewed at http://issuu.com/ukcp-publications. Please take a look and tell us what you think. Do you find it easy and useful to read the magazine in this online format on your computer, smartphone or tablet? Also, let us know if you would prefer to stop getting your printed copies of the magazine entirely, and move over to only reading the online version from now on. Let us know your thoughts – email email@example.com
Learning from complaints: confidentiality The issue of confidentiality is a hot topic. In the past year alone, UKCP’s Complaints and Conduct team has received over 100 calls from members seeking guidance on confidentiality. Here they explain the issues
o most therapists, confidentiality is one of the most important ethical obligations they have to a client and is necessary to building trust in the relationship. On the surface, it seems like a simple concept to apply in practice. However, confidentiality is not absolute, and many therapists struggle to discern the difference between confidentiality and legal privilege or to accurately recognise when it can be violated.
Common pitfalls Most breaches of confidentiality that we see are inadvertent. They also tend to follow a pattern, suggesting that many of our members are simply not aware of the best way to handle these difficult situations when they arise. Below are three common situations that crop up time and time again. Hopefully, by becoming aware of the sort of things that trigger these situations, you can avoid them in the future:
1. Protecting the client Sometimes therapists need to break confidentiality in order to protect their client – if there is a serious risk of harm to their client or to others. However, it can sometimes be difficult to judge in the moment whether a particular situation reaches that threshold. We have seen a number of complaints where a therapist has breached confidentiality by contacting a client’s GP, family member or other agency without the knowledge or consent of their client. Although this has been done with the best interests of the client at heart, it is important that confidentiality is only breached in the most extenuating circumstances.
Comments and queries Do you have any comments regarding confidentiality? If so please contact us: firstname.lastname@example.org
What to do? If you find yourself in this situation, the best thing to do is to seek immediate guidance – preferably from a supervisor. Know and understand the thresholds for safeguarding and always act with the consent of the client wherever possible. It may also be helpful to agree with a client at the beginning of therapy the situations in which you would consider it necessary to break confidentiality and agree the extent and limitations of this.
2. Legal or court proceedings Among the most common enquiries we receive regarding confidentiality relate to legal/court proceedings. Many clients are involved in legal proceedings – in a divorce or custody dispute, for example, or as a victim of crime. In these instances, you may receive requests from legal professionals or the police requesting that you divulge details of your therapy sessions with your client. The relationship between a therapist and client is considered privileged, and legally you are not obliged to break confidentiality unless you receive a formal subpoena. The client can of course choose to waive this privilege, but even in that instance it can be difficult to determine the level of information you should provide.
Being aware of the difficulties that can arise in this work is your best defence What to do? Your professional indemnity insurers are invaluable in situations such as these – they can help you to decide the best course of action, provide advice on your legal obligations, and may even assist with the drafting of reports or help you prepare to be a witness. It can be overwhelming to receive a legalistic (and sometimes very upfront) letter and it is difficult to resist the urge to simply comply with the requests being made. Know your rights and obligations and remember that, whatever you do, you should always try to act with the consent of your client.
3. Working with families Working with couples and families can be challenging and it is often difficult to balance the needs of all individuals to determine the best course of action. This type of work raises unique ethical dilemmas regarding confidentiality and, unfortunately, we consider
ukcp members those who do this work to be at high risk for complaints. Most complaints about confidentiality for this group are based on the difficulty in defining who the client is and handling situations in which one individual discloses information or seeks assistance that other individuals are not aware of. Choosing to see one or more of the clients individually is sometimes necessary; however, it also makes maintaining the confidentially of the couple or family and the individual more difficult. What to do? Being aware of the difficulties that can arise in this sort of work is your best defence. It’s fine to take time to talk through a situation with your supervisor before making a decision and you shouldn’t ever feel pressured to act immediately. Transparency is key here. Clear contracting is of great benefit in helping everyone involved know exactly who is and is not considered a client. The contract must be updated if and when that ever changes. It is also important to make sure you are upfront about what you are doing and what it means if the client relationship changes – both for the client who is leaving and the client(s) who are remaining.
UKCP’s Ethical Principles and Code of Professional Conduct Section three of UKCP’s Ethical Principles and Code of Professional Conduct deals with confidentiality. These clauses encompass everything, from general principles of confidentiality to safeguarding the welfare and anonymity of clients when publishing material. The document is available on UKCP’s website and we would encourage everyone to take a moment to re-familiarise themselves.
Who to talk to? There are many resources available to you if you are unsure whether your actions may constitute a breach of confidentiality. As a first point of call, we always encourage therapists to speak with their supervisor or a peer for guidance, and of course the Complaints and Conduct team at UKCP is always here to help. Something that many members do not know is that their professional indemnity insurers can provide assistance and support with these sort of queries – particularly when they relate to legal obligations. Most breaches of confidentiality are unintentional and can be avoided if the right advice is sought quickly.
Why does psychotherapy research matter to UKCP? All psychotherapists must engage with research asserts Dr Helen Barnes, who explains its relationship to policy and practice
ould I want to go to a surgeon whose practice wasn’t informed by the latest research developments in their field? No. Do I understand that publishing outcome data on surgery can potentially have a negative impact on patients by making clinicians risk averse, unwilling to follow their instincts and less keen to take on complex cases? Yes.
