Issue 66 â€¢ Summer 2017
Personality disorder: what works for whom?
The maga zine of the UK Council for Psychother apy
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contents Feature articles Working with personality disorder: what works for whom? 4 Borderline personality disorder: working at the Cassel hospital 6 Schema therapy: healingÂ from the core 9 Intensive short-term dynamic psychotherapy 12 Mentalization-based therapy and borderline personality disorder 16 The voice of lived experience into a personality disorder service 19 Co-produced psychological education groups 21 The Early Years Parenting Unit (EYPU) 24 A new biopsychosocial programme for emotional instability 27 DBT: a dialectic approach to effective treatment 30 Cognitive analytic therapy 33 Discussion The value of attending a group relations training 36 Working with the medical model: a person-centred perspective 38 UKCP news Obituary: Michael Pokorny 1937â€“2017 41 Learning from Complaints 41 Raising our profile in partnership with Psychologies magazine 42 Helping the public to find a therapist 43 Alternative Dispute Resolution: consultation survey results 44 Professional Conduct Committee 44 Mental health influencing at a local level in the NHS 45 Psychotherapy and the General Election 46 UKCP members UKCP conference 2017 47 Reviews 48 Welcome to our new UKCP members 50
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
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.
Working with multiple transferences 6
Mentalization-based interventions with individuals and groups 16 Feel good; fail to pick up warning signs
Criticising Demanding Inadequate Insecure Anxious Worthless
Seek validation (and rescue?) through male attention
Cruel Powerful Abuser Powerless victim Awaiting rescue
Kindly GP or me health staff or fr takes an interes
Staff or friend express disappointment and/or withdraw
Self-harm and/or overdose (to escape from intolerable feelings)
Abandoning Abandoned Despairing Empty
Inevitable disappointment when care is not ideal and permanent
Cognative analytic therapy
Protective Powerful (Idealised) Rescuer Dependent Powerless Expecting ideal care
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
s I write this, we have just learnt the sad news about the death of Dr Michael Pokorny. Michael was instrumental in setting up UKCP and was the first Chair of UKCP. We only had time to include a short piece about him on page 41 but we hope to celebrate his life in the next issue of The Psychotherapist. UKCP and the profession owe a lot to him and he will be sadly missed In this issue Lesley Day has guest edited this issue of The Psychotherapist on personality disorders, discussing which therapies work for different
people. The contributing authors share their experiences of working in different modalities with people with personality disorders to provide fascinating perspectives on therapy in this complex area. You can also read how we used the General Election as an opportunity to raise the profile of psychotherapy on the political agenda. The Public Policy Team discuss the impact we made and highlight some of the upcoming activity including the local advocacy work on page 46. In the previous issue of The Psychotherapist, Samantha Lind, UKCP
Janet Weisz is the Chief Executive of UKCP and a psychotherapist and psychodynamic counsellor who has worked in the voluntary sector, public sector and private practice for over 20 years. As well as maintaining a private practice, she works in the NHS as part of multidisciplinary teams and has first-hand experience of the demanding pressures for change and evolution in the provision of psychological services – both in the public and private sectors. Janet was elected Chair of UKCP in March 2012. She was formerly the Chair of UKCP’s Colleges and Faculties Committee (CFC), where she guided the committee to enhance the collaboration between the colleges and faculties by maintaining cross-modality standards, considering approaches to diversity between the colleges, and approving college procedures for assessing organisational members’ re-accreditation processes, among many other activities. Janet was also chair of Council for Psychotherapists and Jungian Analysis (CPJA) for three years.
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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.
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Case Manager, provided an outline of the new Alternative Dispute Resolution (ADR) consultation process that we are working on. Since then, we have collected the results of the ADR consultation survey and held our first meeting to draft a policy. You can find out more about the exciting developments with this – as well as hearing from the Chair of the Professional Conduct Committee, Brian Linfield – on page 44. This will be the last of these editorials that I write as your Chief Executive. We are delighted to be welcoming Professor Sarah Niblock who takes up this role in August at an exciting time for UKCP, and also around the time of our office move. I look forward to working with Sarah over the summer during our handover period. Sarah joins us from the University Of Westminster’s School of Media, Arts and Design where she was Associate Dean (Undergraduate) as well as being an author, journalist and broadcaster who has trained a number of award-winning journalists.
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Working with personality disorder: what works for whom? Lesley Day invites us to look at a range of ways of working with people with personality disorders. Aims of this special issue Personality difficulties and ‘disorders’ can scar a person’s personal, family, work and social life and their ability to form and maintain satisfactory relationships with others. Many patients in mental health services will have such difficulties, as will those in the community, but their therapeutic needs are often not attended to, or understood. In this special issue, UKCP members who come from different theoretical and psychotherapeutic approaches, and who mostly do not work in the NHS (18 per
Lesley Day is a UKCP-registered psychotherapist, qualifying in 1995 as an integrative psychotherapist at Metanoia Institute. She was the Head of Service at the Cassel Hospital, a national Tier 4 specialist personality disorder service, for over 16 years, until 2013. She has also been a member of several national committees concerned with developing services and training in the field of personality disorder, and has published in this and other areas of psychotherapy and in social policy. Lesley has been a trainer and educator in this field for many years, and was previously a senior lecturer at Brunel University in the Department of Social Work. Currently, she works in private practice as a psychotherapist, and is a reflective practice and organisational consultant in the NHS. She has recently become one of UKCP’s Adjudication Panel members. 4
cent in 2016 according to a recent UKCP membership survey; The Psychotherapist, spring 2017), are given the opportunity to deepen their understanding of these problems and how they are formulated, and will be introduced to a range of different ways of working with this client group. The contributors to this issue are clinicians, who practise in a range of settings with different therapeutic models of practice, and those with a lived experience of personality disorder who work in this area as trainers and peer-based practitioners. Hopefully, what is communicated to the reader is the passion and compassion with which these practitioners engage in their therapeutic work. As Erskine (2015) reminds us, it is the relationship between the client and the therapist that is at the crux of therapy, and this is of course central to our work with those who have a lived experience of personality disorder.
Personality We all have a personality, which characterises our thoughts, attitudes, feelings and behaviour, no less so for those of us who are therapists. These are not just a collection of traits, but are formed into a coherent and integrated whole by early adulthood. What some refer to as our personality structure may have functional or dysfunctional aspects; and we need to consider how, and to what extent, a person’s personality or ‘character’ style enables him or her to make effective and satisfying enough relationships in the world of work, family and social life. This is, of course, central to our professional relationships with our clients, and what we bring to the therapeutic encounter. For those who are described as having a personality disorder, or difficulties, this
refers to how their ways of relating to others, thinking and behaviour patterns, causes them and others around them a lot of distress. It negatively affects their relationships with others, their everyday lives, and how they feel about themselves. Rather than adopting a binary approach, in which the person is diagnosed or assessed as having, or not having, a personality disorder, it has been suggested by some clinicians that it is more helpful to think of a continuum or spectrum, with `normal’ personality’ at one end and severe and complex at the other. This of course raises interesting and thorny questions about how to define what is ‘normal’. For a full discussion of this, and the difficulties of assessment and diagnosis, see Tyrer, 2015.
Early development Several of our contributors remind us of the complex relationship between attachment and family disruptions, emotionally, sexually and physically abusive, traumatic and neglected childhoods and the development of a personality disorder, leading to severe and complex problems in adulthood. Rex Haigh, one of the authors here, has recently argued that although different clinical disciplines have different languages for describing, making sense of and defining the ‘intensely painful and disabling consequences of disrupted emotional development’, the underlying mental ‘injury’ is the same. It is also not only about mental ‘injury’, as members of this client group have poorer physical health and higher morbidity and mortality rates than those in the general population (Tyrer, 2015).
Language: what is in a name? The different language and terminology used is therefore complex territory, with some clinicians and therapists referring to ‘complex trauma’ or ‘severe and complex problems’ and others referring directly to different classifications of personality disorder, as described in the ICD or DSM. This is reflected in the articles in this special issue. There is no one or ‘right way’ to describe these experiences, and the context in which the clinician works, or the training they have undertaken, will probably affect the language and nuance of meaning in this discourse. Several of the articles are written by those with a lived experience of ‘personality disorder’; and their voices need to be heard in this discussion.
Prevalence Whatever language we use, what we know is that personality disorders are common. It has been estimated that those with a personality disorder represent about 25 per cent of primary care patients, up to 50 per cent of outpatients in mental health services, and 66 per cent of those in the criminal justice system (Tyrer, 2015). They will also be seen in community counselling and psychotherapy services and in private practice. It is also estimated that perhaps one in 20 of the general population has such difficulties but may never receive a therapeutic service (Coid, 2006). Despite the prevalence of this mental distress, it may be that some therapists are less familiar with or able to recognise its many different forms and/or feel less confident or skilled enough to work in this area.
Policy and practice In 2003, there was an important shift in mental health policy with regard to personality disorder. The policy guidance document by NIMHE, ‘No longer a diagnosis of exclusion’, confirmed that many of those with a personality disorder did not receive a clinical or therapeutic service that met their needs; they might be seen as troublesome and difficult, and be thought by some clinicians to be ‘untreatable’. Crucially, this opened up a dialogue and the development of different therapeutic practices that demonstrated that positive changes in interpersonal and psychosocial functioning across the life course were possible. Over the past 15 years or so, there has been much theoretical research and clinical debate about how to treat this mental distress and ‘injury’, and the British Irish Group for the Study of Personality Disorder (BIGSPD) has been an important forum for this. The research evidence on the effectiveness of different models is growing, with some of the treatments and therapeutic interventions recommended in the NICE Guidelines on Borderline Personality Disorder. Some of these welldocumented and researched therapeutic models and interventions are discussed in these articles. These differ in terms of the theoretical and conceptual frameworks they draw upon, the length of treatment, and nature of the relationship that is formed between the practitioner and the client/s.
The models and interventions featured here are: a biopsychosocial model (Rex Haigh); peer-based working (Melanie Anne Ball); psychological education groups (Sally Stamp and Tania Towns); dialectical behaviour therapy (Maggie Stanton); mentalization-based therapy (MBT) for parents with young children (Minna Daum and Nicola Labuschagne); MBT for adults (Monica Doran and Tim Wright), intensive short-term psychodynamic therapy (Kingsley Norton); inpatient psychoanalytic psychotherapy in a therapeutic community (John Glyn); cognitive analytic therapy (Annie Nehmad); and schema therapy (Diana Bogner).
Thus there have been developments in the provision of different therapeutic interventions and models of practice for individuals and families, and importantly the service user’s voice is making itself heard in these developments. The cuts in mental health provision and reduced funding for therapeutic services for adolescents, families and adults are challenging and distressing for clinicians and for service user movements and services in the field of personality disorder. The very recent closure of Emergence Plus, an important and valuable service user-led organisation in this field, has been particularly difficult and challenging, as has the demise of some therapeutic communities which were pivotal in providing services for those with a personality disorder.
Coid J et al (2006). ‘Prevalence and correlates of personality disorder in Great Britain’. British Journal of Psychiatry, 188(5).
The contributors to this special issue have come together to offer one small attempt to discuss, critically explore and bring fresh thinking to this area of work. This issue has also been compiled in the hope that stigmatisation and exclusion from therapeutic services is not rendered even more problematic for those with a lived experience of personality disorder. Improvement and recovery from the severe distress and difficulties across the person’s lifespan are possible, but the continuing development of a continuum of therapeutic services in a range of settings is paramount.
Department of Health (2003). Personality disorder: no longer a diagnosis of exclusion. Department of Health Publications. Erskine RG (2015). Relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. London: Karnac Books. Johnson SM (1994). Character styles. Norton. Livesley JW, Dimaggio G and Clarkin JF (eds) (2015). Integrated treatment for personality disorder: a modular approach. Guildford Press. Newton-Howes G, Clark LA and Charen A (2015). ‘Personality disorder across the life course’. The Lancet, 385: 727-734. Tyrer P, Read GM and Crawford MJ (2015). ‘Classifications, assessment, prevalence and effects of personality disorder’. The Lancet, 385: 717-726.
Borderline personality disorder: working with multiple transferences at the Cassel hospital John Glyn describes treating patients with severe and emerging personality disorder using applied psychoanalysis, a model that combines psychoanalytic thinking and practice in a therapeutic community setting.
he Cassel Hospital is the only NHS tier 4 inpatient service treating patients with severe and emerging personality disorder. In this article, I give a brief background to the hospital, then turn to a particular patient, describing her progression through the institution and detail from her individual psychotherapy. I aim to show how the multiple transferences that occur in this setting become powerful tools in treatment, and are thought about and interpreted in sessions and the daily work of the institution.
The Cassel model The Cassel Hospital dates back to 1919, when it originally treated shell-shocked patients in a more forward-thinking way than was common at the time. Tom Main, a psychoanalyst, became the Cassel’s director in 1946. He introduced a radical institutional approach that remains central to the hospital today. Main saw a hospital as a therapeutic instrument whose culture could also
John Glyn is an adult psychoanalytic psychotherapist. He is currently Head of Psychotherapy and Social Work at the Cassel Hospital, part of the West London Mental Health NHS Trust, and also works in private practice. He trained at the former Lincoln Clinic and Centre for Psychotherapy
Different internal parts of patients are projected into different members of staff and splits within the patients are enacted between the staff members be anti-therapeutic. To be therapeutic, psychoanalytic enquiry needs to be applied everywhere: to patients, staff, individuals and groups. Main coined the term ‘the total culture of enquiry’, in which all transference enactments demanded examination. In The Ailment (1957), he described how different internal parts of patients are projected into different members of staff, and how splits within the patients are enacted between the staff members. By coming together, and unearthing these dynamics, staff can understand patients better, which can lead to healthier functioning. The approach aimed to remove the notion of ‘healthy’ staff and ‘ill’ patients. Patients actively participated in each other’s treatment, while staff became facilitators of the culture rather than attempting to ‘make patients better’. A psychoanalytically informed approach to mental health nursing, termed ‘psychosocial nursing’, was developed in which nurses’ emotional responses and countertransferences became tools with which to take up patients’ defences. The Cassel continues to practise along these lines, taking patients who have exhausted other treatment options, and who present with high risk of suicide, severe self-harm, dysfunctional
relationship patterns, dissociation and psychosis. These problems generally arise as a result of longstanding deprivation, abuse, early disruptions and neglect, and come under the generic diagnosis of personality disorder, with most having borderline personality disorder. I refer here to the Cassel inpatient service, but an outreach service offers London-based patients a two-year community-based programme, which they can either step down to from the inpatient service or enter directly. Most of these patients have had repeated admissions to acute psychiatric wards, where risk of suicide and self-harm is managed mainly through medication and physical containment. The Cassel operates with fewer restrictions and contains risk where possible by responding psychologically and emotionally to the worrying situations that arise. Patients have more responsibility to contain risk within their group. While this usually works well, with staff opening themselves to patients’ disturbances, staff also experience considerable pressure on their capacity to think and to maintain their professional partnerships. A large part of the daily work is to think together about experiences and feelings and to bring together aspects of the patients that have been split off and projected into the team
(Skogstad, 2003). In practical terms, Main’s ‘culture of enquiry’ is a structure of forums that reveal these dynamics, enabling them to be worked through.
Psychotherapy: working with multiple transferences The Cassel approach is mainly group based, with twice weekly individual
psychoanalytic psychotherapy. So, how does it integrate a culture of individual psychotherapy into this collective ethos? From the start, the psychotherapists let their patients know that they routinely discuss their therapy with colleagues. Patients therefore discover that all the therapists are informed about what is
happening in the patient group. However, while patients may superficially accept these facts, they may also have powerful feelings about having to share their therapists, about staff linking with one another, and about an authority structure that seems counter to the utopian ‘we are all equal’ institution they have fantasised about. The task of the individual
Patient Sasha For reasons of confidentiality, details have been changed
asha, a woman in her late twenties, was severely sexually abused from a very early age by her father and a circle of other abusers. Her mother, who she remains in contact with, knew of the abuse but did not act to prevent it. Her parents are no longer together. She has two children, who are being looked after by their father while she is in treatment. Sasha was taken into care in her early teens when it was suspected she was being abused. However, her father was never formally charged. She was bright but dropped out of school and had a long history of severe self-harm, suicide attempts, an eating disorder and dissociative episodes, with many
admissions in the past couple of years to acute psychiatric care. Although on the fringes of criminal groups, she engaged with her community mental health team and formed one close attachment with a mental health professional. She was felt to be too fragile to undertake psychoanalytic psychotherapy but a period of relative stability led her consultant psychiatrist to think she could be referred to the Cassel, where the inevitable disturbance that psychotherapy would stir up could hopefully be contained. Once at the Cassel, Sasha evoked extreme and contrasting responses. It was pleasing that after long periods in secure
wards she could function in the open situation of the Cassel, where patients are free to come and go from the building. Some staff were drawn towards protecting her, seeing her as a vulnerable child whose shocking abuse needed to be countered by corresponding amounts of loving care. However, she could be cruel and denigrating to others, making them feel useless and in turn furious with her. She was a powerful presence within the patient community, becoming central to a clique who saw themselves as ‘anti-treatment’, appearing secretive and conspiratorial, and often extremely destructive. There were periods of intense disturbance, where she was
gripped by persecutory voices, causing anxiety in staff and patients about her risk of selfharm and suicide. Early in her individual psychotherapy, she sat turned away from her female psychotherapist, never making eye contact and mostly saying very little. The sessions were painfully uncomfortable for her therapist, who felt incapacitated. Sasha struggled with intense conflicts between wanting to make use of the sessions while simultaneously fiercely rejecting anything that her therapist offered her. She expressed hatred of herself for being so frightened to talk and despair that she would ever be able to overcome this.
feature article psychotherapist at the Cassel is therefore particularly determined by the place of the therapy in the wider psychosocial setting. The transference is saturated by the patient’s thoughts, feelings and fantasies evoked by the setting and by the therapist’s relationship to the setting. Therapists need to notice and interpret the patient’s wish to pull them away from their institutional relationships towards a pre-Oedipal, ‘just us’ twosome (Bell, 1997). To illustrate these issues, I look at work with a patient (Patient Sasha – see box on previous page) who went through the Cassel inpatient treatment, which I supervised.
Working with a formulation From this sketch, one can see various dynamics and transferences in which internal states that Sasha found too disturbing were split off and projected into various individuals and groupings in the hospital. The team observed how different aspects of Sasha were being taken to her therapy sessions from those described by nurses. The nurses themselves were divided between those who experienced themselves as kind and caring and those who felt attacked and provoked by her. This corresponded to Sasha’s internal situation in which she could feel herself the victim of horrific abuse while also experiencing herself as identified with the abuser, the cruel figure inflicting the abuse. The ‘caring’ staff members were an external embodiment of an idealised ‘all good’ internal object who Sasha would have retreated to from infancy. Such an object is supposed to mitigate against all the external ‘badness’ but its unreality renders it liable to morph into the persecutory system it was supposed to provide protection from. The delinquent clique she led corresponded to an internal gang that jeered at her own vulnerability and propagated the view that survival involved the crushing of all thinking and feeling. With her therapist, all these transferences were felt towards a single person. Her therapist could be the longed-for good loving mother but was at the same time in collusion with her abusive ‘husband’, that is, the (Cassel) institution or individuals
within it. Her ‘goodness’ was therefore merely a deceptive front. Her therapist’s thoughtfulness could be felt as containing but it could also be seen as coming from a part of her mind that privately communicated with another cruel part that had no interest in Sasha’s wellbeing. Her therapist could be seen as a resilient authority, but she could also be seen as vulnerable and naïve, needing to be protected from the abusive figure she was being forced to sit with.
how disturbed Sasha felt by seeing herself as an abuser within the therapy relationship and, conversely, the therapist as a secretively abusive figure. Was the consulting room a place of safety or an enclave in which to carry out exciting transgressions? Sasha often erupted into furious outbursts or retreated into tearful silences. But either way, she had found someone, and a setting, that appeared able to receive her projections and return them in a more digestible form.
Simple countertransference interpretations
In the Cassel community, parallel shifts occurred. The extreme and destructive splitting of nurses decreased and Sasha could recognise the function it had served. The reliance on the delinquent clique diminished and her relationships became more evenly distributed around the whole group. She became less tormented and capable of mature reflection. This was not a magical ‘cure’, and when she left there remained worries about whether she would be able to hold on to the progress or would relapse. However, there were signs that the foundations of a functioning life were in place.
How does one work with this kind of formulation in a way that can benefit the patient? In sessions, these powerful processes seriously affected her therapist’s capacity to think. However, simple countertransference interpretations, such as ‘I think you are needing me to know how terrifying and paralysing it is to be here with me’ or ‘I think it can feel almost unbearable for you to not know what kind of person you are with’, seemed to be containing. Further into the treatment, Sasha was able to hear ‘you think it would be complete madness to open up to someone who you think might turn out to be abusive’. From there, it became possible to interpret Sasha’s deep anxieties about her therapist’s partnerships with other colleagues and her need to create an alternative ‘underground’ base to defend herself against the corrupt power she saw embodied by the therapist and the institution in tandem. About four months into treatment, there was a crisis, and Sasha reacted sharply to the progress she had begun to make. She refused her sessions, was disruptive in the community and became suicidal. Some staff felt she should be discharged and that the treatment might be making her unwell. However, various factors enabled her to come through this and she began to show more resilience and renewed commitment to the treatment. In her sessions, she began to describe her conflicts around receiving help. She was terrified by how she could simultaneously experience an overpowering need for the person offering help together with violent hatred towards that person. Her therapist articulated these conflicting impulses:
Final thoughts The analysis of the transference relationship with the therapist is a cornerstone of psychoanalytic work. In the Cassel model, which I describe as ‘applied psychoanalysis’, it is the multiplicity of transferences to every aspect of the institution that are worked with, not just those to the individual therapist. For very disturbed patients with a personality disorder, defences such as splitting and projection operate at a level that prevents growth and development. An institutional approach that observes, contains and interprets these processes allows many to make substantial shifts in their capacity to lead healthier lives.
References Bell D (1997). ‘Inpatient psychotherapy: the art of the impossible’. Psychoanalytic Psychotherapy, 11: 3-18. Main T (1989). The ailment and other psychoanalytic essays [ed Johns]. London: Free Association Books. Skogstad W (2003). ‘Internal and external reality in in-patient psychotherapy: working with severely disturbed patients at the Cassel Hospital’. Psychoanalytic Psychotherapy, 17: 97-118.
Schema therapy: healing from the core Diana Bogner explains how schema therapy offers a framework to help both therapists and patients go beyond symptom reduction and crisis management, develop a better understanding of the problem, and build unity and collaboration.
his article will briefly outline the schema therapy model, with its focus on schemas, coping styles and modes, and give an overview of how the different techniques are used in the treatment of personality disorder. A case vignette is drawn upon to make more explicit to the reader how this model can be applied in clinical practice. The vignette highlights elements of the treatment rather than providing a full account of the therapeutic work undertaken.
Dr Diana Bogner is the lead clinical psychologist in an inner London NHS treatment and recovery team, where she is also part of a multidisciplinary team specialising in working with personality disorders and complex trauma. She is an advanced accredited schema therapist, supervisor and trainer, as well as an accredited CBT therapist. Diana is passionate about working with personality disorders and she has found schema therapy an invaluable model and framework to engage effectively with individuals who have been scarred by early interpersonal experiences. She notes how her patients have repeatedly commented on how it has helped them make sense of their difficulties, change longstanding negative life patterns, and live more fulfilling lives.
Overview of schema therapy Schema therapy is an integrative therapy that has been developed over the past 25 years to help individuals with longstanding, chronic and severe problem patterns. Developments in cognitive behaviour therapy (CBT) and other psychotherapies such as gestalt therapy (Perls, 1973) and attachment theory (Bowlby, 1979) have directly influenced the theories and techniques of schema therapy. It thus offers an innovative approach to the treatment of personality disorders. Schema therapy is in the NICE Guidelines on Borderline Personality Disorder and there is growing empirical evidence that this form of treatment is highly effective (GiesenBloo et al, 2006). For a comprehensive overview of this research literature, as well as developments in theory, diagnosis, treatment and implementation of schema therapy, please see the Wiley-Blackwell Handbook of Schema Therapy (van Vreeswijk et al, 2012).
