For counselling and psychotherapy professionals
Therapy Today
Therapy
Today
December 2015, Volume 26, Issue 10
Cuts decimate FE
counselling services
Mixed race identity in therapy
Workplace wellbeing in a time
of austerity
December 2015, Volume 26, Issue 10
December 2015, Volume 26, Issue 10
Contents
Features
8. Workplace wellbeing
in a time of austerity
22. Bending boundaries
in oncology counselling
12. The threat to FE
counselling
26. Open Dialogue
Bina Convey reports on
how employers are turning
to counsellors to cut the
costs of sickness absence.
Jane Darougar argues that cuts
within FE organisations
threaten the security of
both counsellor and client.
Jane Hetherington introduces
a model of support for people
with long-term mental illness
based on person-centred
principles and dialogue.
Nicola Codner calls on
counsellors to learn more
about the needs of those
with a mixed race identity.
Val Thomas discusses the
contribution mental imagery
can make to therapeutic
processes across modalities.
16. Mixed race identity
and counselling
Regulars
Caroline Armstrong describes
the dilemmas in her work
as an oncology counsellor
in a large teaching hospital.
3. Editorial
4. Your views
6. News
21. How I became a therapist
30. Mental imagery in
counselling
Karen Cromarty
34.Dilemmas
37.Letters
40.Reviews
44.From the Chair
45.BACP News
47. Professional standards
48.BACP Research
52.Professional conduct
53.BACP Public affairs
54.Classified
55.Mini ads
57.Recruitment
58.CPD
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Editorial
The threat to
FE counselling
Cover illustration by
Michael Parkin
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@TherapyTodayMag
The image of the bulldozer made its
first appearance on the counselling
scene eight years ago with the fight
to save counselling after the arrival
of IAPT. This time it is counselling
services in Further Education that
are being obliterated. Jane Darougar,
herself a counsellor in a sixth form
college, describes the importance of
supporting students in FE colleges,
many of whom are disadvantaged or
adult learners returning to education.
The massive funding cuts to Further
Education have resulted in the demise
of more and more college counselling
services with counsellors having to
support clients through abrupt endings
as their services are being axed.
David Mair, the new editor of
University & College Counselling, writes
about the different pressures faced by
university counselling services which,
while not necessarily facing the cuts
and closures in FE, are operating within
an increasingly difficult culture. As David
puts it, ‘The drive within HE to position
institutions as global success stories
filters down to all of us who work there…
Can university and college counselling
services… really play any meaningful
role in countering the stress-inducing
marketing slogans of our employers
‘Whilst schools have
had their budgets
protected and
universities have
plugged the funding
gaps with tuition
fees, FE colleges
have experienced
phenomenal and
catastrophic cuts’
Jane Darougar (p12)
and wider society, and the additional
pressures these create for students?’
And finally… this is my last edition
as editor of Therapy Today. It’s actually
hard to put into words how this feels after
13 years as editor. I was comforted a few
years ago when I spoke to Rich Simon,
the editor of Psychotherapy Networker,
who had done 30 years as editor and is
still going strong! I took over editorship in
2002 and created Therapy Today in 2005
and have witnessed many challenging and
interesting times in the development of
the profession. It has been a privilege to
read so many inspiring articles and letters
about the work that BACP members do.
And it is heartening to see that in our
latest readership survey 83 per cent of you
find the journal very useful or quite useful
to your work. I hope that the journal will
go from strength to strength and continue
to be an important forum for debate and
sharing of best practice and new ideas.
I would also like to pay tribute to
Laura Read, our Production Co-ordinator,
who will be leaving at the end of the
year. Laura has worked brilliantly
behind the scenes putting the journal
together and managing and developing
TherapyToday.net for the last six years.
I wish you all well for the future.
Sarah Browne, Editor
‘Mixed race people
who are not in
touch with their
true selves may
experience distress
in connection with
their identity as
they will struggle to
dispel the racialised
projections others
make upon them’
Nicola Codner(p16)
‘If we opt out of
political, national,
international and
social issues, what
kind of therapists
and human beings
can we be?’
Val Simanowitz,
Letters (p37)
December 2015/www.therapytoday.net/Therapy Today 3
Your views
Are we really
making worldclass minds?
David Mair reflects on the
challenges facing students
and their university and
college counsellors today
I’m delighted to have been offered the
opportunity to edit University & College
Counselling journal. I’ve been working
both as a counsellor in higher education
(HE) and as a head of service for nearly
20 years and in that time I’ve found the
articles contributed by colleagues from
around the country to be immensely
helpful and informative for the work
that we are all undertaking, whether
in further (FE) or higher education.
Our work has changed significantly
over these last two decades. The main
driver of change has been the massive
rise in demand for counselling support
from students, which has frequently not
been met with an equal rise in resources.
As pressures mount we have had to find
ever more creative ways to deliver high
quality services. In too many cases –
especially within FE – these pressures
have led to the closure of services. A new
emphasis on ‘wellbeing’ has sometimes
led to a redesignation of counsellor
posts as ‘wellbeing practitioners’.
The difference between ‘wellbeing’
and ‘counselling’ may seem unimportant,
but use of language is key in determining
reality. ‘Wellbeing’ suggests something
positive, a state we would all hope to
embody. And this ties in so well with
what is happening in the HE sector.
In the crowded university marketplace
the need to fill courses, to generate
income, to rise up league tables and
become a ‘global’ institution are
key drivers. Alvesson1 contends that
universities have become purveyors of
‘premium’ products. ‘Come to our elite
institution, and you’ll have a better life’
is the underlying message behind many
marketing slogans adopted across the
sector: ‘Making world-class minds’;
4 Therapy Today/www.therapytoday.net/December 2015
‘Minds that Move the World’; ‘Ambitious
and Smart – You and Us Both’ – all
designed to convey to students – and,
let’s not forget, their parents – the
sense that this institution, this course,
will increase their chances of succeeding
in life and achieving ‘wellbeing’. HE
struggles to maintain its intellectual
integrity while expanding its intake of
students year on year and adopting many
of the characteristics of commercial
companies, with highly paid executives
setting the agenda and academic staff
reporting ever-increasing levels of stress.
Students are not immune to such
positioning and stress, and I have heard
colleagues say many times: ‘I’m glad
I’m not 18 any more.’ Without question,
life for today’s emerging adults is more
complex and fraught than it was for my
generation. The anxiety that drives so
many students to seek counselling is one
result of living in a market-driven society,
where getting a degree is now deemed
necessary for all, even though simply
getting a degree is no promise of either
a better job or financial security. When
‘the system’ tells you that a degree, and
possibly a Masters, or even a PhD, is just
the starting point for selection by elite
employers who hold the keys to financial
security, suitability for academic study
becomes secondary to the need to obtain
that certificate. And whereas when I was
at university in the early 1980s, getting
a ‘Desmond’ (as in 2:2) was a perfectly
acceptable outcome from three years
of study, now students fear that anything
less than a 2:1 spells ruination. But how
many students are actually square pegs
in round holes, hammered into an
academic setting when perhaps, with
genuine, properly-funded alternatives,
they would be happier in a manual
occupation, learning through an
apprenticeship or vocational course?
An educational fundamentalism has arisen
in society where certain truths appear so
self-evident that to question them seems
perverse, even though the evidence for
their assertion is mixed at best: ‘The
more education the better;’ ‘The ability
to perform at work is primarily achieved
as a result of education;’ ‘As much
education as possible must be upgraded/
relabelled as higher education.’1
The drive within HE to position
institutions as global success stories
filters down to all of us who work
there. With such powerful drives,
failure becomes something shameful,
to be hidden, disavowed. And yet, as
counsellors, we know that for most of us
world-class acclaim will remain elusive;
that failure and anxiety are as much a
feature of life as success. How do we
maintain our personal and professional
integrity within institutions that adopt
ever-more inflated aims and objectives?
How do we, recalling Freud, help our
clients accept ‘common unhappiness’,
with appropriate coping strategies,
as unexceptional and commonplace?
Can university and college counselling
services, now typically offering between
four and six sessions of therapy, really
play any meaningful role in countering
the stress-inducing marketing slogans
of our employers and wider society,
and the additional pressures these
create for students?
I believe that we can, but only when
we are clear in our own minds that
counselling carries within it a countercultural ability to deal with human
unhappiness, failure and hopelessness
not with condemnation or a quick fix
but with compassion and acceptance
based on a more balanced view of
what ‘success’ means. Judging from
the many discussions I have had with
colleagues around the country, as
therapists working in success-oriented
establishments we can and do work
compassionately with student clients
and challenge them to develop more
realistic, more self-accepting life
narratives. We work primarily for the
good of our clients and, although most
of our work will be focused on supporting
students through their studies at a time
of life when developmental issues are
uppermost, it may also, at times, entail
helping them to free themselves from
overblown academic aspirations and
acknowledge a different, more personally
meaningful path through life.
I’m frequently awed and humbled
by the levels of commitment and
professionalism among counsellors
in our sector who are sometimes
struggling with lack of support from
their institutions, facing closure of
their service, or managing long waiting
lists. The sense of genuinely caring
for students of all ages, nationalities,
genders, sexual orientations, levels
of abilities, and faiths is deep and
tenaciously defended. But in the face
of pressures such as hostile media
articles written by those with limited
understanding of the context in which
we operate, or posts by students and
parents who use social media to voice
frustration arising from unrealistic
expectations of overstretched
counselling services, we need nourishing
and reaffirming in our work. I hope that
I will be able to build on the excellent
work of previous editors in providing
a much-needed source of practical and
theoretical support to those of us who
are engaged in student counselling.
The richness of experience and the
wealth of expertise across the sector
is hugely encouraging and I know that
colleagues will continue to share this
with each other through the journal.
I look forward to working with them all.
David Mair is the new editor of University
& College Counselling, the journal of
BACP Universities & Colleges
Reference
1. Alvesson M. The triumph of emptiness:
consumption, higher education and work
organization. Oxford: Oxford University Press;
2013.
Personal therapy
and training
Karin Parkinson argues for
personal therapy in training
I am a longstanding, accredited
member of BACP and proud of how
the organisation has developed its battle
for the recognition of talking therapies,
its accessible interface with the public
and its many, comprehensive learning
resources. One thing, however, causes
me discomfort: the value I place on
personal therapy as an essential strand
in the development of a counsellor or
psychotherapist is no longer shared
by BACP, as it was in the past.
I teach counselling skills to first year
students at the Minster Centre, where
personal therapy is a requirement for
the duration of training. Students are
embarking on an MA/advanced diploma
in integrative psychotherapy and
counselling that, on completion, makes
them eligible to apply for accredited
membership of both BACP and UKCP.
However, without personal therapy
throughout training, UKCP would not
be an option. BACP requirements for
personal development have changed
over the years; today an evidencing
of self-awareness, however gained,
is deemed sufficient. I doubt that it is.
In training I view the three strands of
theory, skills and personal development
as inextricably woven. When studying
theory, students inevitably think about
it in terms of their own lives; the
experiential nature of skills training
brings further unsettling challenge.
Training asks questions concerning
the very essence of one’s being, in
relationship with self and with others.
Many trainings offer a group experience
where students can actively reflect on
relationship in the here and now. Not
all require ongoing personal therapy.
As a trainer I feel supported by the
fact that the Minster Centre does.
Innumerable times I have said, ‘That’s
something which would be worth taking
to therapy,’ or ‘You are asking me, but
have you raised this with your therapist?’
Personal therapy is the place for
students to take all those very intimate
and personal issues that the earthquake
of training throws up. And I am thankful
for it. It helps keep the classroom clear
for the business of training.
Personal therapy also allows students
to take greater risks in the class room.
Students are usually caring of each
other and their fear of upsetting the
peer-client can get in the way of taking
considered risks. Yet where else can
students courageously experiment
if not in the safety of the classroom or,
later, in supervision? Learning occurs
through an in-depth deconstruction
of the interaction. The trigger from
the client, the therapist’s felt response
and intention behind an intended
intervention; then the perceived
consequence and, in feedback, the
client’s experience, are all essential
to learning. I tell my students, ‘Go for
it, take a risk and see what happens.
You might be surprised at what your
client tells you. And if someone has been
touched, that is probably a helpful thing
and they can take it to their therapy.’
In class they are learning about
establishing a therapeutic relationship
while concurrently struggling with their
own. It seems that student clients have
to move from an ‘observer’ position,
watching and assessing how their
therapist is working with them, to
becoming real participants in the
relationship, for their own sake. All
clients come with their expectations
for and perceptions of therapy, which
provide material for the work. In
addition to an in-depth study of
self, personal therapy gives students
invaluable experience and appreciation
of the challenges from the client
perspective.
Much, if not most, counselling and
psychotherapy takes place in the cradle
of a one-to-one relationship. Evidencing
self-awareness obtained in any number
of ways may be an inclusive gesture
but is not, in my opinion, adequate
for a comprehensive counselling
or psychotherapy training. I find it
extraordinary that BACP does not
make this experience a requirement.
Karin Parkinson (MBACP Snr Accred)
is a counsellor and supervisor and a
trainer at the Minster Centre
December 2015/www.therapytoday.net/Therapy Today 5
News
Impact of bullying in schools
The impact of bullying needs
to be urgently addressed with
more funding for in-school
counsellors and training
for teachers, according to
the Anti-Bullying Alliance.
In a poll of 1,496 young
people aged 16-25 and 170
teachers, carried out by
the Alliance, the majority
of teachers (70%) said
support for mental health
of pupils was inadequate
and over half wanted more
school counsellors.
Bullying at school, plus
the effects of cyberbullying,
led to a host of mental health
issues. Almost half of young
people (44%) who were
bullied reported ongoing
problems with self-harm,
suicidal ideation, anxiety,
depression and body image
issues. Long-lasting effects
included difficulties in
forming relationships
and low self-esteem.
National Co-ordinator
of the Anti-Bullying Alliance,
Lauren Seager-Smith,
wants greater investment
in teacher training, inschool counselling and
more funding in Child and
Adolescent Mental Health
Services (CAMHS). ‘Bullying
is a public health issue. We
all need to play our part
to stop bullying wherever
and whenever it happens –
whether it’s in school, the
community or online – but
it’s vital that we also invest
in support for children and
families,’ she said.
© HEMEROSKOPION/ISTOCK/THINKSTOCK (POSED BY MODELS)
CBT behind
Self-doubt can help clients
couple therapy Having self-doubt as a
distress before and after
People who receive couple
therapy for depression are
more likely to recover than
if they receive CBT, according
to the latest statistics from
IAPT. This is the first time
that the Government has
released recovery data by
therapy type, showing that
52 per cent of people who
receive couple therapy
recover from their depression
compared with 44 per cent
of those who receive CBT.
http://www.hscic.gov.uk/
catalogue/PUB19098/psycther-ann-rep-2014-15.pdf
therapist can be better
for your clients than being
confident, according to
new research.
A mix of self-doubt and
personal self-compassion
among 70 psychotherapists
analysed in Norway was
found to relate to greater
reductions and better
outcomes in clients. The
paper, published in Clinical
Psychology and Psychotherapy,
identified these traits as being
pivotal to the outcomes of
255 clients treated in 16 clinics
who completed measures of
their problems and symptom
6 Therapy Today/www.therapytoday.net/December 2015
treatment and periodically
two years after the treatment.
The researchers found
an interaction between
therapists’ self-doubt and selfcompassion and concluded
that this combination
paved the way for an open,
self-reflective stance with
a flexibility to correct the
course of the work if needed.
The majority of therapists
in the study used a
psychodynamic approach,
with just over 29 per cent
humanistic therapists and
28 per cent used cognitive
therapies.
Support for
employees
Employers are to be ranked in
a public index of best practice
as to how they support the
mental health of their staff,
including the provision of
counselling, online resources
and resilience training.
Mind is to launch its
Workplace Wellbeing Index
in 2016 as a benchmark
to show best practice to
other employers. The
announcement came as
new figures released by the
Health and Safety Executive
(HSE) revealed that more
days are taken off work
in the UK due to stress,
depression or anxiety
above any other illness.
Injury and ill-health
statistics released by the
HSE reveal the average
duration of time off for illness
per person was 15 days but
this rose to 23 days for those
taking time off due to stress,
depression and anxiety.
While the figures have
been largely static for the
last four years, Judith Hackitt,
HSE Chair said that ‘more
could be done’ to prevent
the amount of time taken
off work for illness.
The figures only reflect
self-reported work-related
illness, and could be much
higher because of workers
who give a different reason
for their absence.
Emma Mamo, Head
of Workplace Wellbeing
at Mind, said that stigma
around mental health
prevented workers from being
open about their reasons for
time off. The charity’s own
research last year found that
only a fraction of workers who
took time off for stress gave
the real reason, with 95 per
cent giving another reason.
cCBT o�ers little benefit
Computerised cognitive
behavioural therapy (cCBT)
offers little or no benefit
in treating depression,
according to new research.
The research carried out
by the University of York
sheds light on an area of
treatment in which the
NHS has tried to boost
access for those facing a
waiting list for face-to-face
CBT. The study, the largest
of its kind to date, found
that people did not engage
with computer programmes
and reported difficulties
in repeatedly logging onto
a computerised system
when depressed.
Guidelines for treatment
of depression by the
National Institute for
Health and Care Excellence
(NICE), which endorses
cCBT, are currently under
review. A spokeswoman
said: ‘We recommend
computerised CBT as one
option for treating people
with mild to moderate
depression, but the decision
to offer it should always be
based on clinical judgment
and the patient’s preference.’
The ongoing review of
guidelines for treatment
of depression is expected
to be completed in 2017.
© ONDROOO/ISTOCK/THINKSTOCK (POSED BY MODELS)
Depression and anxiety in new fathers ignored
New fathers with depression
and anxiety are largely
ignored and need more
encouragement from health
professionals to seek help,
according to a new report.
Antenatal and postnatal
depression in mothers is
largely recognised with
women routinely asked
about symptoms. But while
depression around the time
of a child’s birth is just as
likely to hit men, few are
asked directly about their
mental health.
A survey by the Royal
College of Nursing (RCN)
of 2,000 mothers and
fathers found that 27 per
cent of fathers experienced
depression and anxiety
during or after the
pregnancy, revealing
an area of mental health
that is less understood
or explored. It was found
that 64 per cent of fathers
were not asked about their
mental health at all during
their partner’s pregnancy.
Adrienne Burgess,
Joint Chief Executive of
the Fatherhood Institute
has called for depression
in fathers to be normalised
to encourage more men to
seek help. ‘There needs to
be a co-ordinated approach
with recognition of the
negative impact on the child
if the father is depressed.
Health professionals need
to pay more attention to the
father-mother relationship,’
she said.
Stigma around mental
health is more pervasive
when it comes to parents,
according to Carmel
Bagness, Professional
Lead for Midwifery and
Women’s Health at the
RCN. She has also called
for more training and time
to treat the mental health
of mothers and fathers.
‘Too many women
and men are suffering in
silence because of outdated
stigmas. Too often attitudes
towards mental health are
not fit for the 21st century,’
she said.
Suicide rates
rise with
recession
A steep rise in male suicide
and suicide attempts has
been linked with recession,
unemployment and financial
difficulties.
The suicide rate among
men in Britain has risen
significantly since the
2008 global financial crisis
reversing previous trends
where the rate was falling,
according to new research. A
report, from the Universities
of Bristol, Manchester and
Oxford, cited 1,000 extra
deaths from suicide and 3040,000 suicide attempts from
2008-2010 during a global
financial crisis which led
to the deepest UK recession
since World War II, where
young people experienced
particularly high levels of
job losses and unemployment.
Data from the Office for
National Statistics, published
this year, show the trend
for a rise in male suicides
has continued with male
suicides three times higher
than the female rate. Factors
contributing to suicidal
behaviour in the report
included unemployment,
disputes over benefits,
wage cuts or demotions
and reduced hours. The
report also drew on other
studies which showed that
pre-existing mental health
problems were a factor and
concluded that vulnerable
individuals became more
prone to suicidal ideation
during periods of recession.
To read the full report,
please visit http://www.bris.
ac.uk/media-library/sites/
policybristol/documents/
PolicyReport-3-Suiciderecession.pdf
December 2015/www.therapytoday.net/Therapy Today 7
News feature
Workplace wellbeing
in a time of austerity
Bina Convey reports on
a rising tide of workplace
mental ill health and how
employers are turning
to counsellors to cut the
costs of sickness absence
8 Therapy Today/www.therapytoday.net/December 2015
Wellbeing is more than just a popular
buzzword in the corporate world right
now; it has become a fast-growing
business in its own right, and one in
which counsellors can play a key role.
A recent flurry of activity around
mental health in the workplace
includes last month’s Good Day at
Work Conversation – an annual wellbeing
conference for business leaders – where
motivational speaker John McCarthy,
kidnapped and held by Islamic jihad
terrorists in the Lebanon from April
1986 to August 1991, talked about
bullying, survival and resilience.
Meanwhile Mind is to launch a
Workplace Wellbeing Index in early
2016 in which it will publicly rank
employers on their efforts to tackle
what has become both a moral and
an economic issue.
Numerous factors have contributed
to increasingly pressurised work
environments over the last decade.
Despite an economic upturn in the
last two years, an austerity-driven
economic climate has led to costcutting in both the public and private
sectors; doing more for less has become
the norm, as has a culture of high
expectations linked to performance
targets. Technology has also played a
part in blurring the lines between work
and leisure, with smartphones ensuring
employees remain constantly ‘logged
on’ to work, with the effect that many
find it difficult to mentally switch off.1
There is nothing like an economic
crisis to make business and government
sit up and listen. A report published
last year by the Chief Medical Officer
Dame Sally Davies2 put mental health
issues at work firmly on the agenda
and called for ‘urgent measures’.
The report revealed that mental
health-related absence in the
workplace is rising, with the number
of days lost to stress, depression and
anxiety up by 24 per cent since 2009,
at an annual estimated cost of £100
billion a year in working days lost to
mental ill health.
The way employers view workplace
wellbeing is evolving, according to
Emma Mamo, Head of Workplace
Wellbeing at Mind: ‘The focus is
shifting from the reactive management
of sickness absence to a more proactive
effort around employee engagement
and preventative initiatives.’ This,
says Mamo, has led to a rapid increase
in employers requesting training and
resources – an area where counsellors
can play a vital role.
The corporate world is playing
catch-up with the public sector,
which has long recognised the need
for employee wellbeing policies,
particularly in sectors with a high-stress
element such as the NHS, police and
social services. Unsurprisingly, stress in
the public sector is being compounded
by austerity measures, with poor sleep,
headaches, stress-related mental health
issues and digestive problems among
the problems reported by over a third
of public sector workers surveyed
earlier this year.3
More private companies are
promoting resilience measures,
from city firms, such as Goldman
Sachs and JP Morgan, investing in
mindfulness training for their staff,
to the increasing uptake of Employee
Assistance Programmes (EAPs).
An EAP offers employers a package
of resources, including workshops
and face-to-face, online and telephone
counselling. The UK EAP market,
worth over £69 million, has grown
significantly. According to the UK
Employee Assistance Professionals
Association (EAPA), the number of
employees with access to an EAP has
grown from 8.2 million to 13.8 million
in just five years. EAP providers argue
Working with resilience in the workplace
Psychodynamic psychotherapist
Teresa Mulvena has worked as a
staff counsellor and mediator in
the NHS since 2008. Resilience
and preventative training play a large
part in her role as staff counsellor.
Mulvena believes that, no matter
what the stressors are, measures
can be taken to prevent stress and
burnout: ‘The most effective things
an individual can do is have a sense
of meaning and purpose outside
work and have strong connections
with others. These two things
make the stress of work feel smaller.
At work the most effective thing to
prevent burnout is the support of your
immediate supervisor. So someone
who listens and sees their needs is
important.’ She adds: ‘It is empowering
to tell people in resilience training and
in counselling to focus on what they
can influence and change and try not
to get distressed about what is beyond
their control. They might not be able
to change many things about the
organisation but we can all look at
how we look after ourselves outside
work – especially focusing on activities
that really replenish you, and improving
how we relate to others.’
Educating managers on the impact
of stress on their workers is also a
vital part of the work for therapists
working in an organisation: ‘For instance,
it’s useful for managers to know that
support makes a high workload much
less stressful,’ she says.