Key research findings Research evidence, whether based on routine outcome measurement, clinical trials or qualitative studies, is powerful. It’s important that we think through the implications of making research findings on psychotherapy more widely known, for the profession, for individual practitioners and for clients. But I don’t see neglecting to engage with psychotherapy research, whether as an individual or as a professional body, as a tenable position. By this I don’t mean that everyone need necessarily be doing research, but that all psychotherapy and counselling practitioners and professional bodies need to be well informed on key research findings affecting the field, and be guided by them. In this short article, I aim to set out the arguments as I see them.
Dr Helen Barnes is research lead at UKCP and is completing the final stages of her training as an integrative psychotherapist at the Metanoia Institute. She has also had a long career as an applied social policy researcher with interests in the impact of economic and social disadvantage across the lifecourse.
UKCP’s charitable objectives include promoting ‘the wider provision of psychotherapy and psychotherapeutic counselling for all sections of the public’. I also view this as a more fundamental issue of equity and social justice, which lies at the heart of ethical practice. Making psychotherapy available to the broadest cross-section of society means ensuring that it remains available via the NHS and health insurers. In reality, there has been a marked decline in the public provision of psychotherapy (BPC/UKCP, 2015), and primary mental healthcare provision is increasingly dominated by CBT, largely because it has an established evidence base and has been demonstrated to be costeffective over the short term.1 However, the longer-term cost-effectiveness of CBT is unproven, and there is evidence that these services are not always sufficient to meet the needs of those with more complex and longstanding problems (HSIC, 2014; Cairns, 2014). If we care about people on low incomes having access to appropriate treatments, this is not an issue we can afford to ignore.
A credible evidence base Research is needed to provide a credible evidence base that shows under what conditions psychotherapy works, how it works and what kinds of therapy produce best results for particular conditions or client groups. In addition to providing the evidence required to improve the availability of publicly funded psychotherapy, research evidence can also improve public confidence in the profession, promoting quality and informed choice (Roth and Fonagy, 2006).
1 www.journalslibrary.nihr.ac.uk/__data/assets/ pdf_file/0006/117663/FullReport-hta18310.pdf
ukcp members Research evidence can improve public confidence in the profession, promoting quality and informed choice There is also a strong case to be made that engagement with research can help practitioners become better therapists by encouraging reflexivity and ongoing professional development. This is important because therapist factors are known to account for much of the variation in client outcomes (Wampold and Imel, 2015).
Small risks So far, so good, perhaps? But are there any dangers in UKCP having a greater engagement with psychotherapy research? Could research findings undermine the case for psychotherapy, by showing that some clients are harmed by it, that some kinds of therapy are less effective than others, or by showing that most clients improve after just a few sessions? I think these risks are small – research has consistently shown that only a small proportion of clients are harmed by psychotherapy and that common factors such as the therapeutic alliance are more significant than the type of therapy practised (Wampold and Imel, 2015). Moreover, I would argue that our willingness to know these things, in the interests of our clients, should outweigh any narrow personal or professional self-interest. As Anna Freud famously said: If you want to be a real psychoanalyst you have to have a great love of the truth, scientific truth as well as personal truth, and you have to place this appreciation of truth higher than any discomfort at meeting unpleasant facts, whether they belong to the world outside or to your own inner person.2
Delivering what matters In the policy arena, if psychotherapy as a profession does engage more systematically with the evidence-based practice agenda, 2 From a letter written by Anna Freud. In Kohut H (1968). ‘Heinz Kohut: the evaluation of applicants for psychoanalytic training’. International Journal of Psycho-Analysis and Bulletin of the International Psycho-Analytical Association, 49: 548–554 (552–553).
one danger, as with any policy area, is delivering what can be measured rather than what matters, as is arguably already the case with the spread of manualised CBT provision. It is important that research engages with a wide variety of therapeutic interventions, client groups and presenting issues, and that the research strategy adopted is sensitive to the types of outcomes that can be anticipated. Another important risk is that research evidence is misinterpreted – in particular that findings that apply to a particular population, setting or intervention are assumed to apply equally to very different practice contexts. This points to a need for a profession that is more researchliterate, confident in understanding both the outcomes and the limitations of research. This has implications for the initial and continuing education, training and development of therapists. It highlights a key role for UKCP in effectively disseminating research findings to its membership and the wider public, and spelling out what they mean for practice.
It also underlines the need for more and better research on psychotherapy. Over the next few months, I will be working with a range of internal and external stakeholders to develop a strategy to help UKCP strengthen its research activities and structures, improve the dissemination of research findings, and build research capacity among its members and trainees. I’m interested in hearing from anyone with an interest in and experience of these issues.
References BACP (2014). Psychological therapies and parity of esteem: from commitment to reality. BPC/UKCP (2015). Addressing the deterioration in public psychotherapy provision. Cairns M (2014). ‘Patients who come back: Clinical characteristics and service outcome for patients re-referred to an IAPT service’. Counselling and Psychotherapy Research, 14(1): 48-55. HSIC (2014). Psychological therapies, annual report on the use of IAPT services: England – 2013/14. Experimental statistics. Roth A and Fonagy P (2006). What works for whom? A critical review of psychotherapy research (2nd edn). Wampold B and Imel Z (2015). The great psychotherapy debate: the evidence for what makes psychotherapy work (2nd edn).