Case vignette – Sam Sam was a woman in her thirties who had a diagnosis of emotionally unstable personality disorder. She was seen in a secondary care community mental health service and previously received counselling as well as psychoanalytic psychotherapy. She was referred by her psychiatrist for schema therapy because she continued to feel overwhelmed by her emotions and struggled to function in all areas of her life. At the start of therapy, several life patterns were identified with Sam: general avoidance of activities, thoughts and feelings to the point of dissociating frequently or feeling numb; impulsive and self-destructive behaviours such as cutting herself; self-
Schemas comprise memories, bodily sensations, emotions and cognitions that originate in childhood and are elaborated through a person’s lifetime neglect; self-hatred; social isolation; ending relationships.
Early maladaptive schemas In schema therapy, early childhood experiences are understood to be memorised in our implicit and explicit memory by way of schemas. Schemas are comprised of memories, bodily sensations, emotions and cognitions that originate in childhood and are elaborated through a person’s lifetime. Healthy schemas develop when the core emotional needs of a child are met: safety, connection to others, autonomy, self-appreciation, selfexpression, and realistic limits. Maladaptive schemas are thought to develop as a result of the interaction between factors such as the temperament of the child, the parenting style of the parents, and any significant cumulative negative experiences, including trauma. Schemas function as filters through which the ‘self’ orders, interprets and predicts the world. This is why schemas are maintained and perpetuated over a person’s lifetime. Sam’s upbringing was traumatic and characterised by sexual and emotional abuse and neglect. Her parents were emotionally cold, aggressive, punishing and sadistic. Her childhood lacked safety and protection, and her emotional needs for affection, love and caring when growing up were frustrated. Sam expected that others would not understand her and care for her (emotional deprivation schema), that they would reject and abandon her (abandonment/rejection schema), or even mistreat her again and take advantage of her (mistrust/abuse schema). She also believed that she was deeply flawed and
feature article worthless (defectiveness schema). The next step in her treatment was exploring how these schemas linked to her life patterns. This was achieved by mapping out the different sides of her, her ‘schema modes’.
Modes The development of modes in schema therapy is based on the concept that the self is not a unity but functionally divided into parts that can be in conflict with each other. When maladaptive schemas are activated, intense states occur, described in schema therapy as ‘modes’. Modes are conceptualised as moment-to-moment emotional states and coping responses, triggered by life situations the person is oversensitive to. Patients with personality disorders can mode-flip frequently and suddenly in sessions, which is the reason why some therapists can find them challenging to work with. Their modes have also not been fully integrated; a mode may function as a part of the self that is cut off, to some degree, from other aspects of the self. This explains why emotional detachment and dissociation are prevalent features of this disorder. There are essentially four main categories of modes in schema therapy: innate child modes, maladaptive coping modes, dysfunctional parent modes, and the healthy adult mode.
Child modes Child modes involve the innate reactions a child has, and are defined by intense feelings such as fear, helplessness or rage. Sam often felt like a lost, lonely, despairing, frightened, helpless, abandoned and abused child in her adult life. We called this side ‘Little Sam’. This side had a lot of unmet emotional needs and craved adult comforting and nurturing. There was also a side that was angry with others and how she was treated. We called this side ‘Furious Sam’. Furious Sam was easily worked up and wanted to stand up for herself when she felt wronged or unfairly treated.
Maladaptive coping modes Maladaptive coping modes represent the child’s attempt to adapt to living with unmet emotional needs in a harmful environment. While these ways of coping may well have been adaptive in childhood, they are likely to be maladaptive and self-defeating in the wider adult world. For example, a typical maladaptive coping mode in borderline personality disorder
(BPD) is emotional detachment. In schema therapy, this mode is called the ‘detached protector’ mode because it protects the self from further emotional pain through various forms of avoidance and escape (eg social withdrawal, sleeping, substance abuse, dissociation, suicide attempts). Sam called this side ‘The Wall’ because it helped her survive traumatic childhood years through dissociating and detaching from reality. However, in adulthood, it interfered with her ability to feel and connect with others.
Dysfunctional parent modes Dysfunctional parent modes are the internalised messages of parents and other caregivers from one’s early life. In these modes, one often takes on the voice of the parent or other adult in one’s self-talk – thinking, feeling and acting as the adult did towards oneself when one was a child. In schema therapy, this mode is thus called the punitive or demanding/critical parent. People with BPD can often have a harsh and critical parent mode. Sam called this side ‘The Bully’. She frequently cut in this mode because she believed she was bad and deserved to be punished.
Healthy adult modes The healthy adult mode is the healthy, adult part of the self. Every patient has a healthy adult and the aim of the schema therapy is to gradually build and strengthen this mode. At the beginning of therapy, it is the therapist who models this healthy side in interactions with the patient. The goal is that the patient takes over this role from the therapist over time so that by the end of therapy the patient is better equipped to meet their core emotional needs and shift out of unhealthy modes into more healthy ways of functioning.
Core therapeutic techniques Formulation in schema therapy: the mode map. Over the course of therapy, the patient and therapist jointly work on a personalised mode model based on the information obtained from ongoing assessment. This mode map then forms the basis of sessions going forward to help with awareness work and treatment planning. On the opposite page is an abbreviated version of Sam’s mode map.
The therapeutic relationship – limited reparenting and empathic confrontation One element of the therapeutic relationship in schema therapy is limited re-parenting. This can be understood as providing clients, within the therapeutic relationship, with a different emotional experience to help them change their underlying schemas and modes. The therapist goes into the therapy relationship as if she or he were a parent figure to the patient, modelling appropriate parental behaviours and reactions that the patient missed out in their own development. This is often done through imagery or chairwork exercises (see below). However, there is also recognition in schema therapy that the therapy relationship must serve as a source of change, where the patient’s dysfunctional behaviours must be challenged and addressed; just as it is imperative in good parenting that clear limits are set. The challenge for the therapist is to continually find a balance between confronting while conveying empathy for the pain the patient feels, hence the term ‘empathic confrontation’ (see below).
Experiential techniques – chairwork and imagery Experiential techniques focus on experiencing and expressing emotions that are linked to past situations that have led to the development or maintenance of schemas and modes. Research has shown that we can repair some of the damage done by difficult early attachment experiences and ‘unlearn’ old habits (Siegel, 2012). Therapy techniques, like imagery or chairwork, can create new connections and pathways in the brain which enable patients to regulate their emotions and self-soothe. Imagery is used in different ways in schema therapy. At the beginning of therapy, imagery can be used to help patients make a connection with current schemas/modes and the link to events from the past. In later sessions, imagery rescripting is used to help with the emotional processing of traumatic events. In imagery sessions with Sam, the therapist stepped into the image to help her actively change the situation. For example, Little Sam was nurtured and protected, Furious Sam allowed to vent about the violation of her rights, while The Bully was fought and neutralised. Experiencing rewritten memories of having a loving, protective person present (the therapist in imagery acting as a ‘Good Parent’ or ‘Healthy Adult’) slowly over time helped
feature article There is recognition in schema therapy that the therapy relationship must serve as a source of change, where the patient’s dysfunctional behaviours must be challenged and addressed Sam to change her relationship with herself. Being more aware of her inner child and positively parenting Little Sam helped her self-soothe and become more empathic and compassionate towards herself.
different chairs. It is often easier for therapists to challenge maladaptive modes in this way, as patients typically feel less threatened when they are not confronted directly.
An effective way of confronting patients with the consequences of their behaviour, activating their schemas/modes or creating more awareness of their modes, is through chair dialogues. This technique has its origins in gestalt therapy and has been further developed by Kellogg (2014). In chairwork, the different modes or sides of the patient are physically placed onto
In early sessions, Sam was often in Furious Sam mode, angrily ranting about past and present injustices, which made it difficult for the therapist to speak and intervene. As a result, Sam became increasingly dysregulated in sessions and no therapeutic work could take place. This side was empathically confronted by the therapist in a chairwork exercise where Furious Sam
was put on an empty chair: ‘I understand, Furious Sam, that you are angry and that you had a lot to be angry about growing up. How Little Sam was treated was wrong and I know she is hurting. I know you want to protect her from being hurt again. I want to help Little Sam feel better but you keep me away from her with your anger’. Then a discussion with Sam ensued on her experience of this mode and how it gets in the way of therapy and connecting with others. Setting this limit allowed the therapist to focus on Little Sam and her emotional needs. It was agreed with Sam that the therapist would intervene in future sessions to set limits to this mode, which helped her over time be less angry and more in control.
Conclusion Schema therapy offers a particular way of working, which sits alongside other models of therapeutic practice that offer
Abbreviated version of Sam's mode map
My healthy adult Comes to therapy
Punative parent The Bully 'You’re a bad person!' 'You deserve to be punished' 'Everything that goes wrong is your fault' 'You’re fat and ugly'
My ways of coping The Detached Protector
Child modes Little Sam Fears rejection and abandonment Feels defective and like a failure Feels let down and not understood Feels hopeless and helpless
The Wall Stays in bed Thinks of suicide Drinks Feels numb Dissociates
Furious Sam Has angry outbursts when feeling ignored or wronged
feature article patients with a personality disorder the possibility of positive change in their emotional lives and relationships with others. The mode model helps both therapists and patients develop a better understanding of the problem and build unity and collaboration. Therapists using schema therapy can find working with people with complex presentations and personality disorders enjoyable and stimulating. It gives them a framework, unlike in cognitive therapy, which goes beyond symptom reduction and crisis management and instead explores, in a particular and structured way, what implicitly drives patterns on a deeper psychological level. However, we also need to be mindful that schema therapists are not immune to encountering the challenges faced when working with this population, such as difficulties with engagement, therapeutic ruptures and therapy drop-out. Schema therapy is an intensive therapy that requires patients to look deeper within themselves and be curious about what drives their feelings and behaviours and where these originate from. There are patients who are not ready to work in this way, as confronting their inner lives may be too challenging or disturbing for them. These patients would do better with therapies that focus on skills acquisition, non-verbal exploration of their difficulties, or psychosocial interventions.
References Arntz A and Van Genderen H (2009). Schema therapy for borderline personality disorder. Oxford: Wiley-Blackwell.
Treating personality disorders: intensive short-
term dynamic psychotherapy
Kingsley Norton explains the principles and clinical application of ISTDP, which aims to enable those with personality disorders to access and release their repressed or avoided emotions.
ntensive short-term dynamic psychotherapy (ISTDP) was developed by Habib Davanloo (1980) for treating non-psychotic patients, suffering from ‘neurotic’ symptoms, stemming from his work with bereavement and trauma victims under Erich Lindemann. The latter had discovered that naturally occurring crises could accelerate progress in psychodynamic psychotherapy, since survivor victims’ unusually high anxiety levels rendered their defensive systems more amenable to psychological interventions.
Davanloo claimed lasting benefit for patients who experienced complex feelings, previously buried in their unconscious, towards their early attachment figures or significant others with whom they had had neglectful or abusive relationships, and who had insight into their unconscious
Bowlby J (1979). The making and breaking of affectional bonds. London: Tavistock. Giesen-Bloo J, Van Dyck R, Spinhoven P et al (2006). ‘Outpatient psychotherapy for borderline personality disorder: randomised controlled trial of schema-focused therapy vs transference-focused psychotherapy’. Archives of General Psychiatry, 63: 649-658. Kellogg S (2014). Transformational chairwork. Rowman & Littlefield. Perls FS (1973). The gestalt approach and eyewitness to therapy. New York: Bantam Books. Siegel DJ (2012). The developing mind (2nd edition). New York: Guilford Press. Van Vreeswijk M, Broersen J and Nadort M (2012). The Wiley-Blackwell handbook of schema therapy. Oxford: Wiley-Blackwell. Young JE, Klosko JS and Weishaar ME (2003). Schema therapy: a practitioner’s guide. New York: Guilford Press.
Dr Kingsley Norton is a Jungian analyst and an NHS consultant medical psychotherapist working in South West London and at St George’s Mental Health NHS Trust. He has specialised in working with people with personality disorder. He was formerly clinical director of the Henderson Hospital, a democratic therapeutic community. He has subsequently worked in outpatient and inpatient settings and at low and medium levels of security.
The aim is to turn (conscious) ego against its (unconscious) defensive operations defences that kept such feelings at bay but also served to limit emotional closeness with others (Davanloo, 1990). Thus ISTDP conceptualises psychopathology as the failed integration of emotions, cognitions and behaviours (Solbakken et al, 2011). It emphasises the mobilisation of denied, repressed or otherwise avoided emotions deriving from seriously troubled earlier relationships, which have affected personality development (Solbakken and Abbass, 2014). This article discusses relevant aspects of ISTDP’s evidence base and clinical application of the method, which benefits from later modifications, making it relevant to a wide range of personality disorders (Malan and Coughlin Della Selva, 2006; Ten Have-de Labije and Neborsky, 2011; Frederickson, 2013). The three-year training is demanding, involving didactic sessions on theory, coupled with clinical supervision, which utilises role play and extensive use of trainers’ and trainees’ videotaped sessions.
Evidence base A systematic review of ISTDP outcome research has revealed a promising evidence base (Abbass et al, 2012). Identifying 21 studies, it reported beneficial effects on patients’ mood, anxiety, somatic and personality disorders. Meta-analysis of 13 studies found ISTDP significantly more
efficacious than control conditions, with many gains maintained at follow-up. Eight studies suggested ISTDP was cost effective. This research, which represents the highest test of outcome results’ validity, also called for further targeted research, including into the treatment of personality disorder. Subsequently, an evaluation of an eightweek intensive residential treatment programme based on ISTDP principles has demonstrated pervasive and significant improvements on both DSM Axis I (symptoms) and Axis II (personality disorder) variables. These were maintained or further improved during follow-up. Fourteen months after the end of treatment, 64 per cent had recovered in terms of their personality disorder (Solbakken and Abbass, 2016). These outcome data were analysed in relation to diagnosis, using DSM personality disorder clusters. For all three clusters, clinical improvements were substantial, statistically significant and stable at 14 months’ follow-up. The study suggests that ISTDP can be applied to all subcategories of personality disorder. This research derives from an open setting, so would
not have included forensic cases or those compulsorily detained. The approach may not be appropriate for patients who acutely pose very serious risks to themselves or others.
ISTDP methods Before embarking on ISTDP, the patient undergoes an assessment (usually three hours long), to be introduced to different aspects of the therapy. Its agenda includes obtaining the patient’s consent for sessions to be videotaped for supervisory purposes. During this first meeting, the therapist offers any necessary assistance to the patient as part of formulating their presenting problems in terms of an owned psychological or interpersonal difficulty, which entails describing how their problem is manifest, this being prerequisite for their connecting emotionally to it. As the therapist invites the patient to share their emotional response, the latter’s pathway of anxiety response is revealed (see below). Repeating this process of eliciting the patient’s current emotional response in relation to their own story enables the therapist to assess the patient’s ability to identify, label and express their emotions and observe their level of anxiety.
Throughout this initial session, the therapist is relatively transparent, explaining the rationale for ISTDP and sharing their findings about the patient’s ability or difficulty to be in touch with and name their emotional state. As evidence that the patient is grasping the method and learning self-observation skills, they receive praise from the therapist. In this first meeting, the therapist’s close attention to the patient’s emotional state, openness to explanation of the therapeutic process and contingent validation lay the foundation for a firm therapeutic alliance. With this psychoeducational support from the therapist, patients who can identify a psychological focus and connect with it emotionally (ie not simply display anxiety) are offered therapy. Greater emotional literacy and openness (‘low-resistance’ cases) correlate with speedier therapeutic outcomes. Research suggests that this assessment process, sometimes referred to as ‘trial therapy’, can of itself lead to significant symptom reduction (Abbass et al, 2009). A completed course of therapy ranges between one to 100 (average 20) sessions depending on the complexity of the case. Patients with more
feature article complex and deep-rooted difficulties who experience symptoms (such as deliberate self-harming) more as solutions than problems, which is true of many suffering from personality disorder, will tend to need 40 or more sessions. During the assessment, those unable to constrain their impulses to destructive action (for example, displaying intimidating or threatening behaviour during the session) and not able to reflect on any such acting out are not amenable to the ISTDP method.
Treatment method Davanloo envisaged opposing tendencies in patients: a positive emotional investment in their therapist, the ‘unconscious therapeutic alliance’, but also a defensive ‘resistance’ to psychological change, albeit consciously desired (Davanloo, 1990). Thus the task of therapy is mobilising the alliance, so that its power is available to overcome the patient’s resistance, which is also weakened by insight. This is achieved through a structured approach (‘central dynamic sequence’), incorporating: 1 Enquiry into the patient’s symptoms 2 Invitation to experience emotion connected to ‘symptomatic’ situations 3 Identification of defences blocking such direct emotional expression 4 Evident expression of complex transference feelings due to therapist’s persistence (with steps 2 and 3) 5 ‘Head-on collision’ (see below), with the patient’s defensive resistance being expressed in the transference
6 Breakthrough of complex transference feelings, with derepression of feelings and memories towards significant others from the patient’s past 7 Unlocking the unconscious and consolidation of insights obtained in the process. (Malan and Coughlin Della Selva, 2006) ISTDP emphasises the need to differentiate between the patient’s emotions and their anxiety. From observing his own videotaped sessions with patients, Davanloo (2000) inferred that there were different discharge channels along which anxiety seemed to flow. For him, these signify the patient’s current capacity to experience intense emotion (their ‘ego capacity’), which directs the therapist’s choice of subsequent intervention. It differentiates between patients who can tolerate pressure to experience intense emotion from those who require supportive interventions before being able to do so. Patients who show striated (voluntary) musculature are aware of their anxiety and its triggers and tolerate a strong emotional surge, referred to as a welldeveloped ego capacity (Malan et al, 2006). With less capacity, the patient’s anxiety is expressed (‘channelled’) via smooth muscle, characterised by a range of psychosomatic effects or by signs of cognitive-perceptual disruptions (see table 1). This latter state is characteristic of many with personality disorder, who are often unaware of their anxiety or emotions, at least until they become intense and overwhelming, their reflective ability being lost in the process.
Table 1: Channels of anxiety (Malan and Coughlin Della Selva, 2006)
Channels of anxiety
Symptoms and signs
Hand clenching Sighing respiration Tension in legs, arms, shoulders, neck and head
Micturition: urgency or frequency Gastro-intestinal: butterflies, pain, diarrhoea Respiration: bronchiolar constriction (asthma)
Drifting, confusion Dissociation Visual: blurring or tunnel vision Auditory: deafness, tinnitus, hallucination
Patients dealing with anxiety via their smooth muscle channel or being cognitively disrupted (under pressure to experience emotions) require psychological support. The therapist thus administers anxiety reduction techniques (eg deep breathing) and/or reorientation of the patient (recapitulating what has just occurred within their interaction). These supportive interventions, which equip the patient with the self-observation skills needed for progressing to the deeper work on their defences, also serve to strengthen the therapeutic alliance. For patients with personality disorder, supportive ‘ego restructuring’ work may be prominent for many months. Only when the therapist observes their capacity to sustain the striated muscle channel of anxiety are they exposed to the therapist’s pressure to experience affect. The patient’s defensive structure is thus afforded utmost respect, albeit recognised as a major obstacle to adaptive change. The therapist, alone and in supervision, will review videotaped sessions to check for any evidence of anxiety channels, expressed emotions or defensive blocks to expression that may have been missed or misidentified during the sessions. In ISTDP the therapist identifies and names the patient’s habitual defences against anxiety, clarifies their function and discusses the negative impact of their continuing deployment, thereby increasing the patient’s insight and emphasising collaborative working. The aim is to turn (conscious) ego against its (unconscious) defensive operations. Importantly, the therapist is experienced as friend to the
Table 2: Defences typically encountered in ISTDP (Frederickson, 2013)
Intellectualisation Rationalisation Minimisation
Splitting Denial Projection Somatisation Acting out
Vagueness Sarcasm Changing topics abruptly Arguing
feature article patient’s ego (ie their conscious desire to be rid of their psychological difficulties) but enemy to their defences. Defences are conceived as operating intrapsychically and interpersonally. The therapist’s naming of a defence increases the patient’s intrapsychic conflict; hence their anxiety rises. When the latter is flowing in the striated muscle channel (eg signalled by sighing respiration), the patient is judged able to experience previously repressed or denied feelings. Thus the therapist applies increasing pressure to experience the emotion cognitively through their bodily sensations, and with recognition of the relevant impulse to discharge. Strong (oft-repeated) exhortation, peppered with encouragement, is used to remind the patient of the negative consequences of maintaining defences; that is, not gaining access to buried feelings. Based on a solid therapeutic alliance, the therapist now becomes the object of the patient’s powerful (unconscious transference) emotions. Usually, the first intense feeling associated with this development is anger. With personality disorder patients, this is evidenced by a powerful negative perception of the therapist (‘crystallisation of the resistance’), to which the therapist must respond by reiterating and emphasising the sabotaging nature of the patient’s resistance, explaining the negative consequences for the patient’s wellbeing of their not making requisite psychological changes. The therapist reminds the patient that their active contribution is vital for success. The therapeutic aim at this juncture is not to enter a debate but to increase the patient’s intrapsychic conflict so that buried emotions surface. Thus the therapist may communicate the limit of their own therapeutic skills in exhorting the patient to join them in collaborating as fully as they possibly can. Ideally, the patient’s wish to make psychological changes wins out. The successful navigation through this stage of therapy reflects the therapist’s earlier psychoeducational work and alliancebuilding interventions. Although Davanloo’s method borrows Freudian concepts, there is no interpretation of the patient’s transference reaction.
defensiveness, resulting in the unlocking of the patient’s unconscious. The affective power and content, previously directed at the therapist, is reconnected with the patient’s attachment and significant figures. This crossover phase can be dramatic, for example when the patient reports visualising the therapist’s face but with the eyes of the past and seeing the abusive significant person. Reaching this stage in therapy, the therapist takes on the role of sympathetic guide, leading the patient through a modified bereavement process; for example, their sense that their murderous thoughts, feelings and impulses actually did kill their neglectful or abusive caregiver. Initial anger gives way to profound sadness, intermingled with guilt. During this consolidating stage (when the patient’s unconscious resistance is at a low ebb), important historical information emerges, usually without the therapist’s prompting, permitting both to work on creating a more accurate and complete emotionconnecting narrative than existed hitherto. This represents the integration of emotions, cognitions and behaviour, which is the therapeutic objective. Words alone do not do justice to this stage of the patient’s therapeutic journey, hence the value of videotaped therapy sessions for training and other educational purposes.
Conclusions Patients with personality disorder require many return encounters with their unlocked unconscious contents. These become easier with repetition due to the relief afforded. In addition to the insight gained into their psychological functioning, the validating responses of the therapist (as the patient learns to attend, more compassionately, to their internal world) enhance self-esteem. Overall, the effect is to loosen the grip of learned self-defeating and self-destructive coping strategies. Originally solely an individual therapy, ISTDP principles have been incorporated into treatment programmes in residential psychiatric settings, opening the way for more people with complex and severe disturbance to benefit from ISTDP.
References Abbass A, Town JM and Driessen E (2012). ‘Intensive short-term dynamic psychotherapy: a systematic review and meta-analysis of outcome research’. Harvard Review of Psychiatry, 20(2): 97-108. Abbass A, Sheldon A, Gyra A and Kalpin A (2008). ‘Intensive short-term dynamic psychotherapy for DSM-IV personality disorders’. Journal of Nervous and Mental Disease, 196(3): 211-216. Abbass A, Joffres MR and Ogrodniczuk JS (2009). ‘A naturalistic study of intensive short-term dynamic psychotherapy trial therapy’. Brief Treatment and Crisis Intervention, 8(2): 164-170. Abbass A, Town J and Driessen E (2011). ‘The efficacy of short-term dynamic psychotherapy for depressive disorders with comorbid personality disorder’. Psychiatry, 74(1): 58-71. Cornelissen K and Verheul R (2002). ‘Treatment outcome of residential treatment with ISTDP’. Short Term Dynamic Psychotherapy, 6:14-23. Davanloo, H. (1980) Short-Term Dynamic Psychotherapy, New York: Aronson. Davanloo, H. (1990) Unlocking the Unconscious. New York: Wiley. Davanloo, H. (2000) Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo. Chichester: Wiley. Frederickson, J (2013) Co-creating Change: Effective Dynamic Therapy Techniques. Seven Leaves Press. Freud, S. (1925) Inhibitions, Symptoms and Anxiety. Standard Edition, 20, pp. 87-156. Malan, D. H. (1979) Individual Psychotherapy and the Science of Psychodynamics. London: Butterworth (2nd edition). Malan, D. H. and Coughlin Della Selva, P. (2006) Lives Transformed: a Revolutionary Method of Dynamic Psychotherapy. London: Karnac. Solbakken, O. A., Hansen, R. S., & Monsen, J. T. (2011). Affect integration and reflective Solbakken, O. A., Hansen, R. S., & Monsen, J. T. (2011). Affect integration and reflective function: clarification of central conceptual issues. Psychotherapy Research, 21(4), 482-496. Solbakken, O. A. & Abbass, A. (2014). Implementation of an intensive short-term dynamic treatment program for patients with treatment-resistant disorders in residential care. BMC Psychiatry 2014; 14: 12. Solbakken, O. A., & Abbass, A. (2015). Intensive short-term dynamic residential treatment program for patients with treatment-resistant disorders. Journal of affective disorders, 181, 67-77. Solbakken, O. A. and Abbass, A. (2016) Symptomand personality disorder changes in intensive short-term dynamic residential treatment for treatment-resistant anxiety and depressive disorders. Acta Neuropsychiatrica, Volume 28, Issue 5, pp. 257-271. Ten Have-de Labije, J. and Neborsky, R.J. (2011) Roadmap to the Unconscious: Mastering Intensive Short-Term Dynamic Psychotherapy. London: Karnac. Vaillant, L. M. (1997) Changing Character: ShortTerm Anxiety-Regulating Psychotherapy for Restructuring Defenses, Affects, and Attachment. New York: Basic Books.