A firm understanding of organisation
dynamics is also important, both from
the aspect of how the counsellor
works with the organisation and
what might be going on for the client.
‘You always have to keep in mind
the triangular relationship,’ explains
Mulvena. ‘The organisation is also
your client and this means you have
to be very clear about what information
is shared with whom. I think an
understanding of organisational
dynamics is very helpful for a
counsellor. We all take our family
dynamics with us and relate to
colleagues like siblings and the way
we react to authority is informed by
our experience of our parents. Working
in any organisation can make you feel
like a child again having to obey the
rules the adults set and this informs
the counselling work too.’
that this increase reflects a change
in organisations’ human resources
strategies, rather than a surge in mental
health problems in the workplace.
Andrew Kinder, Chief Psychologist
at OH Assist and Chair of EAPA, says
the human resources function with
organisations has become less about
people and more about transactions
between departments: ‘HR has changed;
HR departments have become more
strategic business partners with business
objectives and less about the human
elements. They have outsourced this
element to EAPs with 24-hour helplines,
but there are also a lot of hybrids where
you will have a counsellor that has a
face within the organisation.’
There may be a lingering stigma
surrounding mental illness, but there
has been progress in the last decade.
One view is that a greater willingness
to talk about mental health has given
rise to a sense of wellbeing as a human
right: ‘There is no stress epidemic, there
is just a growing sense that people want
things to be OK and are less willing to
cope with the slings and arrows of life,’
says Kevin Friery, Clinical Director of
Right Management Workplace Wellness
Research by Right Management
Workplace Wellness found that the
majority of cases of depression and
anxiety among their clients’ workforces
were due to personal reasons rather
than work issues, although it is difficult
to identify the extent to which work
pressure can exacerbate a personal
or family problem. However, this is
immaterial, says Friery, because the
result is the same: an unproductive
worker who needs support to feel
more motivated in life and in work.
Companies are also realising there
is economic sense in being seen to do
the right thing. Under the watchful eye
of their shareholders, ticking the box
marked ‘corporation morality’ is a must.
They also need to offer an attractive
package of benefits to employees that
they need to retain, as well as to the
talent they wish to attract.
Friery sees a host of opportunities
for counsellors in the corporate
environment, from delivering workshops
on resilience to mediation and
psychological training for managers.
But he feels that many counsellors
need to change their attitude and
engage with what he describes as a
‘different population’ from those
seeking help from the NHS Improving
Access to Psychological Therapies
(IAPT) services, for instance.
‘The trade of a counsellor traditionally
is you and me in the room. EAP
counselling involves thinking outside
the box and one of my frustrations is
getting counsellors to think differently
December 2015/www.therapytoday.net/Therapy Today 9
News feature
‘We received an email which asked us to finish
as quickly as possible, less than the usual six
sessions. It was implied that those of us who
finished quicker would get more referrals’
Working with EAPS
Rick Hughes, BACP Lead Advisor,
Workplace, says there are challenges
and benefits for counsellors in the
EAP market. ‘This is a tremendously
rewarding sector. An EAP counsellor
could typically have a huge variety of
clients, from shop floor operatives to
senior executives. The flexibility and
adaptability required of a workplace
counsellor is one of the benefits
too. The feedback loop back into
organisations means workplace
counsellors really feel much more
engaged with how and what the
organisation can do to effect
and look at how their skills can be used
in other areas,’ he says.
When it comes to telephone, online
and face-to-face counselling, workplace
provision is a very different model to
that used in private counselling. Sessions
are often limited to six (and sometimes
just six in any 12-month period), and
counsellors are required to agree specific
goals with the client and detail how their
progress will be evaluated. If a particular
method is considered suitable, such as
CBT or solution-focused therapy, clients
may request this and will be assigned
to counsellors with that skill set.
With increased competition in the
EAP market comes the need for more
efficiency measures. One counsellor
with five years’ experience of working
for EAPs, who asked not to be named,
said that counsellors are being asked
by one of the UK’s largest EAPs to
try to reduce the number of sessions.
‘We received an email which asked us
to finish as quickly as possible, less than
the usual six sessions. It was implied
that those of us who finished quicker
would get more referrals.’
10 Therapy Today/www.therapytoday.net/December 2015
lasting, positive changes to the work
experience of the client.
‘There can be session limits imposed
on some contracts or clients, but that’s
the nature of time-limited workplace
counselling. Counsellors can only
really work with what is clinically
appropriate in the session limit
given. So they need to have a good
understanding of the contraindications
to time-limited counselling. In some
cases therapeutic assignments
might be more about assessment,
containment and referral on, rather
than going into any real depth.
The amount of referrals can fluctuate
and the fee rates haven’t really risen
in over a decade. While this is reflective
of competitiveness within the EAP
industry, it can also be symptomatic
of the demand and supply of workplace
counsellors. The healthcare sector has
benefited from the Agenda for Change
policy which helped to set pay bands
for counsellors. It would be helpful for
the workplace to have this too. EAPs
want good and effective workplace
counsellors but they’re commercial
organisations and EAP providers
need to strike the right balance.’
Whether competition is driving down
quality is a moot point. ‘There is a lot of
discussion about the number of sessions
but what is really important is the client’s
readiness to change and their motivation.
It is often a view based on clinical need
where you may say: “Let’s work for three
sessions and then review it” rather than
give six sessions,’ says Kinder.
Workplace counsellors are uniquely
in a triangular relationship – with
the client and with the employer,
and there may also be some crossover
with occupational health, when the
counselling work takes as its focus
how to help the client get back to work.
Being ‘organisationally aware’ is
important, according to the EAPA’s
Counsellor’s Guide to Working with EAPs,4
and Kinder emphasises this: ‘I do think
there is a gap with some private
practitioners who don’t understand
the corporate world. Counsellors are
in their own business and self-employed;
it is vital to have some experience of
working in an organisation.’
In the workplace, each employee
is a commodity; it may seem harsh
that cost is a major factor when it comes
to wellbeing but cost may not be the
only factor. A rise in telephone and
online counselling in this market can
also introduce a new potential client
group to counselling. Says Kinder:
‘It can be about accessibility and
having different ways to support people.
Having a chat online and computerised
Cognitive Behavioural Therapy (cCBT)
opens it up to a new audience. People
find it useful, not just those in crisis,
but as a preventative measure.’
References
1. Arlinghaus A, Nachreiner F. When work
calls. Chronobiology International 2013; 30(9):
1197–1202.
2. Department of Health. Annual report of the
Chief Medical Officer, 2013. London: Department
of Health; 2009.
3. Dudman J, Isaac A, Johnson S. Revealed:
how the stress of working in public services is
taking its toll on staff. Guardian; 10 June, 2015.
www.theguardian.com/society/2015/jun/10/
stress-working-public-services-survey
(accessed 26 November 2015).
4. Employee Assistance Professionals Association.
Counsellor’s guide to working with EAPs. Derby:
EAPA; 2014.
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December 2015/www.therapytoday.net/Therapy Today 11
Further Education
Jane Darougar explores
how the culture of cuts
and closures within
FE organisations
threatens the security
of both counsellor
and client Illustration
by Michael Parkin
At a time of a rapidly shrinking
state, counselling services in Further
Education colleges are under threat.
Many have already closed and others
face big reductions or extreme
reorganisations that jeopardise their
ability to function. This article looks
at how the changing culture within
Further Education threatens the security
of the counsellors and how the instability
is challenging our capacity to act as
secure containers for our clients.
Further education (FE) in the United
Kingdom is in crisis. Whilst schools
have had their budgets protected and
universities have plugged the funding
gaps with tuition fees, FE colleges
have experienced phenomenal and
catastrophic cuts, particularly to adult
education. The funding systems are
complex with different categories
of student funded differently. The
Association of Colleges give figures
ranging from a 17.5 per cent cut in
16-19yrs non-apprenticeship education
to cuts of 22 per cent between 2010-14,
followed by cuts of a further 17 per cent
in the adult skills budget.1 Sixth form
colleges have far fewer adult learners so
have not been exposed to the worst of
this but have been affected nonetheless.
These cuts have resulted in changes
of priority within colleges, new and
often authoritarian management styles
and, sadly, the demise of an increasing
number of college counselling services.
In this piece I would like to say a little
about the FE environment, how the cuts
and anxiety about them have affected the
organisations that I am familiar with, and
how the knowledge of extensive service
closures have affected other existing
services. Historically, counselling
services in FE have run on a shoestring,
with a single practitioner being the most
common model. Given the scarcity of
resources they are vulnerable to closure
if there are cuts. I am particularly
interested in the challenge to counsellors
to continue to provide containment
to clients whose circumstances are
increasingly precarious and whose
hope for the future is rapidly diminishing
whilst the counsellors are feeling under
threat themselves.
I started working at a large inner city
further education college in 2001. At that
time we had approx 15,000 registered
students, including part-time, evening
and day-release. The college is based
in a deprived area with notable indices
of poverty and complexity. Its main
concentration of courses were in four
areas: basic skills, (including literacy,
numeracy and English for Speakers of
Other Languages (ESOL); vocational
skills including construction, plumbing,
hairdressing, beauty therapy etc; trade
union education for employers across
London and the school of supported
learning for students with a range
of disabilities including sensory
impairment and/or learning disabilities.
The college was deeply embedded
in the community with creative and
imaginative programmes to include
groups normally excluded from
education. We had programmes for
school-refusers; ex-offenders; young
people in and leaving care; mental
health service users (including residents
in the medium secure forensic unit);
teenage parents; and the traveller
community. A significant proportion
of our students were asylum seekers
and refugees, including unaccompanied
minors and courses were run in
community centres for those for
whom the college environment was too
challenging; we even ran courses in the
local drug and alcohol service. Clearly
a large proportion of our students were
disadvantaged and it was accepted within
the organisation that adult learners
following functional skills programmes
would have some reason for not having
The threat to
FE counselling
12 Therapy Today/www.therapytoday.net/December 2015
December 2015/www.therapytoday.net/Therapy Today 13
Further Education
attained these skills earlier in life.
Experience suggested that adult
learners had frequently experienced
adverse childhood experiences2 such
as attachment disruption that had
interfered with their capacity to engage
in education. The counselling service
was extremely busy, running waiting
lists for much of the year. We supported
a great number of students who may
well have not completed their studies
without this additional support.
Cuts to further education are not new
phenomena. There was a tension through
the previous Labour Government, with
the introduction of attainment targets
that seemed to misunderstand our
students and the particular difficulties
that they faced. Redundancies were fairly
common but did not prepare us for the
scale of the cuts under the coalition and
the current government programme
of year on year, on-going cuts under
the austerity agenda. The priorities
within the organisation shifted as a
result of the changing political landscape
and as funding changed in the direction
of employability. Dartington, in his book
Managing Vulnerability: the underlying
dynamics of systems of care, explores
society’s response to those who are
vulnerable and dependent on care and
the organisations that exist to support
them. Within this context he quotes
Rice in describing the primary task
of a system as ‘the task which it is
created to perform’ later becoming
‘the task that it must perform if it is
to survive’.3 The primary task of the
college had previously been widening
participation in society, through the
process of learning and the acquisition
of skills. However, in the current climate
of an increase in low skilled, zero hours
contract employment, the soft targets
of keeping people out of hospital, prison
etc, and giving disenfranchised people
some structure for their lives, seem to
have become irrelevant. Funding streams
for many programmes and support
services in the college, and externally
that we could refer to, have disappeared.
The task now was focused on very
specific educational attainment and it
was clear that we might not survive as
an organisation if this was not achieved.
The Principal in one of his staff briefings
spoke scathingly of the old culture
saying, ‘We are not social services nor
are we a care home, but an educational
establishment, if learners are not able
to learn, they do not have a place here.’
Off-site provision was closed and preentry level courses were also ended,
reducing accessibility to education
for the most disadvantaged. Staffing
in the college changed with qualified
teachers losing their jobs and being
replaced by unqualified ‘learning
mentors’ often allocated to some
of the most challenging areas.
Redundancy was an ever-present
threat for teachers and support staff,
as was the feeling of responsibility for
unsatisfactory statistics and the college’s
economic viability being questioned.
The redundancies were extremely
painful, with many staff competing
with long-term friends and colleagues
for ring-fenced positions. The language
was brutal: ‘Your post has been deleted.’
Endings were not marked; people
disappeared from view without
having a leaving do. It was almost
as if an annihilation anxiety response
was evoked amongst the staff. Akhtar
describes annihilation anxiety as fear
located in the ego when there is a threat
of being overwhelmed or annihilated.
He explores Hurvich’s notion that
annihilation anxiety originates in early
infancy and that it can be re-activated
later in life.4 This anxiety activates
primitive defences such as splitting
and projection.5 Splitting is a primitive
defence against anxiety that identifies
people as idealised good or denigrated
bad. Foster describes how anxiety can
‘Whilst schools have had their budgets protected
and universities have plugged the funding gaps
with tuition fees, FE colleges have experienced
phenomenal and catastrophic cuts’
14 Therapy Today/www.therapytoday.net/December 2015
lead to all the bad feelings being
projected onto those who have been
identified as ‘bad’ so that it is no longer
possible to see the good in them.6 This
appeared to have taken place both with
staff who were not on-board with the
new task being identified as part of
the problem, and learners themselves
being redefined from needing support
and nurturing in order to achieve; to
potentially catastrophic vehicles of
destruction of the organisation that
need to be excluded without delay.
Dartington profiles a split between
services and service users that ‘is enacted
between the hopeful and the hopeless;
between the active and the passive;
between fight/flight and dependency;
between resistance and acceptance;
between an assumed omnipotence
and a supposed impotence’.3 It was
notable that there was an increase in
disciplinaries and exclusions of learners
and dismissal of staff. There appeared
to be a disproportionate number of
black and minority ethnic staff and
learners affected by this. A culture
of fear and anxiety was established,
which seemed to encourage people to
dissociate themselves from vulnerable,
struggling students and the services
that were designed to reach out to them.
The cultural narrative has experienced
a return to wide references to ‘benefit
scroungers’, the demonisation of
the disabled and the classification
of deserving and non-deserving poor.
Dartington describes how an ethos
of anti-dependency has fuelled an
attack upon the vulnerable, without
understanding the complexity of
dependency and how appropriate
it can be in certain situations and life
stages.3 The dependency of our learners
while they undertake the potentially
transformative experience of education
may have evoked a tremendous anxiety
about our own potential dependency,
and has made it increasingly difficult
to see the individuals clearly; work
creatively to meet their needs and
create sufficient containment for
them to engage in education. This
can be understood within the context
of a paranoid schizoid position, where
we are unable to manage the anxiety
created by contact with vulnerability.7
As a public sector worker I am
continually aware of the threat
of redundancy and unemployment.
Through contact with my clients I am
exposed daily to the distress caused
by poverty and the very real difficulties
faced by a significant proportion of our
cohort. I can understand how, as Foster
describes, survival of this anxiety may
necessitate some splitting.6 However,
without a container to help us to manage
this anxiety, the splitting can threaten
the services offered to our learners
and may prevent the primary task of
the organisation being met. The wider
container of the organisation has become
impaired as we experienced their shift
to the new focus as a betrayal of our
values. The resultant loss of trust
was exacerbated by their combative
and authoritarian style and apparent
ruthlessness in the restructures and
redundancies. Bloom describes in
detail how authoritarian, bullying and
autocratic styles of leadership flourish
in organisations that are under threat
as dependency grows and difference
and dissent are not tolerated.2 In the
midst of this chaos notifications have
been coming through regularly from
counselling colleagues in colleges
across the country about threats
to and closures of their services. In
spite of repeated efforts by the BACP
Universities & Colleges division to
raise public awareness of the situation,
it feels as though FE remains invisible.
The press seem unwilling to profile any
education story that does not concern
schools or universities. It has made many
of us feel attacked by government, our
References
1. https://www.aoc.co.uk/sites/
default/files/College%20Funding
%20and%20Finance%201%20
May%202014%20FINAL_0_0.pdf
2. Bloom S, Farragher B. Destroying
sanctuary, the crisis in human
service delivery systems: Oxford;
2011.
annihilation being plotted by our own
organisations’ management, and our
plight invisible and unsupported outside
our own small community with only
very recent references to FE funding
in the mainstream media. I wonder if
our organisations, feeling vulnerable
and under threat, are distancing
themselves from the service users
who are likely to be most resource
intensive because of fear of our scarce
resources being depleted further.
Hopper describes trauma as ‘always a
matter of failed dependency on other
people and situations for containment.
Failed dependency provokes a primary
fear of annihilation’.8 A recent post
on Psychologists Against Austerity
described austerity as ‘the systematic
erosion of a person’s social and personal
boundaries to leave them unprotected,
completely defenceless, hopeless and
in real fear of annihilation’.9 Bloom
explores the emergence of parallel
processes when organisations experience
prolonged episodes of stress.2 Amidst
the posts to the FE mail base that call
for support and voice an energy to
fight for our services, others are also
audible… they speak of hopelessness
and resignation. At times it has felt
extraordinarily painful to read the
despair of colleagues describing
how their services are being axed
and how they are supporting their
clients through abrupt endings.
It leads me to question how we
are able to provide the safety and
containment that our clients so
clearly need when we ourselves feel
so undermined and under threat? Ogden
describes Winnicott’s proposition that
the role of the analyst is to provide
a metaphorical holding function, a
psychological space ‘uninterruptedly
to be that human place in which the
patient is becoming whole’.10 In an
atmosphere of threat and anxiety it is
extraordinarily challenging to provide
3. Dartington T. Managing
vulnerability, the underlying
dynamics of systems of care.
[24, 46]: The Tavistock Clinic
Series; 2010.
4. Akhtar S. comprehensive
dictionary of psychoanalysis.
[22]: Karnac; 2009.
this level of containment and holding
for our clients, many of whom have
experienced inconsistent and insufficient
containment throughout their lives.
In order for us to focus on our primary
task as counsellors, it is essential that
we find ways to address these challenges
to maintain the contribution that we
make to the empowerment and
progression of our students.
I left the college that I describe above
a short while before its service was shut
down. It has also now lost its Mental
Health Service. I feel a great sadness
that the students studying there will
no longer have access to the support that
previous cohorts have had. I am certain,
from past experience, that some will not
complete without it. The investment
that adult learners make when they
return to education is enormous,
in terms of hope, energy, financial
sacrifices as well as losing out on family
time. It is a tragedy when a student does
not complete or achieve what they might
have been capable of. For those services
that are still operational, I hope that we
as a community will offer our support
and holding to the counsellors and
psychotherapists to enable them to
play their part in the empowerment
of students who have so often been
failed before.
Jane Darougar is College Counsellor at
Leyton Sixth Form College. She has taught a
variety of counselling courses and workshops
and has an MA in Working with Groups
from the Tavistock & Portman NHS
Foundation Trust. Jane is also deeply
committed to widening participation in
education as a means of challenging social
exclusion and has a particular interest
in the emotional barriers to learning.
Email [email protected]
This article is based on an article published
in University & College Counselling
(September 2015). Visit bacpuc.org.uk
5. Klein M. Envy and gratitude and
other works: new York: Delacorte
Press; 1946.
6. Bishop B, Foster A, Klein J,
O’Connell V. challenges to practice,
practice of psychotherapy series:
book one. [93] Karnac; 2002.
7. www.melanie-klein-trust.org.uk/
paranoid-schizoid-position
8. Hopper E (ed). Trauma and
organisations. [54] Karnac; 2012.
9. Psychologists Against Austerity.
https://psychagainstausterity.
wordpress.com.
10. Ogden T. On holding and
containing, being and dreaming.
In: Winnicott and psychoanalytic
tradition: interpretation and other
psychoanalytic issues. [80]: Karnac;
2007.
December 2015/www.therapytoday.net/Therapy Today 15
Race
Mixed race identity
and counselling
16 Therapy Today/www.therapytoday.net/December 2015
Nicola Codner describes her own identity as a mixed
race woman and calls on counsellors to learn more
about the psychosocial needs of our third largest
ethnic minority group Illustration by Michael Parkin
I felt compelled to submit an article to
Therapy Today because I’m aware that, as
a mixed race woman (of black Jamaican,
Nigerian and white British heritage),
every time I pick up a copy of the journal
I’m scanning for articles on mixed race
identity and counselling/mental health.
I rarely find anything on the topic and
when I do it tends to be a mere few lines
or paragraphs that only acknowledge
the lack of attention paid to this group.
This is disappointing and frustrating.
Mixed race identity and issues are so
invisible in the counselling world,
despite the fact that this section of the
population is the fastest growing and the
third largest ethnic minority in the UK.1
Dialogue around issues affecting mixed
race children, adults and families, is
increasing slightly in the UK but it is still
insubstantial. I notice in the US (where
the mixed race population is also quickly
increasing) this is a different story.
Research on the mixed race population
is more abundant and counsellors are
being made aware that they need to be
able to consider the needs of this part
of the population and be able to show
specific competence in working with
this group. Research in the UK is
minimal and counselling books that
focus exclusively on mixed race people
are absent. As noted by Yasmin AlibhaiBrown,2 social policy makers are taking
a slow-paced approach to including
mixed race Britons, despite the fact
we are the country with the most mixed
relationships in the developed world.
It was only in 2001 that the racial
category of mixed race was added to
the National Census of Population.3
The term is most commonly understood
as applying to people who have one
white parent and one parent from
an ethnic minority. However, this
traditional understanding of the term
excludes those who have parents of
different races where neither parent
is white. Again, there is more dialogue
around this in the US where it is more
commonly acknowledged that our
general understanding of who is
included in the mixed race category
needs to broaden. It’s also important
to acknowledge that not all people
who have parents of different races
will identify as mixed race, which
means the mixed race population could
be larger in the UK than is currently
observed (as an example, some people
of black and white parentage may choose
to identify solely as black). In addition
some mixed race people are of more
than two races which is often ignored.
A largely ignored group
Both black and mixed race people are
over-represented in the mental health
care system4 and in prisons5 in the
UK. Mixed race children are the most
likely to be put into care and also overrepresented in youth justice and child
protection systems.6 Mixed race people
have been reported as more likely to
be the victims of crime.7 However,
discussion around mixed race mental
December 2015/www.therapytoday.net/Therapy Today 17
Race
‘On my counselling course people were able
to learn a bit about mixed race identity and
black identity but only because I and a few
other class members felt the pressure and
responsibility to educate them’
health is seriously lacking. Why is this?
This invisibility only further demonstrates
the way mixed race people are largely
hidden and ignored in our society beyond
superficial recognition. This superficial
recognition is usually attached to
perceived attractiveness and is nothing
more than a form of objectification that
only further stereotypes a group with
no significant social capital.
I have only recently completed a
person-centred diploma in counselling
and one of the things I notice as a new
person coming into the counselling
world is how the topic of race in general
can be sidelined because it is such a
complex and emotional topic for people
to talk about. On my counselling course
people were able to learn a bit about
mixed race identity and black identity
but only because I and a few other
class members felt the pressure and
responsibility to educate them. What
if we hadn’t been on the course? And
why should this obligation have fallen to
us? What if we hadn’t felt like educating?
Who is to say the work we did was even
helpful? Shouldn’t training on race and
culture be a crucial part of the training,
regardless of who is present in the student
population? My group was also typical of
those in counsellor training in that they
were anxious and avoidant when it came
to having anything more than a shallow
conversation about race. This has
obvious implications for counselling
practice. Isha Mackenzie-Mavinga
explores this common trend in her book
Black Issues in the Therapeutic Process.8
Issues for counsellors to consider
We urgently need books on mixed
race counselling as well as guidance
and support for counsellors. It was
only in 2014 that Mooney published
the first empirical research in the
UK into how mixed race identity is
navigated in counselling.9
18 Therapy Today/www.therapytoday.net/December 2015
I can speak from my own experience
and say that finding a counsellor who
can work effectively with mixed race
issues can be an extremely arduous
task. I had to go through several
counsellors (of different races) to
find adequate support. Some of the
difficulties I faced were counsellors
defending against hearing about my
experiences of racism and making
assumptions about how I should
see myself as a mixed race individual
based on their own personal opinions
and prejudices. After these negative
experiences, if 20 hours of counselling
had not been a requirement for the
course I was doing, I would not have
been returning for further counselling.
