The Autonomy Dilemma

One thing that being a client, a therapist and a student of therapy has taught me, is that when we are trusted, we can learn to trust ourselves. When we are allowed to make autonomous decisions, we can grow towards our authentic selves.

Of course, the ethical principle of autonomy is emphasised in the BACP ethical framework. We should, according to the BACP, “respect our clients’ right to be self-governing.”. How does this work in practice, and how do we manage the conflicts this principle raises in the work?

Recently I have been considering the ways in which the counselling profession manages the autonomy of clients, therapists and student counsellors, and where the balance lies between the philosophy of self-determination, and the expectations placed upon those groups.

My interest was recently piqued around a study from the University of Nottingham which found “serious ethical considerations” about mandatory personal counselling for counselling students. One of the prominent issues raised in the study was the conflict mandatory therapy raised with the ethical principle of autonomy. Most therapists would agree that clients get the most out of therapy when they come voluntarily, and that it is important that they seek therapy, and agree to therapy willingly. So it seems like a double standard when it comes to counselling students, with no easy resolution.

I want to qualify this by saying that I think that all therapists should experience counselling as a client. I think that trainee therapists should have a passion for self-exploration and growth, and that ascertaining and exploring this passion should be part of the selection process at universities and colleges. I might be idealistic, but I feel that if that philosophy is communicated and nurtured, we wouldn’t need to mandate therapy – students would feel compelled to sit in the client’s chair and learn about themselves!

I have two friends who went to university with established therapeutic relationships, only to be told that they would have to leave their current therapists and find new ones who had been accredited for a minimum of three years. This experience has been exceptionally upsetting and seems to me to defeat the object entirely. Are universities teaching students to value the therapeutic relationship by arbitrarily causing helpful, established therapeutic alliances to come to a premature and forced end? Where is the autonomy in that? And where is the non-maleficence? It seems that the decision-makers in these situations (at two separate universities) have chosen bureaucracy over common sense and the very values they are aiming to teach.

Many counsellors develop a policy whereby they will not see clients who are also seeing another therapist, even of a different modality. In the spirit of autonomy, I think the therapist has every right to manage their own policies and make their own best decisions about their practice, however I also wonder whether such a policy may miss opportunities for clients to develop their self-determinism and use therapy autonomously, and in a way that works for them.

If a client wishes to see two therapists at once, they may choose to simply not tell their respective therapists, out of fear of termination, which may limit the efficacy of the therapy. My view is that different therapists may be useful to clients for different reasons, and the client is the best person to make decisions about that.

It hasn’t escaped my attention that my philosophy around autonomy poses difficult questions about my pro-regulation stance. If we are to trust in clients to make their own best decisions for their therapy, if we are to trust in students to make their own best decisions about their engagement with therapy, isn’t it incongruent to imply that I don’t trust in therapists to make their own best decisions about their practice?

For me, this is where we have to look at a way to balance our ethical principles where we find them in conflict, and to balance the conflicting needs of clients and those within the profession.

When it comes to regulation, my first thought is the safety needs of clients, because clients are the people we serve, and when harm occurs in therapy, it can have a devastating effect. I feel that it is of paramount importance to mitigate risk of harm however we can without compromising the service we offer. Fears within the profession about regulation restricting the creative and diverse interpersonal way we practice need to be taken seriously in the regulation debate.

It is the danger of therapists losing more autonomy than is necessary to protect the interests of clients, which has led me to the conclusion that compulsory regulation by a range (and choice) of PSA accredited regulatory bodies would be preferable to statutory regulation. I feel that therapy needs to be kept in the hands of therapists, not government regulators.

Autonomy is a tricky issue, and runs through the very heart of our profession at all levels. I don’t have any definitive answers as to how we manage these conflicts, but I hope my thoughts on the matter can provide some platform for reflection and discussion.

Dual Relationships, During and After Therapy

I’ve been thinking about dual relationships, what exactly they are and why they sometimes exist between a therapist and client.