When the buried emotions start to flow through the conscious ego channels, the anxiety level reduces, as does
Mentalization-based therapy and borderline personality disorder: integrating group and individual interventions Monica Doran and Tim Wright define the concepts of mentalization and borderline personality disorder. Using their experience as group therapists working in a psychotherapy department in the NHS, they illustrate how integrating group and individual mentalization-based therapy works to address characteristics of this diagnosis. What is mentalizing? To ‘mentalize’ is to understand our self and others in terms of states of mind. At a certain level this understanding can be implicit but we frequently have recourse to explicit mentalizing: that is, using curiosity, reflection and dialogue rather than making assumptions to understand what motivates people’s behaviour. Mentalizing others and mentalizing ourselves are linked and both imply a good enough ability to read interpersonal cues and to notice and process our emotions and thoughts, rather than somatising, suppressing or acting these out. The concept has its roots in French psychoanalysis but has been developed by Bateman and Fonagy (2006), drawing also on evolutionary science, neuroscience, attachment theory and developmental
Monica Doran is a UKCP-registered psychotherapist, a member of the Institute of Group Analysis, and has worked for many years in the NHS in different mental health trusts. In her current role, she specialises in the treatment of personality disorders as a clinician, and provides training and consultation to staff.
psychology (Freeman, 2016). The psychosocial cognition conferred by mentalizing is seen to have given humans an evolutionary advantage, supporting collaboration and the development of culture. For mentalizing ability to be optimised however, there must be a basis of secure childhood attachment, where the benign attention of caregivers has supported a growing, consistent sense of self, connected to yet distinct from others, and a healthy interest in the outside world. Without this, the ‘epistemic trust’ necessary for psychosocial learning breaks down (Fonagy, 2015) and mental health problems are likely to ensue.
Borderline personality disorder The terms borderline personality disorder (BPD) and emotionally unstable personality disorder (EUPD) refer to the same condition:
Tim Wright has practised as an art therapist since 1996 and for the last 12 years has been head of an NHS arts therapies service. As well as developing mentalization-based interventions in this service, he co-runs treatment groups in an MBT programme for people with a personality disorder.
the former being employed in the DSM, the latter in the ICD. This condition is strongly correlated with insecure attachment in childhood, and also often associated with childhood neglect and abuse (Bateman and Fonagy, 2010). As a consequence, the ability of individuals with this diagnosis to mentalize is generally fragile and easily disrupted. While people with BPD may be exquisitely sensitive to interpersonal signals, they often misinterpret these. This, along with an unstable sense of self and poor ability to regulate emotional arousal and associated thoughts, make interpersonal situations potentially traumatic. All too often, such situations can ‘trigger’ overwhelming affect that overrides the individual’s ability to mentalize and may lead them to resort to destructive behaviour in a maladaptive attempt to re-establish equilibrium. These attachment issues and severe interpersonal difficulties have important implications for how therapy should be conducted if it is to be helpful rather than damaging for the person with borderline personality disorder. It has implications that mentalization-based therapy (MBT) was developed to address.
Mentalization-based therapy: a description of distinctive aspects This MBT programme has a number of component parts. A ten-week psychoeducation programme prepares participants
for the treatment programme by teaching mentalizing principles, attachment theory, how we develop our personalities, and how the treatment programme addresses difficulties associated with the diagnosis. An individual review follows in order to develop a formulation of how their particular difficulties can be addressed in the treatment. The treatment period is 18 months, consisting of a weekly MBT group (1.5 hours) and weekly MBT individual therapy (50 mins) with a therapist who is different from the group therapist. It is made explicit to patients from the start that the group doesn’t exist without the individual therapy and vice versa. Patients meet with group therapists and their individual therapist periodically for therapeutic reviews. Most participants struggle socially, are isolated and yet find themselves craving the company of others, so it is not surprising that the group is more challenging for them than their individual sessions and that splitting may arise. Recognising and exploring this helps to develop participants’ awareness of their responses to different interpersonal situations. All group and individual therapists attend a coordinators’ meeting once per week for an hour to exchange thoughts and experiences about their contact with the participants. This is to support each other and to prevent polarisations being acted out in the team.
There is also monthly supervision with an external supervisor.
How does an MBT treatment differ from a traditional psychodynamic treatment? Since we both have analytic trainings, this is an ongoing question for us. A key difference is that the MBT group is part of a larger treatment system that includes individual MBT sessions and individual therapeutic reviews. Treatment focuses on immediate interpersonal and affective issues and the therapists, both individual and group, adopt a much more active style in aid of this. Group analytic concepts such as resonance, mirroring, group-as-a-whole and matrix (Foulkes, 1964) are used to further develop the richness of the group communication. However, rather than different levels of communication that group analysts strive for, which include intrapsychic and primordial (Foulkes 1964), the focus of the MBT group is to further the mentalizing capacity of the group, that is, individuals’ awareness of their feelings and ability to consider the minds of others. In an MBT group, we actively help individuals to moderate levels of arousal, so they maintain the capacity to think. Transference, countertransference and parallel processes are not at the forefront of the MBT group, but when they are observed as blocking communication they are highlighted and used as material for active mentalizing.
The focus lies on how the group members are left understanding their thoughts, feelings and motivations. Here is an example: A very passive member of the group, Georgina, rarely speaks out unless encouraged either by us or by group members. Even if asked to comment on the group, her response is often to speak about her ‘problems’ and not comment on her experience of being in the group. Her pattern of relating with the group is such that as soon as she speaks, other group members interrupt with advice, often directing her to take action and often powerfully expressed. On one occasion, we said we thought the group mirrored Georgina’s description of family dynamics in which she frequently finds herself, overwhelmed with conflicting advice and instructions from other members of the family. In an analytic group, the intervention would end there, allowing the resonance from the intervention to be explored freely within the group as a whole and the individual members. The MBT group culture is different. MBT therapists are not group ‘conductors’ in the Foulkesian sense (Foulkes, 1986). Their role is more active, directing the group to reflect on group events, focus on emotions, thoughts and interpersonal issues, and actively helping these to regulate affect so as to sustain engagement and minimise acting out (Karterud, 2015). This is actively supported,
feature article as it was in Georgina’s case in her individual MBT sessions.
the therapeutic team where to go from here and would be in touch.
Our intervention was significant to both Georgina and to the group. We first asked Georgina if she recognised this dynamic and then how she felt about it. This helped her to express her love of the attention of others and how she seeks it in her quiet way, but equally feels overwhelmed and resents when strong emotions and directions are expressed, as she experienced it in the group. We then turned our attention to the group and commented on the strength of feelings expressed by some. The resulting material related to their identification with Georgina and their own frustrations with their challenging relationships with significant others.
A period of intensive work in the team followed over an eight-week period. During this time Stefan’s attendance of the group was suspended due to his inability to accept that his behaviour needed to be moderated. Stefan’s continued attendance of his individual MBT sessions, as well as reviews with us and his individual therapist, helped to keep him engaged in the programme and to develop a mentalizing dialogue about how to manage such eruptions of anger and how to understand them and their effects on others. In order to support our own mentalizing, and to be able to work with the dynamics among the other members of the group, we used the weekly coordinators meetings and team clinical supervision.
The next vignette shows group sessions, individual sessions and therapeutic reviews working together to re-integrate a member whose aggressive acting out of un-mentalized feelings touched off extreme reactions in other members and a high state of alarm in the group. ‘Stefan’, a middle aged man of Eastern European origin and a group member for several months, arrived one day in a disturbed state of mind, announcing that he’d only come to the group as he’d had a benefits appointment nearby. He made disparaging comments about two other members whose problems he described as ‘tiddly little complaints’, issuing curt and, to our minds, simplistic prescriptions as to what they should do to solve them. These kinds of comments were not new but whereas previously our interventions had helped him to find a less aroused state and a more reflective stance, on this occasion the aggression continued. He interrupted one member, saying he was sick of hearing their ‘constant moaning about nothing’. They walked out, quickly followed by the other members, all expressing exasperation and anger, leaving us alone with him. We spent ten minutes unsuccessfully inviting him to explore the feelings that could be driving his behaviour and reiterating that his manner of addressing the other members of the group had been unacceptable. It was hard work to keep in mind the fact that in several previous group sessions he had in fact shown real ability to explore difficult interpersonal situations and to identify emotions behind his and others’ behaviour: to mentalize. We ended the session early, informing Stefan that we would discuss with
group. Between the reviews and the individual sessions he became significantly less aroused and more able to think about the dynamics between himself and other members, and as a result his group attendance was resumed. When he returned, Stefan was able to say how the members, whose experiences he’d belittled, in fact reminded him of traumatic experiences of his own.
Conclusion We have outlined and illustrated the salient characteristics of mentalization-based therapy and how the combined use of individual and group MBT sessions can be a fruitful way of working with patients with a borderline personality disorder. We have also explored the key differences between an MBT approach and a psychodynamic approach.
All members of the group continued in the programme, attending their individual MBT sessions, and shortly resumed group attendance. However, most felt unsafe as a result of the incident; it resonated with their experiences of abuse and neglect. Several told us that we had not acted decisively enough to contain the attacking behaviour and protect them. We felt this criticism was justified and acknowledged this, as well as exploring the group members’ anger towards us and towards Stefan. Although one member showed empathy for him, there were strong demands from others that Stefan be expelled from the group. We had to contain the anxieties of group members about the possibly destructive effects of him returning in order to resist this demand and promote curiosity about this difficult interpersonal situation. For example, we asked why the group members had walked out rather than speak up. This exploration enabled some modification of the polarised ‘victim/persecutor’ dynamic.
We have explained how people with borderline personality disorder struggle with relationships and illustrated how this MBT treatment programme, by encouraging individuals to use a mentalizing approach, helps them to engage more effectively with others.
In his first review Stefan remained highly aroused and he reiterated his contempt for the other group members and showed no wish to imagine how others might have felt in the face of his verbal attacks. A week later, in the second review, anger and contempt continued but Stefan was able to acknowledge that he wanted help with interpersonal problems. The following two review meetings continued this process, while his individual MBT sessions helped him to locate why he was so triggered in the group. His individual MBT sessions also helped support him to return to the group by exploring how he might explain his behaviour and engage differently with the
Bateman A and Fonagy P (2010). ‘Mentalizationbased treatment for borderline personality disorder’. World Psychiatry, Feb 9(1): 11-15.
The sometimes overwhelming affective responses that group work can provoke in people with borderline personality disorder make this work extremely demanding at times, particularly when all members of the group have this diagnosis. The combination of MBT group and individual sessions, in the context of a healthy team, makes the process tolerable and ultimately fruitful for the majority of participants in this treatment programme, and for us as group and individual therapists.
References Bateman A and Fonagy P (2006). Mentalizationbased treatment for borderline personality disorder. Oxford University Press.
Fonagy P, Lutyen P and Allison E (2011). ‘Epistemic petrification and the restoration of epistemic trust: a new concept of borderline personality disorder and its psychosocial treatment’. Journal of Personality Disorders, 29(5): 575-609. Foulkes SH (1964). Therapeutic group analysis. New York: International Universities Press Foulkes SH (1989). Group analytic psychotherapy, method and principles. Karnac (Books) Ltd. Freeman C (2016). ‘What is mentalizing? An overview’. British Journal of Psychotherapy, 32(2): 189-201. Karterud S (2015) Mentalization-based group therapy (MBT-G). Oxford University Press.
Walking the tightrope:
incorporating the voice of lived experience into a personality disorder service Melanie Anne Ball lived for a year as a client in a therapeutic community for people with severe and complex problems. She was then employed as a peer worker at the centre for three years. Here she reflects on her experiences. Policy: service user involvement in health and social care Policy initiatives to support and develop service user involvement in health and social care services began in the 1980s. Faulkner et al (2013) refer to the considerable body of evidence showing that peer-based roles contribute to hope and
belief in recovery, improving self-esteem, self-management and the physical health of the clients. In a literature review of the application of peer support within mental health services, Repper and Carter (2011) conclude that ‘careful training, supervision and management of all involved are required’.
Melanie Anne Ball is a lived experience practitioner, researcher and lecturer, currently employed as an external training officer at Rethink Mental Illness and lecturing at Canterbury Christ Church University. She has also worked in NHS mental health services, social enterprises and prisons. Mel is a creative writer and theatre-maker at Heart to Heart (www.hearttohearttheatre.com), with work performed all over the country; she was mentioned at the Saroyan/Paul Playwriting Prize for Human Rights 2016. A recent review of her work stated: ‘This is remarkable theatre: intense, shocking and thoroughly absorbing.’
Coming back: ‘who are my peers now?’ In my role as peer worker, I no longer inhabited the role of the client and yet I never felt fully integrated as a member of staff. I had to negotiate working on a flimsy tightrope, between the client and staff groups. The mantra that allowed me to emotionally distance myself from the feelings brought by these experiences, and latterly to analyse some of the memories I had of this time, was: Though at times it felt deeply personal, it wasn’t really about me, but what I represented. It seems to me that one of the major difficulties with my role was the lack of a ‘template’. As a resident, I had depended heavily on role models to understand how
feature article It felt that the therapeutic hangover from my treatment was invading and rendering futile the professional space I needed the therapeutic community ‘worked’, while initially feeling confused and unfamiliar with the approach to treatment. As a peer worker, I had no map to guide me and the repercussions of this played out in a number of ways. At first, this was at the most practical level: aspects of my job description seemed unclear and further clarification proved unavailable. I was uncertain where in the building I should or could work and which staff areas were open to me. Although I was invited to use staff facilities, I was aware that sometimes when I entered a staff space, conversations became hushed or stopped altogether. At first, I found it difficult to comprehend that these silences were anything more than echoes of my past life experiences, punctuated by paranoia. I later realised that my colleagues held conflicting views about confidentiality boundaries yet no explicit discussion had occurred to clarify those boundaries. How ‘to be’ with those who had been involved in my treatment did not faze me at first. I naively presumed that, given time, I would form civil and professional relationships with those who had previously treated me, and any hangover from my life as a resident would slip away. However, over the three years in my role, I experienced a number of confusing and disheartening interactions, and the most frustrating aspect was their context. It appeared that I had ‘misunderstood’ something about my role as a peer worker and how to interact with staff but this had never been explained to me or discussed openly. My supervisor found it difficult to explain these experiences and I was left feeling that some underpinning ‘theory’ must be informing their interactions and responses to me. But what was it? The tightrope had revealed itself.
Finding my place with the residents Similarly, the ‘real work’ with the residents was challenging for some time. Due to a recruitment gap, none of the clients had experienced anyone in the role of peer worker before. As a result, I believe they found it difficult, and perhaps frustrating, to conceptualise my place in the hierarchy
of the organisation. In a parallel process, I think that the anxiety my very existence (or perhaps that of the role) stirred up in the staff team was unconsciously acted out by the resident group. For some time, they routinely trashed the boundaries of the group I ran with barrages of challenging behaviour. Even when reeling from the most difficult groups, I had to keep reminding myself that there was no ill intent most of the time; a process was simply playing out, just as it had when I had been in their place. I was reminded of my own difficulties in making appropriate relationships with staff when I had been in treatment and wondered whether my current colleagues experienced my own attempts to interact with them in the same way: as invasive boundary-pushing questions. The tightrope revealed itself again.
Finding a place, finding a space As more serious issues arose in the resident group, I realised how important it was for me to have a supervisory space to discuss and reflect on these, distance myself and feed them back to rest of the team. A number of attempts were made to provide these kind of discussions, but the space was not structured or protected in a way that gave me confidence that I was not taking up my colleagues’ valuable time. Worse, it sometimes felt that the therapeutic hangover from my treatment was invading and rendering futile the professional space I so needed. As part of my request for supervision, I asked if I could join the staff’s reflective practice group. This was not agreed – the explanation was that I was not a ‘real’ member of staff and that residents were only willing to engage with me on this basis. It was also felt that this would be a violation of the boundaries integral to the service’s theoretical approach. Once again, I felt that my colleagues were saying that they could only conceptualise me as what I represented, rather than who I was. It felt that it was more comfortable for them to see me forever as a patient rather than acknowledge that someone who had
benefited from their treatment might have a place in the world equal to theirs.
A bittersweet goodbye Although some of my experiences were difficult, as the resident group got to know me, I began to greatly enjoy my work. Slowly but surely, members of the team started to show an interest in my role and the work I was doing. Relationships with colleagues began to form, based on a shared passion for the work, and stopped revolving around my past. My colleagues advised me that I seemed invisible because I worked alone in a deserted office, adding to a dominant staff view that I was not part of the team. Tentatively, I moved location and joined some staff structures, which enabled communication to flow more easily between the different therapeutic structures and further integrated me into the team. It seemed I was learning to walk the tightrope. Although these changes made my role and work easier, as time went on, the realisation that there was no route for progression and the mounting frustration with ongoing difficulties drew my time in the role to an end. My feelings about leaving the work I enjoyed so much were mixed until the day I left. As I said my goodbyes, a colleague who had little experience of working with me absent-mindedly used a farewell phrase commonly said to residents when discharged. It jolted me into a bittersweet certainty about my leaving, reminding me that it wasn’t really about me, but what I represented.
Reflections and recommendations Clearly, at times, walking the tightrope I have described was difficult. What I had not expected to see was that it would be equally, if not more, difficult for some of my colleagues to experience me on the tightrope than for me to walk it. Reflecting on my experiences as a peer worker has not negatively affected my belief in the value and efficacy of the treatment model of this service for people with severe and complex problems. However, it does encourage me to put forward a number of recommendations for any therapeutic service that employs peer workers or is considering doing so. Services should carefully consider their theoretical and philosophical position on working alongside this role to ensure a rewarding
feature article and smooth transitional experience for everyone in the team. I would recommend the following: • Reflection on how the theoretical and philosophical framework of the service fits, or might be antagonistic to, the role and place of peer workers in the clinical team • Training for the whole staff team before the person’s induction on the benefits of peer-based roles, including open discussion about their views and support for peer workers in the organisation • Recruitment occurring in pairs, so that the chances of the peer worker being isolated are reduced • Training in peer support/peer-based working provided for the peer worker as a part of their induction process • Provision of clinical and management supervision for the peer worker, embedded into the organisation • ‘Sponsorship’ from another organisation serving the same client group, ideally sharing a theoretical approach that has successfully incorporated peer workers into the team. This is especially important for the peer worker and their supervisor/ line manager. Finally, from my own lived experience, I would reaffirm the importance of shared reflective spaces for peer workers and their colleagues to address and work through the difficulties that can come with the integration of a former client into the staff team. If structures can be provided which encourage discussion and the maintenance of an open culture of curiosity, new relationships have an opportunity to form and mature. Although therapeutic hangovers may linger, these need to be worked with, so that robust and effective staff teams can function, benefiting each other and, most importantly, the clients of the service.
References Faulkner A, et al (2013). National involvement partnership 4PI. Standards for Involvement. Repper J and Carter T (2011). ‘A review of the literature on peer support in mental health services. Journal of Mental Health, 20(4): 392411.
Co-produced psychological education groups: their place in the care and treatment of people with a diagnosis of personality disorder Sally Stamp and Tania Towns reflect on their experiences of co-facilitating psychological education (usually called psychoeducation) groups, arguing that they are a vital intervention for people with a personality disorder. Placed at different points in the continuum of care, these groups are an important therapeutic addition. Origins of psychological education and contemporary practice Psychoeducation has its early roots in providing support for those with a diagnosis of schizophrenia, with a focus on learning about symptoms. These groups then widened their scope and provided information about other mental illnesses in a range of mental health settings. This way of working continues to develop and evolve, providing an educational space to think about and practise social skills, problem-solving and stress management. It is regarded as an intervention in itself and its therapeutic aspects have been developed. Lukens and McFarlan (2004) offer a comprehensive review of psychoeducation, and argue that its underpinning principles are self-help, collaboration between service user and professional, peer support and a holistic view of the individual. In terms of the psychological education groups we have facilitated, the content has been varied but focused on the knowledge and skills that might be helpful to those with a personality disorder. Group members are introduced to the different kinds of recommended treatment modalities such as dialectical behaviour therapy (DBT),
mentalization-based therapy (MBT), schema therapy, the biopsychosocial model, art therapy, and so on. There is also discussion about what it means to have the symptoms of personality disorder and the factors in early life that are likely to have contributed to its development: trauma, abuse and disorganised attachment. Understanding emotions is key, as is thinking about what is meant by our core emotional needs.
Psychological education and personality disorder The NICE guidelines for personality disorders are currently limited to guidelines for people diagnosed with borderline personality disorder and those for people diagnosed with antisocial personality disorders. Both sets of guidelines emphasise the importance of service users having a choice of interventions, while those for borderline personality disorder recommend that service users should be involved in shaping services. The document Meeting the Challenge: Making a Difference states that ‘building trust, confidence and optimism for change can be crucial foundation stones, especially for someone who has had few good experiences of engaging with other people in caring roles, or with professionals’ (DH, 2014: 53). It is argued that specialist
feature article services should not be restrictive and should provide flexibility and choice for the service user with complex needs. There is therefore compelling support for delivering psychological education groups for people with a personality disorder. As we shall argue later, the co-production of these groups also provides concrete evidence that service users with a personality disorder diagnosis can help form and develop services to meet their complex needs. Psychological education groups are part of this flexible approach, enabling service users to develop confidence and trust, and giving them a foundation for engagement in further treatment at a later stage. The Anna Freud Centre MBT training team states that, when preparing for MBT (a NICE-evidenced treatment for those with a borderline personality disorder diagnosis), service users will gain from attending a psychological education group. There can be a tension between delivering an education-focused intervention while knowing that service users are looking towards the next treatment phase. This has meant that some MBT programmes, for
Sally Stamp trained as a group analyst at the Institute of Group Analysis and as a drama therapist at the University of Hertfordshire. She has worked for over 20 years as a clinician in the NHS, in the third sector and in private practice.
Tania Towns is a senior knowledge and understanding framework (KUF) personality disorder trainer and has worked for Emergence Plus, a service user-led organisation. She is also an experienced facilitator of psychological education groups. Sally and Tanya draw on their joint and different experiences of co-producing and facilitating psychological education groups in a mental health trust, both in a psychotherapy department and a recovery college.
example in Norway, do not recommend the psychological education stage (Karterud, 2015). Our experience is that it is a challenge to balance the education and treatment aspects of these groups because they are, in essence, meant to be therapeutic – the balance can tip towards it becoming a therapy group. However, this can be resisted.
The natural fit From our experience of co-producing and facilitating these groups, we suggest that the ‘natural fit’ for psychological education groups is before commencing long-term psychological treatment or psychotherapy. We do not take the view that service users should not be prepared for treatment. We have found that they find information about treatment helpful, both in understanding themselves more fully and to help them make informed decisions about treatment options. Psychological education groups can be offered in a range of settings, such as a recovery college or community mental health team. A recovery college provides service user-led education and training within mental health services (Centre for Mental Health, 2012). The courses are co-written and co-delivered by people with lived experience of mental illness and mental health professionals. Most important, service users can self-refer to these groups without a prior assessment process. In the case of the recovery college, service users were invested in attending and completing the course, enthusiastic to learn rather than passively receive services and willing to apply the learning to themselves and their past experiences. We found that self-agency was highly significant in counterbalancing persistent patterns of engagement and then disengagement from services. In facilitating these groups, in whatever setting, service users report that membership of a group helps to reduce their anxiety in terms of having greater insight into their state of mind and how they might manage distress. The fact that these groups are co-produced and facilitated enables service users to tolerate greater distress arising from the group.