As a client from an ethnic minority
it can be difficult to bring up the
issue of race any time in counselling
because it is easy to become deterred
by concerns about the counsellor’s
level of competence in supporting your
explorations. The client is the one left
under pressure to broach the topic
and it is naively assumed that they will
raise the issue if it is important to them.
This assumption is made while ignoring
the fear most people have of discussions
around race, the fact that mixed race
people are generally ignored as a group
in society so may not feel empowered
to start the conversation, and the fact
that counsellor competence, skill and
comfort (which counsellor training
does not tend to instil) is crucial in
this area for there to be any therapeutic
benefit. According to research by
Pope-Davis and colleagues (as cited
by Mooney9), it has also been shown
that clients modify what they say to
the skill-set of their counsellor. It has
also been argued by Cardemil and Battle
(also cited by Mooney9) that counsellors
who do not attempt to facilitate
discussions around race in counselling
and simply wait for the client to raise
it may not actually be performing as
helpers. I would agree that counsellors
need to address obvious issues of
difference in the counselling room
and make it known they are capable of
working with issues connected to race,
should the client need to explore them.
Currently counsellors do not have
to show any meaningful level of
competency in their ability to work
with racial diversity. Counselling courses
usually do address the topic of race,
ethnicity and culture at some stage but
it is generally dealt with at a facile level,
and Watson notes10 that tutors are not
given any specific training for working
with students in this complex area.
This leaves all students in a difficult
situation (which some students may
be unconscious of ) when it comes
to their own counselling practice and
race. It also leaves clients from ethnic
minorities likely to be exposed to further
discrimination and misunderstanding.
In her paper Mooney9 argues:
‘Counselling psychologists must have
an awareness of the needs that British
mixed race clients have in terms of
identity and personhood. In doing so,
the practitioner may minimise their
assumptions and biases, thus forming a
therapeutic alliance based on knowledge
of how mixed race people manage
therapy and construct identity’ (p10).
What does this mean for those of us
who are not counselling psychologists?
How do we make sure that we are
working with mixed race clients in
meaningful ways?
Mooney9 also argues that we need
to be less eurocentric when working
with mixed race clients, and we need
to work from a more multicultural and
intersectional perspective where we
acknowledge how all facets of a person’s
being influence their life, including
race, gender, age, sexual orientation,
mental health issues and so on. This
‘Mixed race people who are not in touch with
their true selves may experience distress in
connection with their identity as they will
struggle to dispel the racialised projections
others make upon them’
is the approach adopted in the US,
where specific knowledge is also
required of issues affecting the mixed
race population, such as racism within the
family/from partners, lack of community/
issues to do with belonging, rejection
by mono-racial groups, stereotyping and
being exposed to disparaging comments
in relation to all sides of their racial
identity. This is not an exhaustive list of
the potential issues. It is also a required
part of competence in the US to be aware
of models of identity development for
this group.
Developing an integrated identity
I want to share some of my own
experience of developing an integrated
identity as a mixed race woman while
having person-centred counselling. I
did have to find a counsellor with some
specific knowledge of mixed race identity
in order to support this integration as
well as do a large amount of work on this
alone, including a great deal of reading
(which mainly included US research).
While it’s true that any group in
society can face difficulties in developing
a whole self, it is thought that mixed
race people are more at risk because of
society’s construction of race in overly
simplistic binaries and the responses
mixed race people receive. If certain
aspects of racial identity are not accepted
externally, this can lead to a fragmented
or split off self for mixed race individuals
as described by Mooney.9 The legacies
of colonisation, slavery and current
events concerning race can also affect
how mixed race individuals view their
identities and how they feel about
their wholeness.
We cannot assume that every mixed
race person who comes for counselling
has issues around their mixed race
identity. Some mixed race individuals
will grow up in environments where they
are actively encouraged and supported to
develop an integrated and healthy
identity. However, all mixed race
individuals in the UK will have to
negotiate living in a society where
their identity is only recognised
superficially at a societal level and
where race is still largely constructed in
binaries that often deny their existence
and uniqueness. Mixed race individuals
commonly experience misrecognition
of their identities when people make
assumptions around or interrogate their
identities. In my own experience, I was
often bombarded with not only negative
mixed race stereotypes but black
stereotypes as well, which had a negative
effect on my developing self-esteem.
In terms of person-centred theory,
an individual who is out of touch with
their authentic self (their organismic
valuing process) due to a lack of
appropriate empathy, unconditional
positive regard and congruence in
childhood, is likely to develop conditions
of worth based on others’ desires and
needs. This means that mixed race
people who are not in touch with their
true selves may experience distress in
connection with their identity as they
will struggle to dispel the racialised
projections others make upon them
and to face the constant questioning
they receive around their identity.9
In my personal exploration while
studying on my person-centred course,
I found it useful to explore my racial
identity in terms of the configurations
of self from person-centred theory.
I discovered I held three different
racial identities that I had to work
on integrating more fully. I realised
I had a black, a white and a mixed race
configuration. It was clear when I looked
back over my life that, externally, my
white heritage, followed by my mixed
heritage, had been over-valued at the
expense of my black heritage, because
of the environment I grew up in. The
black and the mixed race configuration
had to be examined and healed in terms
of racist experiences. I did this partly
by reading the stories of black and
mixed race women and using affirming
pictures of black women in particular
(because I had grown up so aware of
society’s racism towards them and
experienced this as personally toxic
for my own identity) to bolster my
self-esteem. Having grown up with
a white mother and black father I
missed out on having role models
to whom I could fully relate and who
could empathise with my experiences
as a female of colour. As an adult I had
to compensate for missing out on this
empathy in my therapy. This is not to say
mono-racial parents can’t successfully
raise mixed race children; however,
some may need additional support and
guidance. My white identity became less
acceptable to me as I explored the harm
done to my mixed and black identities.
I was rejecting of this aspect of self.
While I was feeling rejecting of this
aspect of self I did, however, maintain
a good relationship with my white
counsellor, which I feel is because
she was offering me the appropriate
level of understanding and empathy.
Later I had to do work on accepting
and working to integrate my white
identity, which I did by thinking about
the positive aspects of being part-white
British. Occasionally I have experienced
racial prejudice for this aspect of my
identity as well and this also had to
be worked through in therapy.
While exploring my different
configurations of self I uncovered
several tensions between my black
Jamaican identity and my white British
identity. This was partly due to the
history of slavery and colonisation by the
British in Jamaica and the relationship
between my parents but also due to
cultural differences and clashes that
December 2015/www.therapytoday.net/Therapy Today 19
Race
References
1. Smith L, Mixed race in the UK:
am I the future face of the country?
The Telegraph; 8 November 2014.
2. Alibhai-Brown Y. Mixed feelings:
the complicated lives of mixed-race
Britons. London: The Women’s
Press Ltd; 2001.
3. Parker D, Miri S. Rethinking ‘mixed
race’. London: Pluto Press; 2001.
4. Five-year plan fails to help black
people in the mental health system.
News. Therapy Today. 22 (4); 2011.
5. Institute of Race Relations.
Criminal Justice System Statistics.
http://www.irr.org.uk.research/
statistics/criminal-justice/
6. Mixed race children’s needs.
News. Therapy Today. 25 (3); 2014.
7. Ministry of Justice. Statistics
on race and the Criminal Justice
System. https://www.gov.uk/
government/statistics/statisticson-race-and-the-criminal-justicesystem-2012. 2013.
I saw between these identities. I realised
I had a stereotypical British identity
that was reserved, polite and overly
accommodating but that this was also
in dramatic conflict with what I perceive
as my Jamaican identity, which is more
expressive and direct, and sometimes
outspoken. This Jamaican aspect of
self has come up against very harsh
judgment in British culture. I had to
work on finding a balance between these
two identities so I could stop veering
between them and being confused
about what my personality really was.
I also became more positive about
my expressive Jamaican side and more
critical of the British characteristics,
which have held me back in life in many
instances, particularly in conjunction
with my identity as a woman. Our
socialisation as women is often partly
about pleasing others and putting
others first, to our own detriment.
In addition I had to do a great deal
of work on exploring my black Jamaican,
Nigerian and white British father’s racial
identity, issues and upbringing, in order
to understand his influence on me. This
was the most significant and complex
piece of work I had to do. Because I had
had a difficult relationship with him,
this has also affected my relationship
with the black part of my identity. I
had to work through a large amount
of anger as I began to understand the
impact of racism and a history of slavery
and colonialism on my family at large.
I came to acknowledge my Jamaican
and Nigerian identities were poorly
developed due to a lack of exposure
to Jamaican and Nigerian customs
and culture. I’ve never been to either
country. I never had a relationship with
my Jamaican-born grandfather, and my
Nigerian and British grandmother died
when I was a young child. Most of what
I know about both countries is through
reading. Acknowledging this
20 Therapy Today/www.therapytoday.net/December 2015
8. Mackenzie-Mavinga I. Black issues
in the therapeutic process. London:
Palgrave Macmillan; 2009.
9. Mooney AM. ‘The elephant in
the room?’: an exploration into
how clients construct and manage
the role of being mixed race
within therapy. University of
Roehampton; 2014.
disconnection awakened a process
of mourning in me and I have still not
found a satisfactory way to fill this hole.
Being more aware that it is there and
that it causes some sadness is at least
a beginning.
It has been particularly healing for
me to think of the strengths of having
a mixed race identity, such as being
comfortable with diversity, having
a rich background and being open to
broad perspectives and experiences
in ways that I see many others are not.
Counselling mixed race clients
I think working with theory to help
clients understand their racial identity
is very helpful but it is not something
I have ever heard of outside my own
work on this. The difficulty here will
potentially be the counsellor’s lack
of knowledge and competence around
race and cultural issues and their ability
to facilitate the client’s understanding
of themselves in a non-defensive way.
It’s important to note that the work I
did on configurations of self was born
from my own initiative in my counsellor
training and then from reading books
from the US on mixed race identity
and counselling. I found Biracial Women
in Therapy by Gillem and Thompson11
particularly useful (it was one of the only
books I actually found on counselling
mixed race people). Although my
exploration of configurations of self
did not develop out of therapeutic
work with a counsellor, I did take my
findings to counselling later to discuss.
I think I was privileged here in the depth
of understanding I could develop around
my identity by myself and I wonder how
much counselling practice alone, as it
presently stands, can facilitate significant
and meaningful reflection on identity for
mixed race clients. I found using identity
development models enormously useful,
as well as thinking about how other
10. Watson VVV. The training
experiences of black counsellors.
University of Nottingham; 2004.
11. Gillem AR, Thompson, CA.
Biracial women in therapy: between
the rock of gender and the hard
place of race. New York: The
Haworth Press Inc; 2004.
aspects of my identity affected me as
someone of mixed race, particularly with
regards to gender and class oppression.
In summary, it is important to
remember mixed race identity is
fluid and may change over time and
in different geographic locations,
because of different current events
and so on. I personally know I will have
to keep exploring my identity as a mixed
race woman for the rest of my life.
I’m not sure if this article will have
any impact but I would love to see more
dialogue around mixed race issues in
the counselling world. While it is true
that working with mixed race clients
on issues of race may not necessarily
be commonplace at the moment for
many therapists, this may well change
over time and mixed race clients deserve
appropriate support when they do come
through the door of the counselling
room. In my short experience so far
as a counsellor, I have already worked
with a mixed race client as well as several
women from mixed race households.
We need to make sure we are not failing
this group of people because in many
cases they have already been failed
enough. Successfully integrating a mixed
race identity and navigating mixed race
relationships in a world that constructs
race in rigid binaries and where racism
is still a considerable problem is a real
challenge and can bring up a wealth of
difficult emotional and psychological
issues. I do not think counsellors in
general are even scratching the surface
right now in this area.
Nicola Codner has just completed a
person-centred diploma in counselling
and is currently a volunteer bereavement
counsellor. She is specifically interested in
the areas of race and culture, class, sexuality
and gender. She has a degree in psychology
and English literature and enjoys writing
on social issues.
How I became a therapist
Karen Cromarty
Attending school governor
meetings made Karen
Cromarty realise that
therapeutic intervention
could help children and
young people
My decision to become a therapist was
as a direct result of my work as a school
governor. I regularly sat on Exclusion
Panels and heard narratives of young
people in school whose behaviour
was so ‘bad’ that they were going to
be disallowed from attending school –
either temporarily for an extended period,
or permanently. Now whilst the staff in
schools had ostensibly done their best to
contain these pupils, these young people
NEVER had any opportunity to reflect on
their behaviours or on what might have
caused them, and how they might respond
differently in the future. I wanted to bring
some therapeutic skills to this potential
client base, in the hope of preventing
more such exclusions in the future.
At the time, and this was 1997, my
judgment that counselling might help
children at risk was based upon a ‘gut
reaction’ and a knowledge from the
evidence base that counselling helped
adults. Of course since then times have
changed; BACP has worked on many
and varied research projects that have
studied young people’s counselling,
especially in secondary schools, and
the emergent evidence base is really
highly positive. School based counselling
is associated with significant positive
change. So I had a sense that counselling
in schools would help, but now we have
the studies to show this. And it’s these
studies that convince the politicians
and opinion formers to invest in even
more resource to support cyp mental
health. I’m now involved far more in
presenting the case for counselling
at this level, which is daunting and
exciting in equal measure.
I think being a therapist is probably
a vocation, and my personal view is that
it’s not rocket science! Someone who
genuinely believes people are trying
their best and can do with a helping hand
sometimes – a simple ‘two heads are
better than one’ approach – understands
the basis of the therapeutic relationship.
The best advice I have received wasn’t
actually about therapy, and maybe it was
a maxim rather than advice, but it relates
to the children and young people sector
very well. A great friend of mine, a post
office manager and Dad of two, told me
when my children were young, that he
thought all children went through every
‘stage’ at some point in their formative
years. So that you may as a parent get
a placid baby – but my, they might
really test you in their teenage years!
On the other hand, the young extroverts,
who love to put on a show when they’re
little, will almost certainly go through
an uncommunicative phase when
they will hardly be able to face anyone.
Seems simple really, but it helped me a
lot, especially when working with school
staff who can sometimes think that the
age of the child accurately describes
their developmental stage.
Personal values are really important
to me, as they can be the boundaries
‘Becoming a therapist, even
studying a basic counselling
training, can be life changing,
and I would recommend it
to many’
and touch stones in everything we do.
One that stands out above the rest for
me is integrity – being true to my own
code. Being honest but kind is important
to me as well. Doing my best is up there
alongside working hard. Trying to help
others as well as I can, whenever I can;
being as good as I can be. Influencing
what I can, to the best of my ability,
and letting go of things over which
I don’t have control.
I don’t do much ‘theraping’ these
days – but when I did I felt privileged
to be trusted by others who were feeling
vulnerable. And to see people change
in ways that suited them was always
highly rewarding.
I find my biggest challenge is that
there are only 24 hours in every day.
There’s so much interesting and
exciting work to be done, I could
easily fill another 24 hours. My leisure
time has to be guarded fiercely. I
wouldn’t say I’m a great reader, but
music I find is very inspirational both
through playing (the guitar) and having
an eclectic taste in music from classical
to Runrig.
Becoming a therapist, even studying
a basic counselling training, can be life
changing, and I would recommend it
to many. A six evening counselling skills
course was a game changer for me in
terms of self-awareness, and I became
really hungry for more of that. Once
you begin to become self-aware then
it’s hard to stop. You can’t not know
what you know! I just wish more people
would go in for it. It has also been an
absolute privilege to have individual
clients and supervisees trust in me
and that is humbling.
Karen Cromarty is BACP’s Senior Lead
Advisor and holds the portfolio for children
and young people within the Association.
Although Karen currently has only a very
small private practice, she has been a school
counsellor, supervisor and manager; and
she now uses her ample experience to focus
on children and young people’s mental
health as an author, researcher and
media spokesperson.
December 2015/www.therapytoday.net/Therapy Today 21
Boundaries
Bending boundaries
in oncology counselling
22 Therapy Today/www.therapytoday.net/December 2015
Caroline Armstrong describes the unique dilemmas
raised by her work as an oncology counsellor in a
large teaching hospital Illustration by Michael Parkin
Imagine you’re in hospital and you’ve
been telling the ward counsellor that
you are scared that the excruciating pain
in your head may be a progression of your
cancer. You feel the counsellor listens
carefully and seems to understand,
and you feel a bit calmer by the time she
leaves. Later the consultant comes round
and confirms your worst fears: the cancer
has spread to your brain. How, then,
does it affect your feelings towards the
counsellor when a chance remark makes
it clear that she already knew the results
when you were both speaking earlier?
This may appear to be extreme, but
it can happen. Most ward-based referrals
come from attending ward hand-over
meetings. As a result the counsellor
becomes privy to personal information
without the person choosing to share
it, and they themselves may not even
be aware of some of it. This raises all
sorts of dilemmas, ranging from how
to respond when the client’s story
differs from other versions you have
heard, to anticipating the delivery of
bad news. Perhaps you decide to ignore
the additional information and meet
the client with the material they bring.
Or maybe subtly you choose to encourage
reflection on the possibility of bad news.
Perhaps you delay your visit until the
bad news has been given. Whatever
choices you make within the therapeutic
context, it will affect the relationship.
As an oncology counsellor in a large
teaching hospital, I work alone in an
office close to the main oncology ward.
I provide short-term counselling for
outpatients, as well as providing
emotional support to patients on the
wards. It was a situation similar to the
one above that led me to reflect on the
strange environment in which I work
and the many ways in which boundaries
and ethics can become live issues. These
issues are not unique to the hospital
setting; nor is it possible in this article
to provide definitive answers to the many
dilemmas that can arise. What I hope to
achieve is to increase awareness around
some of them, so that all of us who
find ourselves in similar situations
can make conscious ethical choices.
There are many lone counsellors
working in isolation in hospital units,
with no one but their clinical supervisor
to understand their work fully, and
this is directed in part to them and to
anyone considering a job or placement
in a hospital. The issues are also likely
to have resonances for people working
in other settings.
Information and confidentiality
To some extent information
contamination – that is, information
that has not come direct from the
December 2015/www.therapytoday.net/Therapy Today 23
Boundaries
client – is inevitable. Some people
may suggest avoiding the professional
meetings and minimising additional
information. However, that risks a
lower professional profile on the ward
and fewer referrals. Nor does it fully
avoid exposure: the wards operate in a
culture of information exchange within
the multidisciplinary team and, while
it is accepted that the counsellor will
not share the content of his or her
sessions, it would be a big challenge for
the counsellor to avoid all exposure to
information from other professionals.
Another area of flexibility can be
confidentiality, depending on where
people are seen. In the counselling
room the environment can be controlled:
a contract lays out the ground rules;
conversations are private (other than
those where there is risk of harm to
self or others); notes are kept separately
and can only be accessed by the
counsellor (or the client, with notice),
and any statistical data are anonymised.
In other words, it is very similar to the
standard community-based counselling
service, although it is expected that
any referrer is notified that a service
is being provided.
In contrast, work on the ward is
more fluid. If someone can walk and
they are well enough, it may be possible
to access a quiet room for a counselling
session. However most visits are carried
out at the bedside, often surrounded by
curtains that give an illusion of privacy
but through which conversations can be
heard. There can be interruptions, which
are often not controllable, by people or
activities in the immediate or adjacent
areas. There is no contract and the extent
to which people share experiences under
these conditions is left to them (albeit
with the occasional reminder about the
absence of privacy). Add in that people
on wards are frequently asked personal
questions by other staff so they can
become disinhibited and subsequently
feel exposed. It is important to ensure
that people have real choice about
whether to speak with the counsellor
or not. Most people are ill, vulnerable
and scared, and many are keen to
be seen as a ‘good’ patient. In those
situations they could comply when
they would really rather not.
Flexibility
Thinking back to my early days when
I was training to become a counsellor,
I remember certain ‘givens’: always start
and end sessions on time; expect regular
attendance, and explore the meaning
of absences with the client as part of
24 Therapy Today/www.therapytoday.net/December 2015
their process; be circumspect about
the use of touch; keep things consistent
– eg time and day of meeting, and where
the meeting takes place. In fact I have
always aimed to maintain the first of
these, keeping the allocated sessions
to time. Anyone who works or has been
a patient in a hospital will know just how
different this is to the prevailing culture.
To see how the rest of the given rules can
be affected, consider the following case.
D was a 46-year-old black British
woman who came for one-to-one
counselling midway through receiving
chemotherapy for the second time,
following a relapse of her bowel cancer.
She was understandably frightened,
both of the potential side effects of the
new treatment and of the implications
of relapse. Sessions were arranged to
avoid her worst symptom days within
the three-weekly cycle of treatment.
We did not always meet on the same
day each week, although we managed
to keep to the same time of day. When
she rang to cancel her second session
due to ill health, I accepted it at face value,
and we confirmed the next appointment.
This is not unusual for people receiving
chemotherapy. Over the following three
weeks she turned up late twice; the
reasons could all have been legitimate
but I took the decision to explore them.
What emerged was her fear of facing
the ‘inevitable’ discussion about dying.
I reassured her that we would only
move at her pace and discuss what
she brought. On the strength of that
she felt comfortable to extend her
sessions. Some time later she announced,
‘I’m ready to talk about dying now,’ and
we explored this over several weeks.
Towards the end she realised that she
had probably explored as far as she could,
mainly because she could now see that
‘there’s still life to be lived’ and that at
least one more form of treatment was
available to her should she relapse again.
That may have been the end of the
story but some years later I noticed that
D was an inpatient on the ward. This
time, I heard, she was dying. I was unsure
whether she would want to see me on the
ward, since no one would have known
she had seen me previously. I asked one
of the senior nurses to let her know that
a counsellor was on the ward (giving my
name), and to ask her if she would like
to talk. She was very happy to see me and
had no qualms about the confidentiality
of her previous contact with me, but said
she tired easily. She was candid about
her current predicament, but seemed
accepting of it until she started having
a coughing fit and struggled to catch her
breath. Having alerted the nursing staff I
stayed with her. She was clearly scared so
tentatively I put a supporting arm around
her shoulders, unsure if physical contact
was appropriate, although it felt the
right thing to do. At this point she leant
into me and both of us remained there
while the staff gave her the medication
she needed and the fit passed. She died
peacefully a few days later.
Talking this over in clinical
supervision, what made most sense
was that, at that point of placing an
arm around her shoulders, I stopped
being her counsellor and became one
human being caring about another.
The experience with D illustrates not
only how boundaries can be affected but
the importance of checking things out.
The changes in days could have caused
confusion, but they did not. The lateness
could have been genuine, but by looking
at it together we uncovered some very
potent material and prepared the way
for its exploration once she was ready.
In hospital it is common to see someone
for counselling and then meet them out
of context. Some people can be upset
by recognition, others by a lack of it.
It was possible to check with D but in
other contexts of course you can only
do your best, and perhaps wait for them
to make the first move.
Medical culture
Perhaps the greatest challenge to a lone
counsellor working in a hospital is the
medical setting itself. The professional
paradigm around you is one of being
the expert and problem solving. This
can be a seductive trap for the therapist,
and yet clients feed back that they really
value the counsellor being outside the
medical model – an independent ear who
nonetheless knows the territory. Being
seriously ill can leave people feeling
extremely vulnerable and powerless;
being accompanied by someone who
encourages them to reconnect with
their own agency can be transforming.
In this context counselling is a space
where people with serious illness can
stay with whatever difficult emotional
rollercoaster they find themselves on
without it being seen as another problem
to be solved. This is not to say that the
specialist expertise of the counsellor
is redundant. Many people need help
to develop tools for managing anxiety
and depression. Similarly there are
several points at which it is recognised
that people facing cancer, for example,
can become particularly affected
psychologically by predictable concerns.1
This is about knowing the territory.
‘Counselling is a space
where people with
serious illness can stay
with whatever difficult
emotional rollercoaster
they find themselves
on without it being seen
as another problem to
be solved’
The challenge is to accompany someone
through the terrain while respecting
their unique experiences and abilities.
It can be difficult to stay in contact with
that approach in a ‘problem/fix’ culture.
Another issue where I found myself
drawn into the dominant culture for a
while was access to and use of patient
notes. In the hospital access to
information is always on a ‘need to
know’ basis, but in the case of a lone
worker such as the counsellor this is
left to the judgment of that professional.