I’m going to start by offering my own ideas about what a dual relationship is in the context of counselling. When we form a therapeutic relationship between therapist and client, we do so with the understanding that this relationship will offer something different to other relationships; it will offer confidentiality, an ethical frame and, in particular, carefully considered boundaries which allow the relationship to exist, uncomplicated by the typical demands and counter-demands of human relationships. We do this to allow a safe space for the client to freely express and explore their most difficult experiences, and hidden areas of self.

A dual relationship arises when the client and therapist have an additional relationship which exists outside of the therapeutic frame. Perhaps a business relationship, a family connection, a friendship, a teacher/student role, colleagues or neighbours, members of the same congregation – some relationship which necessitates a different dynamic, different expectations and different boundaries.

My title for this blog acknowledges dual relationships which occur after therapy, and this is because I believe the therapist’s ethical responsibility towards their client exists beyond the termination of therapy. When friendships, business relationships or even romantic relationships occur between therapist and client after therapy, this, in my view, still represents a dual relationship, no matter how much time has passed.

So how do we navigate dual relationships? Well, I suppose I think, for the most part, we ought to avoid them. As anyone who reads this blog regularly is probably aware, I am particularly keen that the counselling profession does more to acknowledge the potential for harm to occur in therapy, and to take collective responsibility for the harm that does occur, and has occurred for many clients.

For me, dual relationships are one, largely avoidable area where harm could foreseeably occur. This is particularly true in relationships where there is a shift from the relationship serving the emotional needs of the client only, to emotional needs of both parties being met within the relationship.

A major benefit of therapy is that the client need not worry about having to hold the emotional energy of the therapist. As soon as the relationship requires two-way emotional holding of the other, there is a shift in the dynamics which is unlikely to meet with the expectations of either party. When this gap between expectation and reality presents itself, there is great potential for hurt to occur, and potentially for this to taint any positive outcomes achieved in therapy.

I find the idea of therapists forming sexual relationships with clients or former clients particularly troubling. The BACP ethical framework states that “exceptionally”, such relationships post-therapy may be permissible, however here I must diverge from the guidance of the framework and say that in my view, there is never a good reason to form a sexual relationship with a former client.

Where an additional business relationship occurs, it is equally important to consider the potential harm to the therapeutic alliance and therefore to the client. Is such a relationship completely necessary? I would think very rarely, and if there is another option, in my view it should always be perused before a dual relationship is arranged.

If a dual relationship is unavoidable, like anything, it needs to be discussed carefully with the client to manage boundaries and reduce the risk of harm. I would also emphasise the importance of ongoing supervision and consultation with colleagues (as per the BACP ethical framework 2018) in order to obtain more objective views on the necessity and ethics of any dual relationship.

Above all, in my view it is vital to be mindful of what it can feel like to be a client. The inevitable imbalance of power in the relationship, the strong feelings that a client can have for a therapist (and vice versa) could easily impact on clear decision-making from either party. Perhaps some clients may feel reluctance to say ‘no’ to a dual relationship, even if they are not sure whether it is what they want – in instigating a dual relationship, I would argue that we cannot always be certain that we are properly upholding the ethical principle of client autonomy.

 

 

The Meaning of Silence

How comfortable are we with silence? Are you somebody who will happily sit for hours and enjoy the peace and tranquility of a silent place? Or are you somebody who will immediately switch the radio on the minute things go quiet?

What about in the therapy room? (and I think we can ponder this either from a therapist or client perspective). Do silences bring with them, anxiety? Do you find yourself thinking “Has this gone on too long?”; “Should I speak?”; “I can’t think of anything to say!”; “Aaargh!”?

I think most people can probably relate to that at some time or other. I particularly remember feeling that way in my early experiences of working with clients. I think my anxiety was about not feeling ‘enough’ and that this silence would lead me to be ‘found out’ by the client. What those thoughts did, of course, was draw me away from the present moment. I became so anxious about what was to come next that I probably missed a great deal of what was happening in the here-and-now.