‘I think it can help to improve my work as a therapist’ UKCP research assistant Dr Katrin Maier explains the value of the real-world research practised by practice research networks (PRNs) and the experiences of practitioner-researchers in UKCP’s Moments of Meeting study Clinicians often feel that research findings do not reflect their practice realities, and so they do not consistently research to inform their practices. (Tasca et al, 2015: 1)
Research with real therapists and their clients A practice research network (PRN) is a tool that aims to close the gap between practice and research in psychotherapy. Originally developed in the USA, the model is widely used in academic contexts, by psychotherapy training organisations and by professional bodies. PRNs can be different sizes, exist for different lengths of time and host several sub-projects, but they usually involve a mixed group of practising psychotherapists with an interest in psychotherapy research and academic researchers (who are often also therapists). Together, group members design a study on a particular topic, and discuss definitions, methods and ethical concerns. They enter themselves as therapists and some of their own clients into the project. PRNs allow
Dr Katrin Maier supports the wider Research Faculty, the RF Committee and the PRN group. She is a social anthropologist and specialises in qualitative/ethnographic research, access to psychotherapy, gender, diversity and migration.
A PRN aims to close the gap between practice and research in psychotherapy clinicians to experience the different stages and processes of what it means to carry out research: develop ideas, discuss ethical implications, agree on definitions, carry out research in the ‘field’ of their own therapy room, and analyse data. In addition, group meetings and follow-up interviews provide an important space to reflect on clinical work – in a similar way to peer supervision. On the one hand PRNs improve the research literacy of their practitioner-researcher participants; on the other, PRN projects utilise the therapists’ deep engagement with and in ‘live’ therapy settings.
UKCP’s Moments of Meeting (MoM) pilot project The Moments of Meeting project at UKCP is one example of research employing the PRN model. The pilot research study emerged from a collaborative workshop held at UKCP. Like other psychotherapists (see Wampold and Imel, 2015) workshop participants saw a need to examine the impact of the alliance between therapist and client on the therapy process and the client’s wellbeing, in particular the idea that special and intense ‘moments of meeting’ between therapist and client may (or may not) have a positive
influence on the client’s improvement. This idea is based on a concept developed by Daniel Stern and the Boston Change Process Study Group (Stern et al, 1998; Boston Change Process Study Group, 2010; see also Stern, 2004). The project’s core group consists of six members, plus two who have joined more recently. All work in private psychotherapy practice in London, though under different modality paradigms. Some have a lot, others very little experience of academic psychotherapy research. For the past three years, the group has met every four to six weeks. They have encouraged each other, reflected on practical issues – one group member described it as a kind of ‘peer supervision with a focus’. But beyond this, they have also discussed examples of special ‘moments’ from their practice and developed criteria for what might or might not be classified as ‘moments of meeting’. More outcome questionnaires are coming in and more follow-up interviews are being carried out, but the group has started to review and analyse the material collected – ranging from the dossier of ‘moments of meeting’ and different outcome measures to interview transcripts.
Being a researcher and being researched: insights into one’s own practice Some of the therapists participated because they were interested in doing research. Others were more motivated by the thematic focus on understanding what happens between the therapist and client that enhances their alliance. Initially, the less experienced practitionerresearchers felt uncomfortable about entering their own clients. Ethical issues around confidentiality and concerns about how participation in the study could change the dynamics in the therapy room featured prominently in group discussions at the beginning: [M]y experience as clinician... that felt like a real development I had to go through. With the notion of ‘using’ patients in this way... [it] was quite a big learning curve. Another group member agreed but added: Once we had a formal consent process and we had headed paper from UKCP, personally I found it quite easy to approach prospective clients in the assessment session. To say: ‘I am
ukcp members One group member described it as a kind of ‘peer supervision with a focus’
interested in research and I am part of this [PRN] group at the UKCP and I think it can help to improve my work as a therapist.’ And clients responded very openly. Only one person declined. But very nicely. It didn’t interrupt or change that work. And with the others, at least in one case, it’s been positive in terms of the therapy. It is true that participating in the research project may impact on the therapy process – but that impact needn’t be negative. And one therapist even felt a positive effect on his work: I think my work changed after joining the group... I was suddenly noticing that Moments of Meeting were occurring in my work and it did seem to help with a few people I’d been stuck with for some time. I felt somehow things got a bit less stuck. One of the more experienced researchers summarises part of the outcomes as follows: There have been two unexpected upshots from this MoM project. One is clinicians finding that the process of observation has added a reflective dimension to their practice and the second is that having a post-therapy
or near-end therapy interview actually adds a dimension to the process that is a big surprise... you learn different things from it than you learn from straight supervision. The group members have not just taken away things for their own psychotherapy practice. They have also given talks about their experiences at conferences and research workshops, contributed to journal articles and are planning to report to their member organisations. If you would like more information or to join UKCP’s PRN, email email@example.com
Note This article is informed by a discussion with the Moments of Meeting core group in January 2015, which I recorded and transcribed. Unless otherwise stated, the direct quotes are from this discussion. I am grateful to all group members for sharing their positive as well as difficult experiences as practitioner-researchers so openly with me.