Co-production as a vehicle for facilitation Co-production refers to a broad range of involvement activities where staff and service users enter a collaborative relationship in which ‘working together and
recognising one another’s different skills and experience are equally valuable’ (DH, 2014). Lukens and McFarlan (2004) do not address co-production as a vehicle for facilitation but this concept lies at the heart of our work. We are referring to a co-produced collaboration, where the key feature is that power is shared equally between service users and staff working in an active partnership. Decisions are made together, influence is shared and the aim is for an equal partnership. It is not about control in the sense that an educational programme is led and owned by the service user. This is in contrast to much of the service user involvement that we see in health and social care, which is usually based on consultation where decisionmaking power remains firmly in the hands of professional staff. In our experience, the co-production of these psychological education groups is living evidence of service user skills and experience being valued equally in both the shaping and delivery of services, and gives a powerful message of validation and hope. In practice, the service user facilitator brings their skills, knowledge and experience to ensure that the delivery and content of educational materials are meaningful and effective. The service user facilitator can get alongside members of the group to understand what they might not be able to put into words and know how and when to articulate this. It also gives members of the group the opportunity to see a clinician in a different role – someone who is sharing their knowledge and skills about personality disorder.
The challenges of co-production This way of working does bring its difficulties. On many levels, collaboration is perhaps the most challenging aspect of co-production. There can be resistance from clinical colleagues, depending on their theoretical orientation, particularly from those from a more traditional psychoanalytic approach, where offering psychological education to service users might be considered anti-therapeutic. There is also a danger that the service user facilitator becomes isolated and unsupported unless they are embedded in the organisation, and that they could become a subject of envy for group members. Within the co-facilitating relationship, there can be tensions about traditional hierarchical roles and prejudices – from
feature article individuals can start to apply these in their lives immediately • Empower group participants with a language to understand their difficulties and states of mind • Are accessed by a wider range of service user where there is the possibility of selfreferral, for example, by men.
Conclusion We have argued that psychological education groups are an important part of the treatment and care continuum for people with a diagnosis of personality disorder. They are not a replacement for longer-term psychological treatments; rather, they are a highly valuable addition to the intervention pathway and the options available to both service users and clinicians.
Service users were invested in attending and completing the course, enthusiastic to learn rather than passively receive services clinician to service user facilitator, and vice versa – and these tensions may emerge in response to stress. Conflict about facilitator roles, where there are different views about the sharing of experiences by the service facilitator as an educational tool, can also emerge. Discussion and reflection about ‘oversharing’ or the clinician being pulled back into a more professional and distant role are vital to this work. Supervision and reflective practice groups are therefore essential support structures. They can provide a safe environment in which to speak openly about co-producing work, so that any potential splits in the working education couple are reflected upon and managed.
Evaluation of psychological education groups Attendance at these groups is some indicator of their value to people with a personality disorder diagnosis. Our initial data suggest that, whatever the context, attendance and retention rates are high (between 80 per cent and 100 per cent) and service users choose to join and belong to the group. This may be because the service users attending psychological education groups in a psychotherapy department have been robust enough to have completed the assessment process and are contained within the structure of such departments;
and that, despite not having had a risk assessment, service users in a recovery college have been motivated to self-refer. Attendance data suggest that there is therapeutic and educational value in being part of such a group and that these are an important part of the continuum of treatment. Formalising evaluation and embedding it in the provision of psychological education groups is important and this needs to be developed. From our own qualitative experience, however, we would posit that psychological education groups have a valuable place in the provision of treatment services for those with a personality disorder; for example, they: • Provide an introduction to and preparation for different types of psychological and psychotherapeutic treatment • Enable service users who might not otherwise be considered suitable or ready for treatment to engage with services • Provide tools arming service users to face possible past traumatic experiences in future interventions
Our experience suggests that both coproduced and clinician-led psychological education groups enable the service user to engage in further treatment by gaining a more informed understanding of the treatment options available. They also increase treatment retention rates. We regard the co-produced psychological education group to be more effective because it offers a powerful, positive modelling that may counterbalance the past relationship experiences of many group members. This can challenge internalised notions about self-stigma, especially around the label and diagnosis of personality disorder. It is our hope that in writing this article we have helped raise awareness of the value of psychological education groups and stimulated open discussion among psychotherapists, other clinical practitioners and managers about how they can find their place in the continuum of care and treatment for people with a diagnosis of personality disorder.
References Centre for Mental Health (2012). Recovery colleges. Department of Health (DH) (2004). Meeting the challenge, making a difference. Karterud S (2015). Mentalization-based group therapy (Mbt-G): a thereotical, clinical and research manual. Oxford: OUP. Lukens EP and McFarlane WR (2004). ‘Psychoeducation as evidence-based practice: consideration for practice research and policy’. Brief Treatment and Crisis Intervention, 4(3), autumn.
• Facilitate and provide learning materials within a therapeutic framework so that
The Early Years Parenting Unit (EYPU): an integrated approach to working with parents with personality disorders and their children under five The EYPU at the Anna Freud Centre is a multifamily day unit for parents with personality difficulties and their children on the edge of care. Minna Daum and Nicola Labuschagne describe the unit’s integrated mentalizationbased intervention, which addresses the parents’ psychopathology, the child’s developmental needs and the parent–child relationship. Personality disorder and the intergenerational transmission of abuse and neglect Borderline personality disorder is understood to have its environmental roots in childhood abuse, relational trauma and neglect. From a developmental perspective, children who suffer emotional abuse and neglect tend to develop disorganised attachment patterns and grow into adults who typically experience significant difficulties in their ability to form stable, secure relationships. They also experience difficulty managing their emotions; they are easily overwhelmed by feelings of anxiety, depression and anger, and manage these feelings in maladaptive and destructive ways (deliberate self-harm, suicide attempts, violence and substance abuse). From this perspective, having a baby can be seen as a
maladaptive response to chronic feelings of loneliness, insecurity and low self-esteem. Many of the mothers who attend the EYPU say that they wanted to have a baby in order to ‘have someone to love [them]’, that their babies are the ‘only ones [they] can trust’, and that being a mother is ‘the only good thing [they] can do’. When people with a borderline personality disorder become parents, their preoccupation with their own overwhelming feelings and chaotic interpersonal relationships mean that they typically find it extremely difficult to keep their children consistently in mind as separate psychological beings, or to provide them with safe, predictable, consistent and emotionally sensitive care. The babies of such parents are typically born into chaotic
Minna Daum is a consultant systemic therapist (UKCP registered) at the Anna Freud Centre. She has many years of experience working in the child protection system, assessing and treating families, involving parents with personality disorders. She co-founded the Early Years Parenting Unit (EYPU) in 2011 with Dr Duncan McLean, consultant psychiatrist in psychotherapy. Nicola Labuschagne is a chartered clinical psychologist with long experience of working with highly complex cases, specialising in working with people with personality disorders. Having worked in the NHS for 16 years, she has been Clinical Manager of the EYPU since its inception.
and unpredictable living environments, including domestic violence and drug and alcohol misuse. At an emotional level, they experience mothers who are emotionally labile, subject to frequent angry outbursts or withdrawal into depression, and are preoccupied with their own feelings. This means that their children are subject to chronic relational trauma and emotional neglect, and are likely to suffer lifelong consequences, often including the development of personality difficulties.
Poorly understood Borderline personality disorder is often poorly understood by child safeguarding professionals. As a result, children’s social care (CSC) involvement with these families is usually long-term and characterised by poor parental engagement and a ‘revolving door’ process involving multiple referrals for assessment and treatment to a range of agencies, leading to little or no change (Daum, 2009). Social workers spend a disproportionate amount of time on such cases but remain anxious and bewildered in the face of parental non-engagement and hostility, and a professional network characterised by splitting, paralysis and loss of authority in relation to managing risk to children (McLean and Nathan, 2007; Daum, 2009). Such parents have historically received very little effective intervention from statutory services. Beyond the welldocumented difficulties of engaging such
feature article Social workers remain anxious and bewildered in the face of parental nonengagement and hostility
families, the fragmentary nature of mental health service provision has meant that it has been impossible for parents with small children to receive treatment for their personality disorder because adult mental health services make no provision for the care of small children. The EYPU was set up in 2011 as a response to this problem. It provides a fully integrated ‘one-stop shop’ intervention, integrating adult and children’s mental health via a comprehensive treatment model, which addresses the parent’s personality disorder, the child’s developmental needs and the parent–child relationship. The model is an extension of mentalization-based therapy (MBT; Bateman and Fonagy, 2003). The aim is to enable parents to care for their children safely, and substantially to reduce service use, including primary care, crisis and emergency services. If parents cannot make use of the EYPU to effect change, the aim is to intervene early to place children in alternative care, thereby reducing the risk of long-term harmful parenting and improving life chances.
The EYPU provides long-term (18 months) and intensive (two days a week) mentalization-based treatment to families referred by CSC. Families participate in multifamily activities, parent–child therapy, individual psychotherapy, video feedback of play sessions, and two group psychotherapy sessions per week (one adult-focused and one parenting-focused group). The EYPU is run as a therapeutic community, meaning that isolated families are enabled to develop social networks, to benefit from peer support and to be active participants in their care.
The challenges of working with complex families In mentalization theory, a parent’s capacity to mentalize (to understand both their own and their child’s behaviour in the context of mental states) is a central mechanism in the formation of attachment relationships. A child whose carer is able to keep his/ her mind in mind, and to both contain and respond to their negative emotional states in a timely and more or less accurate way,
will form a secure attachment relationship with their carer. In functional terms, the child is likely to grow up to be able to recognise and regulate their own mental states and to form stable, reciprocal, trusting attachment relationships with others based on an expectation that such relationships will offer security. Conversely, a child whose carer fails to keep him/her in mind as a separate psychological being, and whose responses towards them fluctuate between withdrawal and overwhelming, hostile and intrusive behaviour, will be left feeling chronically unsafe, with little sense of agency and little capacity to recognise or regulate their feeling states. Such children are understood to develop disorganised attachment patterns, characterised by chaotic, impulsive and highly controlling behaviour. When approached by carers or other adults, they fluctuate between clinging and avoidant behaviour, and demonstrate deep mistrust of the adult world. All these behaviours are evident in the presentation of adults diagnosed with a borderline personality disorder. The primary aim of the EYPU intervention then is to enable these parents to develop an attachment to the unit (staff and other parents), within which they can begin to develop their capacity to mentalize, in relation to themselves and their children, and thereby begin to function as safe attachment figures for their children. The risk of significant harm to vulnerable children brings a sense of urgency; the timescale for change is set by the child and the consequence of failure to change is the child’s removal. This is addressed by establishing and maintaining a triangular relationship between the EYPU, the parent and the child’s social worker, such that treatment is offered within a clear authority structure, enshrined in a threeway therapeutic contract, and supported by open communication of concerns and regular, frequent reviews of progress. Clear limits are set in relation to attendance
feature article on the unit, genuine engagement in its therapeutic programme (eg attendance and contribution to groups) and protecting children from exposure to harmful behaviours such as angry outbursts. At the same time, all possible efforts are made to develop a reliable, safe relationship between parent and unit, for example, by a swift response to failure to attend through home visits.
Balancing parent and child In terms of the therapeutic work, the major challenge is to balance the needs of parent and child in a legal context that privileges the child’s needs over those of the parent and in an emotional context where the parent’s overwhelming unmet needs can lead to a neglect of the child in the therapists’ minds. Structurally, the offer of individual and group work for parents in their own right is balanced with parent– child therapy and direct work with children. In terms of the therapeutic relationship, the parent’s mental states have to be managed and responded to before the parent is able to think about their child’s mental state. Therapists work alongside parents, using video feedback as an important mentalizing tool in enabling parents to think about their own and their children’s emotional states and the interrelationship between the two. Team relationships, supported by reflective groups, enable therapists to manage their countertransference, such as hopelessness and hostility, and remain focused on the child. Setting limits on parents’ harmful behaviour is important. For example, when a parent is overwhelmed by their own emotional state to the extent that they behave in hostile and aggressive ways towards or in the presence of their child, they may need to be separated from their child temporarily until they can calm down and regain their capacity to think.
Clinical example: Joe and Dan Joe, a 29-year-old man, experienced complex trauma and neglect as a child. His father abandoned the family shortly after Joe was born. He was emotionally and physically neglected by his mother, who misused alcohol and drugs, he was physically abused by his mother and her successive partners, and regularly witnessed domestic violence at home. At 12, he was sent to boarding school because of his chaotic, disruptive and aggressive behaviour. The cycle of abuse and neglect continued when Joe became a father to his
A parent’s capacity to mentalize is a central mechanism in the formation of attachment relationships three children. The children were neglected owing to their parents’ significant substance use and they witnessed extreme domestic violence, culminating in a prison sentence for Joe. When Joe’s partner abandoned the children owing to her escalating drug use, CSC agreed to the children residing with Joe on the condition that he engaged with the EYPU with his son Dan to address the impact of his serious personality difficulties on his parenting, especially his difficulties managing anger. Joe’s parenting was harsh and he struggled to show affection to his three children. If his son Dan cried, Joe taunted him, calling him a ‘little girl’. Dan, aged three, had features of a disorganised attachment: he was a frozen, withdrawn, watchful boy, who did not approach adults for help and support. His play was restricted and he made no emotional demands on his father. Joe’s mistrust of authority figures made it extremely difficult for him to form trusting relationships with professionals. He could be very intimidating towards EYPU professionals if they intervened in his harmful parenting, erupting in rage, threatening to leave and accusing the EYPU of working against him to remove his children. At these times, it was necessary to separate Joe and Dan in order to protect Dan from his father’s emotionally abusive behaviour and to help Joe regulate and reflect on his emotional state. Further, Joe was told straightforwardly about the consequences of his failure to use treatment to address his harmful parenting: that is, that care proceedings would be initiated. As Joe developed an attachment to the unit, he became more able to trust that professionals would be reliably available and helpful. His aggressive and delinquent behaviour diminished and he brought his vulnerability to the unit, using groups and individual therapy to think about the impact of his disturbed childhood on his functioning as a parent. Consequently, he grew more able to tolerate his son’s vulnerability, showing him affection, comforting him when he was distressed and becoming curious about his emotional life.
In turn, Dan became more confident, less frozen and hypervigilant, more creative in his play, and routinely showed his distress and anger. Although Joe’s daughters (aged six and seven) did not attend the full EYPU programme because they were in school, they attended during school holidays. Joe described a deeper bond with his daughters and worked with the school to help them access counselling. Since leaving the EYPU, Joe is employed and his children are doing well. No statutory services are involved with the family.
Conclusion For those families who engage successfully, outcome studies suggest that after six months of treatment at the EYPU, the children improve in their functioning across a range of domains, including cognitive, language, motor, social-emotional, and adaptive behaviour. Parents who complete the programme go on to significantly reduce their use of primary and secondary services, and their cases are closed to CSC. Parents maintain contact via monthly leavers’ groups, reunion days and informally building supportive social networks. Furthermore, preliminary findings indicate that parents’ social functioning improves. These outcomes suggest that there are hopeful signs that children treated at the EYPU will not go on to develop personality difficulties as adults.
References Bateman A and Fonagy P (2003). ‘The development of an attachment based treatment program for borderline personality disorder’. Bulletin of the Menniger Clinic, 76: 187-211. Daum M (2009). ‘Assessment and decision making – paralysis in the family and professional system in parents with personality disorder’. In Rt Hon Lord Justice Thorpe and M Faggionato (ed) Mental health and family law. Bristol: Family Law: 31-36. Mclean D and Nathan K (2007). ‘Treatment of personality disorder: limit setting and the use of benign authority’. British Journal of Psychotherapy, 23(2): 231-246. A manual relating to the work of the EYPU can be found at: http://eypu-content.tiddlyspace. com/#Introduction
A new biopsychosocial programme for emotional instability: the Slough model In this article, Rex Haigh explores the ‘biopsychosocial model’, used in a community-based service in Slough. The ethos of the new programme is to help service users escape from a pattern of repeated admissions to hospital by building and using therapeutic relationships – a ‘therapeutic community in the head’.
motional instability’ is a kinder and more accurate term than the DSM’s ‘borderline personality disorder’ or the ICD’s ‘emotionally unstable personality disorder’ diagnostic categories. It is the underlying issue for many with the most severe problems but who are least helped by our mental health services. It also causes untold suffering to families, friends and others, as well as a vast range of severe psychosocial difficulties rarely seen in clinical practice. In many statutory services, when people are treated without the necessary professional sensitivity and human understanding, the emotional instability is maintained, made worse or causes a mental crisis. This article will explore what is called
Rex Haigh is a consultant medical psychotherapist and group analyst who has worked in therapeutic communities for over 25 years. He was clinical advisor to the National Personality Development Programme until its closure in 2009, and founded the Community of Communities and Enabling Environments projects at the Royal College of Psychiatrists Centre for Quality Improvement. He is committed to service user involvement and is involved with several voluntary organisations in the field.
the ‘biopsychosocial model’ and how this is being used in the early days of a community-based service in Slough, Berkshire.
The biopsychosocial model This model implies that ‘all three levels, biological, psychological, and social, must be taken into account in every health care task’ (Engel, 1980). Although it has been called ‘the mainstream ideology of contemporary psychiatry’ (Ghaemi, 2009), the main alternative, the biomedical model, generally predominates in British contemporary practice. However, a biopsychosocial formulation is one of the cornerstones of the 2002–2011 National Personality Disorder Development Programme (Haigh, 2007)) and continues in the Offender Personality Disorder pathway programme (Joseph et al, 2012). ‘Therapeutic community principles’ were defined in 1960 through Rapoport’s themes of democratisation permissiveness, reality confrontation and communalism, and they were a powerful force in the heat of the mid-20th century social psychiatry revolution. But these principles require a closed system to operate (Goffman, 1968) and can only be properly applied in a specialist residential unit. To provide wider scope for the use of therapeutic community principles, a phenomenological description is more helpful. Here the quintessence of a therapeutic community is drawn on: attachment, containment, openness, inclusion and agency (Haigh, 2013). What we might call the ‘therapeutic community in the head’.
Developing the service: the ASSIST programme The service is a response to several contemporary themes: closure of hospital beds; halting of long-term or intensive psychotherapy programmes; intolerance of risk; severe financial restrictions in the NHS and even worse ones for local authorities; increasing regulatory burden on community mental health teams; and the general ‘industrialisation’ of statutory mental health provision. More positive factors include the promotion of ‘recovery’ ideas, recognition of the ‘triple bottom line’ of sustainability (money, people and planet), social capital as an asset, ‘co-creation’ between staff and service users, resilience through interdependence, the need to ‘re-humanise’ healthcare, and a political claim to create a ‘shared society for all’. Those of us involved in designing this therapeutic service see it as an example of health as a social movement rather than a technique or commodity delivered by fragments of services provided by restrictive contracts with experts. A multidisciplinary staff team was recruited: a counselling psychologist with long experience of personality disorder work as a team leader and three full-time clinical team members (a mental nurse, an assistant psychologist and a social worker). As a consultant medical psychotherapist, I provide leadership, clinical supervision and the more complex assessments, on one day per week. Most service users are referred while they are still in hospital. They undergo a
biopsychosocial assessment, undertaken in a relational, exploratory and user-friendly way, usually with more than one of the team members and sometimes with the help of an ‘expert by experience’. It is a two-way process (as much for potential service users to assess us as for us to decide whether they are ‘suitable’), which can take place over several sessions if necessary. The information collected is based on what is needed for a full psychiatric, psychological and psychotherapeutic assessment. As part of this, we often prepare detailed timelines and genograms in close collaboration with the person being assessed and always talk through the formulation that emerges to agree it together. Although a small minority do not want to engage at this stage, this process usually results in service users wishing to join our programme. If they are still in hospital, they are invited to our regular inpatient group, which was set up by service users. Once service users have left hospital, they have one, two or three weekly sessions for 12 weeks. The sessions are very flexible and are held at an agreed location, which could be at home, in a public place such
as a coffee shop or park, or at the local community hospital. The sessions are never with just one team member – we adhere to the principle that we are building a relationship with the team, not a single team member. Usually two or three staff are involved, although people with particularly complex problems might be known by all team members. Sessions are generally about an hour long but are not restricted to psychotherapy time boundaries. All team members receive individual clinical supervision and attend a weekly team meeting where everyone in the programme is reviewed and discussed. Throughout this time, service users generally remain under the care of their sector psychiatrist and care coordinator, with whom we liaise closely.
The therapeutic community: the EMBRACE group While they are in this 12-week phase, those in the programme are encouraged to attend the EMBRACE group, the hub for all the opportunities, services and facilities open to them. The group takes place at a Quaker Meeting House and comprises formal community meetings before and after a communal lunch. Membership is between
15 and 25 and all staff who are not too busy elsewhere try to come; the two senior staff members always attend. The structure of the group, including rules and guidelines, has been co-created by staff and service user members, and the event takes two and a half hours each week. The major part of the opening community is taken up with the check-in, where all members (including staff) describe their previous week and any particular problems or worries they have, and there is the opportunity for members to offer each other support. Staff then have a short debriefing to decide whether any specific actions are needed outside the group. A meal prepared and shared by members and staff facilitates support between members, and between members and staff, and the sharing and celebration of special events. The afternoon community meeting has a more ‘administrative’ agenda, involving discussion of Slough’s other therapeutic activities and what might be helpful for individuals. The intention is to establish an experience of continuity of care for members so they feel attached to,
feature article This therapeutic service is an example of health as a social movement rather than a technique or commodity delivered by fragments of services
and safe in, a network of different services largely of their own choice and under their own control. Members’ previous experiences often involve being sent to fragmented services, with no sense of them being joined up or having any overall consistency. The range of options for members is very wide. There are opportunities in the statutory, voluntary and third sectors for members to develop their interests, skills and experiences, and new projects and groups. The community has distinct phases, with everybody having group reviews every six months. Up to three months is given to the first phase, engagement and continuing assessment (‘getting started’). The second phase of about six months involves planning the programme and preparation (‘settling in’). The third phase, a maximum of 18 months, is where the member undertakes the programme while taking on mentoring and supportive roles for others (‘general therapy’). The fourth phase is where they move into ‘real life’ and ‘recovery’, which can include external volunteering, education, training or employment, peer support and self-help groups.
Sustainability and resilience The programme has grown over the past three years in complexity and service user involvement, rather than in funding or staff numbers. Deeper relationships have been built between the various organisations running the different activities and there is scope for this to develop further. Strategic discussions between NHS, local authority and third sector partners are also leading towards greater cooperation and coherence. This evolving programme was set up to give Slough’s residents a better experience of mental health services against a backdrop of cost-cutting through closure of all local psychiatric beds. While the primary objective was to improve and
develop therapeutic services for those with emotional instability (with a likely diagnosis of borderline personality disorder), detailed analysis of the before and after costs for all the recipients of the service has shown considerable cost benefit. For example, total bed days for the first 24 people for the year before and the year after undertaking the programme dropped from 1,948 to 86. Similar results were found for use of the crisis team, A&E and out-of-hours GP services. The social and economic benefits of this programme are therefore positive and, most important, offer hope, meaningful therapy, work opportunities and the prospect of ‘a life worth living’ to its participants.
Therapeutic community in the head: is it psychotherapy? There is some debate about whether to call the programme a ‘micro-therapeutic community’ (the members and staff are only together for two and a half hours each week) or a ‘macro-therapeutic community’ or a ‘therapeutic community without walls’ (members have it in mind 24/7, and its activities take place across the locality and sometimes beyond). My own preference is to see it as the ‘therapeutic community in the head’, which is the only place where it is ultimately going to make people feel safer and better. The ethos of the programme is to help service users escape from a pattern of repeated admissions to hospital by building and using therapeutic relationships. With the beginnings of trust for those who have barely experienced it, and a glimmer of hope, people who have been considered ‘untreatable’ or ‘too high risk’ can start to see things differently. They can come to realise that enduring change and improvement in their lives is more likely to come about through their own efforts and agency than through hospital admissions and medication.
Recasting of psychotherapeutic principles I would argue that some of the fundamental psychotherapeutic principles need to be recast in a less specialist language. Attachment becomes an experience of trust and belonging; emotional containment is a vital aspect of patient safety; making the unconscious conscious can be achieved with a culture of openness in an enabling environment; paranoid and schizoid states of mind, characterised by loneliness and isolation, might be prevented or at least ameliorated with community-wide social cohesion; individuation and selfactualisation can come through service user involvement and taking responsibility in a way that is interdependent and intersubjective. In these ways, participants find meaning through the relationships they establish. Psychotherapists have high levels of skill, the most subtle and creative often lost in the current dumbing down of psychological treatments. Perhaps one of the best ways of reviving them, as well as offering hope to some of the most damaged and disturbed people in mental health services, is to work closely with others, including commissioners and managers, to build more theory, practice and evidence for a way of working that might be best called ‘applied psychotherapy’.
