Boundaries – The Invisible Electric Fence

I believe very strongly that clear and consistent boundaries are one of the most fundamental elements of the therapeutic relationship. They contain the relationship, frame it and promote trust. Boundaries don’t just come from the therapist; they are agreed upon within the relationship and the client’s boundaries need to be heard and valued.

When clients don’t know where the therapist stands on particular boundary issues, not only can this be very anxiety-provoking, but tripping over the therapist’s unspoken boundaries can be tremendously painful too. I once saw this described on an internet forum as akin to stepping on an invisible electric fence, and this elegant metaphor provides the title for my blog post.

Aside from the obvious ethical violations, there are few clear-cut answers about how we manage boundaries in our practice. There seems to be a lot of differing opinions, and I feel that our ethics, learning and experience provide a frame for making our own best judgements (alongside the honest and open use of supervision) about working in the interests of our clients.

I will say a little bit about some of the most commonly discussed boundaries in the therapeutic relationship:

Time boundaries: I still struggle to understand it when clients report regular therapist lateness; to me this is a straightforward issue of fulfilling the contract. If I have agreed to meet a client at a specific time and place it is my duty to fulfill that. Habitual lateness by the therapist can be very problematic for a client; I have spoken with clients who report high levels of anxiety due to a therapist’s unpredictability. I would argue that this type of inconsistency could trigger feelings relating to childhood trauma or abandonment. It can and should be avoided. Running over time in sessions also may have its pitfalls. A distressed client may appreciate some flexibility about extending the length of a session, and I think it’s important that there is an open discussion about the purpose of that, and when and if the client might expect something similar to be offered in the future. It is also important to pay attention to how the client feels about the extra time. It’s easy to assume that the client is happy to have a longer session, however they could be holding some anxiety about the inconsistency or may feel indebted to the therapist and more reluctant to bring up any problems that arise in the relationship. It is so important to check in with the client about any changes to the session frame.

Self-disclosure: We self-disclose just by being. Our gender, age, race, clothing, body type, accent are all apparent before the relationship has even begun, and it’s really important to be mindful of how we are being received by our clients. I am also aware that my presence on social media is a form of self-disclosure and I pay careful attention to what I post and how I approach my online relationships. my personal social media accounts are also restricted. I feel this is helpful both to myself – I am in pursuit of a healthy work/life balance – and also to my clients – I feel it is important to be mindful of how it might feel for some clients to see me in non-therapeutic roles and relationships. So what about self-disclosure in the therapy room? Congruence, or genuineness is, I believe, fundamental to the efficacy of the therapeutic encounter. If I am not me, then the relationship cannot be real, and as a humanistic therapist, I believe that the relationship is of paramount importance. So how much of myself, and what of myself do I share? These are difficult decisions which take place in-the-moment. There are relationship-specific contexts and multiple therapeutic factors to take into account. As I write this part of the post, I find myself thinking that self-disclosure really deserves its own post. There is so much to consider. Will the disclosure enhance the relationship? Is it the best way to illustrate a point? Are there any risks associated with it? What is the therapeutic purpose? Could it be received as minimising or dismissing the client’s experience? And not to mention: Is the therapist comfortable with revealing this part of themselves? As I so often say, it is essential to ask the question “Who does this serve?”. If the answer is not “the client” then I would suggest that it is not appropriate to disclose. I would also urge caution when faced with an uncomfortable personal question. It seems important that the therapist gives themselves time to reflect on their feelings about the question and the potential impact of giving an answer, rather than feeling pressured into a response.

Out of session contact – It seems to me that the therapist’s out of session contact policy is something that should be decided upon and communicated to the client at the start of the relationship. I don’t think there is any one right way to approach such a policy but I do think it is crucial that whatever the therapist offers, they can deliver on it. As we all know, we need to make time for self-care in order to avoid burnout and I think we have to be really honest about what we are willing to offer, and what we can offer. I think it’s important to avoid a situation where the client uses the out of session contact as it was offered, only for the therapist to feel overwhelmed and suddenly change the boundary. This can be experienced as shaming, rejecting and can be incredibly painful. It goes back to the analogy of the invisible electric fence – the client does not know where the fence is, but it doesn’t half hurt when they tread on it. If the therapist does need to adjust what they are offering a client, I think this has to be handled very sensitively to avoid inadvertent hurt.

Touch – There are many schools of thought on touch, and I think it is pretty much universally agreed that touch should never be forced upon a client, nor does any sexual touching ever have a place in the therapy room. Personally, I believe that any touch should be client-led and client-initiated, and I also feel that the use of touch in the therapy room should happen alongside discussion about therapeutic purpose and the client’s response. It seems to me that like any aspect of the relationship, an ongoing dialogue is really important to the work.