Silence often takes place in my own therapy. My therapist has taught me that I don’t need to have a response straight away, and nor does he. I can now give myself permission to sit with what I am feeling and see what emerges. This gives me an opportunity to communicate with myself, find out what is happening for me, and also to notice what is being communicated, unspoken, in the therapeutic relationship.  I have also grown to be comfortable when silence emerges with clients. In my view it can be a vessel for trust and connection, when its value is recognised, and we remain present, in the moment, noticing our own responses and what we can see occurring for a client. There is also value in discussing silences, how they are experienced and what meaning they hold for the client. Far from being a hindrance or awkward exposure of my impostor status, silence is our teacher and an invisible facilitator of therapeutic movement.

Ancient Chinese philosopher Lao-Tzu told us that “silence is a source of great strength”. I do think it has the power to strengthen our relationships with each other and with ourselves. I think it also provides energy, shifts energy, and allows us to notice where our energy is focused, offering us the opportunity to refocus if we feel stuck, or in need of redirection.

I am not somebody who leaps for the radio when things fall silent, so my understanding of the value of silence in therapy is somewhat shaped by personal attitude to silence in general. But I do want to encourage anybody, not just in therapeutic relationships but anywhere, with anyone, or even by yourself – just notice what happens when things go silent; notice where your thoughts go, what happens to your breathing and where your energy is. So much of what is happening in our bodies and our psyche goes unnoticed as we rush from one thing to the next. Let’s experience the unexperienced, both in therapy and beyond.

BACP Governor Elections 2018 – Who’s Getting my Vote and Why?

This year will be my first time voting in the BACP Governor Elections and I’m really looking forward to having my say on the future direction of the professional body I have chosen for membership.

I’ve read the candidate statements in detail, and there’s one that really stands out for me, so I thought I would just write a little piece about who I am voting for and why.

Karen Pollock is relatively recently qualified (2015) and I find her statement encouraging in a number of ways:

  • As a recently newly qualified practitioner, I feel like she is likely to have an understanding of the issues facing newly-qualified therapists today, particularly the lack of paid employment post-qualification. Karen also benefits from a recent experience of being a counselling student – I think it’s really important that we have a governor who can represent the needs and concerns of the BACP’s student members.
  • Karen has personal experience and professional training around LGBTQ+ issues and I think it’s important that this expert knowledge is present in the BACP. The BACP has been a leading voice against so-called conversion ‘therapy’; I feel appointing a governor like Karen would compliment and strengthen the ethical framework’s commitment to equality and justice.
  • Karen touches upon a couple of areas in her statement which are of particular interest to me as a therapist and as a client. The biggest of these is her commitment to valuing and hearing the voices of those who have experienced harm in therapy. While the BACP has a complaints procedure, I also think it’s important that we hear the voices of those who have been harmed in other, positive and constructive ways, and the fact Karen has the courage to raise this and speak about honouring those experiences is very encouraging to me.
  • Karen wrote in her statement about wanting better regulation of the profession. I messaged her to ask some more about her views on regulation and I found her open and positive about the role regulation has to play in the future of the profession. I am hopeful that her appointment will be a boost for client rights and the promotion of ethical practice.
  • Karen speaks in her statement about having a personal boundary statement which her clients are able to read, which shows me a deep understanding of the importance of clear and consistent boundaries in her practice. I feel that her commitment to and understanding of ethical practice will be of great value to the BACP and its membership.

Profiles of all the candidates for the upcoming governor election can be found here: BACP Governor Elections 2018

Parallel Process

Parallel process is a supervisory phenomenon whereby relational interplay, feelings or experiences which occur in the therapeutic relationship are re-enacted in the supervisory relationship. This can be a result of identification with a client, countertransference processes, or even just an unconscious means of making sense of what is happening in the therapeutic dynamic. I think it is a curious and fascinating occurrence in supervision and that’s why I wish to talk about it here.