I have access to personal patient records
in two ways: electronic data and ward
files. On the wards, all members of the
multidisciplinary team read through
the notes of the patients they are about
to meet and I followed suit. It told me
their diagnosis, who else was involved
in their care, occasionally some
comment on their emotional state, and
what treatments they might be receiving.
I would also write a single line, simply
to say that I had visited and whether
or not those visits would continue. One
day in supervision I mentioned reading
information in someone’s notes and was
shocked by my supervisor’s response.
She felt very strongly that she would
object to that, were she the patient,
and challenged me to think deeply
about my ‘need to know’. This expanded
to a reflection on the electronic data to
which I had access. The whole process
had become so ‘normal’ to me by this
stage that it took this shock to make me
look at it afresh and question my practice.
Initially I wanted to defend my actions
by listing the perceived benefits. That
led me on to explore how else I might
gain that information, whether I needed
it and what I might need to know beyond
the information provided by the person
themselves. I decided to experiment,
and refrain from reading any notes for
a period. The surprise is that it made
very little difference to my actual work
with clients, and by dealing only with
the information that they chose to
share I felt closer to their experience.
This episode was a huge learning curve
for me, and now I only access the hospital
patient records to collect the nonidentifying demographic data on which
I base my quarterly service reports.
Support and exchange
People’s views on the various boundary
issues outlined in this article are likely
to vary according to their counselling
modality, the levels of support that are
available, the pressures on the service,
and any number of other factors. It is
important to be aware of the choices
you make, though, as your decisions
are bound to impact on the client.
For isolated practitioners, regular
clinical supervision and reflective
practice are invaluable, provided
they are used effectively. This can be
augmented through networking with
other practitioners in similar situations,
such as local counsellor networks.
These may bring together counsellors
from different specialisms within one
hospital, or counsellors working in
one specialism across several hospitals.
I have facilitated both, formally and
informally. I hope this article will also
spark debate and ideas more widely.
Conclusion
In the context of hospital-based
counselling, many boundary and ethical
issues can arise. This article highlights
a few: information contamination;
confidentiality, and the challenges to
maintaining it; the need for flexibility
that is based on a foundation of
established good practice, and
maintaining a helpful distance from the
dominant culture of the medical model.
There are no absolute answers to many
of the issues raised here, and I would
suggest resisting the urge to legislate too
tightly on any of them. Conditions and
workplaces vary too greatly for that to
be anything other than a misguided effort
to establish safety and certainty in an
uncertain world. Instead I would suggest
continuing dialogues that are guided by
the principles of the Ethical Framework.
As someone who came into the NHS
from the outside, I had little preparation
as to the kinds of challenges that this
particular way of working would pose.
It would have been helpful to have
been aware of some of the cultural
and practical issues that I was likely
to face. I hope this article both offers
food for thought for others who may
be considering a similar career move
and provides a reminder to those
already working in this and similar
settings of the issues that surround
us daily and to which we can become
blind through familiarity.
Caroline Armstrong MBACP has been an
accredited counsellor since 2002. She is a
trained supervisor and worked in a variety
of counselling settings prior to her eight
years as an oncology counsellor in a London
teaching hospital. She has a special interest
in mindfulness. Email [email protected]
Reference
1. Burton M, Watson M. Counselling people with
cancer. Chichester: John Wiley & Sons Ltd; 1988.
December 2015/www.therapytoday.net/Therapy Today 25
Open Dialogue
Peer-supported
Open Dialogue
Jane Hetherington
introduces a new
model of support for
people with severe
and long-term mental
illness that is based
on person-centred
principles and dialogue
‘The paradox of dialogue may be in the
simplicity and complexity of it on the
whole. It is as easy as life is, but at the
same time dialogue is as complicated
and difficult as life is. But dialogue is
something we cannot escape, it is there
as breathing, working, loving, having
hobbies, driving a car. It is life.’1
I am a principal psychotherapist
working in the NHS for the Kent Early
Intervention Service (EIS). I trained as
an integrative psychotherapist 15 years
ago after careers in law and industry.
My interest in psychotherapy was
sparked after volunteering at London
Lighthouse (an organisation working
with people with an HIV diagnosis) and
I moved from a basic counselling skills
course, through various trainings, to the
Masters in Integrative Psychotherapy at
Metanoia and a radical change in career.
In Kent we are currently participating
in an exciting and innovative project
that is piloting Peer-supported Open
Dialogue in the NHS in England. I am
aware that not all Therapy Today readers
work in the NHS but this pilot has longterm implications for treatment in both
statutory and voluntary sector services,
and for practitioners in the private
sector. The training discussed in this
feature is currently only available to
NHS employees but a three-year training
will soon be available for practitioners
working outside the NHS.
Open Dialogue
Open Dialogue was originally developed
in the area around Tornio in Western
Lapland, Finland, in the 1980s when
the psychiatric services were in a
state of disarray. It initially offered an
alternative to treatment as usual (TAU)
for psychosis but is now the only model
26 Therapy Today/www.therapytoday.net/December 2015
for all mental health treatment in this
area. This has allowed the system to
develop a comprehensive approach
that integrates inpatient and outpatient
mental health services with social care
and external agencies. They now have
the best documented outcomes in the
Western world. At two-year follow-up
82 per cent had non-visible psychotic
symptoms compared to 50 per cent in
the comparison group. Patients also had
better employment status with 23 per
cent on disability payments contrasting
with 57 per cent in the comparison.2
Open Dialogue has since been introduced
to a number of countries, including
most of Scandinavia, Russia, Germany,
France and some states in the US.
Open Dialogue perceives psychosis
from a social constructionist perspective
where ‘psychosis is a temporary, radical,
and terrifying alienation from shared
communicative practices: a “no man’s
land” where unbearable experience
has no words and no genuine agency’.2
Open Dialogue recognises the lack of
adequate provision for service users
and their families in both community
teams and inpatient units. Unfortunately
the NHS is currently structured in serial
or parallel services, which results in an
incompatibility between treatments
offered, lack of consistency and poor
communication between the various
sectors.
Open Dialogue encompasses a
number of theoretical approaches,
including psychodynamic theory,
systemic family therapy, dialogical theory
and social constructionism. The model
involves a psychologically consistent
model in which the service user,
their family and their social network
participate in regular network meetings
where the thinking and decision making
about their care and treatment takes
place. These meetings are facilitated
by specially trained team members, and
this is fundamental to the therapeutic
process. This model encourages service
users, their families, social networks
and support workers to be pivotal to the
provision of care. The empowerment of
the client and their family is at the heart
of the therapeutic model, resulting in an
enhanced experience of comprehensive
support. In addition, improved agency
and awareness may lead to a longerterm reduction in chronicity and
reliance on services.
Peer-supported Open Dialogue (POD)
is the variant of the Open Dialogue model
which we will be piloting in England. It
involves the inclusion in the treatment
team of peer support workers trained
in Intentional Peer Support (IPS). Peer
support workers are currently already
working in some NHS teams and are
seen as experts in their own right
through their lived experience. IPS
involves a training in crisis management
and holistic, person-centred models
of care that is wholly compatible with
the Open Dialogue approach. Within
the treatment teams, staff and peer
workers will be trained together, and
peer workers will be encouraged to
develop a supportive peer community.
POD has been developed in the US,
where the New York boroughs have
been evolving the model. Parachute
NYC is a POD project that offers
alternatives to hospitalisation for
people experiencing emotional crisis.
In the UK the service will evolve with a
uniquely British flavour that is influenced
by the demographics of the pilot site
areas and a range of cultural variants.
Seven basic principles
POD is built on seven basic principles.
1. Immediate help
The first meeting with the team occurs
within 24 hours of receiving the referral.
We are attempting to comply with this
through the introduction of a single
point of access. All participants in the
team are there from the outset and
the psychotic stories are discussed in
Open Dialogue with everyone present.
2. Social network perspective
Those who define the problem are
included in the treatment process.
The team discusses and decides together
who is aware of the problem, who could
help and who should be invited into the
network meeting. Participants could
include family, friends, relatives, fellow
workers and other agencies, including
the police, social workers, or substance
misuse services if relevant. If a network
member lives some distance away
they can be involved through Skype,
conference calling etc.
3. Flexibility and mobility
The response from the service is
adapted to need and is flexible in
relation to the evolving requirements
of the service user and their social
network. The location for the network
meeting is jointly agreed, although the
family home is the preferred choice.
4. Responsibility
The team member who is first contacted
is responsible for organising the initial
meeting. The team takes charge of the
whole process, regardless of the place
of treatment (including inpatient
admission). All the treatment options
and concerns are discussed openly
between the doctor with clinical
responsibility for the person and
the team.
5. Psychological continuity
The team is integrated and includes
outpatient and inpatient staff (if
required). The meetings occur as often
as necessary – normally more frequently
in the initial stages of treatment. The
meetings last as long as required, which
in our experience can be up to two and
a half hours. If there is a further crisis
the core of the team will remain
constant where possible.
6. Tolerance of uncertainty
The model is designed to tolerate
uncertainty in order to create an
environment that can facilitate a safe
enough process. The aim is to encourage
the service user and those closest to
them to develop their psychological
resources so they are able to remain with
the uncertainty and avoid premature
decision making and treatment plans.
7. Dialogism
The emphasis of the network meeting
is to generate dialogue, not primarily to
promote change. The aim is to discover
a language to express experiences that
remain embodied in the individual’s
personal language and inner disturbance
and to recognise the multiplicity of
voices within the meeting – what
Bakhtin identifies as ‘the polyphony’.3
Current POD training
The POD programme is evolving but
currently the initial stage involves a
year of part-time training, which we are
two-thirds of the way through. A multiDecember 2015/www.therapytoday.net/Therapy Today 27
Open Dialogue
‘The core conditions of empathy, congruence
and unconditional positive regard underpin
this model, making it ostensibly a simple,
kinder and more optimistic approach to
working with complex mental health issues’
Using Peer-supported Open Dialogue
I find myself working more dialogically
‘There are challenges attached to
Peer-supported Open Dialogue. First,
not being from an outright educational
background or having training, I was
wondering how I would be able to
cope with the training and meeting
the demands. I was also very wary on
the first day during the introductions,
being in a room full of doctors,
therapists, psychologists and the like.
I was sitting there thinking, “I am only
a support worker.” Initially, however,
I was wondering if I was important
enough, almost, to first undertake
the training and second to practise,
which I have now started doing.
‘Second, something I struggled
with after the initial week in Birmingham
was the idea of roles and how the role
of STR worker fits within an Open
Dialogue framework. My role is very
much ‘to do’: a referral comes for
an STR and a plan is formulated
(this person needs support with
shopping/accessing the community/
finding work) and it is my role to
facilitate that. This seemed a million
miles away from POD, where things
are talked through, the client and their
network are the centre of everything
and come up with the ideas. I saw
myself as having two roles: my STR
role and my POD role. I did realise,
however, that these two co-exist
and, although, I can suggest things
in order to achieve goals, all of this
will be formulated in network meetings
and the support will still happen in
between the network meetings. I am
28 Therapy Today/www.therapytoday.net/December 2015
also finding myself working more
dialogically overall in my work, not
just at network meetings, which is
the way it should be.’
Lauren Markham, STR worker
Just being listened to
‘It’s difficult to feel and openly say you
have a point of view or perspective on
the experiences and events that led up
to and surround mental illness affecting
someone close to you. Open Dialogue
involves you and validates your
thoughts and feelings. What begins
to happen is a unique understanding
of how we all relate to and affect each
other, how we can all better support
each other by talking, and that in turn
gives everyone another way of looking
at the situation. You begin to hear the
emotions of the person suffering, and
you hear yourself expressing yours
and this creates surprising reactions,
always supported by a team.
‘At times it feels like nothing is
happening and that if it was just a
matter of sitting and talking, well,
can’t we do that without any outside
interference? I think that the point
is we don’t; we think these things but
daren’t say them for fear of causing
more distress.
‘When someone is ill it affects
everybody. This is inclusive – just
being listened to when it’s needed
most, allowing these hopes and fears
to come to the surface, and feeling as
if in you are in safe hands.’
Amanda Francis, carer and crisis team
worker
disciplinary team has participated in
a programme involving a partnership
between North East London Foundation
Trust (NELFT) and Gjovik University
College, Norway. The course comprises
four week-long modules covering an
introduction to family therapy and
systemic practice, social
constructionism, family life cycles,
reflecting process, research, and Open
Dialogue as an approach and attitude
to working with families. It also includes
recognition and response to trauma,
working with adolescents, the ethics
of working with families and networks,
exploration of the recovery model and
the therapeutic relationship. There is
a strong emphasis on the humanistic
approach espoused by Carl Rogers.
The core conditions of empathy,
congruence and unconditional positive
regard underpin this model, making it
ostensibly a simple, kinder and more
optimistic approach to working with
complex mental health issues. There
is also an emphasis on the spiritual
aspects of mental health to which
Rogers returned and which he explored
further in the latter part of his life.
The use of self in the therapeutic
alliance is examined and this, together
with the reflecting process and the
high level of self-examination, has
been difficult for many on the course.
This is partly because of the intensity
of the training but another factor has
been the dominance of the medical
model that underpins the core
training of some practitioners. Nurses,
occupational therapists and doctors
have not traditionally been required
to examine their own process and
reflect on their choice of career,
personal history or family of origin,
References
3. Bahktin MM. The problem of Dostoevsky’s
art. Leningrad: Priboj; 1929.
4. Freeth R. Humanising psychiatry and mental
health care: the challenge of the person-centred
approach. Oxford: Radcliffe Publishing; 2007.
5. Shotter J. On being dialogical: an ethics of
‘attunement’. Context 2015; 137: 8–11.
and this has proved to be an emotional
journey for the team. Because of the level
of personal development and awareness
this approach requires, we have also
been encouraged to monitor ourselves
and to use yoga and mindfulness,
which are components of the training.
In Kent we have factored in additional
supervision and support where required,
as we are aware of the possible impact
of the programme on our practitioners.
The team is encouraged to discuss
the logistics of creating the new services
that we will be forming. We are also
exploring the personal and professional
obstacles that we may encounter in
developing client-driven, dialogic
services and establishing greater
levels of acceptance, attunement and
compassion in our professional practice.
from something else, and this is not,
as will become clear, how dialogicallystructured activities – as an aspect of
our Nature at large – actually work.’5
Many participants on the course
have had their own personal experiences
of mental health services as users or
family members, in addition to their
professional training. Jung’s construct
of the wounded healer is relevant to us
as a team. The idea is thought to have
foundations in Greek mythology and
pertains to the centaur Chiron, who was
hit by one of Hercules’ poisoned arrows
and suffered a wound that would never
heal. It relates to the notion that many
of those in the caring professions have
experienced some levels of psychological
distress that has influenced their choice
of career. We as a team are, therefore,
enthusiastic and evangelical about the
aim of services being radically improved:
‘I really believe this is the way mental
health services should be. Transparent,
caring, open, honest and truly person
centred. All these things that services
claim to be, but often fall very short
from the mark’ (Lauren Markham,
trainee POD worker, 2015).
1. Seikkula J. Becoming dialogical: psychotherapy
or a way of life? The Australian and New Zealand
Journal of Family Therapy 2001; 32(3): 179–193.
2. Seikkula J, Olson M. The Open Dialogue
approach to acute psychosis: its poetics and
micropolitics. Family Process 2003; 42(3):
403–418.
Implications for services
It is difficult to conceive how
revolutionary the establishment of
these services will be. When you explain
and expand on this approach with
colleagues in mental health services,
they say, ‘But this is what we do already.’
Unfortunately we do not do this often
enough, or consistently. Rachel Freeth,
who originally trained as a psychiatrist,
then as a person-centred therapist,
discusses openly in Humanising Psychiatry
and Mental Health Care the dilemmas and
constraints that she encounters in her
attempts to be a person-centred clinician
in the context of the NHS.4 We clinicians
often do not listen well and in a dialogic
manner: ‘In the professional world
within which we currently dwell, a
disengaged way of thinking, that we think
of as rational, holds sway. But in this form
of thought, we find ourselves assuming that
there are “things” which are separate
Developing the pilots
The initial NHS pilot for POD
involves four trusts: North East
London Foundation Trust (NELFT),
Kent & Medway NHS and Social
Care Partnership Trust (KMPT),
Nottinghamshire Healthcare Trust
and North Essex Partnership University
Foundation Trust. They will be funding
the setting up of POD services over the
next few years. These pilot POD services
will enable the NHS to evaluate and
expand on the evidence base in order
to inform the NICE guidelines on the
treatment of severe and enduring
mental health problems and promote
more wide-scale take-up if the
improvements in outcomes and
cost reductions remain positive. The
evolving plan is to apply for a grant
for a multi-centre randomised control
trial and to undertake further qualitative
research.
The situation in Kent has evolved
from the original plan and workers
from several teams – principally
Early Intervention Services (EIS) –
have volunteered to be part of the
programme. We currently plan to train
a second wave of practitioners to add
to the original cohort of 15 and to create
a stand-alone team based in one of
the Kent community mental health
divisions. Kent EIS has already
established the peer support role but
additional peer support workers will
be trained in the second cohort. There
is also an aim to embed the model in
the various teams involved in order to
disseminate the POD principles. Once
the Kent team is established, they will
start collecting data from the service
and, with the other pilots, contribute
to the multi-centre study. Should POD
consistently demonstrate sufficient
clinical improvement and reduction
in medication and hospitalisation
costs, then an argument could be
made for a more widespread roll-out,
both within every mental health trust
as well as nationally, via commissioning,
government and clinical guidance
authorities.
The pilots are potentially the first
step in what could ultimately become
a radical shift in national mental health
services and this is what I consider to be
so exciting about these developments.
December 2015/www.therapytoday.net/Therapy Today 29
Practice
Val Thomas discusses
the important
contribution that
mental imagery can
make to therapeutic
processes across all
modalities
This article considers how talking
therapies have made use of clients’ mental
imagery and reflects on how
the patchwork development of this
practice has been shaped by wider
historical and cultural contexts. It
will argue that it is time to develop
more inclusive theory and practice
that supports a deeper integration of
mental imagery into therapeutic work.
The genesis of my research interest
in mental imagery lies in my experience
during the 1990s of working
therapeutically with substance misusers in
crisis. It was my practice to ask these clients
to translate their sense of self into an image
of a building. Unsurprisingly, people
produced a whole variety of images of
structures that were, in general, in a poor
state of repair, often abandoned and
derelict. Then, in the mid-late 1990s, I
started to notice a
new pattern that corresponded with
an epidemic of crack cocaine misuse
in London. As with the heroin and alcohol
misusers, the clients with
crack cocaine habits reported a wide range
of building images but these
all had one thing in common: there
was significant damage to the roof.
I was intrigued that mental imagery
appeared to have the capability to disclose
misuse of specific drugs and
I started to search the literature for similar
reports from other clinicians. After an
exhaustive search I found no other
examples of this type of work.
But I did discover that, although there was
a great deal of literature on working with
mental imagery, in the main it comprised
accounts of two types of
work: either techniques and procedures
developed within particular schools, or
idiosyncratic image-based approaches
developed by innovative clinicians.
There appeared to be very little interest in
developing more inclusive approaches. I
found this puzzling: the therapeutic
potential of mental imagery has been
recognised ever since the inception of
psychotherapy so why has it not moved in
a more trans-theoretical direction?
Therapeutic use of mental imagery
A very brief overview of the therapeutic
use of mental imagery in talking therapies
shows the piecemeal nature
of its historical development. Over
the course of the 20th century different
schools came to the fore and contributed
mental imagery techniques and
procedures informed by particular
therapeutic approaches and paradigms.
Psychoanalysis was developed within
the particular historical and cultural
context of continental Europe during
a period of increasing interest in
studying altered states of consciousness,
dreams and visions. Clinical observations
and experimental investigations were
starting to indicate that people’s mental
images represented communications from
a non-conscious part of the mind.
Influenced by his teacher Charcot (1826–
93), Freud experimented by pressing
his patients’ heads in order to stimulate
mental images.1 However, as he started
to develop his theories about the
defensive, warding-off function of mental
images, he then shifted to
word-based free association.
As Freud’s initial interest in eliciting his
patients’ mental imagery lessened,
another pioneering genius came to the
fore – Carl Jung, whose contribution
to this field can hardly be overstated. Jung
developed a radically different
view of the nature and importance
of his patients’ images and symbols.2 Their
images were not to be interpreted through
the therapist’s frame but were instead
viewed as communications in their own
right arising from the personal and
collective unconscious. In order to allow
more access to the unconscious, Jung
developed his influential method
Mental imagery
in counselling
30 Therapy Today/www.therapytoday.net/December 2015
of active imagination whereby the
client is encouraged to amplify the
original image.
In the 1970s there was a period
of intense interest in imagery, particularly
within humanistic schools and
transpersonal approaches such
as psychosynthesis. These schools
drew on Jung’s pioneering work with
symbols and active imagination but
their methods were characterised by a
more dynamic and interactive approach
to clients’ mental images. In addition,
throughout this time and running in
parallel to the main schools, there
has been a varied range of idiosyncratic
image-based therapies developed mainly
in Europe by innovative clinicians such as
Leuner3 and Desoilles.4
Towards the end of the 20th century
the flowering of interest in mental
imagery began to fade as the relational
turn in counselling and psychotherapy
shifted attention away from methods that
worked with the client’s subjectivity.
However, while most of
the field lost interest in mental imagery,
one school – contemporary cognitive
behavioural therapy (CBT) – went in
an opposite direction and is now at the
forefront of developing imagery as a
therapeutic intervention. The increasing
importance attributed to emotion and
a recognition of the limitations of verbal
language to access preverbal and/or
traumatic memory have combined
to drive practice and research into
investigating the potential for
imagery to be a therapeutic tool.
Whole approaches based on imagery have
recently been developed such
as imagery rescripting techniques
for intrusive traumatic memories.
As would be expected, these procedures
are instrumental and goal-oriented, but
there is increasing interest in adapting
humanistic imagery approaches – Gestalt
dream work, for example,
is being reprised as a masterful example
of guided discovery. Hackman and
colleagues5 sum up the change within this
school: ‘50 years ago, in the heyday of
behaviourism, imagery was not
considered worthy or appropriate
for experimental investigation, though
interestingly it was incorporated into
behavioural treatments such as systematic
desensitisation. Now
the empirical study of imagery links
clinical research, cognitive psychology,
neuroscience and clinical treatments,
creating a body of knowledge that strongly
suggests the rich potential
of imagery-based interventions in
therapeutic practice’ (p204).
The imagination and healing
So how can we explain the way that
mental imagery has been and still
continues to be developed within the
constraints of particular schools? I think
we need to step outside the relatively short
history of psychotherapy and counselling
in order to grasp the
bigger picture. The disciplines of
counselling and psychotherapy are shaped
by wider historical and cultural contexts.
A consistent theme that I have noted in
different clinical contexts is that clients in
general initially find it difficult to take their
imagination seriously. In particular, most
people find it hard to accept that the
mental image is a reliable source of valid
information about themselves: ‘But I’m
just making this
up!’ is a common expression. Where does
this widespread resistance come from?
I would suggest that this unreflective
attitude towards the imagination is a
consequence of the Cartesian mind–body
split. I realise that this is a
common explanatory trope for a range
of problematic issues in Western culture
– therapists will be familiar with this
explanation for the marginalisation
of the body in psychological therapies.
However, perhaps what is less well
known is the profound impact of
Cartesian dualism on Western
understanding of the role of imagination
in healing. In the pre-modern period
imagination was viewed as operating in
both mind and body,
and it was implicated in the cause of
illnesses and also used as a treatment. My
example at the beginning of this article
(of different patterns in mental imagery
linked to the use of different drugs)
would have been consistent
with the pre-modern world view.
The early Greek physician Galen
(130–200 AD) wrote about the use
of dream images as diagnostic criteria
for certain health conditions. However,
this possibility was removed by
Descartes’ philosophical writings
in the 17th century, which separated
mind from body: once the faculty of
imagining was understood as solely a
mental phenomenon then it could not
possibly affect the physiological system.
‘In the predualistic era the expression
“It’s all in your imagination” signified
a key medical principle. In the modern
era it came to signify justification for
dismissing the patient as untreatable.’6
But something more happened
at this point, which I contend is still
influencing the way Western culture
disregards the validity of imaginal
processes: imagination was compared
unfavourably with rational thought.