References Boston Change Process Study Group (2010). Change in psychotherapy: a unifying paradigm. New York: WW Norton. Castonguay Louis G et al (2010). ‘Psychotherapists, researchers, or both? A qualitative analysis of psychotherapists’ experiences in a practice research network’. Psychotherapy Theory, Research, Practice, Training, 47(3): 345–354. Stern D et al (1998). ‘Non-interpretive mechanisms in psychoanalytic therapy: the ‘something more’ than interpretation’. International Journal of Psycho-Analysis, 79: 903-921. Stern, D (2004). The present moment in psychotherapy and everyday life. New York: WW Norton & Company. Tasca, GA et al (2015). ‘What clinicians want: findings from a psychotherapy practice research network survey’. Psychotherapy, 52(1): 1-11. http://societyforpsychotherapy.org/wp-content/ uploads/2015/03/Tasca-et-al-2015.pdf Wampold BE and Imel, ZE (2015). The great psychotherapy debate: the evidence for what makes psychotherapy work (2nd edn). New York/London: Routledge.
Tips from the Moments of Meeting study group If you are thinking of participating in a PRN or even setting up your own, our experience suggests: • The big task is recruiting. • Therapists must be prepared to put themselves and their clients into the projects as participants. PRNs are fundamentally about doing research – this goes beyond talking about an interesting topic. • The group found meeting face to face extremely beneficial; they ‘clicked’ and trusted each other. No question was seen as too naïve and issues of concern were taken seriously. The group size of six to eight was ideal.
• Personal connections, interest in research in general and in the particular research topic were the most important motivations to join the group. • For group members less familiar with academic research, it was useful to have, in accessible language, a written summary of the ideas and theoretical concepts lying behind the study and its line of argument. • A complete ‘participants’ pack’, including research schedule,
questionnaires, etc, should be prepared before recruiting starts. • A central support structure should be put in place: for example, appoint someone who is committed to receiving and administrating research material. Consider using tools such as iPads and phone apps for planning and sending reminders. • Psychotherapists are busy people and may forget to fill out forms. Think ahead about ways to use data that may be incomplete or delayed.
The Shape review: update For those of us on the Shape working group, the General Assembly on 7 March was an important occasion – a chance to hear the views of members about the group’s work on the principles underpinning UKCP, functions of the organisation and proposals for organisational change. It was also a chance to meet with others in UKCP across modalities with time to reflect and explore ideas
he Shape review is a project looking at improving the way UKCP works. Giving up a beautiful spring Saturday to ponder function and structure could be difficult but the room was full of psychotherapists eager to debate the issues.
Rationale for the Shape review The day began with Janet Weisz, Chair of UKCP, laying out the rationale for the review and highlighting the new contexts that had created the need for change. She described the makeup of the working party and stressed that the group was in place to develop the consultation documents and not to make decisions – these would be made by the Board. There were contributions by Benet Middleton, consultant to the process, and presentations by two members of the working party, Andy Cottom and Martin Weaver. These covered principles suggested by the working group and gave a more general overview of the thinking and process of the group.
Extensive consultation Information was given about the multiple methods we have used in this consultation, including focus groups in London, Bristol and Leeds, as well as an online survey and more formal feedback from groups and organisations in UKCP. This feedback showed a range of views but overall support for the suggested principles and the maintenance of a role in regulation, service to the public, promotion of psychotherapy and support for psychotherapists.
To a large extent, the views expressed during the General Assembly fitted well with the results of the first consultation. Table group discussions with feedback to the whole room gave plenty of opportunities to develop ideas and capture difference. Everyone was also encouraged to write personal comments on post-it notes, which meant that views that didn’t make it into the feedback were also included.
Diversity and difference I sat at a table that included people at different stages of their career, from various parts of the UK and diverse ethnic and professional backgrounds. The diversity was interesting and, depending on their make-up, individual tables tended to focus on different points. There was agreement that all the principles listed were important but a number of comments suggested that ‘ethics’ should have more prominence. The feedback from
Judith Lask is a systemic family psychotherapist, teacher and supervisor currently working in private practice and for the University of Exeter. She has had various roles within UKCP and the Association for Family Therapy and has been involved in training and regulation for over 20 years. Currently she is involved with CYP IAPT in curriculum development and accreditation for systemic family practice. Her research interests include the development of the SCORE measure of family functioning.
the table discussions illustrated some of the inherent issues and tensions (I am using the term positively!) in the UKCP community. One issue raised was the need for psychotherapists to be central to all activity in UKCP but the difficulty in finding volunteers to take up the work. Lack of resources in UKCP colleges led some to want the regulatory functions to be taken over centrally, leaving colleges to contribute on modality-specific issues and support psychotherapists through CPD and training.
Special interest groups Many wanted UKCP to promote a gold standard in psychotherapy practice and training. The role of colleges was discussed and many wanted fewer colleges that would meet minimum standards of size and function. There was a lot of support for more ‘special interest groups’, which would draw on modality commonalities rather than difference. The role in promoting psychotherapy was stressed. The group commented that internal as well as external issues affected the practice of psychotherapy. There was some frustration that the issues were familiar and had been discussed before, and a wish to go ahead and make necessary changes.
ukcp members The second discussion focused on organisational change and there was a good deal of support for the idea of greater separation of executive functions from the Board, more opportunities for staff and psychotherapists to work together and a rethink of the Psychotherapy Council. There was the continuing buzz of discussion during and after an excellent lunch.
• The number of Vice Chairs was changed from two to one, and the Vice Chair position was changed to being a trustee position. On the final point, the new Vice Chair role has been filled by Pat Hunt, who was elected unopposed. Pat is already a member of the Board, having been elected as a trustee in January 2014. She has also been Chair of an organisational member in the past.