I make no secret of the fact that I am deeply intrigued by unconscious processes and the way in which our unconscious minds operate seemingly entirely independently with great complexity and purpose. The fact that parallel process offers us a way to notice, explore and utilise our unconscious functioning to enhance our therapeutic work with clients is absolutely thrilling to me.

Without discussing the work I bring to supervision, I want to briefly explore an example of parallel process which once occurred in my own supervision: One session, as I discussed my feelings around some therapeutic work, my supervisor explained how we could explore this in supervision. I suddenly, unexpectedly and disproportionately became very angry with him for explaining supervision to me. The more cross I became, the more he explained himself, and the crosser I became, until suddenly, in a moment of clarity, I realised we were experiencing parallel process. I reminded my supervisor of the previous session where he had stated that my tendency to over-explain therapy and the therapeutic process to my clients in some situations, particularly when I felt under pressure, may not allow enough space for open exploration and self-direction in therapy. I pointed out that he had been doing exactly what he had advised me not to do, and sure enough I had felt stifled, frustrated and not heard.

I think that, on this occasion my unconscious was looking to find a way to make sense of my own process as a therapist, and what potentially could have occurred for clients, and additionally, I feel there may have been an element of projecting my anger and frustration at my own over-explaining onto my supervisor. Those feelings were brought into the room and unconsciously became part of the interplay between me and my supervisor. My supervisor appeared to take on my feelings – wanting to explain himself – without either of us being conscious of the significance of the exchange in the moment.

This tense and difficult session provided a very worthwhile and productive conversation about what was happening for me (and for my supervisor) in that moment which I was able to hold in mind going forward in my therapeutic work. I felt energised from the supervision session and in awe at what both my, and my supervisor’s unconscious had to offer the supervisory process.

This week is International Supervision Week, and today I have met with my current supervisor for the last time as he moves towards semi-retirement. So this feels like the perfect moment to honour the supervisory process, and to thank my supervisor for his part in my journey as a practitioner. Moments of learning such as the one I describe above, undoubtedly nurture my growth as a therapist and teach me both the value of supervision, and of paying attention to the wondrous unconscious.

 

Stigma, Mental Health and Being a Therapist

I’m back to pondering about my comfortable spot on Twitter, engaging with the kind of thinkers, musers and (largely) therapists who inspire me, whom I can relate to and who frankly affirm my world view.

Therapists such as Steph Jones are blazing a trail when it comes to talking about our mental health as therapists. I think it takes a great deal of courage to talk so openly about personal struggle, and I think it important that we recognise the value of our experiences as therapists, whilst of course, remaining mindful of how they might impact our therapeutic work.

My therapist once said to me that my experiences are likely to be the source of my greatest strengths AND my greatest vulnerabilities as a practitioner, and this curious dualism is present in my awareness and my process as a practitioner, as a client and as a supervisee.

In the short time I have been on Twitter, I have seen Steph’s work towards raising awareness of therapists’ mental health go from strength to strength; recently I read her brilliant piece in Therapy Today. She is being heard and that is wonderful. We are talking about our mental health, and the outpouring of support for this topic has been heartwarming. But yet, anecdotally I am still hearing stories of unsupportive colleagues and fellow trainees. I am hearing that judgements on therapists’ competence to practice are being made on the basis of diagnoses, and I think these anecdotal instances indicate that there is still a worrying misconception in some areas about what makes a good practitioner, and the nature of mental health difficulties. While decisions are rightly made about competence at an educational level, employment level, supervisory level and at a personal level, sweeping generalisations, where they still exist are unhelpful and damaging. It is for this reason that I believe we need to be discussing this topic more. We are all managing our mental health. Every human being is managing their mental health. Any therapist who believes themselves to be invulnerable to mental health difficulties is, in my opinion, even more vulnerable to not recognising their own mental health needs, and perhaps susceptible to denial too.