Influential post-Cartesian philosophers
launched a devastating attack on
imagination, and Hobbes’ (1588–1679)
argument that imagination was an
inferior type of thinking was buttressed by
other philosophers such as Locke (1632–
1704), who defined imagination as a
‘decaying sense’. During the following
centuries, informed by the Anglo Saxon
empirical philosophical tradition and the
great technological progress brought
about by applications of rational thought,
December 2015/www.therapytoday.net/Therapy Today 31
Practice
imagination
became conflated with illusion in the
popular mind. Treated contemptuously
by modern science, it was only in the mid
20th century that psychology began to
accept that people’s imagination and their
mental imagery in particular were worthy
of investigating.
Why use the imagination in therapy?
Does this matter? Despite the way
that imagination has been sidelined
in Western culture, its therapeutic
potential has always been acknowledged in
counselling and psychotherapy, each
school contributing to the repertoire
of mental imagery procedures and
techniques. So why should we attempt to
develop more trans-theoretical
approaches to the therapeutic use
of mental imagery? The first reason
is a general pragmatic one. A great wealth
of knowledge, procedures and techniques
has been developed within the different
schools and image-based therapies; more
inclusive frameworks for practice would
allow integrative therapists to draw on all
of these.
The second reason is that it is time
to take on board that other disciplines are
generating new ideas about the embodied
nature of cognition. These empiricallygrounded theories lend support to the
long-held understanding in psychotherapy
that imagery accesses non-conscious parts
of the mind.
In particular, Lakoff and Johnson’s
important theory of conceptual
metaphor7 provides a compelling
explanation of the way in which
mental images can shed light on how
the person is cognitively structuring
his or her perception of the world.
My example of imagery work with
substance misusers is an illustration
of a particular conceptual metaphor:
ie the self is a building (small
capitals are the accepted convention
for conceptual metaphors). Lakoff and
Johnson argue that these deep-level
conceptual metaphors (non-verbal
experiential gestalts) emerge directly
out of embodied experience. Gibbs
and Berg8 go on to make the case that
representing a conceptual metaphor
as an image will not only reveal the
person’s sense of self, it will also disclose
their experience of their embodiment.
This was confirmed for me in the case
of the crack cocaine users, where damaged
roofs appeared to represent
the impact of taking a particular physical
substance into the body as well as the
concomitant psychological processes.
The implications for counselling
and psychotherapy are that, by
viewing and interacting with image-based
representations of conceptual metaphors,
we can gain more direct access to the
cognitive processes (and associated
embodied aspects) involved in therapeutic
processes. Conceptual metaphor theory
would support the
idea that changes in the metaphor
would be mirrored in changes in how
the person experienced his or her self.
I saw that in action when I used imagery
interventions to help crack cocaine
misusers deal with the problematic
psychological conditions that arose after
stopping taking the drug. One procedure
involved temporarily securing the
damaged roof by visualising a tarpaulin
covering the hole. This change to the
image usually resulted in an immediate
reduction in self-reported paranoia –
a classic crack-cocaine related state.
Going forward
I have argued that it is time to move
towards more trans-theoretical
perspectives on the practice of mental
imagery, but how can this be achieved?
I think there are three ways forward. First,
it is important to develop the evidence
base. Mental imagery has suffered until
‘The therapeutic potential of mental
imagery has been recognised ever since the
inception of psychotherapy so why has it
not moved
32 Therapy Today/www.therapytoday.net/December 2015
recently from a lack of research interest in
the counselling
and psychotherapy field. One of the
advantages of CBT being the current
driver of developments in this practice
is its commitment to empirical evidence
for interventions. This commitment
is evident in the increasing range and
volume of research studies being carried
out into the efficacy of therapeutic
applications of mental imagery. The
findings often confirm long-held clinical
assumptions about effective practice. One
such example would be Holmes and
colleagues’ study, cited in the study by
Hackmann et al,5 which seems to support
clinical observations that therapeutic
work is more effective when clients view
their mental images from a first person
rather than third person perspective.
A second way forward would be to
develop trans-theoretical frameworks
for the practice of mental imagery.
This could take the form of generating
something similar to Clarkson’s five
relationship modality framework,9
which allows a means of drawing
on differently theorised approaches
to mental imagery. An integrative
practitioner could then use techniques
and procedures developed within different
schools in a way that responded to the everchanging requirements of the therapeutic
process. Another possible approach could
involve a search for commonalities in its
practice in different schools. An example of
the latter would
be a research study that identified a range
of common functions in the way that
mental images operate as agents of
communication between the conscious
and non-conscious aspects of the self.10
And third, we can start to develop
practices whereby mental imagery is
viewed as an integral aspect of talking
therapies. Such practices would mirror the
way that mental imagery is increasingly
understood to be fundamentally
implicated in embodied cognitive
processing. Rather than
being an add-on, such as a technique
or something separate such as an imagebased approach (this is not to disparage
the usefulness of these), the client’s mental
images would be more deeply interwoven
into the fabric of the therapeutic work.
In the following very brief vignette
(all identifying details have been changed
to protect anonymity), I give an example
of how this can work. In this case, the
building image is being used throughout
the therapy as a site for ongoing work and
meaning-making.
Vignette: Vicky
When Vicky first came for therapy,
her presenting issue was her sense of
hopelessness and despair. She reported
that she had never managed to establish a
fulfilling life. Initially she was shocked
when she produced a representation
of her self-structure in the form of an
abandoned, moss-covered hut. However,
on reflection, she reported that its flimsy
nature resonated with her fragile sense
of self and she linked its abandonment
to the ending of a dysfunctional
relationship 20 years previously.
Vicky said that she was ready to
focus on strengthening her sense of self.
From clinical experience, I was aware
of the importance of creating a sense
of containment while clients engaged
on working on their self-structure. So I
recommended that she visualised a little
caravan parked up by the hut, which she
could use as a temporary base. During the
first couple of months of the therapy,
Vicky visualised being inside the site
caravan and gazing out of its window at
the abandoned hut. Through this activity
she was able to reflect on and come to
terms with the negative long-term impact
of the relationship on her life.
As the therapeutic work deepened,
Vicky started to revisit her childhood
and this corresponded with her first
tentative explorations of the inside
of the hut. Here she began to realise
that it was poorly constructed and
the floorboards were rotten. She felt
that there was something bad that was
emitting noxious fumes underneath one
corner of the floor. Imagining herself
prising up one of the rotten floorboards
triggered a difficult psychological process
of uncovering repressed memories of
childhood sexual abuse. This painful
process unfolded over several months
as Vicky used the safety of the therapeutic
sessions to begin to
recall incidents from her childhood. Every
now and then I would encourage her to
return to the building image to anchor
and monitor the therapeutic work. At
points when the process felt
overwhelming and threatening, Vicky
would be reassured by the concreteness of
the metaphor of the building and
the security offered by an exterior
perspective, symbolised by the caravan.
By the end of the first year the rotten
floorboards and the noxious contents
from under the floor had been removed.
Although Vicky’s sense of self was still,
understandably, insecure, she reported
that she no longer felt so despairing –
the image of the hut ready for new
foundations gave her hope for the
future. (Readers who are interested
in using mental imagery in this way
are referred to my published guide.11)
Conclusion
Counselling and psychotherapy have used
the therapeutic potential of clients’ mental
imagery in a range of ways, but
its development has remained harnessed
to the paradigms of different therapeutic
approaches. Now is the time to recognise
the fundamental importance of mental
images in cognitive processing and move
its theorisation and practice beyond the
limits and partial perspectives of
particular schools. A deeper integration of
mental imagery within talking therapies is
long overdue and would resonate with
wider historical and cultural processes
that are moving beyond Cartesian dualism
and its unhelpful deprivileging of
imagination
in healing processes.
Dr Val Thomas is a counsellor, supervisor
and trainer. She was formerly course
leader for counselling training at Anglia
Ruskin University. She currently works
at The Minster Centre developing postqualification programmes.
References
1. Breuer J, Freud S. Studies on hysteria. In:
Strachey J (ed). The standard edition of the
complete psychological works of Sigmund
Freud, vols 4 & 5. London: Hogarth Press; 1955.
2. Jung CG (ed). Man and his symbols. New
York: Dell Publishing; 1968.
3. Leuner H. Guided affective imagery: mental
imagery in short-term psychotherapy: the basic
course. New York: Thieme-Stratton Corp; 1984.
4. Desoille R. The directed daydream. New York:
Psychosynthesis Research Foundation; 1966.
5. Hackmann A, Bennett-Levy J, Holmes EA.
Oxford guide to imagery in cognitive therapy.
Oxford: Oxford University Press; 2011.
6. McMahon CE, Hastrup JL. The role of
imagination in the disease process: Post-Cartesian
history. Journal of Behavioral Medicine 1980; 3(2):
205–217.
7. Lakoff G, Johnson M. Metaphors we live by (2nd
ed). Chicago: University of Chicago Press; 2003.
8. Gibbs RW Jnr, Berg EA. Mental imagery and
embodied activity. Journal of Mental Imagery 2002;
26(1–2): 1–30.
9. Clarkson P. The therapeutic relationship
(2nd ed). London: Whurr Publishers; 2003.
10. Thomas V. The therapeutic functions of mental
imagery in psychotherapy: constructing
a theoretical model. In: Goss S, Stevens C (eds.)
Making research matter: researching for change
in the theory and practice of counselling and
psychotherapy. London: Routledge; 2015
(pp106–121).
11. Thomas V. Using mental imagery in counselling
and psychotherapy: a guide to more inclusive
theory and practice. London: Routledge; 2015.
‘Most people find it hard to accept that the
mental image is a reliable source of valid
information about themselves... Where
does this widespread resistance come
December 2015/www.therapytoday.net/Therapy Today 33
Dilemmas
Confronting challenges in
the supervisory relationship
This month’s
dilemma
Refer to the original
contract
James Rye
Counsellor, psychotherapist,
supervisor, and trainer working in
King’s Lynn
I found it helpful to approach this
problem by considering three areas:
the original supervision contract, the
dissatisfaction with the supervision
service, and the limits on the
responsibility of care. Therapists
know that problems with clients can
sometimes be helped by reference to
a good contract. The same is true with
supervision problems. Did the initial
contract contain information on
these key areas? Was there a clear
understanding about contact between
sessions? Was such contact permitted
and, if so, under what circumstances?
Was there any reference made to
intended response times on behalf
of the supervisor, how disagreements
34 Therapy Today/www.therapytoday.net/December 2015
Pat, an experienced counsellor in
private practice, has been in regular
monthly supervision with Sylvie for
over a decade. He has greatly valued
her supervisory input over that time,
and their relationship, though strictly
professional in the early years, has
grown increasingly personal and
he is very fond of her. In his mid-60s,
Pat considers himself to be in the latter
stage of his career; some 10 years older
than him, Sylvie gives no indication
she’s thinking about retirement.
Over the last year when something
urgent relating to his work with
clients has arisen and he has needed
to contact Sylvie between supervision
sessions, Pat has found it increasingly
hard to receive a timely response from
her to his phone messages and emails.
He has also noticed that she’s been
forgetting details about his clients
at an increasing rate over the months.
Because he knows well enough how
it feels to be getting older, he has tried
gently to talk to her about these issues
but feels his efforts have landed on
deaf ears. Furthermore, he knows
Sylvie has had some extremely difficult
issues to deal with in her private life
and he has a lot of compassion for her.
He also intends to wind down his own
practice within the next couple of years
and would rather try to improve the
situation than find another supervisor.
What should Pat do?
Please note that opinions expressed
in these responses are those of the
writers alone and not necessarily those
of the column editor or of BACP. You
can read additional responses to this
month’s dilemma at TherapyToday.net.
might be resolved, or how the contract
might be modified if necessary?
It is clear that Pat is dissatisfied
with parts of the service he is receiving.
He has expectations that Sylvie will
respond to his contacts within a
certain timeframe and will remember
details of all the clients that he brings
to supervision. The supervisor may or
may not think that those expectations
are reasonable, and reference to a good
written contract, or an updated and renegotiated one, might resolve the issue.
Pat is assuming he understands the
reasons for Sylvie’s behaviour. Although
he has been talking to Sylvie, it seems
that he has largely framed the issue in
terms of her growing old (which makes
it personal, and perhaps inappropriate),
rather than in terms of the professional
issue (his concerns about aspects of
his experience of being supervised).
Pat may have grown close to Sylvie
over the 10 years, and feel responsible
for part of her care. However, it is not
the supervisee’s job to take responsibility
for the supervisor’s health and fitness
to practise. The supervisor’s supervisor
should be monitoring that. At the heart
of this problem there is a professional
disagreement about the quality of service
being provided. It feels as if that is in
danger of getting lost.
In my view Pat should seek to raise
the issue with Sylvie, framing it as a
professional dissatisfaction and, if
possible, refer to the current
understanding about what and how
supervision should take place in this
professional relationship by referring to
the written contract or initial discussion.
It may be that Sylvie is happy to make
changes in her behaviour and revise
the contract. It may be that she feels
‘At the heart of this
problem is a professional
disagreement about the
quality of service being
provided. It feels as if that
is in danger of getting lost’
ILLUSTRATION BY LARA HARWOOD
times, and also additional support in
specialist areas when this is appropriate.
As far as this supervision is concerned,
we do not know how useful Pat continues
to find it in terms of his client work. If his
work continues to benefit from Sylvie’s
supervision he could consider continuing
to see her while also seeing another
lead or supplementary supervisor.
This arrangement would need to be
transparent to the practitioners involved.
If Pat has concerns about Sylvie’s
continued ability to practise, and
evidence of this, then there is a further
ethical dilemma as to how she may be
encouraged towards retirement. Sylvie’s
supervisor should also be involved in
this. The only formal mechanism we
have at present is a Professional Conduct
Procedure. A ‘capacity’ stage before this,
with assessments, would be useful here.
It would be helpful to have more support
and guidance from BACP when we come
to an age where cognitive decline is
more likely.
Pat’s expectations are unreasonable.
If Sylvie is not willing to accommodate
the changes Pat requires, Pat either
has to accept that or thank Sylvie for
her work over the years and seek a
new supervisor. Some would argue
that a new supervisor after such a long
time might be a wise move anyway. If Pat
feels genuinely concerned about Sylvie’s
apparent condition, he can express
that to her, but he must leave her (and
her supervisor) with the responsibility
of considering the validity of that
judgment and of caring for herself.
Other supervision
is needed
Mary Russell
MBACP (Snr Accred) counsellor
and supervisor in private practice
On the face of it there is a clear answer
to this dilemma as far as Pat is concerned.
In various ways his supervision with
Sylvie is no longer meeting his needs
and therefore those of his clients, and
other supervision is needed. The fact
that he may retire in a couple of years
is beside the point as the needs of the
clients he will see in that time are
obviously as important as those of
the clients he saw earlier.
If we look at the reasons this
supervision has become problematic,
the strongest indicator is that Pat has
tried to talk to Sylvie about his issues
but ‘his efforts have landed on deaf ears’.
This indicates that, in this area, she is at
present unable to show the reflectiveness
and curiosity essential to our work as
counsellors and supervisors. There
may also be a problem with Pat’s ‘gentle’
approach. The knowledge that he is
moving towards retirement himself
may mean that he feels less robust and
has less clarity about his supervision
needs. He also needs to explore this in
supervision. A robust review in which
both Pat and Sylvie explore their work
together, as well as re-visiting their
contract (including supervisor
availability), is essential.
The other problems mentioned are
Sylvie’s difficulty remembering Pat’s
clients and her failure to reply to his
need for support in a timely manner.
Neither of these in themselves proves
a cognitive decline, which might
necessitate retirement. Our practice
at any age is influenced by life events
and these are also in play here. We will
all have periods, such as holidays, when
we are unable to meet the needs of
clients and supervisees. As we grow older
we sometimes use notes more than we
did previously. This may be easier with
short-term rather than long-term work.
Arguably we should all have more than
one source of supervision, even though
we have a lead supervisor. This means
that we have supervisory support at all
Why maintain the
status quo?
Helen Tattersall
Person-centred counsellor and
supervisor working in private practice
and in an NHS IAPT counselling service
It sounds like the boundaries in this
supervisory relationship have become
blurred due to a personal element
developing over time, which appears
to be unacknowledged. It feels like
Pat is having difficulty separating how
he feels personally for Sylvie from his
needs as a supervisee. He appears to
be struggling with being fully congruent
with her because he cares about her and
doesn’t want to be critical of her, and can
also identify with issues that may be age
related. He also appears protective of her,
being aware she is experiencing a difficult
time personally. Unfortunately Sylvie
does not seem to have awareness of
these issues and the effect they are
having on Pat, and is not picking up
on his attempts to communicate his
concerns. Another element is Pat’s
reluctance to start afresh with a new
supervisor. His reluctance to address
the issues more openly with Sylvie
may be related to his fear of fracturing
the relationship, which could result
in him having to change his supervisor.
It may be helpful for Pat to reflect on
his reluctance to be more challenging
with Sylvie and explore what need is
December 2015/www.therapytoday.net/Therapy Today 35
being met in him by staying with the
status quo. As our behaviour is motivated
by our needs, Pat could benefit from
becoming more aware of what emotional
need is behind his current dilemma.
He seems to be reluctant to leave the
security of the longstanding relationship,
despite the change in the nature of it
with regard to his needs as a supervisee
being fully met. An open discussion
with Sylvie, owning his reluctance to
challenge her but clearly sharing his
concerns in a direct way and how they
are affecting him, may help Sylvie be
more open to hearing his concerns and
addressing them. Ultimately Pat is going
to have to decide what is more important
to him: the personal relationship that
has developed or his desire to have a
supervisor he feels fully confident in and
who has the capacity to be consistent and
fully present in her role as a supervisor.
Separate friendship
from the contract
Jim Holloway
MBACP senior accredited supervisor,
partner in Cambridge Supervision
Training and co-author of Practical
Supervision (JKP, 2014)
First of all, what’s this anxious feeling
in my gut? The tale of Pat and Sylvie
has got me squirming a little. I haven’t
experienced their situation in reality
but can recognise myself in both of
them. I guess my gut is saying: this could
all too easily happen to me, so be careful.
February’s
dilemma
36 Therapy Today/www.therapytoday.net/December 2015
And I am worried about Sylvie. Assuming
she is providing counselling or therapy
and not just supervision, how risky
has her forgetfulness and unreliability
become in her contact with clients?
Pat’s concern is presumably shared by
her other supervisees, who might also
feel their caseloads are inadequately
supported. Sylvie’s decline, to put it
bluntly, is probably adversely affecting
a large number of people in her direct
or indirect care. I wonder what her
supervisor is doing about this.
Pat’s dilemma stems largely from
his dual relationship as a fond friend
and professional colleague. Such a
relationship can be wonderfully
restorative; it can also completely
flatten collegial rigour. He has been
a good friend by telling her honestly
what he has noticed in her behaviour
but, significantly, his words have ‘landed
on deaf ears’. Putting aside the fact that
at her age Sylvie is likely to have actual
hearing loss, this phrase is telling. I
imagine she has profoundly enjoyed
her work for decades; surviving her
extreme personal difficulties has
deepened her passion for it even more.
She might feel invincible, believing
she will work till she drops. If so, the
challenge for her to unlock her denial
and enter a new phase of life outside
her profession could be huge. However,
if she seems mostly unaware of her
memory loss, the challenge might be
more to do with Alzheimer’s disease.
Pat could discreetly ask one or two
people who also know Sylvie well if they
have noticed the same uncharacteristic
changes in her that he has. He will be
Anton is the counselling co-ordinator
for a substance misuse charity where
he supervises qualified members
of staff and student counsellors on
placement, as well as holding his own
client caseload. Following the Savile
Inquiry, the charity introduced a policy
that requires counsellors working
with clients who disclose historical
sexual abuse to encourage them to
disclose the name of the perpetrator,
if they are still alive, and collect as
much information as possible with
a view to the client then sharing
this information with the police.
In addition to his paid employment,
Anton also volunteers for a local
counselling centre where the
approach is psychodynamic. He has
asked his supervisor and the centre
director whether this same approach
should also be followed there and has
‘Sylvie’s decline, to put it
bluntly, is probably adversely
a�ecting a large number
of people in her direct or
indirect care. I wonder
what her supervisor is
doing about this’
reassured if he knows that someone
else is also respectfully confronting her.
He has spoken to Sylvie ‘gently’ about
things. Understandably, he doesn’t want
to hurt his friend or damage his highly
valued supervisory relationship by
speaking more forcefully, but he has
an ethical duty to put his professional
commitments – to himself and his
clients – first. Compassion is the
toughest of all the virtues. I want him
to step up a gear and be firmer with her,
face to face. Then he could also write
his concerns in a letter (I mean a proper
old-fashioned letter, not an email),
as she might be able to ‘hear’ him more
acceptingly in a tangible form like that.
Pat must change to another
supervisor – specifically someone
who does not know Sylvie – for the
last two years or so of his career.
This would remove the risk to his
practice presented by Sylvie’s cognitive
impairment (albeit as yet medically
undiagnosed). His ethical task is
to separate his personal friendship
with Sylvie from his supervisory
contract with her. Pat would then
be free to be wholly her friend without
compromising his professional integrity.
been told it shouldn’t. He is currently
working with a client who is a survivor
of sexual abuse and who has given
him the name of his abuser, and he
is concerned about the ethics of not
working with him in the same way
he would if he was in his workplace.
He is particularly anxious about the
possibility that he may be the only
person that this client has told, and the
risk that, as the perpetrator is still living,
other children may be being abused.
What should Anton do?
Please email your responses (500
words maximum) to John Daniel at
[email protected] by 20 January
2015. The editor reserves the right to
cut and edit contributions. Readers
are welcome to send in suggestions
for dilemmas to be considered for
publication, but they will not be
answered personally.
Letters
We can’t ignore
politics
I am shocked by Denise Pickup’s letter
requesting less coverage of political,
social and international issues. Surely
the individual cannot exist in a vacuum
outside his/her social, cultural and
political context? If we opt out of
political, national, international and
social issues, what kind of therapists
and human beings can we be?
Has it not occurred to Denise that the
lack of funding for Relate in Lincolnshire
and the reason why it had to close might
be related to cuts in government funding
for local government? Government
policies on welfare have also been the
cause of many of the mental and physical
health difficulties which drive our clients
to seek our help.
I think this individualistic and
solipsistic stance, in which counsellors
and therapists separate themselves
from the ‘political’ (which has also
often played a big part in the formation
of our inner psyches as well as our
values and meanings), gives the
whole therapeutic project a bad name.
I welcome the fact that Therapy Today
is not insular and, while addressing
national and local ‘therapeutic’ issues,
also covers practice with refugees and
people in China.
Val Simanowitz
MBACP senior accredited counsellor
and supervisor
Walking the walk
I am writing in support of Frances
Bernstein’s view (‘Personal therapy is
important,’ Letters, November Therapy
Today) concerning the importance
of personal therapy in this work – a
wider issue than that of distinguishing
psychotherapy from counselling.
Frances states that she was required to
be in personal therapy for the duration
of her five-year training. It was the same
for my three-year MSc, and this was
not just any therapy – as the training
was psychodynamic the therapy also
needed to be weekly and psychodynamic
or psychoanalytic. I would go further and
suggest that, as learning is continuous
throughout life and our formal
qualifications are steps along a journey
rather than a completion, we benefit
from continuing our own therapy.
Worryingly but not surprisingly
due to lack of regulation, it seems there
are now many courses that require no
therapy, or a minimal amount (eg six
sessions). This is, perhaps, compounded
by the absence of any requirement for
therapy in NHS CBT trainings for roles
in IAPT services. Besides potentially
encouraging omnipotence, this could
carry the damagingly normalising
message that we don’t ourselves need
to experience what we are expecting
our clients to experience.
I believe it is ill-advised that BACP
some time ago removed the requirement
for personal therapy, as it represents
an omission in itself and also has
implications for the profession’s
status, linking with the relatively low
pay (compared with other professions)
that many practitioners complain of.
I don’t think other kinds of personal
development, beneficial though
they may be, can be substituted for
undergoing the kinds of journeys
(at times painful) our clients are
taking with us.