If you are interested in knowing more about Pat, read her manifesto on our website (see www.psychotherapy.org.uk/news/ukcp-vicechair-election). Also see the website for the complete set of articles, byelaws and standing orders for UKCP (www.psychotherapy.org.uk/about-us/ objectives-and-legal-documents).
Looking outwards The afternoon contained some interesting vox pop presentations by Kids Company about the wellbeing course they are running, and from a service user, Emily Otway, from the Islington Borough User Group (iBug). It was good to look outside the immediate confines of UKCP and I know many were inspired by the presentations. Before the General Meeting later in the day there was opportunity to welcome a new member organisation: Therapy and Counselling Teeside. The Director Karen Hough gave a short presentation and was warmly welcomed. The day was busy and full, representing some of the complexity that surrounds the therapeutic encounter and the commonality and diversity that run through the organisation. This is what I wanted from joining UKCP and I look forward to many other days like this.
Constitutional changes The day also included a formal general meeting where a series of changes to the constitutional documents of UKCP were considered and voted on. Some were technical changes that our lawyers have advised us to make. Others were more significant improvements to governance following the first Shape report last year. They included: • We shortened the notice period for elections to the UKCP Board to 60 days, which should be quite enough for lively democracy. • We provided proper connections between the UKCP complaints system, the therapist register and membership of UKCP. • We deleted a rather primitive clause about banning from the Board UKCP people who own shares in UKCP organisational members and replaced this with a much more thorough approach to managing potential conflicts of interest. • We required the Board to be very clear when delegating any of its powers to staff or committees.
Core principles Taking into account members’ and others’ contributions to the Shape review, the working group proposed a set of core principles that will shape any future changes to UKCP. The Board welcomes and supports these core principles.
1. Serving the public interest drives everything UKCP does The public interest includes: • safeguarding • ensuring that diverse approaches are available • helping to encourage diversity of both therapists and clients • enabling access to therapy • ensuring the quality of therapy available • modelling good practice.
2. Psychotherapy is at the heart of UKCP • Striking the right balance between psychotherapists’ and UKCP employees’ contributions to running UKCP. • Harnessing the creative tensions that can arise from difference. • Recognising the value of both publicly trusted regulation and psychotherapists’ personal self-regulation and maintenance of standards.
3. UKCP is participative • Providing the opportunity for therapists to shape the UKCP agenda and actively seeking to empower UKCP members to take part. • Supporting a vibrant regional presence or network that members can engage with, including encouraging local psychotherapy clubs and special interest groups. • Where UKCP has representative or elected posts, post-holders to be chosen on the basis of one member one vote. • Individual members and organisational members are vital parts of UKCP.
4. UKCP promotes and values diversity among those who access and those who provide therapy 5. UKCP promotes and values difference in modality, ways of working, work settings (eg private, charitable and NHS) and client groups 6. Everything UKCP does is open to scrutiny and, where appropriate, done in partnership • Other professional groups, policymakers and lay users should be part of UKCP standard-setting and regulation. • There should be transparency across the UKCP structure.
7. UKCP can demonstrate to members and the public the value of UKCP registration
ukcp members Books about psychotherapy: write a review? As you will know if you are a regular reader, we often publish book reviews in the discussion pages of The Psychotherapist. Would you be interested in writing a review of a book that may be of interest to our members? If so, we would be delighted to hear from you. You can write a review of any book related to psychotherapy that you have enjoyed and believe members should know about. Or you could choose a book from our list of suggestions (available online at http://bit.ly/ukcp_books), or a publication from the UKCP books series (see below). On the right are examples of books from our list that you might like to read and review.
The Forgiveness Project: Stories for a Vengeful Age
Love in the Age of the Internet: Attachment in the Digital Era
Neurobiology and the Development of Human Morality
Linda Cundy (editor)
With forewords from Desmond Tutu and Alexander McCall Smith, this book brings together the personal testimonies of both survivors and perpetrators of violence, and asks whether forgiveness may have more currency than revenge in an age which seems locked into a cycle of conflict.
Written by psychotherapists with expertise in attachment theory, this highly topical book examines the profound impact of digital technologies upon human relationships today.
In this book, Darcia Narvaez argues that morality goes ‘all the way down’ into our neurobiological and emotional development, and that a person’s moral architecture is largely established early on in life.
New and forthcoming in the UKCP books series For the best new thinking in psychotherapy and psychotherapeutic counselling
Handbook of Working with Children, Trauma, and Resilience: An Intercultural Psychoanalytic View Aida Alayarian
Cradling the Chrysalis: Teaching and Learning Psychotherapy: Revised Edition Mary MacCallum Sullivan and Harriett Goldenberg
A psychoanalytic discussion on the effects of trauma and torture on children, with a specific focus on how professionals can use a resilience-focussed approach to help the child reach wellbeing.
What is the ethical and philosophical basis for the teaching and learning involved in becoming a psychotherapist? How can training prepare prospective psychotherapists, counsellors, and counselling psychologists for clinical practice, whilst engaging them in their own process of transformation and emergence?
Managing Difficult Endings in Psychotherapy: It’s Time Lesley Murdin Endings can be difficult. How can psychological therapists help a person to live well, and face the endings that confront all of us with honesty, and the acceptance of our human fragility?