So these are a few of the potential electric fences as I see them. There are plenty of other boundary issues I have not been able to cover in this post – gifts and dual relationships both spring to mind, and it is probably not the last time I will look at boundaries in this blog.

As I began by saying, the boundaries of the relationship are essential, they are what makes it safe. They are what makes it therapy. We can’t (and shouldn’t) take away the safety of the boundaries, but what we can do is make those boundaries as visible and clear as possible, so nobody has to trip over an electric fence.

From a Place of Care, not Judgement

Psychotherapy is a profession I love. I would not be motivated to write about it were it not for my deep respect for the theories, philosophies, practitioners and clients. As I write about harm in therapy and its impact on clients I am conscious of the potential for my position to be misinterpreted as anti-therapy, or anti-therapist. I think this would be a terrible shame. 

My desire to become part of a debate around harm in therapy is motivated entirely by my love for the therapeutic process. I want this profession to be the best it can be, and ultimately I want clients to get the best from their therapy.
So when I think about clients who have had difficulties in previous therapy, I am seeing a gap in training; I am seeing a gap in the conversation and that’s where my interest lies.
Yes, conversations around avoiding harm are important, and I’ll continue to be part of that debate, but I also want to pay attention to how we work with clients who experience harm, and how we meet their needs, so they do not feel abandoned by therapy; I feel like that’s our collective responsibility. This isn’t about choosing a camp or polarising a debate, it’s about looking at client needs and working towards developing our profession. That’s what I really want to be a part of. 

Writing to Promote Wellbeing

I have written poems for a number of years and have found poetry provides a frame for an intense and focused kind of journaling. The compact nature of the form forces me to go directly to my feelings, and helps me to create imagery which adds colour and depth to my experiences. If I were so inclined, I could probably produce several anthologies of poetry I have written during my own therapy. As my writing has developed I also find myself writing nonsense poetry and children’s rhymes – finding fun and silliness in the meaningless and absurd.

These are not poems intended for publication, but for myself; sometimes I share my writing with friends and family, or a writing group I attend, but essentially I write for me. It is a part of my self-care. I take great joy in the craft of poetry and reading the work of others. I particularly adore the poetry of Spike Milligan. As well as his famous nonsense children’s verse, Spike wrote movingly about his deep struggles with his mental health. Below is perhaps one of the most poignant poems I have ever read on the subject of mental health:

Manic depression 



The pain is too much
A thousand grim winters
   grow in my head
In my ears
    the sound of the
    coming dead.
All Seasons
All Sane
All Living
All Pain.
No opiate to lock still
     my senses
Only left,
   The body locked tenses.

Spike Milligan, St Luke’s Hospital, Psychiatric Wing, 1953/54

The words of this poem have always stuck with me, evoking as they do a torturous struggle and an intense loneliness which feels ever starker in the poem’s sparsity.

An increasing number of therapeutic practitioners are actively using therapeutic writing in their practice. I have recently become a member of Lapidus, a writing for wellbeing organisation, and I see the subject gaining traction both in literature and in practice. I have attended workshops both to participate and to learn more about the benefits and uses of writing in a therapeutic setting. The network is growing and that’s really pleasing to see.

Poetry also allows me to connect with the therapeutic world at an experiential level, digging below theory and practicalities and exploring the personal meanings which emerge for me in becoming a therapist. Earlier this year, I was honoured to see my poetry poster win the McGraw Hill prize for ‘Inspirational Poster’ at the 9th Annual Conference for Psychological Therapies and Mental Health at Leeds Beckett University.

The connection and depth of feeling which can be communicated in poetry is one of the reasons I believe creative writing can provide such a powerful tool for communication in the counselling room, particularly when working with clients who find verbal disclosure and exploration of feelings overwhelming. The use of metaphor, as with art therapy, can also contribute to making exploration feel safer.

I wish to learn more about the benefits of writing therapy for vulnerable client groups, in different settings and therapeutic contexts, individually, in groups and more. I feel that this burgeoning branch of therapy can only continue to blossom and seed.

 

 

Reflections on Unintended Harm in Psychotherapy

Yesterday evening I watched an hour-long Skype conversation between John Wilson and Philip Cox in the Onlinevents library (a UK based online learning platform). The topic of the conversation was ‘Exploring Unintended Harm in Psychotherapy’ and the discussion raised many interesting talking points, some of which I’d like to discuss in this blog post.

Firstly, Philip presents the following definition of harm, which will also be the definition I will adopt for the purposes of this blog post:  “Harm must be relatively lasting i.e. this definition excludes transient effects, such as in-session anxiety or between session sadness, and must be directly attributable to the quality of the therapeutic experience or intervention”.