I agree with Frances’ view that
‘personal therapy is as important as
ongoing supervision for working in
depth and for working with complex
need’. CBT doyenne Christine
Padesky’s words, quoted in a review
of a book about self-reflection for
CBT practitioners (‘Experiencing
CBT as a therapist,’ Reviews, November
Therapy Today) could well apply to
personal therapy: ‘Your credibility,
the therapeutic alliance and client
adherence are enhanced when you
have “walked the walk”.’
Why a Christian
counselling centre?
Counsellor in private practice.
www.roslynbyfieldcounselling.co.uk
Lincolnshire Relate
Roslyn Byfield
‘If we opt out of political,
national, international and
social issues, what kind of
therapists and human beings
can we be?’
I was interested in the responses to
the dilemma discussed in November’s
Therapy Today. Much of what was
covered was excellent.
I was wondering, however, about
the little bit of information that nobody
picked up on, other than the oblique
comment that Avril might have support
‘from her Christian Counselling Centre’
– about the setting being a Christian
counselling service. This is a particular
kind of information. It might have been
a ‘large city centre’ service, for example,
which would have prompted me to think
about people possibly going there hoping
for anonymity, or that parking might be
an issue. It is one sort of information.
But the reference to Christian sets a
frame for thoughts and fantasies about
certain sorts of beliefs and values, or
our ideas about them. It could well
have some bearing on why a counsellor
might want a voluntary placement there,
or why a couple might look for therapy
there. Whatever the counsellor’s stance,
it is bound to have an influence on what
the clients think, either knowingly or
unconsciously. And should therefore
be part of a background discussion
about what a couple are hoping for
and what might be acceptable to them.
What if the people had Muslim names
and the counselling centre had been
described as Islamic; would that also
not have been mentioned?
Your respondents’ comments were
all valid and pertinent. But it did feel
to me like the Christian bit was an
elephant in the room!
Annie Hargrave
Retired psychotherapist
Relate would like to reassure readers
of Therapy Today that by the end of
November the ongoing relationship
support needs of people in Lincolnshire
will be being met. This follows a letter
in the November issue of Therapy Today
(‘Relate branch closed’) from a reader
December 2015/www.therapytoday.net/Therapy Today 37
Letters
who was understandably concerned
following news of the closure of
Relate Lincolnshire.
Relate is a federation with a central
national charity and 59 centres, which
are all separate charities and separate
limited companies. We all rely on
funding from various sources to
subsidise the services we provide
for clients. We were very sorry to
see Relate Lincolnshire close in
October after 53 years of supporting
local couples, families and young
people. The centre had experienced
financial difficulties caused by a
number of factors, including the
loss of a major contract.
We apologise for the short gap in
service delivery and any inconvenience
and upset caused to clients and our
dedicated staff. Relate as a national
charity is committed to continuing
to provide services for the clients
and communities of Lincolnshire
and we acted quickly to ensure
clients were offered telephone and
email counselling while services were
re-established. We are pleased to say
that the full range of services will be
up and running again by the end of
November, provided by Relate as a
national charity but delivered locally.
The way people want to access
relationship support is changing
and Relate, like all providers, needs
to constantly review how we provide
services in the most accessible and
affordable way for our clients. That
is why, in addition to our commitment
to provide face-to-face counselling,
we have also developed online support
counselling services using web-cam
and email. Our innovative Live Chat
service also provides clients with a
one-off, 30-minute, targeted support
session with our trained counsellors.
Despite tough economic times we
know that the demand for relationship
support is growing. As such, we are
determined to make sure that
relationship support is available across
the country. Relationship breakdown
costs the economy an estimated £47
billion, which is why Relate and other
organisations are calling for the
Government to triple to £22 million its
promised £7.5 million for relationship
support. This will provide much38 Therapy Today/www.therapytoday.net/December 2015
‘Being fit-to-practise includes
recognising the value of
further therapy, even or
perhaps especially when
not deemed “necessary”’
needed investment for interventions
that we know make a difference.
Chris Sherwood
Chief Executive, Relate
Integrity, not
qualifications
I refer to the recent correspondence
attempting once again to differentiate
counsellors and psychotherapists –
a continued debate that is both
anachronistic (witness BACP’s own
guidance on the subject) and demeaning
to the profession, judging by the nature
of some of the correspondence. There is
surely a simple and dignified answer: the
difference lies in the nature of the work
and the integrity of the practitioner, rather
than the person and their qualifications.
David Sherborn-Hoare
MNCS (Accred), MBACP Reg.
www.cheltenhamcounsellor.co.uk
Personal work
integral to CPD
Reading Frances Bernstein’s letter
(Therapy Today, November 2015) about
the importance of personal therapy – ‘in
my view having had personal therapy is
as important as ongoing supervision for
working in depth’ – I would add that indepth personal work is integral not only
to both counselling and psychotherapy
training but also to continuing personal
development; that being fit-to-practise
includes recognising the value of further
therapy, even or perhaps especially
when not deemed ‘necessary’.
Jane Barclay
AHPP (Accred), UKCP Reg
psychotherapeutic counsellor, Exeter
Counselling and
CBT?
Someone I know recently had a screening
interview with one of the London NHS
Psychotherapy Services. He had asked for
counselling via his GP due to depression.
At the end of the interview he was asked,
‘What would you prefer – counselling
or CBT?’ He was told that CBT has a
good track record. He said he’d prefer
counselling. It doesn’t seem right that
they seem to have been put into two
quite separate categories.
Pam Laurance
Counsellor in private practice (who uses
some elements of CBT)
IAPT ethnic
imbalance
With regard to Gillian Proctor’s article
(Therapy Today November 2015), I
would add that there remains also an
often unreported factor in the delivery of
the IAPT initiative – the ethnic imbalance
between those delivering IAPT and those
receiving it, along with disparities in
ethnicity between those who actually
do get referred to and receive the
service, and those who do not.
Richard Bryant-Jefferies
Retired counsellor
First, do no harm
‘First, do no harm’ is the primary maxim
of every physician, and should also be
ours as therapists as we seek to adhere to
the ethical principle of non-maleficence.
In light of this, therapists should be made
aware that there is another side to a short
news item in November’s Therapy Today,
‘CBT could help ME’. The article rightly
says that The Lancet published research
carried out by Oxford University
which found that sufferers of
Chronic Fatigue Syndrome or Myalgic
Encephalomyelitis (ME) may be helped
by CBT and GET (Graded Exercise
Therapy), and that after two years,
sufferers found significant improvement
in their symptoms.
A closer reading of the study however,
reveals that the findings were quite
different to what has been reported.
The abstract of the study published in
the Lancet Psychiatry, 27 October 2015
says this: ‘There was little evidence of
differences in outcomes between the
randomised treatment groups at longterm follow-up.’ This means that those
in the GET and CBT groups had no
greater improvements, long term,
than those following a different form
of treatment, and those who did nothing
at all. The authors hypothesised that the
reason for the lack of different outcomes
could be because those in the non GET
groups did Graded Exercise after the
study. However, they have no data or
evidence to suggest that this is the case.
The study was a follow up to a
previous study, the PACE trial, which
itself was found to be significantly
flawed. Six scientists from American and
English universities sent a joint letter
to The Lancet calling for an independent
re-analysis of the PACE trial data, due to
what they feel were multiple flaws in the
research methodology. The open letter
(http://www.virology.ws/2015/11/13/anopen-letter-to-dr-richard-horton-andthe-lancet/), states: ‘The PACE study
was an unblinded clinical trial with
subjective primary outcomes, a design
that requires strict vigilance in order
to prevent the possibility of bias. Yet
the study suffered from major flaws
that have raised serious concerns about
the validity, reliability and integrity of
the findings.’ The letter summarises the
main flaws of the trial, and concludes:
‘Such flaws have no place in published
research. This is of particular concern
in the case of the PACE trial because
of its significant impact on government
policy, public health practice, clinical
care, and decisions about disability
insurance and other social benefits.
Under the circumstances, it is incumbent
upon The Lancet to address this matter
as soon as possible.’
If it is true that the NICE guidelines
are misleading, this matters for clients
who may seek the help of a therapist,
asking for GET. The ME Association
reports (http://www.meassociation.
org.uk/wp-content/uploads/2015-ME-
Association-Illness-ManagementReport-No-decisions-about-me-withoutme-30.05.15.pdf ) that 74 per cent of ME
patients are harmed by GET, leaving
some permanently disabled. As
therapists, we can’t be expected to
question every piece of research that
dictates best practice for the way we
work, especially those published in
highly reputable medical journals like
The Lancet. However, if we are to be
practitioners who first do no harm,
we do need to consider this one.
Stephanie Bushell
BACP Accredited integrative counsellor
and supervisor in London
Counsellor training
and therapy
It is not true, as Frances Bernstein
implies (Letters, Therapy Today,
November 2015), that counselling
training does not require trainees to
have personal therapy, and I am surprised
to read this from a qualified supervisor.
Some courses do not have this
requirement – a mistake, in my view –
but many do. I trained as a counsellor
at Re-vision, the Centre for Integrative
Psychosynthesis, and we were required
to have personal therapy for the duration
of the three-year course. I found this an
invaluable experience, which enabled me
to integrate the learning from the course,
and especially to learn from my own
experience about the value of a relational
stance in working with clients. Many of
us continued with our personal therapy
for some time after the course, and
continue to return to it as a resource in
times of personal or professional need.
Maeve Allison
MBACP (Accred) Registered Counsellor
and EMDR Europe Accredited Practitioner
‘“First, do no harm” is the
primary maxim of every
physician, and should also
be ours as therapists as we
seek to adhere to the ethical
principle of non-maleficence’
On the wrong list
In 2006 I applied to a charity that was
looking for new trustees. In return
for my counselling expertise, I gained
the experience of being a trustee. I
resigned in 2008, not realising that my
confidentiality was already breached.
Two years later, at a family party,
people were googling each other’s names
to see what could be gleaned about them
from the internet. When it came to my
turn, I was astonished to be told that my
postal address, phone number and date
of birth were freely available. I had no
idea how Google had accessed these
details and made strenuous attempts to
get them removed but with no success.
When Google started to help
individuals who wanted their out-ofdate information erased, I discovered
that the charity had mistakenly listed me
as a director and so my name and address
had been placed on the Government’s
Companies House website. The only way
to get my details removed was to prove
that my life was in danger. However,
my name and date of birth would remain
on the site for ever, even if my address
was removed. If I wanted to be delisted,
I had to pay £55 for each incorrect listing,
enclose a letter from a police inspector
in support of my application, and provide
an alternative address. In 2014 I decided
to pay £165 and submit all the required
paperwork. Fortunately my application
was successful. As soon as I heard from
Companies House, I googled my name
and found that nothing had changed.
There was one further problem.
Companies House had sold my details
to other websites. I had to contact each
one and apply to be delisted. This took
until the end of March 2015. Therapists,
beware of getting on the wrong list!
Bella Hewes
Contact us
We welcome your letters. Letters may be
cut and edited at the Editor’s discretion
and those not published in the journal
may be published on TherapyToday.net.
Please email the Editor, Sarah Browne,
at [email protected]
December 2015/www.therapytoday.net/Therapy Today 39
Reviews
Fear of climate
change
Environmental melancholia:
psychoanalytic dimensions of
engagement
Renee Lertzman
Routledge, 2015, 221pp, £90
isbn 978-0415727990
Reviewed by Anne Gilbert
In recent times it has
become fashionable
to argue that we do not
take action to safeguard
the environment because
we are apathetic. In this
delightful and original
text the author uses
psychoanalytical theory and psychosocial
research to explore issues of public
engagement and apathy in relation
to environmental issues.
The opening section, ‘Why
psychoanalysis matters’ sets the
scene and explores the arguments
for applying psychoanalytic concepts
to environmental issues. Qualitative
research undertaken by the author
is outlined, together with a detailed
rationale for the research methodology
selected. The author describes the
in-depth interviews with respondents
she conducted in Green Bay, Wisconsin
about their responses to the degradation
of their local environment.
In ‘Psychic Dimensions’, she
presents the research findings and
analysis. Chapters 4–6 cover themes
of loss, mourning, melancholia and
ambivalence that emerge. Lertzman
concludes that far from being apathetic,
her research subjects are stuck in what
she labels environmental melancholia,
a chronic form of mourning for
environmental losses. The sense of
loss experienced is so profound that
it is difficult for participants to make
sense of. She also concludes it is the
situation of stasis from their grief that
prevents respondents moving on to
anger and action, rather than that they
are apathetic. Chapter 7, the final one,
explores ways of moving from loss
to engagement in local communities,
by inviting creativity. The lengthy
40 Therapy Today/www.therapytoday.net/December 2015
appendices provide more detail of the
research respondents and methodology.
Although this is a densely written
text, I found it novel and very thought
provoking. It will be of interest to those
wishing to apply therapeutic frameworks
to wider social issues. A couple of
caveats: I really wish the photographs
were colour rather than black and
white in order to provide a more vivid
depiction of the local terrain. Also, this
is a very slim volume and it is difficult
to understand why it costs £90.
Anne Gilbert is a Gestalt psychotherapist
and supervisor
A therapy novel
The training patient: a novel
Anna Fodorova
Karnac, 2015, 242pp, £9.99
isbn 978-1782202202
Reviewed by Anne Power
I never tire of novels
about therapy and I
found this one both
enjoyable and interesting.
Whilst not the strongest
in terms of the depth of
the therapeutic dialogue,
the book breaks new
ground by focusing on the experience
of a trainee. The story is set in a
psychoanalytic training so our novice
therapist needs first to find herself
a patient who will come twice a week
and the treatment is conducted within
a classical frame – or at least is meant
to be.
Like almost all therapy novels the
story involves some suspension of belief
– in this case the therapist plays fast
and loose with the frame in a way that
detracts considerably from veracity. She
becomes in effect a stalker to her patient
– a narrative that fits with the patient’s
presenting problem of being followed.
The therapist’s countertransference
and its enactment thus form a major
part of the book.
Another theme explores the
protagonist’s weekly visits to her
benign supervisor. Here we see her
struggle to admit the muddles she is
getting into with the frame. We also
see her with her own therapist, or
rather with two successive therapists
where she experiences two different
types of transference.
The story includes many of the
aspects to training which I have not
seen covered in fiction: relationships
with peers, the struggle of different
trainees to keep going and the group’s
interactions with their tutor. An
important subplot is the death of a
therapist. It was very good to see this
explored in fiction as this is a remarkably
common experience and, as in the real
world, no one was available to protect
the interests of patients by putting
the case for responsible retirement.
For those whose training is
psychodynamic the world described in
this story will be very familiar. For those
of other modalities it may be interesting
to take a look at a different process. In
terms of literary style, the book is mixed.
There are some moving passages, but
sometimes the effort to describe and
convey this rarefied world results in
rather heavy writing. For me the interest
in the story overcame the awkwardness
in style.
Anne Power is an attachment-based
psychotherapist and author
Understanding
the Muslim client
Islamic counselling: an introduction
to theory and practice
G Hussein Rassool
Routledge, 2015, 296pp £29.99
isbn 978-0415742689
Reviewed by Myira Khan
As a Muslim counsellor,
trained in psychodynamic
counselling, I approached
this book with much
curiosity, wishing to
further my understanding
and knowledge of
working with Muslim
clients using a faith-based model. I
found the range and depth of topics
that the book explored quite staggering
and beyond my expectations. In Part
One, the book presents Islamic context
Film review: The Lady in the Van
Chris Rose reviews The Lady in the
Van, a film that makes you question
your own sense of tolerance
The lady in the van is the person most
of us would avoid – cantankerous,
irrational, ungrateful and filthy, with
an overpowering odour of urine dusted
with Yardley’s lavender talc. Her arrival
and subsequent 15-year stay in Alan
Bennett’s drive is by now a familiar
story, and Nicholas Hytner’s film
movingly recreates both the humour
and the squalor. ‘Caring is about shit,’
Bennett (Alex Jennings) sagely observes
as he treads in it once again on his drive.
The smell seems to waft from the
screen to where I sit, certainly
challenging my own sense of tolerance.
How did Bennett manage this for 15
years? The film presents us with two
versions of him – the one who lives
in the house and the one who writes
about it, and their witty, waspish
dialogue questions the nature of this
tolerance. Is it indolence, compassion,
timidity, guilt for having put his own
mother into a care home?
Whatever his motives, it made
me think about who and what can
be tolerated. As counsellors and
psychotherapists we might pride
ourselves on our tolerance, but for all
of us there is a point where it runs out.
Disgust, anger, fear, revulsion – these
are some of the things that can erode
our capacity to stay in relationship
with the other. Appropriately or not,
we draw boundaries to protect our
limited capacities to relate.
Bennett protects himself in part
by turning Miss Shepherd into a subject
for his writing, but nonetheless, 15 years
of tolerance is a remarkable feat. Yet
the story goes beyond Bennett himself.
The community of neighbours that
the film gently mocks are also tolerant
to a degree that I doubt would be the
case today. The contemporary culture
demands that those who challenge our
emotional security are ‘fixed’, quickly
and cheaply, or removed from our
particular back yard. The film is set
in an era when it seemed more possible
and acceptable to provide long-term
consistent support for those whose
problems were not ‘solvable’.
The film shows how, in a very English,
restrained manner the relationship
between the characters develops in the
context of this long-term consistency.
We are rewarded with a glimpse of who
this woman might have been in other,
kinder circumstances. Miss Shepherd
is revealed as an accomplished pianist,
fluent French speaker, motoring
enthusiast, and wartime ambulance
driver. In a remarkable performance,
Maggie Smith brilliantly transforms
an unbearably filthy and untouchable
character into a multidimensional
human being capable of charming us.
She becomes, bit by bit, tolerable. As we
become able to see her vulnerabilities,
her capacity to laugh, her childlike
delight in painting her vehicles custard
yellow or freewheeling down the street
in a wheel chair, the smell becomes less
overwhelming. At the end of the film she
is at last bathed, hair washed and dressed
in clean clothes. Now she can ask
Bennett to hold her hand. ‘It’s clean,’
she tells him. The transition from
intolerable to touchable is complete.
Chris Rose is a group psychotherapist,
writer and Therapy Today Reviews
Editor. If you would like to write a film or
theatre review, email [email protected]
(theory), covering basic principles
in Islam, spirituality, personal
development, cultural and religious
influences upon mental health,
working with Muslim clients and
Islamic ethics relating to counselling.
I would recommend that for any
counsellor this is essential reading
to develop understandings of Muslim
clients and their context of religious
and cultural dynamics. It underlines how
these impact upon accessing counselling
and of how clients may perceive the
ability to change through counselling.
Rassool goes on to present an 11step practical model using directive
and non-directive techniques, skills,
guidance and spiritual interventions.
This is derived from an integrative
theoretical modality of Islamic
counselling, which includes elements
from mainstream counselling theories
that are congruent with Islamic
principles, such as the core conditions.
This illustrates how many mainstream
principles/values/ morals are shared
with the Islamic understanding of
‘good’ characteristics and principles.
Rassool also explores how to use an
Islamic counselling perspective for client
assessments and working with particular
presenting problems, ie addictions and
alcohol problems. Throughout the book
he does not claim his model to be a
fixed template for practice but as a
“preliminary mapping exploration”
for further development (p219), which
reflects a robust yet flexible foundation
for counsellors to use and build upon.
Rassool identifies that the challenge
facing counsellors is fundamentally
to be ‘responsive’ to clients’ health
beliefs/practices and their religiouscultural needs. Although subtitled
‘An introduction to theory and practice’,
the topics covered are more far reaching
than implied by ‘an introduction’ and
it is essential reading for all counsellors
working with Muslim clients. The
flexibility it offers, to use theory and/or
practice to develop culturally-competent
counselling, allows us to incorporate
elements which we feel would best
support our clients in accordance
with their religious-cultural beliefs.
As the first mainstream textbook on
Islamic counselling, I think Rassool has
successfully created a comprehensive
December 2015/www.therapytoday.net/Therapy Today 41
Reviews
resource to further develop culturallycompetent counselling for Muslim
clients as well as providing a faith-based
practice model for counsellors who are
looking to offer Islamic counselling.
Myira Khan is a counsellor in private
practice and founder of the Muslim
Counsellor and Psychotherapist Network
Freud’s history
The hidden Freud: his Hassidic roots
Joseph H Berke
Karnac, 2015, 245pp, £25.99
isbn 978-1780490311
Reviewed by David Goldstein
Throughout his life
Freud dissimulated and
denied his Jewish roots,
in an attempt to re-create
himself as a Viennese
professional and to
protect his creation,
psychoanalysis, from
the anti-semitic charge of being a
‘Jewish science’. Despite this, he
joined the Vienna B’nai Brith in 1897,
shortly after his father’s death, and
(by administration of morphine)
chose the Jewish Day of Atonement,
Yom Kippur, as the day of his death.
In this intriguing and rewarding work,
Berke examines Freud’s family history
and Jewish education, tracing his line
back to his grandfather, Shlomo, an
Orthodox Hassidic Jew living in a
Galician shtetl. Most of Freud’s circle
and followers were Jewish, and many
were descended from notable rabbis
and scholars.
The book does not read as a coherent
argument and is perhaps best considered
as a collection of essays or ‘free
associations’, weaving together ideas
from psychoanalysis and explorations
of the lives of Freud and other
psychoanalysts, with themes from
Kabbalah and Hassidus and Berke’s
own original psychoanalytic and
Jewish mystical interpretations.
I found the chapter on ‘Lowness of
spirit’ of particular interest. Hassidic
thought distinguishes four kinds of
what we commonly call depression.
Three, nemichat ruach (lowness of
42 Therapy Today/www.therapytoday.net/December 2015
spirit), lev nishbar (contrition, brokenheartedness), and merrirut hanefesh
(bitterness of soul) are seen not as
pathologies but states of spiritual
falling-short and calls to renewed
effort. These are important distinctions
to be made in clinical work.
Similarly, the chapter on ‘Reparation’,
comparing Klein’s concept with Jewish
ideas of t’shuvah (repentance, return)
and tikkun (repair), also has the potential
to deepen our work with clients.
In his enthusiasm to establish
Freud as an essentially Jewish thinker
Berke is sometimes guilty of hyperbole.
A conversation with Rabbi Safran
(a future chief rabbi of Romania)
becomes ‘several meetings’ (p104)
and a consultation from the Hassidic
Rebbe Rashab ‘must have brought Freud
back to his Jewish roots’ (p19). Must
have? Annoying as it is, this tendency
is forgivable given the overall quality,
depth and interest of Berke’s writing.
As counsellors and psychotherapists
we need to be able to respond to our
clients’ (as well as our own) strivings
for meaning, spiritual depth and
wholeness. This book reveals some of
the spiritual sources of psychoanalysis
and is a valuable resource for any who
choose to delve into it.
David Goldstein is a counsellor
Refugee children
Handbook of working with children,
trauma and resilience: an intercultural
psychoanalytic view
Aida Alayarian
Karnac, 2015, 205pp, £24.99
isbn 978-178220193
Reviewed by Jeanine Connor
Aida Alayarian has
almost 30 years’ clinical
experience and is the
founder, Clinical Director
and CEO of the Refugee
Therapy Centre (RTC)
in London. Her book
combines research,
theory and practice, focusing on the
experiences of refugee and asylum
seeker children, with the explicit aim
of examining the impact of torture.
The opening chapter reminds us
that one quarter of asylum seekers
are children and that the trauma they
endure is threefold; encompassing
stressors endured in their country
of origin, their flight to safety and
their new environment. The author
acknowledges her feelings of pain
and anger in response to the children’s
narrative but acknowledges also that
this will not help them and is not what
they need. The book contains many
clinical vignettes depicting the horror of
refugees’ experiences. It is difficult not to
be pained or angered by them, providing
a stark example of the challenge of
working with this client group.
I found Alayarian’s no-nonsense
style of writing appealing. She draws
on a wealth of psychodynamic literature
including Freud, Erikson, Bowlby,
Stern and Ainsworth. Readers without
a psychoanalytic background may
find this a challenging read, although
Alayarian does a sterling job of making
the underpinning theory accessible.
She identifies post-trauma anxiety
and depression as normal responses
to environmental stress rather than
signs of mental illness. Similarly, the
importance of recognising adaptation
strategies as a sign of health is illustrated,
for example, by identifying ‘healthy
dissociation’, which moves the focus
away from trauma and provides a
much needed psychic break.