References Engel GL (1980). ‘The clinical application of the biopsychosocial model’. American Journal of Psychiatry, 137(5): 535-544. Ghaemi SN (2009). ‘The rise and fall of the biopsychosocial model’. British Journal of Psychiatry, 195(1): 3-4. Goffman E (1968). Asylums. Essays on the social situation of mental patients and other inmates. Aldine Transaction. Haigh R (2007). ‘The 16 personality disorder pilot projects’. Mental Health Review Journal, 12(4): 29-39. Haigh R (2013). ‘The quintessence of a therapeutic environment. Therapeutic communities’. International Journal of Therapeutic Communities, 34(1): 6-15. Johnson R and Haigh R (2011). ‘Social psychiatry and social policy for the 21st century: new concepts for new needs – the Enabling Environments initiative’. Mental Health and Social Inclusion, 15(1): 17-23. Joseph N and Benefield N (2012). ‘A joint offender personality disorder pathway strategy: an outline summary’. Criminal Behaviour and Mental Health, 22(3): 210-217. Rapoport R (1960). Community as doctor. London: Tavistock Publications.
DBT: a dialectical approach to effective treatment for people with complex problems Dr Maggie Stanton discusses the theoretical and philosophical underpinnings of dialectical behaviour therapy, the model of practice, and its evidence base as a treatment for personality disorder.
ialectical behaviour therapy (DBT) offers a novel approach to the treatment of personality disorder, particularly borderline personality disorder (BPD), by taking a dialectical viewpoint. This dialectical philosophy influences the way in which personality disorder is conceived and treatment implemented.
Evidence base DBT was developed by Marsha Linehan (1993) as a treatment for people with severe self-harming and suicidal behaviours meeting American Psychiatric Association (1994) DSM criteria for borderline personality disorder. Since her first randomised control trial in 1991, the evidence base for the effectiveness of DBT has grown (Dimeff et al, 2002), with the
Dr Maggie Stanton is a consultant clinical psychologist and an accredited therapist with BABCP and the Society for DBT for UK and Ireland. Maggie was formerly head of the psychological therapies service in a large NHS trust. Currently, she works privately as a trainer, supervisor and consultant, both internationally and in the UK. She is an honorary lecturer at Bangor University and has published on a variety of topics, including as co-author of two books on mindfulness, Teaching Clients to use Mindfulness Skills and Using Mindfulness Skills in Everyday Life.
treatment successfully adapted for different client groups including adolescents (Rathus and Miller, 2015) and people with substance abuse disorder (Linehan et al, 1999). DBT has been researched internationally, with 29 randomised controlled trials (RCTs) conducted by 21 independent research teams (NREPP, 2012). In the DBT treatment arm of the studies, the outcomes are generally positive for clients, showing a reduction on various measures including suicide attempts, non-suicidal self-injury, depression, hopelessness, anger, substance use and impulsivity. There has been criticism that the treatment only addresses symptoms. However, Bedics et al (2012), using Lorna Benjaminâ€™s structural analysis of social behaviour scale (Benjamin, 2003), found that people in the DBT treatment group had significant improvement in their scores for appreciating and valuing themselves and significant reductions in scores for attacking and rejecting themselves (eg negative judgments about self). Certainly the overarching goal in DBT goes far beyond symptom reduction being a â€˜life worth livingâ€™ (Linehan, 1993).
A biosocial model Linehan (1993) put forward a biosocial model for understanding BPD, suggesting that difficulties result from the transaction between biological vulnerability for frequent and intense emotional responses and an invalidating environment. There is thus a reciprocal relationship between biology and environment where each influences the other. An invalidating environment is one where behaviour is negated or dismissed regardless of whether it is valid
The therapist moves between teaching and coaching strategies to help the client solve the problem while validating the difficulty of doing this
or not. In addition, increasing emotional responses are reinforced and there is an oversimplification of problem-solving. Consequently, the individual does not learn skills in understanding, labelling, regulating or accurately communicating their emotions or tolerating their distress. Instead they rely on the social situation to provide cues on how to respond, swinging between inhibiting their emotions and intense emotional responses. This reliance on the social environment can lead to interpersonal difficulties, with the individual maintaining relationships even when they are detrimental to them. This transactional model explains the development and maintenance of the difficulties, while also providing a real message of hope for change and basis for the treatment. Just as the reciprocal relationship can work to increase problems, so the influence of the environment on the individual, and vice versa, can work in a positive direction, whereby learning occurs, self-validation is nurtured, and skilful behaviours are developed and reinforced.
A skills deficit model We can see from the description in the proceeding section that DBT is a skills deficit model, with a strong focus on emotion. From this viewpoint, difficulties that characterise a diagnosis of BPD are conceptualised as behaviours that either serve the function of regulating emotions or are a natural consequence of emotion dysregulation (Linehan, 1993). In order to overcome these difficulties, the treatment focuses on increasing the individualâ€™s capability by acquiring, strengthening and generalising skills in understanding, tolerating and regulating their emotions, handling interpersonal situations effectively and acting less impulsively. Thus skills are taught and applied in emotion regulation, interpersonal effectiveness, distress tolerance and mindfulness. Mindfulness is a core skill because it is a component of all the skills and its emphasis on acceptance without judgment provides a balance to the changed focus (Dunkley and Stanton, 2014). While undoubtedly people with these problems have behaviours they need to change, when developing the treatment,
Dialectics provide the framework whereby the two traditions of behaviour therapy and Zen can be brought together in synthesis within one therapy Linehan found there was too much emphasis on change invalidating the difficulty and challenges they faced. Conversely, while acceptance of the person and their struggles was imperative, too much emphasis on acceptance led to hopelessness in the individual. The solution was to develop a treatment with dialectics at the core, where the emphasis is on embracing opposites while seeking to find synthesis between them. DBT is thus a therapy where the focus is on acceptance and change.
A dialectical philosophy By embracing a dialectical philosophy, DBT offers a novel approach to understanding and treating people who meet the criteria for personality disorder. Dialectics influence the way in which the difficulties are understood and the treatment is
implemented. The first evidence of a dialectical philosophy is in the foundations that underpin the therapy. These come from the traditions of behaviour therapy (change) and Zen philosophy (acceptance). Behaviour therapy guides us in understanding the principles of behaviour, where behaviour can be anything a person does, internal or external â€“ a thought, emotion or action (Hayes et al, 2004). Behaviour therapy incorporates exposure, contingency management, problem-solving and skills training as methods for changing behaviour and views motivation as moving a behaviour up the response repertoire by increasing the likelihood of it occurring. By contrast, Zen philosophy emphasises acceptance, compassion and wisdom developed through practice. It focuses on experiencing the world, as it is in the
feature article DBT goes far beyond symptom reduction being a ‘life worth living’ moment, losing judgment or attachment to things being a certain way. In DBT, the principles of Zen are learned through acquiring, strengthening and generalising the skill of mindfulness. Through carrying out practices and generalising the skill into their lives, the individual learns a different way of being (Dunkley and Stanton, 2017). Dialectics provide the framework whereby the two traditions of behaviour therapy and Zen can be brought together in synthesis within one therapy.
Dialectical balance, skills and strategies A dialectical balance is apparent in the skills taught to clients in DBT, with mindfulness and distress tolerance being acceptanceoriented skills, and emotion regulation and interpersonal effectiveness being skills directed towards change. The principle in DBT is that the skills are helpful to clients and therapists alike, and therapists are expected to learn and practise the skills, particularly mindfulness (Stanton and Dunkley, in press). Dialectical balance is not just apparent in the skills but is also emphasised in the strategies used by the therapist. The core dialectical strategies are problem-solving (change) and validation (acceptance). The therapist moves between teaching and coaching strategies to help the client solve the problem while validating the difficulty of doing this. Linehan (2015a,b) likens this to a dance where the therapist moves backwards and forwards to achieve speed, movement and flow in the session, doing what is required in each moment. In DBT, the style in which the therapist does this is defined by the two sets of stylistic strategies: reciprocal communication, which lies at the acceptance pole, and irreverent communication at the change end. Reciprocal communication is used to equalise the imbalance that can occur in therapy through showing warmth and by revealing the therapist as a genuine person in the therapy, using appropriate self-disclosure to aid client learning. By contrast, irreverent strategies are at the
change end of the dialectic and aim to help the client see a different perspective. The therapist, in their tone, content or actions, does the unorthodox or surprising and thus demonstrates a different point of view. The final sets of dialectical strategies used by the therapist are concerned with managing the environment: consultation to the client (change) and environmental intervention (acceptance). DBT provides a fresh approach by emphasising the need for the therapist to teach and coach the client in how to manage their environment (consult to the client), rather than stepping in to act for them. This maximises learning for the client while also conveying confidence in their ability, with the appropriate coaching, to manage the situation skilfully.
Therapy for the therapist Finally, a dialectical philosophy is also apparent in the DBT consultation team. This is the weekly peer supervision group for therapists, where the principles of the therapy are applied to the therapists to increase their capability and motivation in providing DBT (Heard and Swales, 2016). In the consultation team, as in other areas of DBT, dialectical tensions are welcomed, so that when a difference of opinion occurs, both (or more) viewpoints are taken as valid. The task is then to look for the nugget of truth in each perspective and work to find a synthesis. In a dialectical assessment, the question, What is left out? is considered. So, if no difference of opinion occurs, the task in the consultation team is for at least one member to take an opposing point of view, and for the group to explore the validity in this perspective, upholding the principle that there is no one truth but many ways of seeing a situation.
Conclusion Dialectics balances acceptance and change in orientation, skills taught and therapist strategies. When emotions are high, the style of thinking becomes more rigid. A dialectical philosophy counters this by emphasising flexibility and suggesting that there are many ways of viewing a situation and that different, seemingly opposing points of view can be true at the same time. Thus we have seen that dialectical principles infuse the therapy and provide a fresh perspective when working with clients with a personality disorder and their complex problems.
References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (DSM-IV) [4th edn]. Arlington: American Psychiatric Association. Bedics JD, Atkins DC, Comtois KA and Linehan MM (2012). ‘Treatment differences in the therapeutic relationship and introject during a 2-year randomized controlled trial of dialectical behavior therapy versus nonbehavioral psychotherapy experts for borderline personality disorder’. J Consult Clin Psychol, Feb; 80(1). New York: Guilford Press. [1st edn 1993, 2nd edn 1996, paperback 2003.] Benjamin LS (2003). Interpersonal diagnosis and treatment of personality disorder. Dimeff L, Koerner K and Linehan MM (2002). Summary of research on DBT. Behavioral Tech, LLC. Dunkley C and Stanton M (2017). Using mindfulness skills in everyday life: a practical guide. New York & Hove: Routledge. Dunkley C and Stanton M (2014). Teaching clients to use mindfulness skills: a practical guide. New York & Hove: Routledge. Hayes SC, Follette VM and Linehan MM (2004). Mindfulness and acceptance: expanding the cognitive behavioral tradition. New York: Guilford Press. Heard HL and Swales MA (2016). Changing behaviour in DBT: problem solving in action. New York & London: Guildford Press. Linehan MM (2015a). DBT skills training handouts and worksheets [2nd edn]. New York & London: Guildford Press. Linehan M.M (2015b). DBT skills training manual [2nd edn]. New York & London: Guildford Press. Linehan MM (1993). Cognitive-behavioral treatment of borderline personality disorder. New York & London: Guildford. Linehan MM, Armstrong HE, Suarez A, Allmon D and Heard Hl (1991). ‘Cognitive-behavioral treatment of chronically parasuicidal borderline patients’. Archives of General Psychiatry, 48: 10601064. Linehan MM, Schmidt H, Dimeff LA, Craft JC, Kanter J and Comtois KA (1999). ‘Dialectical behavior therapy for patients with borderline personality disorder and drug dependence’. American Journal on Addiction, 8: 279-292. NREPP (2012). Comparative effectiveness research series: dialectical behaviour therapy: www. linehaninstitute.org/downloads/NREPP-2012-%20 DBTComparitiveEffectivenessResearch.pdf (accessed 10 January 2017). Rathus JH and Miller AL (2015). DBT skills manual for adolescents. New York & London: Guildford Press. Stanton M and Dunkley C (in press). ‘Teaching mindfulness in DBT’. In MA Swales (ed) Oxford handbook of dialectical behaviour therapy. Oxford: Oxford University Press.
Cognitive analytic therapy: three decades of engagement with ‘personality disorder’ Annie Nehmad argues for the use of cognitive analytic therapy as a positive, effective and relatively inexpensive first line of intervention for those with personality disorders. CAT’s applicability and advantages Cognitive analytic therapy (CAT) is probably the most cost-effective psychotherapy for people with a diagnosis of personality disorder: 24 individual sessions at weekly intervals, with one to three follow-up appointments. NHS clinicians increasingly recognise the value of CAT, especially for people with a diagnosis of personality disorder and others considered unsuitable for either CBT or psychodynamic therapy. CAT is used in forensic secure units and personality disorder services, as well as in primary and secondary care psychology and psychotherapy. CAT is one of seven specific therapies included in the University College London (UCL) competence framework for psychological interventions for people with a personality disorder, which is being piloted and will be rolled out nationally to NHS primary care psychology (IAPT).
Dr Annie Nehmad is a founder member of the Association for Cognitive Analytic Therapy (ACAT) and a member of UKCP. She was the clinical lead for CAT in a secondary care NHS psychotherapy department until 2013. She now works privately as therapist, supervisor and visiting lecturer on university and CAT courses. She is the author of two chapters in a book on CAT supervision (Pickvance, 2017).
Development of the model CAT is an integration of aspects of cognitive therapy, psychoanalytic (especially object relations) theories, Kelly’s personal construct psychology, Lev Vygotsky’s activity theory and Mikhail Bakhtin’s dialogism. Dr Anthony Ryle developed it from the mid 1970s, initially comparing and integrating personal construct psychology and object relations (Ryle 1975). His aim was to bring together, into a coherent unitary model, the findings of different schools of psychotherapy and developmental psychology. CAT was not intended specifically for people with a diagnosis of personality disorder. It is suitable for a wide variety of people, problems and settings, including primary care, private practice, couple therapy and learning disabilities. From the early 1980s, Anthony Ryle was a consultant psychotherapist at Guy’s and St Thomas’ NHS Trust, serving a deprived inner London population with a high prevalence of personality disorders, comorbidity and complexity. He modified his earlier model, bringing the object relations component to the fore, and found it effective for many people previously deemed unsuitable for psychotherapy. Twenty years ago, many mental health staff (including psychotherapists) found it difficult to work with people with a borderline personality disorder (usually considered untreatable). In this context, Ryle wrote a book about its treatment, stating: In general, I like borderline patients; I have learned a great deal from them, and I have found that, once I have come to know their
CAT considers borderline personality disorder to be the outcome of emotional deprivation and abuse stories, I have usually felt moved and filled with respect for what they have endured and achieved. To be able to like them it is necessary to understand them […] making sense of their often painfully destructive experiences and acts. [The person then becomes] less filled with anger and more aware of underlying pain and loss but also of possibility. (Ryle, 1997b: xii; emphasis in the original)
The CAT conceptualisation of personality development Human beings relate from birth. We internalise ways of being with another, and our own reciprocation to this. For example, we may feel: • secure and lovable in relation to a caregiver who is nurturing and attuning • scared and powerless in relation to a caregiver who is powerful and punitive. The words in italics are reciprocal roles. They give rise to reciprocal role procedures – patterns of thinking, feeling, and behaviour, for example a striving, perfectionistic procedure in response to conditional love (‘in order to be loved and accepted, I have to excel’). We internalise both the caregiver pole and the ‘child’ pole, and they become part
feature article of our repertoire. A small child who says, ‘Naughty dolly! I am going to smack you!’ is enacting a punitive ‘parental’ pole that she has experienced. Reciprocal roles become aspects (or ‘self-states’) of the personality that are enacted with others and towards oneself (I nurture myself; I punish myself). Most parents have more than one style. For example, they may be ‘nurturing’ when relaxed, and ‘irritable/punitive’ when stressed. When a child’s experience includes a) sufficient benign reciprocal roles, b) an absence of serious trauma and c) at least one person who can help them make sense of their confusing and ‘bad’ feelings, they are likely to become relatively well integrated, with a broad repertoire of reciprocal roles, able to choose appropriately between them, and able to reflect and make changes if necessary.
The CAT conceptualisation of borderline personality disorder Individuals whose childhood experience was dominated by abuse and/or neglect, with no ‘integrating adult’ who could name and help process their feelings, are unlikely to integrate the structures of the self, so they may lack a coherent sense of identity and experience their self-states (reciprocal roles) in extreme ways, unmodulated by contact with the rest of the self, including the capacity to reflect. CAT considers borderline personality disorder to be the outcome of emotional deprivation and abuse. People with this diagnosis often switch ‘inexplicably’ from one self-state to another (eg from idealising to angrily criticising, or from cordial collaboration to angry rejection). This is confusing for them and for those around them, including professionals.
‘Cynthia’ – brief story and diagram Cynthia is 29, with a diagnosis of borderline personality disorder. Both parents were prone to criticise her, and rarely praised her. Her father was regularly violent to her. During summer holidays, she was sent to her grandmother’s farm. She idealises her grandmother’s ‘perfect care’, but also felt abandoned at the end of every summer (‘couldn’t she guess what was happening to me?’). Cynthia’s pattern is to have relationships with men who seem strong and protective but turn out to be possessive and abusive. When she encounters kindness or concern (in friends or in professionals) she expects ideal perfect care. When this does not happen, she feels abandoned and devastated. She has had numerous episodes of self-harm and overdoses. The diagram summarises her key reciprocal roles, and patterns. Seeing it all on paper is a new experience for Cynthia. It also forewarns the therapist of likely transference and countertransference invitations. Feel good; fail to pick up warning signs
Criticising Demanding Inadequate Insecure Anxious Worthless
Seek validation (and rescue?) through male attention
Cruel Powerful Abuser Powerless victim Awaiting rescue Kindly GP or mental health staff or friend takes an interest
Staff or friend express disappointment and/or withdraw
Self-harm and/or overdose (to escape from intolerable feelings)
Abandoning Abandoned Despairing Empty
Inevitable disappointment when care is not ideal and permanent
Protective Powerful (Idealised) Rescuer Dependent Powerless Expecting ideal care
Furthermore, someone who has not experienced ‘being soothed’ will not know how to ‘self-soothe’. Instead, when their most painful self-states are triggered, they often act out in order to immediately escape from unmanageable feelings, for example through substance abuse (temporarily feeling good); self-harm (turning emotional pain into physical pain and/or signalling one’s pain to others); violence (becoming the powerful abuser rather than the powerless victim).
Tasks and tools of therapy Though internalisation of reciprocal roles is most powerful in childhood, it happens throughout our lives. This makes CAT an optimistic endeavour, as patients can internalise the therapist’s benign reciprocal roles (eg respectful and collaborative). They can also learn to reflect with the therapist as a step towards self-reflection, experience emotional pain in the presence of the therapist as a step towards tolerating emotional pain on their own, and observe and understand their own behaviour and processes with the therapist’s help so they can later do it for themselves. Therapies are often said to be about either ‘being with’ or ‘doing to’ the patient. CAT sees itself as ‘doing with’. Key tools in CAT are the reformulation letter, diagrams and goodbye letters. The reformulation is written around session four to six. It is a summary by the therapist of the patient’s presenting problems, underlying reciprocal role procedures, strengths and aims, linking these to the patient’s past experience, especially in childhood. This offers a compassionate reframing of their experience and behaviour. The reformulation is read out to the patient and discussed over one or more sessions. The patient is encouraged to make changes to it so that it becomes a collaboratively developed joint understanding. Some diagrams are simple loops showing self-reinforcing problem procedures. Others are more complex, showing all the person’s reciprocal roles (self-states) and the shifts between them. These diagrams have a powerful integrating function, as patients can see all their different ‘selves’ (or self-states) on one piece of paper, and can start to observe, understand and ultimately modify the transitions
feature article It is remarkable how much improvement can take place for so many people within quite a short space of time between them, which no longer feel random and outside their control. Like the reformulation letter, diagrams contain the patient’s language and are produced collaboratively. Between sessions, patients are encouraged to self-observe, especially their problem procedures and aims or exits (ie more adaptive alternatives) and their shifts between self-states. The ending of therapy can be a reparative experience, as many people with borderline personality disorder have experienced unplanned and traumatic losses. Contradictory feelings such as anger and gratitude can be felt and processed within a supportive and accepting relationship.
patients, we are less likely to be ‘recruited’ by them into familiar roles (eg ‘rejecting’) or fantasised ones (eg ‘ideal carer’) when armed with a diagram of the patient’s reciprocal roles. However, even experienced therapists require supervision, adequate in quality and quantity, to notice and correct ‘recruitments’ (projective identification in psychodynamic parlance). In addition to individual therapy, CAT is useful for mental health teams. Understanding a patient’s diagram and how each member of the team has been, or could be, ‘recruited’ into different reciprocal roles can help to explain (or prevent) ‘splitting’ of the team (Carradice, 2013; Kemp et al, 2017).
At the final session, patient and therapist exchange ‘goodbye letters’ – each summarises what has happened in therapy, and how it has felt. This is an important exercise in reflection and (like the diagrams and prose reformulation) something the patient keeps. It acts as a ‘transitional object’ and as a reminder of their problem patterns and exits.
In CAT, the understanding of transference and countertransference derives from psychodynamic concepts, but is expressed and used differently and more digestibly. In CAT, we do not interpret in a psychoanalytic sense; we describe, usually in relation to an agreed diagram. Psychodynamic interpretations (especially ‘transference interpretations’) often lead to individuals with borderline or narcissistic personality disorders feeling exposed, or simply being unable to make sense of them. It may be easier for them to accept ‘I think we have just been here’ (pointing to a pair of reciprocal roles on the diagram), for example, when the patient has enacted, or elicited, a particular reaction.
Among personality disorders, CAT’s expertise and research has developed mainly in relation to borderline personality disorder. However, a randomised controlled trial (Clarke et al, 2013) obtained good results with CAT (but not with treatment as usual) in patients with any one or more of the ten personality disorders listed in DSM.
For a fuller account of CAT theory and practice, see Ryle and Kerr (2002). For more on the CAT model of borderline personality disorder, see Ryle (1997a,b). CAT therapists have found that, when treating complex, poorly integrated
Evidence emerging from randomised controlled trials indicates that this is a ‘popular and promising’ intervention, although it is argued by Calvert and Kellett (2014) that the depth and breadth of the evidence base is currently limited. For a comprehensive evaluation of CAT outcome research, see Calvert and Kellett (2014).
Concluding thoughts, and my own experience I have worked with people with ‘personality disorders’ since 1986, when I started seeing patients under the supervision of Dr Ryle. I have witnessed and been part of the development of the model. Like Dr Ryle, I generally like people with this diagnosis and I enjoy working with them. This is because I understand something of their dynamics, and how to enable insight and change, while remaining curious about each individual.
While some people with personality disorder are not helped by CAT, it is remarkable how much improvement can take place for so many people within quite a short space of time, even in the hands of (well-supervised) trainees. I attribute this to two main factors: the integrating function of ‘diagrams’ for both patients and therapists; and the integrating function of good supervision, which is an essential component of CAT. From my clinical experience, it is easier for patients to commit to a course of CAT than to a full-time group programme. CAT is not a panacea but it is acceptable to most patients, and it is less expensive than most other interventions and has a relatively high rate of therapy completion (Calvert and Kellett, 2014). I would therefore argue that it could be a first line intervention for most, if not all, patients with borderline personality disorder.