The Psyche in the Modern World: Psychotherapy and Society Tom Warnecke The Psyche in the Modern World sets out to bring the concept of the Psyche, and psychotherapy discipline itself, into the realm of interdisciplinary discourse.
To order a book, or for more information on the full UKCP books series, go to: http://bit.ly/book_series
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continuing professional development ASSOCIATION OF JUNGIAN ANALYSTS
Information Day 2–4pm on 10 October 2015 For psychotherapists wishing to become Jungian Analysts The Association of Jungian Analysts (AJA) is a Londonbased Jungian organization, offering experienced therapists the opportunity to train as Jungian analysts. This specialized training course enables practitioners to make the transition from psychotherapist to Jungian Analyst. Candidates may come from many different backgrounds and trainings – psychodynamic, arts therapy, humanistic and integrative, individual and group, and would normally be members of BPC or UKCP. AJA is among the more pluralistic trainings in Analytical Psychology in London and includes a wide range of seminar leaders with international reputations on the training faculty. The training leads to membership of AJA, IAAP (the international umbrella organization for Jungian Analysts worldwide based in Zurich), BPC (British Psychotherapy Council) and UKCP (UK Council for Psychotherapy). To book a place or make enquiries, email our Training Administrator at: firstname.lastname@example.org or call 07901 590015
Emotionally Focused Couples Therapy Externship with Professor Scott Woolley from San Diego Centre for EFT 9–12 September 2015 A four-day foundation workshop offering the first step to becoming a certified Emotionally Focused Couples Therapist. Training includes presentations, experiential group work, video sessions and a ‘live’ couple session.
Attachment Narrative Therapy with Prof Rudi Dallos and Prof Arlene Vetere A 40-hour course working systemically with attachment narratives. 22–23 January, 26–27 February, 18–19 March, 15–16 April 2016 For more information contact email@example.com or visit www.thebowlbycentre.org.uk The Bowlby Centre is a Company Limited by Guarantee no. 3272512. Registered Charity no. 1064780/0
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M.A. in Transpersonal Child, Adolescent and Family Therapy This two-year p/t transpersonal, integrative training takes place on Fridays and 12 weekends. It is UKCP-accredited and is validated by University of Northampton.
Diploma in Transpersonal Couples Counselling & Psychotherapy This one-year p/t post-graduate course offers a holistic and integrative approach to working with couples and takes place over nine weekends.
Diploma in Transpersonal Supervision This course covers individual and group supervision from an integrative and transpersonal perspective. This is a one-year p/t course, held over 30 weeks with four weekend seminars. Supervised practicum work is an integral part of the training.
Post-Graduate Trainings in Dreamwork under the auspices of CCPE's Dream Research Institute One-year Dreamwork Certificate (Essentials and Advanced) One-year Dream Guide Diploma One-year Lucid Dreaming Certificate All courses are part-time and commencing January 2016.
Weekend Seminars 2015 19 + 20 September - Life Crisis 17 + 18 October - Facilitating Spiritual Growth 7 + 8 November - Alchemy of Relationships
Cost: £185 per workshop (non-refundable deposit £100) Times: Sat/Sun 10am – 5pm
CCPE, Beauchamp Lodge, 2 Warwick Crescent, London, W2 6NE email@example.com, www.ccpe.org.uk,Tel: 020 7266 3006
UKCP – The Psychotherapist – June Issue 2015
continuing professional development
Our CPD Programme Diploma in Supervision
Gestalt in Organisations
Led by Gaie Houston & Jane Puddy
Workshops run throughout the year.
12 days spread between
• Core Concepts for Working with Organisations (2 days)
October 2015 & June 2016.
Certificate in Groupwork Workshops run throughout the year. • Understanding Group Dynamics • Developing Effective Group Facilitation • Conflict Challenge and Confrontation in Groups • Group Facilitation 10-week Intensive
We offer Personal Development Groups in on-going and weekend formats.
• Gestalt in OD: In Practice (2 x sets of 3 days) • Gestalt in OD: Masterclass (10 days spread over 9 months)
The Large Group An exciting and empowering new experiential learning event. 22 - 25 July 2015.
MA in Gestalt Therapy Theory Studies We are now recruiting for the 2015 intake.
We also offer accredited training in counselling and individual and group psychotherapy leading to professional qualifications.
www.gestaltcentre.co.uk | firstname.lastname@example.org | 020 7247 6501
CPD OPPORTUNITIES IN CHILD COUNSELLING/CHILD PSYCHOTHERAPY www.artspsychotherapy.org
Adult/Adolescent to Child Psychotherapy Conversion Course: Diploma in Integrative Child Psychotherapy (UKCP Reg.) For registered counsellors or psychotherapists who want to gain: • A wealth of clinical skills for working with children • A sound working knowledge of principles in child therapeutic practice, child law and child protection, essential for working safely and ethically • An in-depth knowledge of child psychiatry, diagnostic categories and medication used with children
P/T Certificate in Cognitive Behavioural Therapy with Children (12 days)
020 7704 2534 THE INSTITUTE FOR ARTS IN THERAPY AND EDUCATION 2-18 Britannia Row London N1 8PA 44
A must for people who are already working therapeutically with children. Trainees will become skilled in applying CBT techniques to their therapeutic work with children and teenagers. The course aims to resource practitioners with a rich array of CBT materials: games, home activities and therapeutic exercises. The course will teach trainees how to use CBT to work effectively with feelings of anxiety, depression and inappropriate anger, leading to resilience and increased self-esteem, improved ability to relate and to learn. www.ukcp.org.uk
continuing professional development
Post-Qualification Doctoral Programmes Joint Programmes with Middlesex University Doctorate in Psychotherapy by Professional Studies
The DPsych (Prof) is renowned for its innovation and quality in practice-based research. A scholarly community of more than 100 graduates have made significant contributions to the development of the psychological therapies. The Programme is aimed at re-vitalising and nourishing senior qualified practitioners. It offers an alternative to traditional research based PhDs or academic, taught doctoral programmes and can be completed within three and a half years. During the first year of the programme taught modules take place approximately once a month. Candidates are then supported to develop a research submission which is project - rather than thesis - based.