The ‘resilience’ part of the RTC
model encourages a shift away from the
traditional ‘deficit, disorder, problembehaviour’ paradigm and instead
encourages a focus on competencies,
capacities and resources; in other words,
the emphasis is on the haves rather than
the have-nots.
Alayarian’s caution against
pathologising and the provision of
medication is refreshing. She advocates
a systemic approach that considers
the multiple factors and needs of the
children themselves, as well as their
families and schools. If only the services
of the RTC were available nationally and
for all refugee children! An excellent
and timely publication.
Jeanine Connor works as a child and
adolescent psychotherapist in private
practice and CAMHS, and as a writer,
supervisor and trainer
The pleasures of life
Unforbidden pleasures
Adam Phillips
Penguin Random House UK, 2015,
198pp, £14.99
isbn 978-0241145791
Reviewed by Jane Cooper
Is it only nice if it’s
naughty? Adam Phillips
thinks not. This slim
volume, originally
delivered as
interdisciplinary lectures,
is a plea for the ordinary
pleasures of life to be
allowed a place. ‘It is extraordinary,’
Phillips argues, ‘how much pleasure
we can get from each other’s company,
most of which is unforbidden’ (p195).
We have been brought up to split the
world in two – what is allowed and what
is forbidden, with the latter held centre
stage. The pleasure and affection one
might feel, say, in having coffee with a
friend, is seen as a poor cousin to the
illicit pleasure of the forbidden affair.
I like the way Phillips describes the
therapeutic process as a reassessment
of the forbidden and the unforbidden
in our lives. This process often reveals
that we are ‘the casualty of forgotten
obediences’ (p82) and Phillips makes a
helpful distinction between two kinds of
obedience – the pathological kind that he
suggests stems from a tantalising mother
and what he calls a more promising
obedience that acknowledges reality.
So what would a society based on
unforbidden pleasures be like? Phillips
draws on the evidence of an unusual
traffic experiment, which took place
in the Netherlands in 2003. Traffic lights
were removed from busy intersections,
leading to an improved flow of traffic
and fewer accidents as drivers
rediscovered the unforbidden pleasures
of co-operation and attentiveness, which
Phillips likens to the kinds of attunement
witnessed between mothers and babies
when things go well.
The chapter I found most useful for
my work as a counsellor is his treatise
‘against self criticism’, available for free
as an LRB podcast at www.lrb.co.uk/v37/
n05/adam-phillips/against-self-criticism
We are invited to imagine the superego
as a person to whom we get chatting
at a party and soon realise is living in
the aftermath of a catastrophe. He’s
accusatory, narrow-minded and ‘like
the referee in football, always right
even when he is wrong’ (p109). Phillips
makes a valuable suggestion as to how
this cruelty can be moderated with a
return to the ego ideal, the forgotten
part of the Freudian superego. This is
‘inner critic’ work at its best.
Jane Cooper is a counsellor and supervisor
Shelf life
The ‘Shelf life’ feature has been extended
to include books that readers would
recommend as long lasting good reads
relevant to counselling and psychotherapy,
as well as classic and much loved books
already on their shelves.
Junkie Buddha: a journey of discovery
in Peru
Diane Esguerra
Eye Books, 2015, 256pp, £8.99
isbn 978-1903070994
Reviewed by Deborah Keays
Whether it’s due to a
lack of time or inclination
I rarely get to read a
book which a client of
mine has enthused over.
I’m pleased, in the case
of Junkie Buddha, that
I made an exception.
The dichotomous title intrigued me;
a few pages in and I was hooked.
A year after discovering the body of her
half-Colombian adult son following his
accidental heroin overdose, the author
travels alone to Peru to scatter his ashes
at the Inca citadel of Machu Picchu – a
place to which the young man, who had
walked the Inca Trail and loved travelling
in South America, had longed to revisit.
It isn’t long before she discovers
that Peru’s stunning landscape and
anguished history mirror her son’s
troubled psyche. This provides the
backdrop for her attempt to come to
terms with the fraught journey they had
shared and its heart-breaking conclusion.
The mystery and awe-inspiring beauty
of the country help to reconnect her with
life. She befriends several Peruvians who
have also been closely bereaved – a son
who has lost his mother and a mother
who has lost her son, which prompts
her to stop asking ‘Why me?’ and to
start asking ‘Why not me?’
Whether she is flying over the
Nazca Lines in a wobbly plane, meeting
an Inca witch, rowing out to floating
islands, or finding herself in the
middle of a soap opera film set,
Diane Esguerra’s eloquent writing
and self-deprecating humour make
this a surprisingly rewarding and
uplifting read. I was able to gain a
deeper understanding of the beneficial
nature of ‘continuing bonds’ and also
of loss-induced post-traumatic growth
– which, she believes, has made her a
more empathic psychotherapist.
The journey is a courageous one;
so, too, is her willingness to share
raw emotion with her reader and her
determination to create both meaning
and value out of some truly heartbreaking life experiences.
Deborah Keays is as a CBT/EMDR
therapist and supervisor
Reviewed on
TherapyToday.net
Happier people healthier planet
Teresa Belton
Silverwood Books, 2014, 372pp, £13.95
isbn 978-1781322604
Reviewed by Charles Gordon-Graham
‘For those who are
concerned about issues
of individual, societal and
ecological wellbeing, this
book is not a comfortable
ride, but neither is it a
doomsayer’s almanac that
could only lead to despair.’
December 2015/www.therapytoday.net/Therapy Today 43
From the
Chair
Andrew Reeves
reflects on
counselling as a
political activity
I went for a coffee with
colleagues recently and
we were chatting about
everyday life, passing
the time, as you do. The
conversation moved to the
current state of counselling
which, in turn, moved us
on to the wider positioning
of counselling and its place
in society. At this stage we
realised that the caffeine
was really beginning to kick
in, and the juices started
flowing and we found
ourselves in a conversation
that really began to energise.
We were thinking about
counselling as a political
activity; political with a
small ‘p’ – although perhaps
the small ‘p’ informs the
bigger ‘P’ at some level,
but it was the small ‘p’ that
was grabbing our attention.
The discussion resonated
for me because I had just
recently finished writing
last month’s Chair’s column,
in which I was talking about
the importance of the role
of advocacy as part of being
a counsellor: to advocate
for individual clients, with
their consent, but also to
advocate for change when
we encounter wrong-doing,
or oppression, or
discrimination, and so on.
When I trained as a social
worker my motivation was
to be part of societal change.
This was before the advent
of ‘community care’ and
what became known as
the ‘purchaser-provider’
split in social care services:
where one part of the system
assessed and purchased care
from the other part of the
system. I was very clear that
my role was on the ‘provider’
side in delivering the best
quality mental health and
therapeutic services, and that
while I was not diminishing
the importance or skill of
the purchasers, that really
was not my bag. However,
I quickly moved into
becoming a counsellor
because it seemed to me that
social work was becoming
less about social change
and more about social
facilitation. Counselling,
it seemed to me, had grown
from communities and
networks and provided a
real opportunity to make
a difference.
I am now minded to
reflect on the nature of
the difference counselling
makes. I am entirely
convinced, and the
evidence supports this,
that counselling can really
make a significant difference
in many people’s lives. For
over 25 years I have seen
people who have attended
counselling and have left
feeling very differently about
themselves. I truly believe
in the value of counselling
and the things that can be
achieved. How much might
we also contribute, however,
to helping people think about
the bigger picture? If we see
clients living in crushing
poverty and deprivation,
with systems preventing
them from finding escape
from those difficulties, we
can support the individual
in that situation but could
we not do more? If we help
people who encounter
discrimination on a daily
basis because of age,
disability, culture or
sexuality, for example, we
can help those individuals
tend to those emotional
and psychological wounds,
but could we do more?
This is where the
discussion over coffee really
got going. If we witness a
pattern of discrimination
across clients but do not take
that observation beyond the
confines of the counselling
space, do we not run the risk
of colluding with it? Indeed,
we run the risk of becoming
silent witness to the anguish
of many, unless we find a
collective voice to advocate
for those who are in a position
of not being able to do that
for themselves.
I think we have much to
learn from those cultural
perspectives that place the
individual in the context of
group: family, community
and society. As counsellors
we need to be trained to
think from a systemic
perspective, both for the
individual client and for
the wider issues that present
in our counselling rooms.
In locating our own authority
and finding collective ways
of representing what we
know, we can become
formidable agents of change.
Either that, or I start drinking
decaffeinated coffee and go
for a quieter life.
Officers of the Association
President
Michael Shooter
Lynne Jones
Martin Knapp
Juliet Lyon
Glenys Parry
Julia Samuel
Pamela Stephenson Connolly
Chair
Andrew Reeves
Deputy Chair
Elspeth Schwenk
Company limited by guarantee 2175320
Registered in England & Wales
Registered Charity 298361
Chief Executive
Hadyn Williams
44 Therapy Today/www.therapytoday.net/December 2015
Vice Presidents
Sue Bailey
John Battle
Robert Burgess
Bob Grove
Kim Hollis
News
Recognition and evolution
of the way the Association
is governed among our
members. The intention he
said, was to ‘promote further
engagement with governance
so that those who steer the
direction of BACP represent
the diversity that is found
in the membership’.
Andrew described BACP’s
new strategy as one that
‘speaks to the heart of what
counselling is fundamentally
all about’. He added: ‘There is
no doubt that the membership
of BACP is our most important
resource in facilitating change.’
We look forward to
announcing details of our new
strategy soon, and continuing
to work with you as BACP
enters this exciting new
stage of its development.
Our AGM took place last
month, and with it the
opportunity to reflect on the
achievements of the past year
and to look forward to the new
direction we’ll be taking in
2016. Andrew Reeves captured
these themes of reflection and
change in his Chair’s Address,
in which he gave an overview
of the Association’s work in
2015, as well as a taste of the
exciting things to come.
Andrew looked back on the
work that has already been
done on the new Professional
Conduct Procedure, Ethical
Framework and strategy. These
three key elements of our work
will be launched next year and
each has been facilitated
through comprehensive
consultation with our
members. Andrew
acknowledged this, saying,
‘Each and every one of us
is able to provide our own
influence through challenge,
debate, encouragement,
affirmation and advocacy.’
The AGM also saw the
election of a new member
of the Board of Governors.
Eddie Carden is CEO of
Renew Counselling in Essex
and an ordained minister
in the Church of England.
He brings with him a wealth
of knowledge in the field of
mental health. Two more
Governors, Fiona Ballantine
Dykes and Elspeth Schwenk,
were congratulated on
their re-election. Andrew
expressed at the AGM his
aim of raising awareness
CPR journal
to go online
in 2016
Good Practice in Action
From March 2016 your
BACP research journal,
Counselling & Psychotherapy
Research (CPR), will become
primarily an online journal.
Printing and despatching
45,000 copies of CPR
four times a year creates a
substantial carbon footprint
and moving to an online
circulation for members
will significantly reduce
this. Members will have
fast and secure access to
CPR online and will be
emailed contents alerts.
Members who still wish
to receive a print copy should
notify [email protected]
with your name and
membership number
before 31 December 2015.
We’re working on a series
of Good Practice in Action
resources to support you
in your work. The first 10
of these new resources are
available now and are free for
BACP members to view and
download from www.bacp.
co.uk/ethics/newGPG.php.
With subjects ranging
from choosing a supervisor
to confidentiality and ethical
decision making, these
documents are a valuable
addition to your counselling
toolkit. Presented in a
range of formats, including
FAQs, fact sheets and
legal resources, these 10
documents are just the
beginning of a comprehensive
online library of publications
that will support you in
your practice. We’ll keep
you updated as more
resources are added.
Counselling
MindEd
As part of this work, we’re
looking at producing further
resources to support you
in making ethical decisions.
It would help us if you would
complete this short survey at
https://www.surveymonkey.
com/r/N5GF66D to tell us
more about how you currently
make ethical decisions. Your
feedback will help us find out
how we can best support you.
A very big thank you to all
of you who have given your
time by offering feedback
and reviewing new resources
– your input is vital in making
our publications as relevant
and useful as possible. If
you are interested in joining
one of the focus groups to
offer feedback and review
forthcoming publications,
email [email protected]
and let us know the topics
that would interest you most.
Those of you who work with
children and young people
will already be aware of the
Counselling MindEd e-portal.
This project, funded by the
Department for Health and
managed and delivered by
BACP, provides free online
resources on children and
young people’s mental
health for practitioners
working in the CYP sector.
A wealth of counselling
knowledge is available to
support the training of
school and youth counsellors
and supervisors working in
primary, secondary, tertiary
and community settings,
and in the independent sector.
An independent evaluation
of the Counselling MindEd
e-portal was completed
earlier this year by Cathy
Street & Associates and
Youth Access. One of the
key conclusions is that
Counselling MindEd has
been generally welcomed
by practitioners and is seen
as having the potential
to build knowledge and
understanding of children
and young people’s mental
health and emotional
wellbeing across all services
that work with these groups.
Recommendations for
improvements and further
developments are also made
and these are being addressed
as part of the next stage.
You can read the full
evaluation report online
on the ‘Resources’ pages
of the MindEd website
at www.minded.org.uk,
where you can also access
Counselling MindEd’s
46 e-learning sessions.
We look forward to
bringing you further updates
on this project as it evolves.
December 2015/www.therapytoday.net/Therapy Today 45
News/Professional standards
BACP registration deadline
As the 31 March 2016
registration deadline for
MBACP members
approaches, places are filling
fast on the free Certificate of
Proficiency (CoP) assessment
days early in the New Year.
If you still need to sit an
assessment, we’d advise
you to check availability at
your closest venue by going
to the BACP Register website
at www.bacpregister.org.uk.
You can book online or call
us on 01455 883300.
Around 13,000 members
have already passed the CoP.
Despite some initial concerns,
many have found it a good
experience and a fair
evaluation of therapy skills
and practice. You can watch
members talking about their
experience on a new video
on our YouTube channel.
Accredited members,
or those who have passed
a BACP accredited course,
can still join the Register
just by signing up to its
Terms and Conditions.
You can do this online or
call us for a printed copy.
If you’ve recently passed
the CoP, don’t forget you also
need to sign the Register’s
Terms and Conditions to
complete your registration.
Some members have
queried their eligibility for
the BACP Register because
they are not ‘in practice’.
We define practice as
including practice
management, training,
supervision and research,
as well as actually seeing
clients. So you can register
if you have done any of
these in the last three years.
If you are not practising,
you could move to our new
Retired Member category,
which does not require
registration. Please call us
if you are unsure and would
like to discuss the options.
Have your say about BACP membership
Early in the New Year we’ll
be emailing you with a survey
looking into your experience
of membership, what you
value most about being a
BACP member and in what
ways you think we can
improve. Your feedback
will be absolutely vital to
us as we look into the services
and benefits we offer, and
will help us focus on what’s
most important to you.
There will be an added
incentive to take part in the
survey, so keep an eye on
your inbox in the New Year
for the details.
Editor for University & College Counselling
We are delighted to welcome
David Mair as the new
editor of University & College
Counselling journal. David has
a wealth of sector experience
and is currently Head of
Counselling and Wellbeing at
the University of Birmingham.
He joins our other divisional
editors, subject to contract,
on 1 December.
University & College
Counselling is a quarterly
professional journal for
counsellors and
psychotherapists in further
and higher education, which
is free to members of BACP
Universities & Colleges.
For more details, please
visit www.bacpuc.org.uk
Log-in issue on TherapyToday.net website
Apologies to readers
experiencing problems
logging on to the
TherapyToday.net website
or accessing specific articles.
We are working on resolving
this and currently all articles
on the site are free for
everyone to read.
If you find that you
still can’t access a specific
article then please email
[email protected]
with ‘TherapyToday.net
46 Therapy Today/www.therapytoday.net/December 2015
article’ in the subject line.
Include in your email the title
of the article, the author(s),
and the month and year the
article was published, and
we’ll send you the article as a
Word file as soon as possible.
Skills needed
to support
employees
Employee counselling is
a fast-growing sector, with
thousands of you working
as affiliates for EAPs and/or
staff counselling services in
the public and private sector.
Counsellors play a vital
role in supporting the
mental health of employees
at work, but the feedback
from EAPs and recruiters
is that qualified practitioners
need further skills and
competencies, beyond
their initial training, to
meet the specific needs
of this emerging sector.
Rick Hughes, BACP’s
Lead Advisor for Workplace,
puts it like this: ‘Counselling
in workplace settings is a
complex task because, as
well as the traditional clientcounsellor relationship,
therapists need to appreciate
the role, relationship and
responsibility of the
organisation in the process.’
BACP Workplace is our
specialist division for
members working with
employees, employers and
EAPs. Through this division,
we are developing a range
of resources to support
you in understanding the
complexities of employee
counselling and to expand
your competence and skills
within the sector. At the
Practitioners’ Conference
next spring we’ll be offering
learning opportunities
specifically tailored to those
of you who would like to build
your practice and develop
skills fit for today’s workplace.
Find out more about the
BACP Workplace division at
www.bacpworkplace.org.uk
A�ordable, accessible learning
When it comes to CPD
in 2016, we’re focusing
on offering you access to
the best possible learning
opportunities using methods
you will find both affordable
and accessible. With this
in mind, we’ve got a couple
of webcasts already planned
for 2016 that really fit the bill.
In April we’re offering a
live webcast of the OCTIA
2016 conference, which will
look into Relational Depth
and Emotional Connection
in Online Therapy. The
conference is aimed at
practitioners who are working
in or interested in online
counselling and a range
of speakers will present their
varied experiences of working
with clients online.
A couple of weeks later
we’ll be broadcasting day
one of the UKESAD
conference. This webcast
is designed for practitioners
who work with clients with
addictions, or are interested
in this field. Throughout
the day a studio panel will
conduct interviews with
guests in the studio, as
well as engage in discussions
with delegates online.
For more information
about these events and
to book your place, visit
www.bacp.co.uk/webinar
Natasha Lumley
Newly accredited
counsellors/psychotherapists Sarah McCowen
Nancy Ajavon
Denise Askew
Fiona Astbury
Keith Bales
Sue Baxter
Alison Bean
Rowan Bolland
Gill Brennan
Tracy Buckle
Margaret Buckley
Sadie Cissell
Elaine Craig
Nelson Davis
Gareth Desmond
Tabitha Draper
Katrina Durant
Daniel Fensom
Lisa Gee
Ramona Haetzer
Sarah Hamilton
Jane Harris
Charlotte Hastings
Tamara Howell
Zsuzsanna Hutchinson
Elizabeth Jakeman
Sarah Jump
Alison Kennedy
Vida Kennedy
Sharon Lascelles
Lisa Lau
Galit Levy-White
Lucy McDonald
Rachel Mckechnie
Anne McKinley
Philip Meek
Helena Michaelson
Catherine Millican
Miriam Mitchell
Denise Monet
Michael Montgomery
Jacqueline Moran
Sarabeth Morrison
Nuala Moseley
Abbie O’Connor
Elizabeth O’Connor
Elizabeth Oliver
Lei Myo Oo
Nicola-Jayne Parker
Antonia Phillips
Trevor Pierce
Kara Rogers
Jackie Rogers
Janet Seabrook
Charlotte Simpson
Diana Simpson-Hinds
Emma Skala
Paul Smith
Sarah Soden
Margaret Stickland
Cigdem Tas
Paul Thorley-Ryder
Claire Turner
‘Pick and mix’ conference
Do you see clients presenting
with a broad range of issues?
Does your practice span a
number of settings? If so,
the BACP Practitioners’
Conference on Saturday
30 April in London is a
tremendous opportunity
to gain CPD on a wide
variety of pertinent topics.
There will be a packed
programme of guest speakers
and practical workshops,
as well as networking
opportunities. You can
create your own ‘pick and
mix’ programme, tailoring
your learning to suit your
professional needs. You
can meet practitioners
from different sectors, share
ideas and experience a range
of perspectives. You can
network with peers working
in similar settings and review
current thinking in your
specialist area of practice.
This conference is ideal
if you work in workplace,
healthcare and coaching,
have a portfolio of work
spanning a number of
settings, have a range of
CPD requirements or wish
to network with a wide variety
of different practitioners.
To register your interest
and be first in the queue for
future updates, email jade.
[email protected]
Helen Walker
Jan Willmott
Siobhan Wilson
Julie Wray
Brunel University London
Wimbledon Guild
For a full list of current
accredited services, visit the
service accreditation webpages
Christine Gander
Angelina Gibbs
Patience Gray
Janet Grimes
Jenny Hall
Selina Hoey
Diana Jack
Nigel Law
Elizabeth Leese
Catherine Ma
Carole Marco
Wendy Morrison
Diane Phillips
Trevor Plumb
Susan Popplewell
Andrew Stanton
Katharine Taylor
Pat Thompson
Helen Voller
Nina Wright
Susan Wyld
Members not renewing
accreditation
Member whose accreditation
has been reinstated
Newly senior accredited
counsellor/psychotherapist
Christine Wells
Newly senior accredited
supervisor of groups
Kathleen Nisbet
Organisations with
new/renewed service
accreditations
Susan Ashmole
Ann Boyle
Margaret Cairns
Christopher Carroll
Chris Coburn
Shirley Crookes
Clair Dinsdale
Patricia Elliot
Helen Evans
Diana Simpson-Hinds
Member whose accreditation
has been restored
Dorothy Ramsay
The above details apply for 1–30
October 2015 and are correct at
the time of going to print.
December 2015/www.therapytoday.net/Therapy Today 47
Research
Putting
PRaCTICED
into practice
Sally Ohlsen,
Kate Ashley, David
Saxon and Michael
Barkham report
on some of the
practical challenges
of running the
PRaCTICED trial
In June 2013 Therapy Today
interviewed Professor Michael
Barkham about embarking on a
large-scale randomised control
trial (RCT), funded by the
BACP Research Foundation
and based at the University
of Sheffield, that aimed to
assess whether counselling
for depression (CfD) was noninferior to CBT for patients
with moderate to severe
depression when delivered in
IAPT services. The trial is being
conducted in partnership with
the Sheffield IAPT service. Two
years into the trial members
of the research team provide
an update on some of the
in-practice challenges that
have arisen in conducting an
RCT within a local IAPT service
and the solutions that, it is
hoped, will overcome them.
or one of the NHS clinical
support officers (CSOs). If the
patient meets the trial criteria
and consents to take part, they
are randomised to receive
CBT or CfD. Hence PWPs
have a crucial supporting role.
To date the research team
has recruited over 150 patients
to the trial; the target is to
secure 275 in each of the
CfD and CBT arms. However,
while the design is simple,
the implementation of a
trial set within an NHS
clinical setting is complex and
challenging. It is a continual
process of solving puzzles
(where we have some warning
of impending problems) and
firefighting (when we don’t).
Developing a strategy
Most of the problems we
have encountered concern
bridging the gap between
The PRaCTICED trial
research and practice. While
The acronym for the trial is
the agenda and language
PRaCTICED – Pragmatic
underpinning PRaCTICED
Randomised Controlled Trial
is rooted in the world of
assessing the non-Inferiority
research, the priorities of
of Counselling and its
practitioners within IAPT
Effectiveness for Depression.
services are determined by
Its aim is to gain robust
a combination of patients’
evidence for the effectiveness
needs and NHS targets.
of CfD relative to CBT. CfD is
The key issues faced by
one of the four NICE-approved
the team include: 1) securing
psychological therapies for
a sufficient number of referrals
the treatment of depression,
other than CBT, offered within on an ongoing basis; 2) building
bridges with the IAPT service,
IAPT services.
and 3) securing a priority for
The trial design is simple.
the trial and maintaining its
Patients presenting with
integrity amid the relentless
depression to IAPT services
pressures placed on IAPT
will typically first be seen
services from ever-changing
at Step 2 by a psychological
NHS and Department of
wellbeing practitioner (PWP).
Health targets. In light of
The PWPs are the gatekeepers
our experiences, we have
to the trial as they are
developed and implemented
responsible for informing
a strategic approach to
those patients about the trial
who are likely to be stepped up resolving these issues.
Following the move of our
to a high-intensity counsellor
full-time research assistant
or CBT therapist. A patient
to another project, we had
presenting with depression
to decide whether to fill the
requiring a high-intensity
therapy is invited to a screening post with a further research
assistant or adopt a different
interview carried out by a
model. We had become
member of the research team
48 Therapy Today/www.therapytoday.net/December 2015
increasingly aware of a gap
in our knowledge of the
intricacies of the IAPT service.