References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th edn) (DSM-IV). Calvert R and Kellett S (2014). ‘Cognitive analytic therapy: a review of the outcome evidence base for treatment’. Psychology and Psychotherapy: Theory, Research and Practice, 87: 253–277. Carradice A (2013). ‘Five session CAT consultancy: using CAT to guide care planning with people diagnosed with personality disorder within CMHTs’, Clinical Psychology and Psychotherapy, 20: 359-367. Clarke S, Thomas P and James K (2013). ‘Cognitive analytic therapy for personality disorder: randomised controlled trial’. British Journal of Psychiatry, 202: 129-134. Kemp N, Bickerdike A and Bingham C (2017). ‘‘Map and Talk’ – a cognitive analytic therapy informed approach to reflective practice in a forensic setting’. International Journal of Cognitive Analytic Therapy & Relational Mental Health, 1: 147-163. Pickvance D (ed) (2017). Cognitive analytic supervision: a relational approach. Routledge. Ryle A (1975). Frames and cages: the repertory grid approach to human understanding. Sussex University Press. Ryle A (1997a). ‘The structure and development of borderline personality disorder: a proposed model’. British Journal of Psychiatry, 170: 82-87. Ryle A (1997b). Cognitive analytic therapy and borderline personality disorder: the model and the method. Chichester: Wiley. Ryle A and Kerr I (2002). Introducing cognitive analytic therapy. Wiley. UCL competence framework for personality disorder: www.ucl.ac.uk/pals/research/cehp/ research-groups/core/pdfs/Personality_ Disorders/Personality_background_document. pdf (accessed 10/4/17).
The value of attending a group relations training: a personal account Dr Sharon Pettle reflects on a group relations event she attended in Italy and asserts its relevance for all those interested in trying to function better personally and to consider the wider system in which they work.
s part of my personal continuing professional development (CPD) plan I recently attended another group relations training (GRT). The previous one, about 15 years ago, lasted five days in London. I found it a weird and unsettling experience that took me many months to make sense of – but there was learning on many levels. It helped me understand a toxic, irrational management system and to leave a position where I was unhappy
Sharon Pettle qualified as a clinical psychologist in 1983 and completed advanced training in systemic practice in 1989. She worked in a variety of NHS services, increasingly involved in management and service development. Her clinical experience ranges across CAMHS: paediatrics, adolescent units, trauma and attachment difficulties, and links with parental mental health. She moved into independent practice in 2010. She has a significant expert witness practice and works with families created with donor gametes and surrogacy. (DrSharonPettle@popsiiiicle.com). For more information, email email@example.com
because I had little power to influence it and realised that my own capacity for clear thinking and creativity was being impaired.
The right time Over time, I thought that another GRT, ideally residential, would be useful, but I could not and did not want to commit the time and associated cost of one lasting two weeks. I thought that benefits would accrue as I had more awareness of what I was ‘letting myself in for’. It was timely as I was establishing a charity and the relationship between me as clinical director and the trustees would have to emerge. I anticipated that an opportunity to think about my relationship to authority and leadership would help me to be more conscious of the unfolding process. For those unfamiliar with such events, I recommend some reading (such as Brunner, Perini and Vera, 2009; Cardona, 2003; Huffington et al, 2004), although this does little to prepare you for a structure which holds the lack of structure, tasks that are vehicles and not ‘real’ tasks as one would consider them in the outside world, and a ‘bubble’ in which one can safely experiment. Set all this in a context where ‘managers’ and consultants’ are in prescribed roles in the uniquely created system in which one lives for a finite period, and who might appear very separate and lacking in human responsiveness. This part of the experience is interesting and leads to
fascinating projections, and to an awareness of an array of thoughts and feelings one rarely has conscious access to about those in authority, and one’s relationship to them and with other participants.
A certain charm I heard about ALI (Diamond, 2009) running a residential GRT in Italy. As a lover of all things Italian, this had a certain charm. More seriously, people who speak the same language struggle to communicate and a conference stating explicitly that it would work in Italian and English offered a chance to explore this further. The theme (Liquid Boundaries – Solid Borders) resonated on a European, global and political level. I emphasise that my attendance was very personal. I do not think presence at a GRT can ever be otherwise. I was vaguely expecting to feel in the minority – at my previous GRT I experienced myself as carrying the badge of ‘difference’. A few of us others realised that we represented the non-Christian/ secular, non-heterosexual and non-white aspects of the temporary society and felt unsafe and unwelcome. With hindsight and more information about this particular organisation, I was able to fit this into a wider narrative and recognised the attempt by a new staff member to develop and widen its brief. It has often struck me how variable the extent to which ‘management’ is a reflective organism – unless all who are part of it take deliberate steps to prioritise this. Diamond’s paper raised the issue of being an outsider very starkly but it did not deter me. I went alone, with the intention of trying to bridge communication challenges with my scant Italian. On arrival, I experienced the authority held by others, I felt a little unnerved and curious about my response. Reflecting on this has made me mindful of how I behave in situations when I am that authority, or perceived to be so by others.
Collective anxiety Looking at the sea of participants in the sunshine, alone or in small groups, I sensed a collective anxiety and considered my own consciously, together with excitement and a sense of inner personal authority. I quickly realised that in some ways I was in a minority – I was one of only two participants attending from the UK, while others hailed from Japan, Israel, Columbia and Spain. I am always fascinated by the assumptions
made as to one’s origins, regional as well as national, and the stereotypes that follow. In the end, we are all individuals and feeling oneself to be in a minority or alone is a question of perspective. Always remember that you are absolutely unique. Just like everyone else. (Margaret Mead) The language ‘barrier’ slowed down interactions – helpfully at times; at others, translation was irritating and pedantic. It is remarkable how much one understands what is being said through tone and gesture if attention is focused in the now. It also served to interrupt communication, and it was interesting to note when someone speaking the ‘other’ language intervened – not so different from when people spoke softly and excluded others through this. It was also a source of laughter, especially when even the speakers of the same language could not understand what someone was trying to impart! My fragile and grammatically impoverished Italian was appreciated – I found words of Ivrit/ Hebrew lurking in my brain, schoolgirl Spanish and phrases learned in Japan from a trip more than a decade ago. Willingness
It has often struck me how variable the extent to which ‘management’ is a reflective organism to speak, listen and hear, with the aim of understanding another and oneself – finding one’s place and way to be, moment by moment – were all grist for the mill.
Sharing experiences Participating a second time rendered the structure more understandable. During the first day, memories of my earlier GRT flooded back. I needed time to process these new reflections. The B group was useful for this – and sharing experiences formed part of introductions in the working group. In my clinical practice, I enjoy collaborative relationships with colleagues who have a strong psychodynamic background. I value psychodynamic ideas, but as a systemic thinker and psychotherapist my tendency is to look at hierarchies and alliances, to reframe and consider multiple perspectives. So I was ‘different’ in another way – but this was not devalued or scorned. I was fascinated by the subsystems, and initially less drawn to some of the psychoanalytic
concepts that abounded. As I expected, I felt the ‘gritty rub’ as the theoretical worlds collided (in my head at least) and this too was productive. Thinking about my own capacity to project – onto other participants, and those in management and authority roles; considering if, how and when I felt propelled to fill a void in groups; allowing myself to be pushed into action before I was ready as a result of finding inaction almost unbearable; my ability to sit with quiet, and why this was sometimes very hard to do; pondering on what I was feeling and then what to do with anxiety, fascination or boredom or my wish to contribute; choosing what and when to say – or when to think and consider – were all part of the ebb and flow.
Pivotal moments There were some pivotal moments: some in relation to ‘authority’, which led me to ponder what, why and how I/we give this to others, and the notion of personal authority, which I confirmed for myself is an entity
discussion that I do not have to abdicate from. Thus I decided to be absent from one session – to digest what I was learning. I did not want my absence to be excessively interpreted so I told one person but they chose not to share this with the large group. Another participant had left early and the group was caught up in a wave of discussion about destruction, annihilation and death! Ordinary explanations had little space to breathe at times. Like psychodynamic therapy, direct suggestions were rare. There were a few people who often commandeered ‘air time’ in the large group – usually provoking shared looks and ‘eyes rolling towards the ceiling’, gestures that were understood across language and cultural divides. It was useful to observe who shared looks with whom, but no one commented openly. The collective wish for these people to allow some quiet in which others might find their voice was sometimes stated but was more of a refrain over coffee. I was struck by the reaction of one of these people in my final B group who mentioned s/he was aware that s/he spoke too often and too much, which irritated others, but yet again took up much of the space. I quietly added that I hoped that s/he would find his/her ‘off’ button. The initial response seemed angry but I calmly refuted that my comment was not intended to close them up entirely but a recognition of their wish and mine that s/he became more cognisant of, and sensitive to, the delicate interplay between self and group. This particular voice was less prominent in the remaining groups.
A greater sense of self In the ebb and flow of days, in the various small and large groups and during the time spent over coffee and meals, I developed a greater sense of myself in relation to others. I knew little of their personal details. It was a rare opportunity to learn by being – listening to what was said around me, to me and about me, and considering my own contribution. One precious interaction was sharing a language lesson improving English/Italian through family histories – of love, illness, death, divorce, parents, siblings, etc. It was a jewel of an evening, full of laughter, and I learned more about this person than I did of all the others put together. Yet I felt a deep sense of knowing and being known by the people in one small group and we felt a bond that has continued with a multilingual WhatsApp
group that connects us intermittently with a thread of lives lived in across countries and continents. I took some of my learning back into the real world very quickly: a trustees meeting in which the very name of the foundation (which had been in my thoughts for almost a decade) was to be reconsidered. We started to form as a group, and negotiate our roles and decision-making processes. I also thought about it in relation to my work leading a team running groups for children who are conceived through third-party reproduction, and how this role relates to the charity under whose auspices these are run.
An active retreat In trying to describe the experience to some colleagues and friends, I have used words such as ‘an active retreat’, as having an intensity that is hard to match while also having the potential for change on many levels. It is ‘really real’ and can challenge ideas of yourself and how you think you operate – and it provides invaluable insights and opportunities to take risks. It offers an experience that individual or group supervision cannot, and is relevant to anyone working in clinical and therapeutic services (in- or outpatients) and academia. A group relations event enables learning about self, role and task, authority and leadership in a unique context and has relevance to anyone in any organisation who is interested in trying to function better personally and in considering the wider system in which they work.
References Brunner LD, Perini M and Vera E (2009). ‘Italian group relations between adaptation and innovation’. In E Aram, R Baxter and A Nutkevitc (eds). Adaptation and innovation: theory, design and role-taking; Group relations conferences and their applications, volume 2. London: Karnac Books: 73–88. Cardona F (2003). ‘The manager’s most precious skill: the capacity to be psychologically present’. Organisation & Social Dynamics, 3(2). Diamond J (2009). ‘Lost in translation: experiences at an Italian group relations conference’. Therapeutic Communities, 30(3). Huffington C, Armstrong D, Halton W, Hoyle L and Pooley J (2004). Working below the surface: the emotional life of contemporary organisations. London: Karnac Books, Tavistock Clinic Series.
istorically, the person-centred stance of rejecting the medicalisation of psychological distress has served to ostracise itself from the powerful influence of the medical model, thus sabotaging its own capacity to challenge that authority. It has led to assumptions that the person-centred approach is only adequate for helping those with ‘less severe conditions’. A lack of research in quantifying personcentred therapy’s effectiveness has meant that it is often considered less valuable than other therapeutic approaches. Such judgments have had sociopolitical implications, where cognitive behaviour therapies (that did generate measurable outcomes) have gained the monopoly on funding and are the primary choice for provision of therapeutic treatments.
Redressing the disparity This disparity is being redressed: personcentred therapy is defining its voice in the debate of what makes effective therapy for psychological distress. Research is validating its capacity to compete with other therapeutic approaches,1 which means that it has now been recognised by NICE in its Guidelines for Depression and has become an integral part of the IAPT programme as an element in the competency frameworks for non-CBT therapies. By re-engaging with the debate surrounding psychopathology, person-centred therapy has become more enabled to help people in their psychological distress.
Wendy Platt is a personcentred psychotherapist working in private practice in Worcestershire, where she also offers EMDR therapy (Eye Movement Desensitisation & Reprocessing). With an interest in education and supporting other care professionals, Wendy has worked for many years as a supervisor for the NHS and with trainee and qualified counsellors, while also lecturing in counselling. For the last five years, she has been a trustee for a voluntary counselling service in Worcester.
Working with the medical model: a person-centred perspective Wendy Platt finds value in the medical model as a tool in her person-centred approach. If we take part in the debate exploring psychopathology, she says, we give our clients the opportunity to evaluate for themselves what makes effective therapy.
Such a revolution takes time and real transformation comes, I believe, in the training of emerging person-centred therapists who become the future generation to influence change. My practice has been a product of my training experience, which began with a hazy understanding of psychopathology because my study was influenced by the desire to extricate the person-centred approach from the medical model. I have carried with me a latent concern that the person-centred approach may not be sufficient, and while I can accept this as part of my own self-doubt, I am also certain that the political bias influencing the perceived status of therapeutic approaches has prejudiced my belief against concluding that it is sufficient. To engage analytically with the medical model, I will inevitably have to use particular terminology, but as a person-centred counsellor I resist such reductionism both on behalf of those who become categorised in this construct and
on behalf of my own reluctance to reinforce that authority. I will therefore at times in this writing signpost my critical distance from certain terms or concepts with the use of italics to show that as a person-centred counsellor I am resistant to such language.
The medical model The medical model, which proposes that diagnoses require treatment, is predominantly a western ideology that presents itself as a truth based on scientific fact. Other cultural health solutions are regarded as ‘alternative’ (with connotations of being deviant) or more commonly rubbished as being ineffectual. Such otherness, where there is an implicit questioning of the wisdom in departing from the standard, is regarded with deep suspicion: why is a different approach being considered when the medical model has been proven to be the right and only way to treat people? This unquestioned dominance is reflected in the DSM, which was originally
designed by a culturally narrow and exclusive group of western male white psychiatrists. Although the latest edition of DSM-52 has developed considerably from its originator in attempting to address cultural difference and diversity, it is nevertheless a remodelling of the same construct that adds to and modifies what has gone before. In this classification system, there is a worrying risk of marginalising minority cultural representations, which are potentially disempowered to voice any opposition. Homosexuality was originally included as a pathological diagnosis in the DSM but political opposition resulted in its removal. ‘Gay, lesbian, bisexual’ is now an interest group of the American Psychiatric Association (APA), which may invite opportunity for more dialogue. But perhaps the DSM can never truly be representative of modern cultural diversity unless it becomes an entirely new composition that has been created from scratch.
discussion The stigma of diagnosis I have worked with clients who appear to crumple under the stigmatising pressure of a psychiatric diagnosis. They have believed that the diagnosis defined them. It was who they had become (or had always been) and they had to learn to live with it. Clients recognised the impact of treatment, medication that helped alleviate the distress but could bring with it negative side effects (which also had to be accommodated) or therapy that had taught them how to mediate the tensions generated by their psychiatric illness. Either way, the diagnosis served to determine the client’s difficulties so that any response relied upon that fixed classification. If the client’s condition didn’t improve in response to treatment, there was a loss of hope in the inevitability of the belief that this is how it’s always going to be. Improvement will come with the prescribed remedy, and I have often seen this equation internalised where clients perceive no respite and conclude that it is their fault that the proposed solution isn’t working. This further adds to their distress and possible sense of hopelessness. Perhaps subjecting people to this methodology can have a detrimental effect on their mental health and, rather than alleviate distress, even augment it. Moreover, as counsellor, I have also felt disempowered where my capacity to help the client has been subject to the same delineation that implies that I cannot make a difference either.
The notion of a continuum Part of my learning has been to reconceptualise the demarcation that the DSM determines so that I allow for the notion of a continuum (in which we all participate) showing the range and variety of elements that can contribute to the varying degrees of psychological health. 3 This helps to deconstruct the hierarchy of well versus ill and enables us all to acknowledge the frailty of our shared humanity, which means that any one of us can be vulnerable to psychological distress. For me, such a reframing has the potential to redress the power imbalance that positions people as patients and generates the fearful response that they are broken and need fixing. This puts me more on a level with my clients rather than promoting me as
the expert and I am happy to relinquish that power. I prefer to consider psychiatric illness as a disruption in self-development that is characterised by ‘incongruence, discrepancies in behaviour, the experience of threat and the process of defence, breakdown and disorganisation’.4 This concept locates psychological distress as part of a person’s internal processing rather than as a fixed and rigid condition.
Perhaps the DSM can never truly be representative of modern cultural diversity unless it is created from scratch Holding the tension These conclusions about my own theoretical position invite me to explore the DSM with curiosity, rather than rejecting it outright. I can hold the tension of knowing its potential power to categorise people as symptoms of psychological disorder while also recognising its possible benefit in presenting intricate knowledge of psychopathology in a systematic manner that might be helpful to me in understanding such complexities. The question is not whether I use DSM; it is more a case of how I use the DSM. If the DSM’s classification system becomes the starting point of therapy, consulting it as a template for shaping my practice, the danger is that it may dictate my response to my client, where I anticipate I know my client before I have even met him/her, or I become preoccupied with looking for the DSM characteristics rather than relating to the person with me in the room.
A resource of valuable information What is far more useful for me is to use the DSM classifications to inform me of the factors that may influence my capacity to relate with my client or how a client may find it challenging to relate with me. It may be useful to know that someone with a tendency to shy away from social interaction with a fear of being criticised or shamed may view themselves as socially incompetent and unlikeable, therefore unwilling to risk involvement with others without certainty of feeling accepted, all
traits that might be attributable to the diagnostic criteria for Avoidant Personality Disorder. With such information I can surmise that trust will be an essential element in the successful development of a therapeutic relationship and that the experience of unconditional positive regard for this person is likely to be something elusive (and perhaps even frightening).5 I would not be surprised if this person cancelled appointments, seemed to have an ambivalent response to being with me or was even antagonistic towards me. The value of this information for me is in exploring how I might react to such ways of relating and how this may impact on my experiencing of the conditions to enable the relational depth that will promote therapeutic healing. It would be nonsense to imagine that I might be impervious to the effects of working at building a therapeutic relationship with someone who may be resistant to that process. I can acknowledge that such a challenge may be disappointing and even frustrating for me, and this would be something I would explore continually in supervision.
Taking part in the debate Considering psychological disturbance as a process rather than a fixed condition helps deconstruct the bleak inevitability of a psychiatric diagnosis. I am hopeful that those emerging from the school of personcentred theory will not reject outright the medical model, as their predecessors might have done, but instead welcome it as a resource of valuable information. If we participate in the debate exploring psychopathology, we offer our clients the opportunity to evaluate for themselves what makes effective therapy and I think our clients will be the better for it.
End notes 1 Cooper M (2008). Essential research findings in counselling and psychotherapy. London: Sage. 2 American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Washington: APA. 3 Joseph S and Worsley R (eds) (2005). Personcentred psychopathology: a positive psychology of mental health. Ross-on-Wye: PCCS. 4 Tudor K and Worrall M (2006). Person-centred therapy: a clinical philosophy. London: Routledge. 5 Warner MS (2001). ‘Empathy, relational depth and difficult client process’. In S Haugh and T Merry (eds). Empathy. Rogers therapeutic conditions: evolution, theory and practice. Ross-onWye: PCCS.
ukcp news Obituary
1937–2017 Champion of a united psychotherapy profession Michael was a psychiatrist, psychoanalyst and psychotherapist who made outstanding contributions to the field of psychotherapy. He was instrumental in the move to unite the profession. Over a period of ten years in the 1980s, he chaired the working party that led to the formation of UKCP. He was our first chair before we were even UKCP, taking up the role in 1989 of what was then the UK Standing Conference for Psychotherapy until UKCP was launched in 1993. He then set in motion, as the first chair of the Registration Board, our regulatory process. He remained actively involved in the profession. He was made an Honorary Fellow in 2007 in recognition of his great contribution to psychotherapy. The profession owes Michael a huge debt of gratitude for his work, not only in the UK but also in Europe because of his involvement with the European Association of Psychotherapy. We are considering how best to celebrate his life and achievements.
Issue 65 • Spring 2017
The future of psychotherapy
Psychother apy he UK Council for The maga zine of t
UKCP conference special
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2016 Issue 64 • Autumn2049-4912 ISSN
Psychother apy he UK Council for The maga zine of t
Psychodrama and action methods in group and individual psychotherapy
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Issue 62 • Spring 2016
Psychother apy he UK Council for The maga zine of t
The creative use of self in research Explorations of reflexivity and research relationships in psychotherapy
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Could you help shape The Psychotherapist? We’re looking for consulting editors to join our editorial team. As consulting editor, you will: - oversee material submitted for publication and ensure a degree of balance in the representation of diverse views, perspectives and modalities - scrutinise material submitted and consult as necessary to ensure accurate representation and high standards of debate and discussion - check submitted articles for fairness and accuracy and, if appropriate, identify potential sources of alternative views to ensure balanced coverage - support the editorial board in its work. If you would like to get involved and have experience overseeing a magazine, we’d love to hear from you. Get in touch at firstname.lastname@example.org.
Fifth UKCP Research Conference: Claiming research as a clinical resource Sat 30 September 2017, London Hosted by the UKCP Research Faculty Committee, this biannual conference is focused on the potential of psychotherapy research for clinicians and psychotherapy organisations. In particular, the conference will explore ways in which individual clinicians and organisations might use their experience to develop research from their practice, and the value of mainstream psychotherapy research literature and tools for clinical practice. The conference will address the broader issue of the differences between stakeholders in relation to psychotherapy research. For further information and to reserve your place with an early booking discount, please go to www.psychotherapy.org.uk/events or contact the Events Team on 020 7014 9966
Learning from Complaints: Sat 28 October 2017, London Save this date for our third Learning from Complaints workshop. More details to be released shortly.
Raising our profile Richard Hunt reports on UKCP's partnership with Psychologies magazine.
s I write this, we are into the third month of our unique partnership with Psychologies magazine. Almost 500 members have signed up to the partnership, and many are using the dedicated LifeLabs channel on the website to discuss a variety of issues.
What is the Psychologies partnership? The Psychologies partnership allows members to have a presence on the magazine’s LifeLabs website. For a small fee (£20), you can create a profile on their website, upload articles and blog posts, and interact with their readers about how you can help them. Both Psychologies and UKCP actively promote the articles and blogs that our members contribute to LifeLabs on our social media channels. The partnership also gives us a button on Psychologies magazine homepage, linking through to the UKCP website. Our analytics show that this route is a common way people find their way to UKCP, and that our visitor numbers are increasing. In addition to this online promotion, we also receive a full page advertorial in the magazine each month, with a Q&A provided by a UKCP member.
Why Psychologies? One of our key strategic aims is to increase awareness of psychotherapy among the public. In terms of its reach and readership, we can’t really have chosen a better outlet. This magazine is widely available in supermarkets, newsagents and further afield, reaching all sorts of people. Their website receives 250,000 unique visitors
Richard Hunt UKCP Head of Communications
per month, and 65 per cent of those are searching for answers to their emotional problems. Their article contributors are qualified psychotherapists, counsellors and representatives from the other psychological therapies. Increasingly, they are looking to UKCP members for articles as they see the quality of the writing on the LifeLabs channel. Not only that, Psychologies really wants our members to succeed in reaching the public. They have created a training area including information on how to get the most out of being on LifeLabs. They also hosted a free online workshop on how to promote yourself as a therapist to the public and the media.
Why we set up this partnership In our membership survey at the end of last year, members were asked what the most important activities UKCP should undertake were. 90 per cent said: improve public understanding of psychotherapy and psychotherapeutic counselling. 89 per cent said: raising the profile of the profession through media and press work. 87 per cent said: help ensure that the highest quality and range of psychotherapies is made available to all. There was also a clear desire for us as an organisation to help improve the employment situation of members, most of whom work in the private sector and run their own individual practices. We feel that the partnership between Psychologies and UKCP is a step towards responding to these findings.
Tell us what you think Although on the whole we’ve had encouraging feedback, we’d like to hear your views. Is the Psychologies partnership a step in the right direction for UKCP? Send your views to email@example.com. uk.
Find out more Please have a look at the blogs and articles created by members: lifelabs.psychologies.co.uk/channels/629ukcp-therapists-channel For more information about the partnership, including how to sign up, visit our website: www.psychotherapy.org.uk/news/ psychologies-partnership/
Some differing viewpoints ❛ This partnership will help us
build a relationship with a group of people we might otherwise never get to talk to. As with all relationships, it will develop over time and may take time on our part to create and nurture. We may even learn from each other as well. When you see my profile, do stop by and say ‘Hello’, and feel free to comment on any of the posts or videos that I publish. Let’s get talking.
I just wanted to question UKCP’s affiliation with this magazine which, as I understand it, is a rather crass women’s magazine with a pop-psychology theme. I am ever mindful that our work is often mistakenly (or perniciously) grouped with ‘alternative’ or ‘complementary’ practices and that our credibility suffers for it. I don’t want to be too hard on Psychologies magazine, and I don’t know to what extent its editorial content is overseen by people who are qualified to judge it, but I worry that an association with a professional body such as UKCP might dignify it with more status than it actually deserves.