With this definition in mind, Philip points to recent research suggesting that the figure for clients who feel they were harmed in therapy is as high as 10%, and that these figures become substantially higher when looking at clients from minority groups and clients who are therapists themselves. I have to confess that I am not surprised by these statistics at all. My feeling is that the more we listen to the experiences of clients, the more we will come to understand the scale of, and reasons behind this high level of harm.

I do not wish to make any assumptions about why minority groups and therapists report greater harm, but I find the fact that ethnic minorities, people with disabilities, and those who identify as LGBTQ+ are reporting higher rates of harm in therapy particularly concerning. Unless we begin to face up to these challenges and address them, I feel we are not fulfilling our ethical responsibilities of non-maleficence and justice as a profession.

Philip made a great point about therapist flexibility as a vehicle for positive therapy experiences and outcomes; as he explored, this is likely to be particularly important when meeting with a client with a different cultural frame of reference. When the therapist sticks rigidly to a paradigm which doesn’t meet the client where they are, they risk alienating the client, and ultimately damaging the relationship. Those statistics leave me with a renewed awareness of the importance of endevouring to understand the client’s frame of reference, and retaining a dialogue with each client about the relationship throughout the process. By having conversations with the client and checking in with their experience of counselling, I would hope that any issues could be caught and resolved more readily, reducing the risk of harm.

Philip highlighted the importance of the therapist’s openness to feedback. I would like to shout this point from the rooftops. My personal experience of therapy has shown me that when a therapist is willing to hear their client’s concerns and accept feedback non-defensively, the relationship can become stronger and more trusting as a result. It sounds obvious, however I think it can be difficult to keep that notion in our consciousness when faced with clients who may challenge us. For me, it is important to remember that I am, as a therapist, in service of the client; whether or not I recognise what the client is feeding back to me, it is my duty to reflect, both upon my actions, and the significance of what is occurring in the relationship in the context of the work. This can be explored in supervision and, where appropriate, brought into the counselling room. Philip described co-creating a relationship strong enough to withstand therapist errors, and I think a non-defensive attitude towards feedback is essential in creating the level of trust required for this kind of work.

John mentioned the idea of having a “fresh pair of eyes” on the relationship, which supervision offers us. Philip rightly pointed out that this objective input serves both the therapist and the client, and when issues occur, the Counselling and Psychotherapy Union can also offer non-judgmental support for therapists. These are undoubtedly excellent resources which benefit all parties, including the therapist’s caseload of other clients, whose counselling could be potentially affected by an unsupported practitioner going through the process of a disciplinary proceeding, for example.

Unsurprisingly, I find myself wanting to borrow the idea of a ‘fresh pair of eyes’ and make a shift of emphasis to what might be happening for a client in a difficult situation. Therapy can be an isolating experience for a client, as well as a practitioner, and as I have mentioned before, clients do not have the benefit of supervision or any objective voice which might be able to point it out if things go awry. How is a client even to know that things aren’t right?

Happily, there are more resources available today than there used to be. As I have previously discussed, the BACP offers a free and confidential advisory service for clients who are concerned about any aspect of their therapy. The international organisation Therapy Exploitation Link Line (TELL) also offers support, resources and advice for those who have been in exploitative or abusive therapy. In addition, online peer support forums and chatrooms exist where clients can check in with others about aspects of their therapy, usually anonymously, and hear different perspectives. I don’t think these resources are to be feared; it seems to me beneficial to the integrity of the profession that we welcome scrutiny and offer transparency.

I am encouraged and impressed by the way Philip has sought to address the problem of unintended harm in therapy. It seems vital that we as practitioners are having these kinds of discussions and looking at ways to reduce those worrying statistics.

So alongside working to avoid causing harm in therapy, for me the next logical step is looking at how we can best support those who have experienced harm. I feel it is important to acknowledge the fear that many clients are likely to experience around returning to therapy and becoming vulnerable again in a therapeutic relationship.

How can we meet these clients’ needs in a new therapeutic relationship? Perhaps more therapy won’t be the way forward for all clients – what do they need? What support do clients need when going through a complaints procedure? Are we doing enough? These are all questions which I feel require much more investigation. I am excited by the good work already happening, and I feel confident that client experiences will inevitably improve as long as we remain curious, and keep these conversations alive within the profession.

Reference:

Cox P & Wilson J (2017). Exploring Unintended Harm in Psychotherapy. [ONLINE] Available at: https://www.onlinevents.co.uk/exploring-unintended-harm-in-psychotherapy-philip-cox/. [Last Accessed 03/12/2017].