Therapists sometimes say “therapists are human too” and that phrase makes me cringe a little. As I write this, I pause to think about why I have such a response to that idea, and I think it is because of the inference that there is an assumed superhuman quality to therapists. Perhaps it is true that some people do believe therapists to be beyond human vulnerability, and I think I must own my own discomfort when that notion is acknowledged. I am aware that one of my core personal processes centres around rebellion against, and rejection of hierarchical power-dynamics in relationships, therefore it stands to reason that I should feel an intense discomfort around the notion of being thought of as having somehow figured out the secret to eternal happiness. This, of course, is mine to manage and I will undoubtedly further reflect on what is emerging for me as I write this.

As a profession I think we are very good at talking about self-care and yet sometimes less keen to explore why self-care is so important. Burnout, vicarious trauma, and emergence of unresolved material in our own processes all happen, and can be harmful to both ourselves and our clients if we do not address them. I feel that we are headed in the right direction – we are starting to speak up, we are engaging with personal therapy when we need to, we are talking about self-care. I think the key to changing attitudes within the profession is in challenging misconceptions and continuing to speak the truth. As therapists we have the right and responsibility to co-create the kind of profession we want to be a part of.

Endings, Transitions and Change

I am experiencing quite a few endings and transitions at present, and I have more to come over the next few months.

My university course is now finished, and my newly-qualified peers and myself are dispersing and moving on to new and multifarious next steps.

I will change supervisor next month, which brings with it both sadness and excitement; I have enjoyed working with my current supervisor, but I am pleased to have found a new supervisor with whom I believe I will be able to continue to develop and grow as a practitioner.

In the next couple of months I will be leaving one of my placements, which of course means endings with clients, and I am mindful of the difficulties this transition might bring for them, as well as managing my own feelings about ending.

I have recently embarked on a new thread to my career, as a content writer for an online educational counselling resource, which is very exciting and challenging, and represents a wonderful opportunity to bring together my twin-passions of psychotherapy and writing.

Lastly (I think!), I will be moving house in the next couple of months. So the landscape of my life and my routine are likely to look quite different by the time I start my research master’s in September.

So how do we manage endings? With regards to my university, I notice in my own process a sense of unreality about finishing the course. This has probably been reinforced by the fact I am returning for the master’s top up, however I will not be seeing peers, engaging with PD and so on; things will be very different and I don’t think my heart has caught up with my head when it comes to the reality of that.

With ending at one of my current placements, I find myself very focused on managing those transitions in a way which is helpful for my clients. While this is undoubtedly an appropriate focus for the therapy room, I need to be aware of the potential emotional impact which these losses are likely to have, probably in part at an unconscious level, and how those processes might become conflated with other change which is occurring in my life. I am in an ongoing process of examining this in supervision and in personal therapy to ensure that my needs in this regard are met outside of my relationships with clients. This isn’t a perfect science of course, but I hope that my awareness of the challenges ahead, and awareness of my patterns in dealing with loss and change will allow me space to navigate this in a way which is as helpful as it can be for all concerned.

I think it is especially useful to look at how we manage change and loss because we will inevitably come face-to-face with loss, grief, feelings of abandonment, difficulty with change and upheaval, and all the feelings which go along with it – from sadness, powerlessness, fear, anger, to excitement and uncertainty – in our work with clients. So our responses to it, how we manage it, our own discomfort and previous experiences are always present and in need of attention in supervision and beyond.

I know from my own experiences as a client that even extended breaks can feel like difficult transitions in the therapeutic relationship, and it may take time for trust and rapport to reestablish after a therapist returns from leave. Are we sufficiently attuned to our clients’ feelings around breaks and changes to the therapeutic frame? I think endeavouring to hear each client, and an openness to therapeutic meta-dialogue are, as ever, vitally important.  I would argue that even changes to session time or a room change may represent difficult transitions for some clients, and it’s important to be alert to this, and open to therapeutic discussion.

So as I take these floating thoughts and feelings and try to make sense of them in my own process, I return to my own imminent transitions and uncharted territory ahead. As I reflect on what is to come, I feel rather comforted by reminding myself that many of the relationships, experiences and memories I will carry forward with me into my master’s year were, just a few years ago, uncharted territory too.