Helping the public to find a therapist
hen we created the new UKCP website, one of our key aims was to develop a much improved ‘Find a Therapist’ function to make it easier for people to find the therapist they need. We listened to feedback from members and the public in designing the new Find a Therapist and featured it on the home page so that it is easier to find and use.
Our online advertising campaign
magazine. It is the second most visited page on our website, after the home page. In May our visitor numbers increased thanks, in part, to our partnership with Psychologies and the extra publicity we received because of our campaigning work during the General Election. Since we launched our new website, we have been steadily climbing up the search engines and are now seeing just under 103,000 unique page views per month.
Can we improve Find a Therapist?
We are promoting Find a Therapist with our first ever advertising campaign on Google and social media. Our aim is to reach out to a range of audiences who have turned to the internet to find out more about health and wellbeing concerns.
From the feedback we’ve received, one of the things that we know people struggle with is finding enough information about the therapists in their search results. A bit like online dating, searching for a therapist involves finding someone who you feel you can talk to.
Find a Therapist is also being promoted through our partnership with Psychologies
One of our members told us: ‘A friend asked for my help in finding a therapist for her
daughter. The young woman had tried using UKCP’s Find a Therapist facility, on my recommendation, but hadn’t found it helpful. I undertook to find a few names that I might feel comfortable to suggest. I really wish I hadn’t. Out of more than 600 names, I found three. Call me picky, if you will, but I was looking to ‘recommend’. I was surprised at how few profiles had website addresses, pictures or photos, or information offering the potential client an overall idea of the kind of person they might imagine the therapist to be.’
How to update your profile So you can see how important it is to complete your profile. If you are on Find a Therapist, please do it now! If you need help, we have put together a step-by-step guide on how to complete your entry, which can be found on our website at www.psychotherapy.org.uk/website-faq.
ukcp news Alternative Dispute Resolution: consultation survey results
’m pleased to announce that the results of our Alternative Dispute Resolution (ADR) consultation survey are in! We had an overwhelmingly positive response to the survey, and I wanted to share some results with you.
The consultation ADR is a voluntary process and one that only works if both parties agree to participating and engage with the process. We therefore thought it only right that we speak directly to those who are going to be using the process on a day-to-day basis. To do this, we put a series of questions out for public consultation. The survey was formally launched at the Complaints Workshop in Manchester on 14 October 2016 and closed on 10 December 2016. It was designed to cover a broad array of topics that you, our members and clients, have told us are important to you. This includes (but is not
Samantha Lind UKCP Case Manager
limited to): what sort of tools and types of resolution you would like available; whether mediation should be handled locally or more centrally; the confidentiality of mediation sessions; independence and transparency of mediation; cost of mediation; and mediation training.
Your experience with ADR As part of the survey, we asked respondents to tell us about their experience with mediation or ADR. In particular, we wanted to know the sorts of things that worked well or helped to deliver a positive outcome, and those things that did not work well or could have been improved. Most people who responded to this question were glad that they had been offered the opportunity to resolve their concern through mediation. It was clear from the comments that the best way to ensure mediation is successful is to ensure that the process is: • Non-confrontational, supportive, open, and a place where difficult conversations can be held safely • Easy to understand and access, and • Quick and informal, with the flexibility to tailor a solution to the specific issues at hand.
Professional Conduct Committee
s I write this, my third report as Chair of your Professional Conduct Committee (PCC) is before the UKCP Board and will soon be published. This has been a busy year for the PCC as far as getting information out to members is concerned.
This year we have facilitated two very well attended workshops, one in London and
Brian Linfield Chair of the Professional Conduct Committee
the other in Manchester, about our work and the triggers that result in the complaints we receive. Members’ feedback from both was extremely positive, with the Manchester event achieving a 100 per cent satisfaction rating from the 55 members who attended. It was also great to see and speak to colleagues from BACP and BPC who were also in attendance. Following the success of these two events, we will run another in London later this year. This will also be an excellent opportunity for members to hear about the work that has been taking place on Alternative Dispute Resolution. Supervision has been an issue that has kept cropping up in complaints over the last two years and was an issue that animated members in Manchester. It was good to hear
We were pleased to see these results, as they accord perfectly with our vision that ADR should be an informal process that emphasises a cooperative and constructive way forward for the parties involved.
ADR and the Complaints and Conduct Process (CCP) As you know, we have a formal complaints process in place for complaints that suggest that there is a real risk to the public if the therapist continues to practise without restriction. These complaints involve behaviour by the therapist that has breached our Code of Ethics and amounts to serious misconduct. ADR is designed to complement the CCP and handle other grievances or concerns that may not meet the criteria for the CCP, with less stress and anxiety than a formal complaints process can produce. As part of the survey, we were also interested to know about respondents’ experiences with complaints processes – what worked well and what didn’t – and curious to understand the sort of situations that you felt were appropriate for each process. It was clear from the results that everyone agreed that situations of a very serious nature, such as sexual misconduct, safeguarding issues or allegations of abuse, were not appropriate for ADR and must be referred to the CCP. However, it was pleasing to see a consensus that most other situations
UKCP commit to holding a workshop in 2017 purely looking at supervision. Members also requested advice on contracts, complaint leaflets and record keeping. We are looking to get guidance out on these, with the usual caveat of only using what works for you. The PCC also aims to carry out more indepth profiling of complaints to try to identify any high-risk groups and ways of preventing complaints. In 2016, one of the main root causes for complaints was breaches of confidentiality by the therapist, caused either by not protecting client information or by disclosing information about clients without consent. Confidentiality was also one of the main root causes for complaints in 2014 and seems to be a recurring theme. We have some suggestions for therapists who find themselves in a situation where they feel the need to break
ukcp news could be addressed by ADR, such as misunderstandings or misattunements, money or contractual issues, and communication breakdowns. It is our hope that 80 per cent of the complaints received by UKCP will be able to be resolved by ADR, with the other 20 per cent taking the more formal path under the CCP.
The shape of the ADR policy The rest of the survey was dedicated to the shape of the ADR policy – what sort of tools would be useful to help resolve matters, confidentiality of the ADR process, costs of the ADR process, and the importance of local resolution. The full report is available to read on the UKCP website, and I would encourage you all to take some time to review the findings as it makes for a very interesting read.
Next steps The next stage of the process is to produce a draft ADR policy. As part of this process, a working group (comprising representatives of UKCP’s colleges and organisational members, members of the Professional Conduct Committee, and professional mediators) will review the results of the consultation survey and work with me to produce a final policy. We hope to put this before the Board of Trustees for approval in July this year.
confidentiality: For example, if there is a serious risk of harm to their clients or to others: they could 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. I’d like to pass on my sincere thanks to Ruth Yudkin, Jane Hetherington, Margaret Headland and Niki Reeves. All four are UKCP members who have left the PCC over the last 12 months. They will be greatly missed. It was great to work with true professionals who clearly respected and wished to maintain the public’s confidence in psychotherapy and UKCP as a first-class regulator. The voluntary hours they have contributed to our work has been highly valued. Thank you. I welcome four new PCC members. Three are professional UKCP members, Sheila Foxgold,
Mental health influencing at a local level in the NHS
or some time UKCP has been working to influence national policies. In recent months this has included pushing for high-quality therapy on the NHS and campaigning to end benefit sanctions. While we will continue this important work, we’re also now beginning to work at a local level.
I have recently been appointed as Policy and Advocacy Officer. It’s a new role at UKCP that aims to ensure local NHS psychotherapy services will have more of a permanent place in our policy landscape. I will be taking a closer look at mental health services across the UK. While the main purpose of this is to support members in regions suffering from a lack of funding and resources, there will be other benefits. It will help to shine a light on how national cuts affect local services and will raise the profile of the deterioration of mental health that may not be
Elisabeth Dobres, Policy and Advocacy Officer
Henry Adene and Kedzie Penfield. The fourth is a new lay member, Graham Briscoe. You can find out more about them later in the report. Katrina Ashton is to join us as the interim representative from the Ethics Committee. Below are the headline figures for complaints and enquires received by UKCP in 2016. You can see there were 120 general enquiries, 208 complaint enquiries, and 31 actual complaints received, with two taken forward
Number of CCP cases received Number of cases accepted Number of cases ongoing General enquiries received Complaint enquiries received Number of Adjudication Panels Number of Interim Suspension Hearings
visible at a national level. It will also help supplement our national policy work by giving us specific examples of the effect mental health cuts are having in communities across the UK. I’ve started by getting in touch with college chairs to see if they have directly experienced local service closures and deteriorations. As a result, I’ve met with a number of psychotherapists from areas such as Bristol and Kent to gain more of an understanding of grassroots issues. This has been incredibly useful in helping me to understand more specific problems that Trusts and clinical commissioning groups (CCGs) are experiencing. These have included extremely low numbers of NHS psychotherapy posts, the poor ratio of clients to psychotherapists and therapist workplace stress. I now need to gain a fuller picture of what’s happening in other regions across the UK. The more direct experiences I gather, the more we can do to pressure the government to change this. So, whether it’s a reduction of psychotherapy posts, longer waiting times or service deterioration, if you or someone you know are experiencing cuts in your area, please do get in touch. You can email me at firstname.lastname@example.org.
to an Adjudication Panel. There were four cases ongoing from the previous year. More detailed information can be found in the PCC Annual Report online. Complaints activity Finally, I can once again assure the public and members that UKCP has a complaints process that is fit for purpose and is working well.
Jan–Mar 7 0 0 36 56 1 0
Apr–Jun 9 0 0 38 26 3 0
Jul–Sep 10 0 3 17 63 1 1
Oct–Dec 5 2 3 29 63 2 0
Psychotherapy and the General Election W
e have just witnessed one of the most exciting general elections of recent times. When Theresa May called the vote on 18 April, everything appeared to be a foregone conclusion: pundits agreed that the Conservatives would win an increased majority, and the Labour party would be crushed. The only question, it seemed, was by how much. However, it didn’t work out like that. By the close of polls, the vote was on a knife-edge, and a hung parliament resulted. UKCP was active throughout the campaign. We managed to be the first organisation across the entire mental health sector to issue our set of ‘asks’ for parties to include in their manifestos. We then built on this, taking the lead in writing the sector-wide asks on behalf of the We Need To Talk coalition – a group of over 20 leading professional bodies and charities, including Mind, Rethink and the Royal College of Psychiatrists. Using our growing contacts within political parties, and pressure applied by UKCP members who wrote directly to their candidates, many of our calls made it into party manifestos. While the Conservatives unfortunately did not agree to any of our asks, Labour, the Lib Dems, and the Greens, all took on board at least some of our suggestions – meaning that huge numbers of MPs were elected on a platform favourable to psychotherapy. With Parliament so finely balanced, that could be very useful over the coming months and years.
So what did we call for? We called for what members wanted. In the 2016 members survey, the overwhelming
Peter Kunzmann Policy and Public Affairs Manager
policy priority that UKCP members wanted the organisation to pursue was to get more high-quality therapy on the NHS. We ran with this. We called for more access, better quality, shorter waiting times – and most importantly, the funding required to make these things a reality. Why these specific calls?
Access The unfortunate truth is that only 16.8 per cent of adults who need therapy are able to get it on the NHS. The government’s target, prior to the election, was to raise that figure to 25 per cent by 2020/21 but that still leaves that vast majority of people unable to get the services they need. For children, the story is not much better – with an access target of 35 per cent by 2020/21. We called for all political parties to raise their ambitions and aim to see an extra million adults and 500,000 children per year over and above current plans.
Quality We know it’s not enough to simply push for more access, so we pushed for quality service too. Quality means enough therapists to provide enough sessions to properly help children, adults and families resolve the issues they face. Quality means a choice of therapies, not just one-size-fitsall. And quality means employing therapists trained to deal with the complexity of cases they face. We made clear that access and quality must go hand in hand. There’s little point giving lots of people access to poor quality services, and little point in giving good quality therapy to only a tiny proportion of those in need.
Waiting times We also emphasised waiting times. There is a strong relationship between the length of time a client sits on a waiting list and their chances of recovery. Current waiting times are simply too long. For adults, the waiting time targets are for 75 per cent of people to be seen within six weeks, and 95 per cent within 18 weeks. For most children’s services, no waiting time targets exist at all.
We argued for a maximum 28 day waiting time target from referral request to first treatment appointment, for both adult and child services. This is not a perfect target, a 14 day, seven day, or even one day target would be better – but 28 days is an achievable first step that we believed politicians could sign up to.
Funding and ring-fencing Unsurprisingly, our calls cost money. They require more therapists and for those therapists to have the time and capacity to offer clients the number of session they really need. We set out a provisional costing of £1.5 billion for our plans, which not only provided for a considerable increase in the number of therapist posts, but also for our quality calls to be met. In primary care, for example, we costed for a doubling of the average number of sessions that could be offered to clients. £1.5 billion may sound a lot, but in government terms it is a relatively small amount. The annual NHS budget is around £120 billion, so our call was really for just over one per cent extra to take a big step towards a genuinely high-quality therapy service. Importantly, we also called for the mental health budget to be ring-fenced. Too often local NHS commissioners decided that money that was meant to go to mental health ends up propping up other services. This makes a mockery of government spending pledges. Ring-fencing the mental health budget would help stop this – and ensure that money pledged for mental health services actually goes to mental health services.
The future The election may now be over, but our campaigning work is not. Pressing parties to include pledges in their manifestos is just one way to influence the political process. We are now seeking to build on our election campaign by speaking to MPs, and highlighting our work in the press and social media. We will continue to argue for the kind of high-quality psychotherapy on the NHS that UKCP members want and clients deserve.
Iain McGilchrist gives his keynote address while fellow speaker Richard Erskine and Vice Chair Pat Hunt listen
UKCP conference, March 2017
The future of psychotherapy: science, politics and best practice
or those of you who know me, you know I have run and organised 20 international conferences over the past two decades. Rather than going on about those, I want to talk today about the conference I attended yesterday organised by the United Kingdom Council for Psychotherapy. I should declare an interest in that my best friend and colleague Fiona Biddle, whom I have run all of the above mentioned conferences with, was on the conference committee which put on yesterdayâ€™s event. I have to say that in the past, I had felt a note of dread going to psychotherapy conferences. They are usually dry, navel-gazing affairs. However, this was different. This event was held in the magnificent facilities of Regentâ€™s University in London. There was a dynamism about this conference that I had not experienced in a psychotherapy conference before. The Conference Chair, Patricia Hunt, oozed confidence and professionalism. The keynote addresses by Iain McGilchrist and Richard Erskine were informative, entertaining and thought provoking. One of the highlights for me was the three chairs' discussion which took place after the keynotes. The three chairs represent UKCP,
Shaun Brookhouse Hypnopsychotherapist, Chair of International Committee and Hypno-psychotherapy College
BACP and BPC. Martin Pollecoff, Andrew Reeves and Gary Feredy represented these professional bodies most ably. Having been a member of UKCP for more than 21 years, it made me proud that my organisation is involved with this collaborative project, which is designed to help psychotherapy and counselling speak more with one voice. After lunch, I attended a workshop on wellbeing which was presented by two psychotherapy legends, professors Emmy Van Deurzen and Digby Tantam, as well as Peter Kunzman, the Policy and Public Affairs Manager of UKCP, and chaired by Fiona Biddle. A fascinating discussion ensued about the sociological and philosophical implications of wellbeing and how psychotherapy can help to facilitate wellbeing nationally. After a brief coffee break we were treated to the Psychotherapy Question Time, professionally hosted by boradcaster Michael Collie. The panel of experts were the Rt Hon Professor Paul Burstow, Jenny Edwards of the Mental Health Foundation, Professor Andrew Samuels and Judith Lask of the Institute of Family Therapy. The questions posed were both thoughtful and insightful. The answers were well defined and sometimes a bit controversial. I was left with a feeling of how wonderful it was to see professionals discussing the issues of the day professionally and dynamically. The conference closed with UKCP Chair Martin Pollecoff launching what I am sure is to be a great campaign, 'The Campaign for Real Psychotherapy'. I believe this will not only give the public something to think about but also we, the professional psychotherapists, will be challenged to find a way to discuss and describe what it is that makes our psychotherapy 'real psychotherapy'.
ukcp members Book review
Out of This World: Suicide Examined Antonia Murphy ISBN 978-1-7822048-7-9; £ 19.99
he purpose of this book is to examine suicide from all perspectives. This makes for a hugely interesting read, where the author writes about her experience of working with people who feel suicidal and for whom suicide is a significant risk. Antonia Murphy explores and addresses the perceptions of suicide here in the UK and around the world, referencing relevant experts and their understanding of suicide. It is important that Murphy emphasises that suicidality is not a mental health ‘illness’, and that she looks at the unconscious process and the importance of psychotherapy in supporting the suicidal client. I particularly liked how she uses facts and quotes from around the world to highlight the complexities of this emotive subject. As someone who supports a team of psychotherapists working with suicidal clients and clients who have been affected by suicide, I found this book has helped me be less fearful and more understanding. I highly recommend this book to everyone who works directly or indirectly with suicidality. Samantha Taylor, Practice Manager, The Wright Initiative Psychotherapy Practice
The Mother in Psychoanalysis and Beyond: Matricide and Maternal Subjectivity Edited by Rosalind Mayo and Christina Moutsou ISBN: 978-1-138-88505-9 (paperback), Routledge; approx £24
his set of essays deconstructs much traditional psychoanalytic theory and suggests a direction for a vibrant maternal subjectivity. Matricide, which can be understood as the symbolic silencing of the mother’s discourse, forms the first half of the book. Part two explores maternal subjectivities as a creative response to matricide.
Amber Jacobs reconceptualises the Oresteian myth by radically rethinking Greek mythology. Her analysis of the Greek myths shows us the limitations of previous readings by Freud and Lacan.
A key strength of the book is its willingness to tackle the complexity of ‘matricide’ and explore the creative/destructive dialectic inherent in this term. It finally helped me to understand Kristeva’s iconoclastic claim that ‘matricide is our vital necessity’.
Rosalind Mayo explores feminism’s collusion with youth culture as a form of matricide, while Melissa Benn urges us to be honest with our daughters about the depths and demands of becoming a mother and the need for them to fight for their due – to take on the world, not retreat from it.
The editors contend that discourses and narratives of ‘the Mother’ are marginalised at the sociocultural level and within psychoanalysis and philosophy. They argue that ‘the maternal’ is the foundation of the human condition, influencing how we live our lives, and how we situate ourselves culturally, politically and within intimate relationships. Contributors explore how ‘issues of personal and gender identity are shaped by the ideals of separation from the mother, and look at the anxieties of merging with the mother and discourses that lead to mother blaming’. Lucy King explores maternal ambivalence through her readings of Ferenczi, Winnicott, Kristeva and Rozika Parker. Christina Moutsou re-examines the Metis-Athena myth and its underpinning of patriarchal ideology. She is concerned that the mother should be viewed as an actual other, not reduced to a container, mirror or breast.
Christina Moutsou and Rosalind Mayo have curated subtle, provocative and thoughtful perspectives from psychoanalysis, politics, personal testimony, mythology, anthropology, poetry, music and art. The book enters fearlessly into the disputatious territory of psychoanalysis in a refreshingly plural, panoramic and maternal manner, making it a valuable resource for both trainees and advanced practitioners. Dr Paul Caviston FRCPsych Consultant child and adolescent psychiatrist; psychoanalytic psychotherapist (UKCP-accredited)
References Chodorow N (1978). The reproduction of mothering. ISBN-13: 978-0520221550. Froula C (1996). Modernism’s body: sex, culture and Joyce. Cambridge University Press; ISBN 0-231-10443-X.
Anxiety Island: work with your child to overcome fear, phobia and anxiety (app) by Audrey Sandbank
KCP-registered family psychotherapist Audrey Sandbank has created a gateway to an interactive programme based on sound behavioural principles and knowledge of child development. Audrey has long-term experience of working with the families of small children. Her app, Anxiety Island, is designed for children to use with their parents or carers. It uses the imagery of an island and invites the child to fight a dragon, which represents one of a number of anxieties such as fear of separation, going to school, simple phobias and compulsive behaviours. The externalisation of the anxiety in the form of a dragon is a sound principle and the animations and voices, which are appealing to a young child, follow accepted desensitisation
principles. I think that it may be applicable to a narrower age range than suggested, however, and would probably work best with four- to nine-year-olds. There is some good evidence that computer-based programmes and parent-directed CBT, such as Coping Cat, can be effective with children’s problems, as long as the problems are not too severe. There are a number of other anxiety apps around but they are mainly designed to help children articulate feelings (for example, Positive Penguins) or encourage mindfulness. Audrey’s offering is a welcome development and uses a child-friendly programme to engage children in gradually overcoming their anxiety, supported and guided by their parents or another adult. It takes children through small steps and repetitions, and rewards success with virtual stickers.
The information provided for parents could be presented in a more engaging manner and it would be helpful to have links to further information and help in the parent section. Parents often want help in knowing whether an anxiety is just a ‘normal phase’ or something to take more seriously, and a little more guidance on this would be helpful. The identification of unhelpful comments and behaviours would be another useful addition. It is easy to suggest small tweaks, such as breaking up the repetitions with encouragement or reward, but this is a useful programme, which can be followed with limited computer skills. I would recommend it to clients as an adjunct to therapy, as well as more generally to parents. Judith Lask, Chair of the College for Family, Couple and Systemic Therapy and member of the Faculty for the Psychological Health of Children
Time-limited Art Psychotherapy: Developments in Theory and Practice Edited by Rose Hughes, Routledge, (2016); ISBN: 978-0-415-83477-3, p227
owadays, so many mental health ‘services’ in the NHS are being forced into the straightjacket of linear, manualised therapies driven by cost-cutting and targets. So it is reassuring to find a book describing work being done in the NHS committed to the belief that therapy should be fashioned to meet the needs of each individual. Rose Hughes introduces the book with an exploration of how time constraints imposed on therapists in NHS services can be used creatively. Hughes also maps out the contextual background to time-limited therapy with a brief but thoughtful discussion about the philosophical, developmental, cultural, commercial and political dimensions of time.