A Poem on Therapy

Therapy, when at its best,
Provides a healing place
Where clients can explore their needs
With clarity and space.

The pressures of existence
May be brought into the room
Untangled and reorganised
Like cotton through a loom.

Or thoughts and feelings buried
Like anger, shame or fear
Are voiced and processed gently
In a caring atmosphere.

Relationship is central;
The therapist must be
A warm and kind companion
On the therapy journey.

And when those client needs are met
With empathy and care
That healing space is possible
When it feels safe to share.

Some thoughts about working with clients who have experienced harm in therapy

A bad experience with a therapist can be painful, scary and traumatic. These feelings are often exacerbated by the client’s vulnerability in counselling and can leave the client suffering considerably and afraid to seek help.

At the time of writing this post, I am not aware of any specific training for therapists in working with the unique needs of this client group. I think that is a shame, and something I hope will change, not least because the client/therapist dynamic in the new relationship is central to the work and also likely to be heavily impacted by the client’s previous experiences. Both the client and the therapist are likely to be experiencing certain anxieties about the work. Here I am going to think about some possible feelings which could occur for both therapist and client:

 

Possible client concerns:

  • I can’t start over again. There is a high possibility that the issues which first brought the client to counselling have not been fully addressed in their previous therapy. These might not be immediately apparent if the client is primarily expressing distress over their experiences in therapy. The client’s original issues may not be brought into the room for some time. The client is also likely to be ambivalent about disclosing upsetting details of their life again; the experience is difficult enough in itself, and is likely to be compounded by a damaged trust in the profession. The therapist must demonstrate patience with the client’s process, even if the client’s previous experiences in therapy remain present for many months or more after the start of therapy. The client must be allowed to process their negative experiences of therapy as much as, and for as long as necessary, just as they would with any other type of trauma, abuse or grief. I would suggest this is the key to the client experiencing the level of safety required in the relationship to ‘start over again’ with the issues that brought them to therapy.
  • Will my new therapist report my old one? Some clients who have experienced poor therapy may be protective of their previous therapist. They may have some fear of getting their therapist into trouble, or equally, they may worry about the emotional stress of their traumatic experiences being aired in front of an ethics committee. It is essential for the autonomy of the clients that the limits of confidentiality are explained clearly at the contracting stage and the client feels confident about what would or would not be reported, so that they are able to make autonomous choices about what to disclose. The client may also fear their new therapist negatively judging their old one, and it is important that the therapist is validating of the client’s experiences and feelings, while remaining cautious of expressing their own frustration or anger towards the previous therapist. This is not to say it is always unhelpful to express your feelings about what has occurred, however it is important to be mindful of how this might be received by the client. It is a tricky balance and requires a degree of intuition and also meta-dialogue with the client about how they are experiencing the new relationship. Supervision provides a space to explore strong feelings which might be stirred for the therapist.
  • What if the new therapist does not believe me? Clients, especially those who have experienced similar situations in their past, are likely to be very afraid of the feelings of rejection and disempowerment which come with not being believed. The therapist might feel tempted at some level to view the situation from the perspective of the previous therapist; after all, that is likely to be the frame of reference most familiar to them, and they may wonder or fantasise about how they would have responded in the situation the client is describing. I would suggest that the therapist needs to catch themselves if they find they are slipping into this way of thinking and remember that in the counselling room, the client’s frame of reference is the relevant one. Any intervention which appears to be missing the client’s experience may be received as a judgment or that the therapist is not taking the client at face value. If trust is damaged at this stage, effective therapy would be extremely difficult. Again, supervision is the appropriate arena for processing such thoughts and fantasies.

 

Possible therapist concerns:

  • What if this client reports or complains about me? This is a valid anxiety and if the therapist ignores it, it may emerge in conscious or unconscious defensiveness towards the client which is likely to be damaging to the therapeutic relationship. The therapist must examine the origin of these kinds of feelings. They are likely to be triggered by some part of the therapist’s inner-process. Some self-doubt about their competence, perhaps?  A negative experience of disciplinary proceedings? A perceived existential threat to the therapist’s career, and therefore identity? This kind of anxiety is likely to be disproportionate to any actual likelihood of such an event occurring. By processing it earnestly in supervision and perhaps personal therapy, the therapist can ensure it does not impact negatively on the client work.
  • What if I know the previous therapist? The counselling and psychotherapy community in the UK isn’t huge. There is a chance the current and previous therapists may know each other, and the chances are increased in a small town or rural area.  As with any potential conflict of interest, a judgement needs to be made by the new therapist as to whether they can work with this client or whether it would be better to refer them to another therapist. Factors to consider will include how well they know each other, how the situation is likely to impact on the new therapist, and what problems may arise as a result. Conversations with a supervisor are important, and the client’s best interests, as always, are paramount.
  • I am tired of hearing about this therapist. Many feelings could be occurring for the therapist which lead to impatience with the client’s process around their previous therapy. The therapist might feel impatient to get to other areas of the work; they may feel ‘stuck’ and helpless in the work; or even jealous of the love and attachment the client may still hold for their previous therapist. It seems to me that being consistently self-reflective and separating their own material from their client’s is key for the therapist here. By bringing these frustrations into awareness, the therapist can examine what these feelings are saying about the work and the relationship, what transference and countertransference processes are at play, and this extra knowledge and understanding of the relational dynamic can facilitate rather than hinder the process. I think it is important to be aware that feelings around abandonment or childhood abuse may have been triggered by the client’s previous therapy experiences. In addition, a client reentering therapy may be still grieving the loss of their previous therapist. All these feelings are complex and need to be managed delicately.
  • If this therapist can cause so much harm, so could I. This is unlikely to be a conscious anxiety, at least initially. It is my feeling that the profession as a whole shies away from confronting the great harm that can be done in therapy; having a clearly traumatised client in front of us forces us to face up to the power we hold, and the harm we can do. That is really scary. For this reason, I feel that great harm can be done by therapists who are unaware of, or in denial about the impact of their actions and words on clients – by those who would rather keep this aspect of the profession’s shadow deeply buried. Working with clients who symbolise this part of our shadow is deeply challenging at an existential level and this must be brought into our awareness both as individual practitioners and as a profession. We must not compound mistrust or trauma, we must seek to remedy it. I believe that to do this as fully as we can, we must acknowledge our potential to do harm.

 

Why is it important to be a member of a professional body?

There is no mandatory regulation of counsellors and psychotherapists in the UK. Even as I write those words I find the situation difficult to comprehend. I imagine readers from other countries being baffled by the situation – No licensing? No minimum qualifications? No mandatory complaints procedure?

Luckily, the profession has become self-regulatory and a therapist has several options as to which professional body or bodies to join. Arguably, the two best-known in the UK are the BACP (British Association for Counselling and Psychotherapy) and UKCP (United Kingdom Council for Psychotherapy) while regional options exist for Scotland (COSCA) and Ireland (IACP) and other general and specialised options exist, many of which are accredited by the Professional Standards Association (See the counselling directory for a more comprehensive list: http://www.counselling-directory.org.uk/accreditation.html ). For the purposes of this article, membership refers to either individual or organisational membership.

So why should counsellors join a professional body? Is it enough to acknowledge and abide by their ethical frameworks, or is membership the only ethical way forward?

I’d like to look at this from the perspective of a first-time client. Our imaginary client feels they might benefit from some counselling and so types “counselling” and the name of their local town into Google. Up pops the name of a local therapist in private practice. Her website states she has 10 years’ experience, she specialises in the area of the client’s issues and is affordable. The client looks at the picture of the therapist and thinks it is somebody she might get along with, so she gets in touch and books an initial session. It has not crossed the client’s mind to check whether the therapist is a member of a professional body. The client is not aware that counselling is not a regulated profession, and assumes that the therapist is bound to a code of ethics.

The therapist might rationalise that she is ethical. That she follows the BACP ethical framework but simply does not like the bureaucracy of the professional bodies. She might surmise that she has been working effectively with clients so far in her career and membership to a professional body is simply an unnecessary expense. As far as she is concerned she is working ethically, and as far as the law is concerned, she is doing nothing wrong. She mentions nothing about her lack of membership in her contract.

The alarm going off in my mind as I imagine this scenario is screaming the word AUTONOMY!

The client has not properly been made aware of what service is being offered by the therapist. I would argue that the therapist’s actions amount to deception by omission. It seems vital to the integrity of and public trust in the profession that clients are fully aware of what they can expect from counselling, and this must include what options are available to them should they wish to make a complaint at any stage.

If our imaginary client were to investigate the possibility of making a complaint against her therapist and discover that there were no options available to her, this could feel like a terrible betrayal, potentially damaging not just trust in the therapist, but in the profession as a whole.

I am a strong supporter of mandatory regulation of the profession. I feel there are many benefits – which I will undoubtedly explore in the pages of this blog – and in my view those benefits outweigh any cost. But while we remain in a situation where membership is not mandatory, let us ensure that our clients are offered the security of professional body involvement should they need it, or at the very least be clear in the contract about what the implications of lack of professional body membership are for your practice and your clients’ rights, so that they are able to make an informed choice.