Doctorate in Psychotherapy by Public Works
This award appeals to senior, accomplished, practitioners, who have already made a substantial contribution to the field of psychological therapy through a range of publications and/or public works such as: the development of innovative therapy services; major organisational change; establishment of successful training programmes. Candidates are supported to undertake an intensive reflexive 12-18 month audit of their existing achievements.
For full details, please contact Mandy Kersey, our Senior Academic Coordinator on 020 8579 2505 or email her at email@example.com Metanoia Institute, 13 North Common Road, Ealing, London W5 2QB Registered Charity 1050175
Study Group Are you a psychotherapist with at least 5 years of postqualification experience in private practice? Are you finding that your clients are moving into territory that your original training did not prepare you for? Are you uncertain about how to engage with negative transference and regression? Do you have doubts about your vocation as a therapist? This study group starting in October 2015 will be an opportunity to read psychoanalytic and Jungian literature and to discuss clinical and vocational dilemmas. For details contact David Henderson, PhD, on firstname.lastname@example.org. Website: www.dhenderson.co.uk
Harley Therapy – Psychotherapy & Counselling We are looking for experienced UKCP accredited psychotherapists who are competent in at least two psychological models one being CBT or third wave psychotherapy model. You will work at least 10 hours a week (evenings and/or weekends) on a long-term sessional basis from our rooms in Canary Wharf, City of London or Harley Street. Hourly rates of pay apply. We welcome applications from therapists who are compassionate, hard working, committed to professional development and to promoting clients’ mental health. For more details and to apply please visit:
Parent Infant Psychotherapy Diploma
January 2016 – July 2017 Applications are invited for our parent infant psychotherapy programme from qualified and appropriately registered mental health professionals. 25 training days over 5 terms, based in Oxford. This training is in the process of being accredited by APPCIOS. OXPIP also offers a range of short training courses related to parent infant mental health and attachment. web tel
www.oxpip.org.uk 01865 778034 45
continuing professional development
COST-PRICE, HIGH-QUALITY TRAINING TO INSPIRE CONNECTION Certificate in Relational Supervision B uild y our c onfi d e n c e i n p ro v i d i n g s u p e rv i si on to peers, col l eagues, trai nees and supervi sees, bas ed on r elat i o n a l p ri n c i p l e s . P a rti c u l a r attenti on w i l l be gi ven to usi ng body process, to w or king
wit h s ham e and to mo me n t-b y -m o m e n t re l ati onal dynami cs.
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DEEPEN RELATIONAL CONNECTION IN YOUR WORK AND THE WORK OF OTHERS EXTEND YOUR PRACTICE, JOIN A SUPPORTIVE GROUP, FULFIL RECOGNITION REQUIREMENTS DATES: 5-6 October, 2-3 December 2015, 12-13 February, 9-10 April, 6-7 June 2016 LOCATION: Historic central Cambridge (45 minutes from Kings Cross) COST: Only £1200, self-funded with early-bird discount
LED BY LAURENCE HEGAN: Laurence is an international trainer with 30 years experience in the NHS and in private practice as a therapist, trainer and supervisor. Laurence has a special interest in developing practitioner resilience.
Changing Relationships: Certificate in Couples Work B uild y our c onfi d e n c e a n d s k i l l s i n p ro v i d i ng coupl es counsel l i ng and psychotherapy. W hen w e wor k wit h a c ouple, th e re a re e n o rm o u s o p p o rtuni ti es for creati ve change, for both the i ndi vi dual s c onc er ned and fo r th e w i d e r fa mi l y a n d c ommuni ty. Thi s course i s provi ded i n partnershi p w i th Relat ional Cha n g e (www.RelationalChange.org).
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DEVELOP ABILITY IN WORKING WITH SEXUALITY, INTIMACY AND EMBODIED PROCESSES WORK WITH CONFLICT AND DIFFICULTIES BETWEEN COUPLES AND WITH THE IMPACT OF THE WIDER CONTEXT DATES: 15-16 October, 30 Nov-1 Dec 2015, 14-15 January, 11-12 April, 19-20 May 2016. COST: Only £1200, self-funded with early bird
LED BY DR LYNDA OSBORNE: Lynda works privately as a psychotherapist, supervisor and international trainer. She has 35 years experience of couples work and has taught in the UK and internationally on the subject.