Coincidentally, in January 2015
Sally Ohlsen joined the wider
research group in the School
of Health and Related Research
(ScHARR) at the university
and initially provided support
at the front end of the trial:
namely, by supporting PWPs
in securing patient referrals.
What became apparent was
that her knowledge of the
NHS, drawn from being an
occupational therapist, gave
the team access to the finer
details and nuances of NHS
ways of working and provided
an immediate down-to-earth
point of contact with PWPs.
As we saw connections and
communications being built
up, we realised that we needed
to provide a more permanent
link between the trial and
the IAPT service. The
PWPs already provided
the gatekeeping function
for referring patients and
seemed to be key in building
the bridge between research
and practice. However, adding
further demands to their
workload would simply
create an additional burden
given the pressures already
placed on PWPs.
In April 2015 our solution, in
partnership with the Sheffield
IAPT senior management team,
was to second three PWPs for
half a day a week each into the
research team for six months to
work specifically on supporting
referrals and encouraging other
PWPs to make appropriate
referrals to the trial. The
PWPs knew the individual
GP practices across the IAPT
service (there were potentially
over 90 of them) as well as all
the PWPs in the service.
The strategy of embedding
NHS expertise within the
trial bore fruit with an almost
immediate increase in referrals,
suggesting the potential for
filling the research assistant
post with a half-time PWP
seconded from the IAPT
service. With the endorsement
of the IAPT senior
management, we took
the decision to advertise a
12-month seconded half-time
post for a PWP to work with
the research team. The tasks
of the post would cover both
the front end (referrals) of
the trial and the back end in
terms of securing follow-up
data. In October this year, we
appointed one of the original
seconded PWPs (KA) to the
12-month post. In addition,
a further PWP took up a new
six-month post working half
a day a week. The remainder of
this article presents examples
of how this NHS expertise
embedded in the research
team is helping to resolve
key challenges for the trial.
The difference made by the
NHS expertise can probably
be grouped into three main
components: 1) knowledge
and expertise concerning the
NHS and local IAPT service
(ie systems); 2) a shared IAPT
language with colleagues (ie
personnel), and 3) direct access
to the secure and confidential
IAPT database system (ie IT).
Two other factors are being
innovative and responsive
and a developing system
of communication pathways.
Knowledge and expertise
While Sheffield IAPT is a
single service, there are four
geographical sectors that
operate in differing ways and
that vary considerably in terms
of their levels of economic
wealth and deprivation as well
as cultural mix and ethnicity.
An added complexity is that
not all GP surgeries have a
dedicated CBT and CfD
practitioner. For the non-NHS
research team, it had been an
all-consuming task to collect
the information that was also
constantly changing. Whereas
previously it was a little like
trying to complete a jigsaw
puzzle in which many of
the pieces kept changing,
the embedded PWPs in
the team gave us immediate
and inside knowledge about
who worked where, when
they worked, and how best
to engage IAPT staff with
the trial. This organisational
knowledge has been crucial.
Shared IAPT language
Sheffield IAPT employs a large
workforce of approximately
130 practitioners comprising
PWPs, counsellors (both
CfD and non-CfD), and CBT
therapists. Having members
of the research team who
understand the language of
IAPT and the tacit knowledge
and context of the organisation
has encouraged members of
the IAPT service to have
conversations with us about
aspects of the trial and we
have also seen their confidence
within the research setting
begin to grow, as well as the
number of patient referrals.
Potential issues have been
highlighted earlier in the
process and solutions derived
collectively with IAPT staff.
IAPT data system
The local IAPT database
captures service level data
from which we can learn the
status of a patient’s therapy
(ie number of sessions so far,
whether they have completed
therapy etc). The embedded
PWPs and CSOs have access to
this system, which has enabled
the research team to keep the
trial data up to date, especially
in relation to managing waiting
times for each therapy at the
different surgeries. It has also
been invaluable in allowing
us to rapidly update the IAPT
system with any information
gathered from contact with
the trial, such as any risk
highlighted during the
screening appointments.
crucial; without it, the trial
simply would not be possible.
Being innovative and
responsive
Recommendations
During the course of the
trial we have had to balance
adhering to the trial protocol
with the reality of the
practitioners delivering
an NHS service – this is the
nature of a pragmatic trial.
Innovations have included
using previous anonymised
local data to identify the
natural rise and fall of
referrals due to staff and
seasonal changes (ie school
holidays). We have also created
a core team of referrers at
sites where both CfD and
CBT practitioners are available
to encourage a steady flow of
referrals. And we have initiated
a central waitlist and city
centre venue, allowing access
to the trial for patients who
would not have had that option
due to lack of resources in
their local GP practice.
Communication pathways
Underpinning all of the
above has been a developing
system of informal and formal
communication pathways
between the IAPT service and
the research team. Beyond the
informal pathways established
by the seconded PWP, there
are also pathways with the
lead CfD and CBT practitioners,
and all are members of the
Trial Management Group
that is responsible for the trial’s
operational running. Their
contribution sits alongside
other members who bring
their expertise in the form of
lived experience of depression
and represent public and
patient involvement. In
addition, there is a clear
communication pathway to
the IAPT Head of Service and
the IAPT senior management
team. This involvement of
senior management has been
Our overall strategy of
embedding NHS personnel
and expertise within the team
reflects the trial’s pragmatic
design. It has also given a
small number of PWPs the
opportunity to develop their
skills and experience within
a research environment and
has engaged CfD and CBT
practitioners with the
potential for future
collaborative research.
Crucially, it is also a reflection
of the commitment of the
IAPT senior management
team to the trial and their
collaboration with the
research team.
In sum, the lessons learned
from our experience are
two-fold: first, to factor in
seconded staff from the service
environment within which the
trial (or study) is taking place;
second, to start the process
of inputting service knowledge
from practitioners, as well as
managers, at the design stage
of a trial. As we have so often
found, the devil is in the detail
and seconded staff embedded
within the trial or study are
best placed to identify, address
and resolve such issues.
Sally Ohlsen is a research
assistant and occupational
therapist supporting the
PRaCTICED trial. Kate Ashley
is a psychological wellbeing
practitioner seconded part-time
into the trial. David Saxon is the
PRaCTICED Trial Manager,
and Michael Barkham is
Professor of Clinical Psychology
and Director of the Centre for
Psychological Services Research
at the University of Sheffield.
The authors would like to thank
members of the PRaCTICED
research team and all staff in
the Sheffield IAPT service for
their ongoing support.
December 2015/www.therapytoday.net/Therapy Today 49
Research
Learning
from research
Andy Hill talks to
BACP PhD scholar
Emma Broglia
about her research
and where she
hopes it will lead
Andy Hill: Tell me a little
about yourself and your
academic interests.
far and what you have found
and b) your plans for the
remainder of the scholarship?
Emma Broglia: I have quite
EB: My PhD broadly aims to
a broad academic background.
Initially I was interested in
psychology and worked on
various projects from
cognitive function to sleep
disorders, and learnt about
lifestyle factors and their
impact. My main interest
was in understanding why
things go wrong and what
can be learnt to prevent
them recurring. I think more
face-to-face contact rather
than computer experiments
helps people. I’m now in my
second year and thinking
about my third year.
AH: What attracted you to
the BACP PhD scholarship?
Why were you interested
in this area?
EB: I was drawn to the
scholarship as I wanted to
be part of BACP’s research.
I wanted to include everything
I learnt from working with
different services. My interests
were improving psychological
functioning and the need
for embedded psychological
services – this was exactly the
challenge I was looking for.
I worked at Birmingham
University for seven years,
with various lecturers in
the psychology department,
and wanted to become more
involved in counselling and
therapeutic services with
schoolchildren or university
students. I wanted to be a
mediator between doing the
research and being involved
in clinical practice; the BACP
scholarship made this possible.
AH: Can you tell us in a
nutshell what your PhD is
about, perhaps outlining
a) the work undertaken thus
50 Therapy Today/www.therapytoday.net/December 2015
explore clinical academic and
institutional outcomes from
university counselling and to
develop an evidence base to
help support services. I also
want the work to inform a
design for a RCT trial to make
an impact and get an evidence
base to show counselling is
effective in keeping students
in university and helping
clinical outcomes.
I started with a systematic
scientific literature review to
see what types of research in
terms of design had already
been done. I wanted to map
the different university
counselling services and
do an annual survey of 113
services. Second, I wanted
to explore the technology
with heads of service –
this is very popular but also
potentially risky. Third, we
did a pilot study and initial
evaluation of studentspecific clinical measures
in comparison with CORE-10,
as the annual report revealed
a lot of embedded counselling
services were using CORE
but not measuring academic
stress, family distress, alcohol
misuse etc. We were able to
embed this student-specific
clinical tool alongside
CORE in two UK universities,
with encouraging results.
We now have another eight
to 10 services on board and
hope to repeat this next year.
Mobile phone apps are being
recommended without
knowing the risks or quality
or potential benefits, so
we would like to do some
focus groups with clients/
counsellors to see what
their experiences have been.
Then we would like to use
the results from all the work
to inform the design of a
feasibility trial – the main
aim being to explore the
possibility of integrating or
supplementing face-to-face
counselling with embedded
counsellors using online
support or mobile phone apps
to promote self-monitoring,
goal setting and homework.
We want to explore the
technical component of
this and also encourage
counsellors to work more
flexibly to see if face-to-face
working can be supported
by other means, because
what came out of our
research so far is that dropout and engagement rates
with students in therapy is
a big issue as students want
support outside office hours
and at weekends. So we would
like to inform the design of
something like a mobile
phone wellbeing app, drawing
on the contextual experiences
that embedded counsellors
have to improve engagement
between the client/counsellor.
This feasibility trial is the
main project left to do on
the PhD so I have set a year
aside for this work.
AH: What has been your
experience of the scholarship
so far?
EB: It has been absolutely
fantastic and exceeded my
expectations. I have worked
with many people who
have inspired me to want
to do good quality research.
I had thought there would
be resistance, but it’s been
quite the opposite: university
heads of counselling services,
counsellors and even clients
have been very excited about
being involved. I’ve also felt
incredibly supported by BACP.
AH: It’s good to hear that your
experience of practitioners is
that they are interested
in research. This is a shift
in recent years really. What
do you think will be the
implications of your work
for the counselling and
psychotherapy field?
What will be its legacy?
EB: I hope my work
inspires services to get more
involved with research by
demonstrating how simple
it can be and how quickly
services can benefit by
collaborating with each other
and sharing experiences.
In terms of legacy, this work
will hopefully result in the
development of UK norms in
student counselling services.
got some really exciting
data and have a good chance
of securing a funding bid
to design a full scale RCT.
AH: What plans do you
have for yourself and the
end of the scholarship?
EB: Outside of academia my
main hobby is running and
I quite like the idea that, by
the end of the PhD, I will be
able to run my first mountain
marathon. It has really helped
me cope and I have run a few
half marathons so I’m looking
for the next challenge.
BACP’s involvement and
want to influence the sector
as a whole rather than a
professional body. It’s a wider
agenda than just BACP’s, and
it covers the whole sector. I’m
based at Sheffield University
and having the Head on
board, who is affiliated to the
UKCP, has helped broaden
the outlook.
AH: I think that’s true. It’s
thoughts about a full-scale
trial based on your design?
EB: I think it helps me cope!
EB: Yes, we have a few initial
to work across different
organisations and
stakeholders?
the kind of work that will
benefit the field as a whole.
Even though BACP is funding
the initiative, the overall
intention is about promoting
research across the whole
professional field. I think
it’s really good that you are
presenting the work in this
broad way.
Now to the last question:
do you have any advice for
BACP about funding further
PhD scholarships? Should
they continue to provide
such opportunities?
EB: I’ve never worked with a
EB: Well the main
AH: Do you have any
designs; a lot will emerge
from the final feasibility
trial, but one important
thing is looking at the use
of outcome measures and
developing student-specific
versions. Not just using
clinical outcome measures
to keep management happy
or as a form filling exercise
but using them as studentspecific tools to help facilitate
discussion between clients
and counsellors to improve
the therapeutic alliance.
AH: Thinking about the
future, is this something you
would be interested in, getting
funding to scale up the project
into a fully scaled trial?
EB: Yes definitely; we’ve
already thought about that.
We are trying to see what
would appeal to potential
funders for next year to
support a full-scale
randomised controlled trial
based on what we have found
so far because I think we’ve
AH: So you like to challenge
yourself physically as well
as mentally?
AH: What has it been like
professional organisation like
BACP before, so I didn’t know
what to expect, but looking
back I’ve been very grateful
for their involvement; it’s
driven me to do bigger and
better research. Everyone
involved in research wants
to make a difference and my
aims are in line with BACP’s
to make a wider impact on
services. Having BACP
involved has definitely helped
get people on board because
they realise BACP is really
trying to help the sector.
It’s been difficult
managing different
individuals’ expectations
while also ensuring that our
research aims are portrayed
realistically. It is only a
three-year PhD so we need
a focused approach but we
don’t want to exclude other
professional affiliations, who
may feel daunted because of
observation is that services
have responded really well
to the research so far and
are keen to participate, but
the main issue is that there
isn’t enough capacity in
the sector to have a research
area linking together and
supporting evidence-based
practice. We have had such
a good response to our work
so far, with people saying
it’s great that your PhD is
addressing these issues.
It’s been a long time coming.
My advice would be to
keep offering PhD student
scholarships because it has
been a fantastic research
opportunity but also, from
the perspective of university
counselling services, it has
done a lot of good.
AH: It’s been a pleasure
having a chat with you, Emma.
Thank you.
Feedback on
CHI paper
Mick Cooper (University
of Roehampton) and John
McLeod (University of
Oslo) are seeking feedback
on a draft paper on how to
conduct a Client Helpfulness
Interview (CHI) study.1
CHI is a type of
‘psychotherapy process
research that asks clients,
directly, what it is that they
found helpful and unhelpful
in their counselling and
psychotherapy; and also,
potentially, their perceptions
of the process of change’.
A recent audit of BACP’s
dissertation database by
Jennifer Loy found that just
15 per cent of post-graduate
research concerned clients’
experiences of counselling
and psychotherapy. Cooper
and McLeod are keen to see
this increase.
One of the main advantages
of CHI research is that it
really tries to listen to the
voices and experiences of
clients, rather than
perceptions of therapists
or observers. It is hoped
that the CHI method will
provide researchers with
an opportunity to contribute
to the development of the
counselling and
psychotherapy profession by
focusing on the experience
of service users.
The paper is free to
download from http://tinyurl.
com/pqlpeaw. Professors
Cooper and McLeod would
welcome feedback on the
working draft of this paper.
REFERENCE:
1. Cooper M, McLeod J. Client
helpfulness interview studies: a
guide to exploring client perceptions
of change in counselling and
psychotherapy. Working paper;
2015. https://www.researchgate.net/
profile/Mick_Cooper
December 2015/www.therapytoday.net/Therapy Today 51
Research/Professional conduct
Last call to apply for awards
BACP Outstanding
Research Award
If you have completed
or written up a piece of
counselling/psychotherapy
research in the past three
years then you are eligible
to apply for the BACP
Outstanding Research Award.
This award aims to reward
excellence in counselling and
psychotherapy research by
enhancing awareness of the
evidence base for counselling,
psychotherapy and its guiding
principles; improving the
overall quality of counselling
and psychotherapy research
by example, or encouraging
and inspiring future
generations of researchers.
The winner will be presented
with a specially designed
plaque at the BACP Research
Conference in May 2016.
CPR New Researcher Award
Submissions are being invited
for the CPR New Researcher
Award, sponsored by Wiley.
The winning entry will receive
£100 worth of book tokens. To
be eligible for consideration
you must currently fulfil one
of the following criteria:
1. a current student who
has completed a research
project in counselling and
psychotherapy, or
2. graduated in the last 24
months and have completed
a research project in
counselling/psychotherapy
as part of your course, or
3. had a paper accepted for
publication in Counselling
and Psychotherapy Research
(CPR), which will be your
first publication.
Submissions are in the
form of a research paper
and the applicant must be
the first author. They must
not have had work published
in any journal previously.
The deadline for submissions for
the above awards is 29 January
2016. For details of how to apply,
go to www.bacp.co.uk/research/
resources/awards.php or email
[email protected]
Thank you from Research
BACP Research would like to
thank the many people who
contributed to our work in
2015. Over the past 12 months
we had the pleasure and the
benefit of working closely
with many people who kindly
gave their time and expertise
to further research at BACP,
for which we are very grateful.
We would like to mention
the people below for a special
thank you, although the list is
not exhaustive. Please forgive
us if we have unintentionally
missed anybody out.
Michael Barkham, Jennifer
Beecham, Emma Broglia, Mick
Cooper, Sir Cary Cooper,
Richard Davis, Andy Fugard,
Susan Hajkowski, Catherine
Hayes, Anthony Hickey, Trish
Hobman, Stephen Joseph,
Chris Kelly, Michael King,
Thomas Mackrill, Nick
Midgley, Naomi Moller,
David Murphy, John Norcross,
Glenys Parry, Peter Pearce,
Jo-Ann Pereira, Gillian
Proctor, Kaye Richards, Maggie
Robson, Anthony Roth, Aaron
Sefi, Roz Shafran, William B
Stiles, Ladislav Timulak,
Andreas Vossler, Panos
Vostanis and Jeannie Wright.
With best wishes for a
happy and healthy 2016 from
the BACP Research team.
52 Therapy Today/www.therapytoday.net/December 2015
Sanction compliance
Carol Gordon
Reference No: 519410
Surrey CR0
BACP was satisfied that
the requirements of the
sanction have been met.
As such, the sanction
reported in the June 2015
edition of the journal has
been lifted. The case is
now closed.
This report is made under
clause 5.2 of the Professional
Conduct Procedure.
Sanction compliance
Susan Campbell
Reference No: 541500
Sheffield S8
BACP was satisfied that
the requirements of the
sanction have been met.
As such, the sanction
reported in the June 2015
edition of the journal has
been lifted. The case is
now closed.
This report is made under
clause 5.2 of the Professional
Conduct Procedure.
BACP Professional
Conduct Hearing
Findings, decision
and sanction
Stephen Hockett
Reference No: 624046
Essex SS9
The complaint against the
above individual member
was heard under BACP’s
Professional Conduct
Procedure and the
Professional Conduct
Panel considered the
alleged breaches of the
BACP Ethical Framework for
Good Practice in Counselling
and Psychotherapy.
The Panel made a number
of findings and it was
unanimous in its decision
that these findings amounted
to Professional Malpractice
in that the service for which
Mr Hockett was responsible
fell below the standards
that would reasonably be
expected of a practitioner
exercising reasonable skill.
The Panel found that Mr
Hockett was incompetent
and provided inadequate
professional services.
The Panel found some
mitigation and imposed
a sanction.
Full details of the decision
can be found at http://www.
bacp.co.uk/prof_conduct/
notices/hearings.php
BACP Professional
Conduct Hearing
Findings, decision
and sanction
Yvonne Builth
Reference No: 541446
Staffordshire DE13
The complaint against the
above individual member/
registrant was heard under
BACP’s Professional
Conduct Procedure and
the Professional Conduct
Panel considered the alleged
breaches of the BACP Ethical
Framework for Good Practice in
Counselling and Psychotherapy.
The Panel made a number
of findings and it was
unanimous in its decision
that these findings amounted
to Professional Malpractice
in that the service for which
Ms Builth was responsible
fell below the standards
that would reasonably be
expected of a practitioner
exercising reasonable skill
in that she was incompetent,
reckless and provided an
inadequate professional
service.
The Panel found some
mitigation and imposed
a sanction.
Full details of the decision
can be found at http://www.
bacp.co.uk/prof_conduct/
notices/hearings.php
Public affairs
School-based counselling
The Youth Select Committee
Inquiry into Children’s and
Young People’s Mental
Health has published its
recommendations to the
Government for ways in
which to improve the mental
health of children and young
people in the UK.
BACP submitted written
evidence to the Youth Select
Committee of 11 young
people aged 13–18 years, who
launched an inquiry into ways
in which the UK Government
could improve the mental
health of children and young
people. The committee
invited BACP to provide
oral evidence in Parliament
in June, to elaborate on
the written evidence,
which highlighted the role
of school-based counselling.
BACP wrote that schoolbased counselling is effective
in improving the mental
wellbeing of young people by
being both easily accessible
and a quick response
treatment, allowing a
counsellor to intervene early
before the young person’s
mental health deteriorates
further, and onward referral
to more specialist support
if required.
BACP’s Children and
Young People Lead Advisor
Karen Cromarty, who
represented BACP at the
committee hearing, said:
‘Our research shows that
counselling can lower levels
of distress in young people.
It can help them to attain
better results in school.
Young people tell us it helps
them with their learning.
Senior school staff – deputy
heads and head teachers –
tell us that young people
who have been to counselling
work better in class; they do
Consultations
better in their studies; they
attend school more often.’
The committee’s final
recommendation, published
in mid-November, was that
a trained counsellor should
be available in all schools.
The committee also said
funding for young people’s
mental health services should
be proportionate to that of
physical health to achieve
parity of esteem; that there
should be compulsory
training for GPs on young
people’s mental health; that
teachers should be provided
with training on mental
health issues, and that
more work should be done
to mitigate the negative
impact of cyber-bullying
through social media.
The committee is now
awaiting a response from
the Government to its
recommendations.
Westminster debates gay conversion therapy
Westminster recently saw
a debate on gay conversion
therapy, led by MP Mike
Freer, who called on the
Government to explore
ways in which gay conversion
therapies can be banned.
Freer raised his concern
that people who might
be confused about their
sexual orientation might
potentially be referred
on by an NHS professional
to see a psychotherapist
for ‘treatment’.
BACP welcomed the
debate as we oppose any
psychological treatment,
such as ‘reparative’ or
‘conversion’ therapy, that is
based on the assumption that
homosexuality is a mental
disorder, or on the premise
that the client or patient
should change their sexual
orientation. BACP published
a statement saying: ‘We
believe that socially inclusive,
non-judgmental attitudes to
people who identify across
the diverse range of human
sexualities will have positive
consequences for those
individuals, as well as for the
wider society in which they
live. There is no scientific,
rational or ethical reason
to treat people who identify
within a range of human
sexualities any differently
from those who identify
solely as heterosexual.
‘BACP, along with 13 other
organisations, is a signatory
to a Memorandum of
Understanding (MoU)
on Conversion Therapy in
the UK. Supported by NHS
England, NHS Scotland and
the Scottish Government,
the MoU sets out an agreed
framework for activities to
help address the issues raised
by the practice of conversion
therapy in the UK.’
In response to the debate,
Public Health Minister
Jane Ellison MP said that
the Government does not
believe that being lesbian,
gay, bisexual, or transgender
is an illness to be treated or
cured. Jane Ellison continued
by saying she will ‘continue
to challenge the Government
to go further on this issue’.
An integral part of
BACP’s lobbying strategy,
consultations are an effective
way for the Association to
communicate its views on
a wide range of issues to
governments, parliaments
and non-political
organisations.
BACP has recently been
responding to the Northern
Ireland Public Health
Agency’s consultation on the
Lifeline Crisis Intervention
Service. Lifeline is a freeto-call, 24/7, confidential
telephone helpline for
people in Northern Ireland
who are experiencing an
emotional crisis and are at
risk of self-harm or suicide.
The Public Health
Agency was calling for
views on the proposed
future of the Lifeline service
and associated suicide and
self-harm prevention services
beyond 2015. One of the
primary thrusts of the new
proposal is to replace the
existing helpline service,
currently staffed in part by
counsellors, with a telephone
crisis helpline delivered
directly from the Northern
Ireland Ambulance Service.
While the proposed new
helpline would still refer
people on to trained
therapists, BACP opposed
changing the helpline staffing
model as we felt it would
compromise the service being
provided to people in crisis.
To read BACP’s full
response to the Lifeline
consultation, see www.bacp.
co.uk/policy/consultations/
If you wish to contribute
to any of BACP’s consultation
responses, email the Public
Affairs team at publicaffairs@
bacp.co.uk and we will add
you to our consultation
experts database.
December 2015/www.therapytoday.net/Therapy Today 53