Of course, all psychotherapy is timelimited, so brief may be a better description. The trend towards brief interventions has partly been driven by demand outstripping supply and by the recognition that, for some people, a brief intervention is safer and more effective. This ambivalence about brief work among clinicians is found throughout this book. As time-limited art psychotherapy so far lacks the research base that providers would probably take into account when commissioning services, it is most likely to be taken up when used in conjunction with other ‘tried and tested’ approaches. The varied contributions, all from therapists working with people with complex needs in different NHS services, elaborate how brief art psychotherapy is integrated with other approaches such as mentalisation-
based therapy and cognitive analytic therapy, both dynamically informed brief therapies with an established research base. I would recommend this book to psychotherapists of all persuasions to guide thinking when making referrals and to broaden their awareness of the varied uses of art therapy. It also deserves to be read as a significant contribution to the literature on brief or ‘time-limited’ psychotherapy. Dr Rachel Pollard, UKCP-registered cognitive analytic psychotherapist
Welcome to our new UKCP members Psychotherapists
Rebecca Catherine Phil Abul Emma Catriona Daljinder Rebecca Ayse Tom Freya Fiona Caterina Rowena Bhawna Kirstin Anja Diane Mike Christopher Jean Emma Carol Jan Chryssa Michaela Melanie Annette Laina Daniel Michel-Eric Elspeth Julia Helena Fiann Sarah Virginia Karen Hannah Kathryn Gary Federica Kirsty Lawrie Claudia Katy Katie Juliet David Gulya Fiona Elizabeth Leah Lucy Lynda Michelle Louise Ruth
Madalina Edwards BPA Polly Anna Patricia Egharevba AFT Lori Appleton FPC Lorna Evans NGPC Maureen Archbold NGPC Oktober Evennett IATE Octavia Arthington AFT Patty Everitt NLPtCA Alison Awal ACOMP Sarah Faithorn AFT Ruth Azzopardi MET Beverley Dawn Finnigan NGPC Norma Baillie SPTI Elizabeth Fritz MC Sharon Bal RSPP Lucy Fuller TER Dagmar Ballard AFT Victoria Fulljames BCPC Myrena Banbridge MET Veena Ganapathy WPF Diane Barber UPCA Linda Gaskell RV Petra Barrett BCPC Stella Giatra AFT Nikki Barrett BCPC Ilknur Girgin MC Jacqueline Elizabeth Baskerville BCPC Edmund Giszter IATE Antje Bell FPC Mandy Greenwell NGPC Rachel Bharakda AFT Audur Gudmundsdottir AFT Carolyn Bicknell MC Angela Haley AFT John Baptist Bjorlo PT Jasmin Han AFT Annabel Blake SCPTI Jo Harding MC Beth Brooks CCPE Charlotte Hart AFT Harriet Burford RSPP Sarah Helps AFT Ann Burke UPCA Judith Henjes SPTI Maria Antonieta Cameron IATE Franziska Hewitt AFT Mariana Carrington NGPC Ian Patrick Hickey CFET Margaret Cassidy GPTI Michelle Hodgkiss CCOPPP Charulata Chalkia MC Joanna Holroyd RSPP Stratis Chamberlain BC Sonja Hookway WPP Tania Charnock NGPC Patricia Howard RSPP Alessandra Cheek CCPE Jodien HutchesonPrabashny Cigman RSPP Wisby CHF Lisa Amanda Cizniar MET Paolo Imbalzano MET Bianca Cockerell CCOPPP Catrin John BCPC Rajita Conklin FPC Claudine Eleanor 'Ella' Jones BCPC Tanya Cook FPC Kamal Kainth MET Emma Coombs WPF Sonia Kalia AFT Agnieszka Cowdrey IATE Tessa Keeble SCPTI Ian Craven WPF Lauren Kelly RSPP Fay Cross TER Lawrence Kilshaw BC Andrew Cruttenden MET Agnieszka Korzeniewska CCPE Sarah Cutts MET Imogen Koufou SEA Charissa Daines RSPP Simon Lacey CSP Duncan Dalla Vecchia IATE Collette Lambert CCOPPP Beata Darwent AFT Sheelagh Lauder FPC Myriam De Cesare AFT Sarah Lawson WMIP Hannah Delaney AFT Nicholas Leake RSPP Susan Catherine Dias MC Tina Leniuk-Wright IPS Simon Diener ADMP Alison Leverett-Morris NCHP Philippa Dixon FPC Claire Limmer NGPC Ed Diyarova COSRT Aleka Loutsis ADMP Ishtla Downie CCPE John MacDonald RSPP Anita Downing MET Susan MacGregor AFT Lynne Drane AFT Fiona Mackey IFT Karen Draper FPC Ishwinder Kaur Mahon CCPE Elizabeth Drinkwater RV Helen Marsh CCPE Catherine Dykstra IGA Bridget Frances Marston AFT Dorothy Dymoke CAP F Claire Maskery SPTI Konstantinos Eden AFT
Maslen RSPP Richard Taylor ACOMP Maxwell AFT Lucas Teague RV McCamley UPCA Emma Thomas CCPE McCoy IATE Tanja Van Oudtshoorn IATE McGivern AFT Janette Warran UPCA McGowan CCPE Naveen Webber MET Mckinnon UKATA Karen Whiteside WPP McMahon NLPtCA Judy Williams BC Meister AFT Luke Williams MET Mercken AFT Linda Williamson BCPC Metta IATE Rebecca Wood FPC Miles AFT Donna Wright AFT Millard MET Agnieszka Anika Wycislik MET Mitchell-Jackson AFT Ariane Zegarra AFT Moore GASW Charmain Zwart MCCP Morgan KI Morgan NGPC Psychotherapeutic Counsellors Mullin AFT Darren Abbs CHF Murray UKAHPP Marion Astin NGPC Newton MET Paul Cassedy SCPTI O'Brien AFT Joan Doherty IPS Oldknow CCPE Ellen Drew MCCP Olguin Cigarroa RSPP Jane Fior UKAHPP Panayides MC Helen Gilbert UPCA Parker MET Lilly Harrington ARBS Parmar-Yee MC Susan Janet Henthorn MCCP Pasdekis MET Victoria Holtum CHF Perotta Clarke FPC Maggie Jardine IPS Petrolati UKPCPA Giuliano Labban CHF Pillay AFT Sylvia Large MCCP Platts MET Victoria Leeson NGPC Raabe NGPC Sophie Lopez-Welsch UPCA Rajeshwar BPA Kieran McCrystal UKAHPP Refson Marks RSPP Katherine Neve CHF Regan AFT Leah Orr MCCP Religa AFT Sally Parsloe UPCA Richardson BC Ann-Marie Pederson TACT Roberts AFT Elizabeth Pollard UPCA Roberts SPTI Danielle Quirke IPS Rohlfing BPA Helen Reynolds NGPC Russ MET Sarah Robb NGPC Russell AFT Cheryl Louise Stoney-Jones TACT Salter BEELEAF Linda Tayler UKAHPP Sarens MET Sarah Tomley MCCP Saxton AFT Sarah Tomley MCCP Scarth ADMP Elizabeth Anne Van't Hoff NGPC Schwab RSPP Simons AFT Organisational Member Simons MC Association of Core Process Psychotherapists Singh CSP (ACPP) Smith IATE Stevenson IGA Storrie IATE Straker MET Sutton GUILD Swift CCPE * Received UKCP membership with The Taliouridis * European Certificate of Psychotherapy
ACAT Association for Cognitive Analytic Therapy · ACPP Association of Core Process Psychotherapists · ACOMP Accrediting Organisation for Medical Psychotherapy · ADMP UK Association for Dance Movement Psychotherapy UK · AFT Association for Family Therapy and Systemic Practice · ARBS Arbours Association · AWAKEN Awaken School of Outcome Oriented Psychotherapies · BCPC Bath Centre for Psychotherapy and Counselling · BC The Bowlby Centre · BEELEAF Beeleaf Institute for Contemporary Psychotherapy · BI The Berne Institute · BPA British Psychodrama Association · CAP Confederation for Analytical Psychology · CCOPPP Canterbury Consortium of Psychoanalytic and Psychodynamic Psychotherapists · CCPE Centre for Counselling and Psychotherapy Education · CFET Caspari Foundation · CHF Childhood First · CPJAC Council for Psychoanalysis and Jungian Analysis College · CPPC Counsellors and Psychotherapists in Primary Care · FIP Forum for Independent Psychotherapists · FPC Foundation for Psychotherapy and Counselling · GAPS The Guild of Analytical Psychologists · GCL Gestalt Centre London · GPTI Gestalt Psychotherapy Training Institute · GUILD Guild of Psychotherapists · HIP Hallam Institute of Psychotherapy · IATE Institute for Arts in Therapy and Education · IFT Institute of Family Therapy · IGA Institute of Group Analysis · IGAP Independent Group Analytical Psychologists · IPS Institute of Psychosynthesis · IPSS Institute of Psychotherapy and Social Studies · ITA United Kingdom Association for Transactional Analysis · KI Karuna Institute · LSBP London School of Biodynamic Psychotherapy · MCCP Matrix College of Counselling and Psychotherapy · MC Minster Centre · MET Metanoia Institute · NCHP National College of Hypnosis and Psychotherapy · NGP Northern Guild for Psychotherapy and Counselling · NLPtCA Neuro Linguistic Psychotherapy Counselling Association · NRHP National Register of Hypnotherapists and Psychotherapists · PA Philadelphia Association · PCP PCP Education and Training · PET Psychosynthesis and Education Trust · PT Psychosynthesis Trust · RSPP Regent’s School of Psychotherapy and Psychology · SCPTI Scarborough Counselling and Psychotherapy Training Institute · SEA Society for Existential Analysis · SITE Site for Contemporary Psychoanalysis · SPCRC The Regent’s School of Psychotherapy and Psychology · SPTI Sherwood Psychotherapy Training Institute · ST South Trent · TACT Therapy And Counselling Teesside · TER Terapia · UKAHPP UK Association of Humanistic Psychology Practitioners · UPCA Universities Psychotherapy and Counselling Association · WMIP West Midlands Institute of Psychotherapy · WPP Welsh Psychotherapy Partnership
continuing professional development
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The Psychotherapist is available online You can now read a digital version of The Psychotherapist online. The issue that you are holding in your hands, plus many other back issues, can be viewed online at https://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? If you would prefer to stop getting your printed copies of the magazine entirely, you can let us know by logging into the website and updating your mailing preferences. Let us know your thoughts – email email@example.com
continuing professional development Your advert here The Psychotherapist, UKCP’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.
To find out more, email firstname.lastname@example.org A PRACTICE IN CENTRAL LONDON Therapy rooms to rent in LONDON VICTORIA If you are a psychotherapist or counsellor who wants to establish a practice in a quiet therapy room in a highly accessible part of London, preferably for 1 day or more, please phone or email us to discuss available rooms: Phone David : 07939 649356 Email : email@example.com Website : www.wiltonconsultancyltd.co.uk
Do you ﬂy or fall in your dreams? I am a doctoral student at Metanoia and am looking for volunteers who have experienced gravity dreams. If you are interested in helping, I would really value an hour of your ?me to hear about your experiences. Please contact me: Claire Mitchell firstname.lastname@example.org
Qualified Accountant available to assist fellow counsellors and psychotherapists with tax returns, accounts and other financial needs. Please contact Paul Silver-Myer FCCA, UKCP [Reg.] 020 7486 0541 or email@example.com
ABERDEEN · BRIGHTON · EDINBURGH · LONDON · MANCHESTER · MIDLANDS · NORTH EAST OXFORD · TURVEY (BEDS) · YORK
Training and Development in Group Analysis Providing training for over 1100 individuals every year throughout the UK, the Institute of Group Analysis is the premier provider of group analytic and group work training in the UK. Relevant to anyone with an interest in the dynamic relationship between the individual and the group, the IGA Foundation Course in Group Analysis introduces students to an exploration of our essentially social nature and the wide range of applications of group analytic theory. Group analytic training will equip students to understand and to participate more fully in a range of group settings including: work, family, social, learning and therapeutic. Institute Of Group Analysis
Graduates of the IGA Qualifying Course in Group Analysis are eligible to become full members of the IGA and to gain professional registration with the UKCP. Suitably qualified and experienced therapists (including from non group trainings) can continue their learning and development with an IGA Qualifying Training in Group Supervision or our new Qualifying Training in Reflective Practice in Organisations which lead to IGA associate membership (subject to terms and conditions). If you would like to know more about group analysis and group therapy, or how to continue your learning journey, join one of our free events or courses.
1 Daleham Gardens London NW3 5BY
020 7431 2693
The IGA provides: • Foundation Courses • Introductory Week-ends • Professional training (UKCP accredited) • Short Courses • Personal development and CPD workshops • Bespoke Training and Consultancy • Group and individual therapy referrals • Supervisor and TGA referrals • Reflective Practice in Organisations
020 7431 2693 www.groupanalysis.org
The IGA is a charity registered in England and Wales (280942), and in Scotland (SC040468); and is a company registered in England and Wales 01499655
continuing professional development
Applications are open for these TA Psychotherapy courses… Transactional Analysis (TA) Psychotherapy courses in Exeter
TA Psychotherapy Foundation Course: Our popular entry level course runs 1 weekend (Saturday and Sunday) per month, over 9 months. Starts 11th November. TA Psychotherapy Advanced Course: Completion of a TA Foundation Year allows progression onto this 3 year course. Runs 10 weekends a year. Starts 23rd September.
TA 101 Workshops: The Official Introduction to Transactional Analysis - a 2 day (weekend) workshop. Runs regularly throughout the year, in Exeter and Poole.
For further information and to apply: 01392 219200 / firstname.lastname@example.org
Post-Qualification Post-Qualification Doctoral Doctoral Programmes Programmes Post-Qualification Doctoral Programmes
Metanoia 1_BACP_May_17.indd 1
continuing professional development
international conference on psychological & social approaches to psychosis
30 August - 03 september 2017, liverpool
CALLING ALL PSYCHOTHERAPISTS & COUNSELLORS Come and contribute to this multi-disciplinary conference, bringing together experts by experience and profession from around the globe. Focused around the theme of ‘making real change happen’, we are welcoming inspiring plenary speakers and offering lectures, workshops and symposia to suit every interest. All this take place in the wonderful, recently renovated, city of Liverpool with a series of social events to help you make the most of your time with us. Our keynote speakers include: Jacqui Dillon, Jim van Os, Kwame McKenzie, Alison Brabban, Grainne Fadden, Rachel Waddingham, Svein Friis, Jon Vidar Strømstad and Anne Berit Eie Torbjørnsen Topics include: art therapies . social justice . mentalisation . group analysis . CBT . dreams human rights . culture . phenomenological and psychoanalytic perspectives on psychosis listening to voice-hearers . paradigm shift . working with families . open dialogue . migration creative approaches to challenging stigma and prejudice . withdrawing from medication . digital innovations . dissociation or psychosis . power
WE ARE HAPPY TO OFFER A LIMITED NUMBER OF FREE BURSARY PLACES FOR PEOPLE WITH PERSONAL EXPERIENCE OF PSYCHOSIS AND NEWLY QUALIFIED MENTAL HEALTH PROFESSIONALS
BOOKING NOW OPEN: WWW.ISPS2017UK.ORG - email email@example.com 54
continuing professional development
“At the Tavistock, you are taken care of academically. You’re valued as an individual. There’s no judgement. There’s high respect. Really the sort of thing we offer our clients.” Syma Sandford
Let our clinician-tutors take you to the next level. Whether you work with children, young people, couples or adults, we have a course for you. Visit us at an upcoming open day book your place online.
Search for Tavistock and Portman Training tavistockandportman.nhs.uk/training
Feel. Connect. Learn #mytavi
continuing professional development BSc (Hons) Therapeutic Counselling (Top-Up)
The Minster Centre Pioneers of integrative training since 1978 Part-time training in Queens Park, London
Designed for counsellors or psychotherapists looking to top-up their qualifications to an honours degree, this course will enrich professional development and practice. Learning from experts who are researchinformed and research active, you will study with other qualified counsellors and psychotherapists. Upon completion of this course, you will also be in a position to pursue further study at Masters level.
Apply now for courses starting in January
Both full and part-time study options are available. Full-time students are eligible to apply for a student loan for payment of fees.
Our courses offer a unique opportunity to qualified counsellors and psychotherapists to extend their expertise by studying advanced clinical practice or supervision in small supportive groups to Diploma, PG Diploma (1 year or less) or MA Level (2 years).
For more information and to apply visit
• PG Dip / MA in Advanced Clinical Practice th
Next open events on 16 September & 4 November
• Diploma / PG Dip / MA in Supervision th
Next open events on 15 September & 20 October
Book onto an open event or contact Betti to discuss your options at firstname.lastname@example.org For more information see 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
Diploma in ISAT Sex Addiction Counselling
The Institute for Sex Addiction Training
CPCAB Accredited (Level 5) Course Directors: Paula Hall & Nick Turner
The Diploma in Sex Addiction Counselling has been developed to provide counsellors, psychotherapists and addiction specialists with the tools to assess and treat sex addiction. Delegates will also gain the necessary skills to work with partners and support couples in recovery. Module 1: Introduction to Working with Sex Addiction Module 2: Working with Complex Cases and Partners Module 3: Advanced Skills for Working with Sex Addiction
The Home of Existential Therapy Applications throughout the year • • • • • • • • •
Foundation certificate in Psychotherapy, Counselling and Coaching MA in Existential Coaching (blended)* MA in Existential and Humanist Pastoral Care (blended)*** MSc in Psychotherapy Studies (online)* MSc in Autism and Related Neurodevelopmental Conditions (online)* MA in Working with Diversity (online)*** DProf in Existential Psychotherapy and Counselling** DCPsych in Counselling Psychology and Psychotherapy** Professional Certificate Existential Supervision and Group Leadership * ** ***
Validated by Middlesex University Joint courses with Middlesex University Subject to validation
In partnership with
Available in London & Leamington Spa
FOR FURTHER INFORMATION Existential Academy 61– 63 Fortune Green Road London NW6 1DR
For full details, please email email@example.com or call London: 0207 965 7302 • Leamington Spa: 01926 339 594
T 0207 435 8067
0203 515 0223 | E firstname.lastname@example.org www.nspc.org.uk
continuing professional development We help individuals, couples, families, teams, organisations and communities find improved outcomes through better relationships. Relational Change Gathering: The Mask that reveals the Unlived Life
This low cost day will be led this year by Dr Sue Congram. We will have a chance to explore, through the medium of mask, movement, imagery and expressive art, ways of working that can illuminate parts of ourselves that are longing to live. Date: Thursday 30 November 2017, Central London
Supervision – A Relational Change Process PostGraduate Certificate/Diploma
This course is suitable for therapists, counsellors and coaches wishing to supervise others. The course will be based on our new model of a deeply relational approach to supervision and supervisory practice. Date: Starts 14-15-16 December 2017, Kingston-Upon-Thames, Surrey
REGiSTER TODAy fOR OUR 2017/2018 COURSES
Relational Organisational Gestalt (ROG)
This is a holistic and practical approach to facilitating organisational and individual change. Informed by Gestalt psychotherapy, it is structured around our SOS (SELF, OTHER, SITUATION) framework which holds at its centre the importance of developing and nurturing ethical presence. Date: Starts 1-2 December 2017, Esher, Surrey.
Couple Work Certificate/Diploma
This programme focuses on effective, relational couple work. It includes a combination of theoretical frameworks, experiential learning and relevant skills as well as working with embodied process and experimental interventions. Date: Starts 12-13 January, 2018 - Kingston-Upon-Thames, Surrey.
For more information and to JOIN US visit
New Opportunities for Psychotherapists The Prime Minister has recently announced that more emphasis is needed and that funding will be made available to treat and prevent children’s mental health and related problems. PTUK has estimated that 22,700 therapists are required to meet this need. It is also estimated that there are only 4000 fully qualified therapists trained to work with children.
Working therapeutically with children requires special skills. Often children with psychological problems can’t or don’t want to talk about them. When children are given a choice of using therapeutic creative arts media only 7% of the session time, on average, is spent talking.
New! Advanced Diploma in Counselling Children and Young Persons Using Play and Creative Arts Therapies. Builds upon and integrates talking therapy skills with play and creative arts therapies. 15 days training over 9 months. Academic award by Leeds Beckett University at level 6. APAC trains over 500 practitioners a year at post graduate level to work therapeutically with children.
The effectiveness of play and creative arts therapies is validated by PTUK’s clinical evidence base of over 26,000 case measures. Between 77% and 84% of children receiving therapy using PTUK’s Integrative Holistic Model show a positive change.
Phone Dee Rose for start dates and venues at APAC:
01825 761143 Or email: email@example.com www.playtherapy.org.uk The Psychotherapist
continuing professional development Study Group Are you a psychotherapist with at least 5 years post-qualifying experience in private practice? Have you found that over the years your clients have moved into territory that your original training did not prepare you for? Do you have doubts about your vocation as a therapist? This on-going group offers an opportunity to read psychoanalytic and Jungian literature and to discuss clinical and vocational dilemmas. It is led by David Henderson, PhD., Association of Independent Psychotherapists, British Association for Psychoanalytic and Psychodynamic Supervision and the Centre for Psychoanalysis, Middlesex University. For details contact - firstname.lastname@example.org.
EMDR Therapy Accredited Training
3 Part Psychotherapy training delivered by Matthew Wesson
EMDR Trainer, Supervisor, Psychotherapist, Military Veteran
Attractive consulting rooms in Great Portland Street, London W1, within established practice. Rooms available weekdays and weekends, including a newly refurbished room which could suit a practitioner wishing to move an existing practice as well as anyone seeking a minimum 4 hour bloc of time. Excellent location for public transport. Contact email@example.com or 07791 532 036
CAMBRIDGE body psychotherapy CENTRE
OPPORTUNITY to train to teach on the Diploma in Body Psychotherapy (weekends structure). You should be UKCP registered and qualified as a body psychotherapist. For more details and to arrange an initial visit contact firstname.lastname@example.org DIPLOMA and MA IN BODY PSYCHOTHERAPY Next course starts September 2017 on weekends
NICE / WHO recommended for PTSD Also effective in many other conditions Enjoy learning how to integrate EMDR into your existing clinical toolbox
Small, friendly trainings including lots of video & demonstrations Competitively Priced Training in:
London, Leeds & Chester “This was far and away one of the best trainings I have been on!”
Tom Tomaszewski- Psychotherapist Clinical Manager
In-house / on-site training also available
To book visit: www.emdracademy.co.uk 01829 732721 email@example.com
CBPC is a full organisational member of UKCP and Collaborative partner of Anglia Ruskin University
Job Vacancy External Moderator for the United Kingdom Association for Transactional Analysis (UKATA) The External Moderator (EM) regulates the processes within UKATA. Their main role is to assess that the UKATA is delivering all that they say they do. The EM acts as a resource for UKATA, advising, liaising, interpreting and helping to uphold both HIPC and UKCP policies as well as advising UKATA on the implementation of UKATA policies and procedures. The remuneration for this appointment is £1200 p.a. (PAYE) plus out of pocket expenses. The length of the contract is four years. Applicants must be a senior psychotherapist, UKCP registered and a member of the Humanistic and Integrative Psychotherapy College (HIPC). They need to have familiarity with regulatory standards e.g. UKCP, HIPC, PCIPC, QAA Subject Benchmark Statements, QAA Frameworks for Higher Education Qualifications and their implementation by training centres. For full job description please contact the UKATA Administrator via email to firstname.lastname@example.org The closing date for applications is 15th September 2017. Application forms can be found: https://form.jotformeu.com/71285251819359 United Kingdom Association for Transactional Analysis, Unit 4, Spring Gardens, Park Lane, Crowborough, East Sussex, TN6 2QN. Registered charity no 1062624. Limited Company no 3364220.
continuing professional development PODS training days Are you ready to specialise?
PODS (Positive Outcomes for Dissociative Survivors) delivers CPD to counsellors, psychotherapists, psychologists and anyone working with complex trauma, dissociation and child sexual abuse:
Do you want to stand out from the counselling crowd?
Trauma, Dissociation & Recovery: Healing the Brain 8 Jul 2017 in London Child Sexual Abuse: Hope for Healing 14 Jul in Birmingham Working with Relational Trauma: Disorganised Attachment 7 Jul in London // 24 Nov in Peterborough Dissociation and DID: The Fundamentals *NEW* 13 Oct in Bristol // 3 Nov in Nottingham
2-Year, Part-Time Diploma in Clinical Sexology March 2018 to February 2020
Working with Dissociative Disorders in Clinical Practice *NEW* 29 Sep in Peterborough // 14 Oct in Bristol 4 Nov in Nottingham // 2 Dec in London
Enrich your practice by taking the CICS Diploma in Clinical Sexology and qualify as a sex and relationship psychotherapist with leading specialists in the field. Designed to meet the requirements of COSRT, EFS and ESSM you will learn how to work with and treat psychosexual and relationship problems with individuals, couples and multiples, addressing the biological, psychological and social aspects of sex and relationship health and wellbeing. One Friday & Saturday a month in Cambridge.
£85 including CPD certificate & extensive delegate pack. Group discounts and concessions also available. All training is led by Carolyn Spring, author of Recovery is my Best Revenge: My Experience of Trauma, Abuse and DID.
dissociation & trauma
COSRT Approval Pending
For more info & an application form visit cambridgeinstitute.co.uk or email email@example.com
This course now just £50
Book online at: www.pods-online.org.uk/training or by calling 01480 878409 t: 01480 878409 e: firstname.lastname@example.org w: www.pods-online.org.uk
CPD OPPORTUNITIES IN CHILD COUNSELLING/CHILD PSYCHOTHERAPY www.artspsychotherapy.org
Adult/Adolescent to Child Psychotherapy Conversion Course: Diploma in Integrative Child Psychotherapy (UKCP reg.) Forregisteredcounsellorsorpsychotherapistswhowanttogain: • Awealthofclinicalskillsforworkingwithchildren • Asoundworkingknowledgeofprinciplesinchildtherapeuticpractice,childlawandchild protection,essentialforworkingsafelyandethically • Anin-depthknowledgeofchildpsychiatry,diagnosticcategoriesandmedicationusedwithchildren
❚ Professional Diploma in Therapeutic Life Story Work (University validated)
020 7704 2534 2-18 Britannia Row, Islington London N1 8PA email@example.com
Diploma in CBT with Children (University validated)
MA in Integrative Child Psychotherapy (UKCP reg.)
Diploma in Parent-Child Therapy
Diploma in Wellbeing Practice for Children and Young People 59
continuing professional development
CCPE Centre for Counselling and Psychotherapy Education
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) and one-year Lucid Dreaming Certificate All the above courses are part-time and commencing January 2018.
Weekend Seminars 2017 23/24 September 21/22 October 11/12 November
Life Crisis Facilitating Spiritual Growth in therapy Alchemy of Relationships
Cost: £200 per workshop (non-refundable deposit £100) Times: Sat / Sun 10am – 5pm
CCPE, Beauchamp Lodge, 2 Warwick Crescent, London, W2 6NE firstname.lastname@example.org, www.ccpe.org.uk,Tel: 020 7266 3006