Certificate in Relational Coaching B uild y our c onfi d e n c e a n d s k i l l s i n p ro v i d i ng coachi ng - i n pri vate practi ce, i n formal organi sa t ional c oac hing- c ont e x ts a n d a s p a rt o f e v e ry d a y l i fe and w ork. U nl i ke many other coachi ng courses, t his pr ogr am m e loc a te s p s y c h o l o g i c a l c h a n g e fi rml y i n the rel ati onshi p betw een the coach, the coa chee and t he wider s i tu a ti o n .
• • • •
EXTEND YOUR PRACTICE. BUILD ON YOUR EXISTING SKILLS, STRENGTHS AND EXPERIENCE OPTIONAL FOLLOW-UP ACCREDITATION PROCESS (WITH THE NHS-RECOGNISED ILM) SUITABLE FOR COUNSELLORS/THERAPISTS NEW TO COACHING AND SUITABLE FOR EXPERIENCED COACHES DATES: 7-11 March 2016 COST: Only £1000, self-funded with early-bird discount
LED BY SIMON CAVICCHIA AND MARK GAWLINSKI: Simon is an international organisational coach and consultant and a psychotherapist. He is also joint programme co-ordinator for the MA/MSc programme in coaching psychology at the Metanoia Institute, London. Mark is a psychotherapist, coach and consultant, and former senior lecturer in leadership.
FOR MORE INFORMATION OR TO BOOK: Web: www.TheRelationalAcademy.org E-mail: admin@TheRelationalAcademy.org Phone: +44 (0) 1223 967 971 Training venue location: St Andrews Hall, St Andrews Road, Cambridge, CB4 1DH The Relational Academy is a non-profit organisation that aims to inspire connection
WITH CAMBRIDGE COUNSELLING SERVICE
continuing professional development
Psychodynamic Psychotherapy with Couples At the Tavistock Centre we offer a unique training opportunity within the NHS for clinicians interested in working with couples. This two-year training course, accredited by the British Psychoanalytic Council, will expand your understanding of psychodynamic theory and practice and give you the tools and experience to enhance and diversify the work you can do both within the NHS and in private practise. The course is also tailored to provide a top up qualiďŹ cation for psychodynamic psychotherapists who want to see couples.
Starting date October 2015 Location The Tavistock Centre, 120 Belsize Lane, NW3 5BA Contact Billie Josef, 020 8938 2314, BJosef@Tavi-Port.ac.uk To apply, visit www.tavistockandportman.nhs.uk/d59c The Tavistock and Portman NHS Foundation Trust is a centre of excellence for the research, dissemination and clinical application of psychotherapeutic thinking and practice.
The Minster Centre Pioneers of integrative training since 1978
Organisational Member of BACP and UKCP, Collaborative Partner of Middlesex University. Part-time professional training, provided in Queens Park, London.
Our new Postgraduate Diploma / MA in Professional Practice, Counselling & Psychotherapy offers a unique opportunity for professional counsellors to attain a higher level qualification in either supervision or advanced clinical practice. There could be an APL option for applicants who already have a supervision qualification and want to top-up to masters level. If eligible, you could join the programme halfway through in October this year. Please contact Course Developer Dr Val Thomas to discuss your options at
Your advert here The Psychotherapist, UKCPâ€™s flagship publication, is sent to over 8,000 psychotherapists and psychotherapeutic counsellors and to more than 70 organisations, placing it at the heart of the psychotherapy profession and making it a great place to advertise training, events and other services for the psychotherapy community.
email@example.com. www.minstercentre.org.uk The Minster Centre, 20 Lonsdale Road, Queens Park, London NW6 6RD. Registered charity no 1042052. Company registered in England and Wales number 2966937
To find out more, email firstname.lastname@example.org
FOURTH UKCP RESEARCH CONFERENCE
How do we know we make a difference? Outcome, process and wellbeing in psychotherapy
Saturday 18 July 2015 · 9:30 to 17:00 · Drinks reception till 18:00 Regent’s University, Inner Circle, Regent’s Park, London NW1 4NS Hosted by UKCP’s Research Faculty Committee with Regent’s University The fourth UKCP Research Conference will offer an opportunity to engage in dialogue about how psychotherapy works best to improve clients’ wellbeing. Join us for a rich and balanced programme with interesting case studies, quantitative evaluations, insights into the use of particular outcome measures, hands-on workshops and four great keynote speakers.
Themes in parallel sessions include
Rolf Sundet Buskerud and Vestfold University College, Norway Measure and conversational tool: feedback from service users and the adventure of collaboration
• Uncomfortable knowledge – what can we learn from negative outcomes, and from areas we would rather ignore?
Markus Bidell Regent’s University / City University of New York LGBT psychotherapy: making a difference by turning personal experiences into professional outcomes John Mellor-Clark CORE-IMS Learning from CORE Measurement: Reflections on Two Decades of Data Judith Lask and Peter Stratton Association of Family and Systemic Psychotherapists Researching therapy through its effects on the everyday lives and relationships of client
• The impact of the therapeutic relationship on change • Psychotherapy in the wider context • Implicit, unconscious and unvoiced processes • The impact of supervision on therapy process and outcome • Systematic explorations of therapy outcomes in particular contexts • Explorations of the meaning of ‘change’ • Using routine outcome measures in research and clinical practice: CORE, SCORE and others Book your place: http://bit.ly/researchconf2015
IN COLLABORATION WITH
For further information about UKCP events, please email email@example.com or telephone: 020 7014 9966 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