A Client First

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.

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.

My latest realisation will probably be old news to anyone who is involved with social media: It has come to my attention that Twitter is something of an echo chamber. That is to say, I have found that my views about issues pertaining to counselling and psychotherapy have been almost completely affirmed by the therapists I have engaged with on Twitter, and somewhat naively, this has lulled me into the false assumption that most therapists in the UK are in accord, particularly when it comes to the issue of statutory regulation of the profession.

My views on regulation of counselling and psychotherapy in the UK have been touched upon in this blog before. I believe that the current situation does not do enough to protect vulnerable clients, and affords too many freedoms to anyone who fancies calling themselves a psychotherapist. I think there is an assumption of accountability which simply does not exist when a therapist in private practice chooses not to be a member of a professional body. For the dissatisfied or abused client, there is nobody to complain to, and nobody to turn to. To me, this is completely unacceptable, and by allowing the status quo, I feel we as a profession are failing in our collective duty of non-maleficence to clients.

So anyway, back to my naive assumption that most therapists think along these lines. Recently, on a closed internet forum, I have been engaging with therapists who are overwhelmingly against statutory regulation. In fact, I believe I have been the sole voice in favour on some of the forum discussions. So much for pottering around my comfortable corner of the twittersphere!

So why the divide? Why is there seemingly this silent split in the profession? And how do we constructively bring these these sides of the debate together for meaningful dialogue?

I do want to say that I think many of the anti-regulation arguments are actually valid concerns that need to be addressed. How, for example, do we ensure that regulation does not lead to homogenisation of the profession? I think it’s very important that any move towards regulation is respectful of the diversity and evolutionary development of psychotherapeutic practice in this country, and does not seek to standardise or snip at the edges of the relational tapestry.

Recently, several professional bodies have come together to work on a framework of competencies for counselling and psychotherapy. I find this encouraging and concerning in equal measure. On the one hand, it seems like common sense that the public should have clarity about what therapy entails, and crucially (to my mind) what the minimum requirements for qualification are. On the other hand, its development has hardly been inclusive; not all professional bodies have been invited to take part (read here for the NCS’s open letter in response to the framework) and membership consultation has been invisible as far as I am aware. I think, if we want to move towards regulation, we need to think carefully about whom we want to do the regulating, and how we ensure that we properly represent the needs of the practitioners who will be impacted by it, as well as their clients.

I have heard a (kind of) compromise suggested, whereby the titles of counsellor, psychotherapist, psychoanalyst etc, become legally protected titles, and anybody wishing to practice under these titles must join a register, justifying their use of the title and stating which professional body they will maintain membership of, adhering to their chosen body’s ethical framework and being accountable to them in the event of complaints. To me this sounds like a promising compromise, avoiding the need for non-expert interference from state regulators, reducing the risk of homogenisation, and also safeguarding clients. While a lot of work would be necessary to realise such an ambitious project, I think it has mileage, and should not be discounted. It has to be preferable to division and mudslinging, which, sadly, I am beginning to feel exists, in pockets, on both sides of the current debate.

From the perspective of a client, I know how a no-regulation system can disenfranchise and disempower. I say this with caution, as I am aware that my own experiences could be used to attempt to invalidate my perspective. I would argue that there is no objective voice in this debate because everybody with investment in the regulatory process brings their own perspectives. So I will say this. My first therapist claimed to be a member of the BACP; this was a lie. Several unethical actions later, I would have liked to have had the opportunity to make a complaint. Of course, this was not possible; there was nobody to complain to. If this individual chooses to practice again, they are free to do so. I have found this set of circumstances extremely difficult to accept, and I sought further therapy, in part to come to terms with this injustice.

I have heard it argued that there are such a small number of these types of cases (I’m not sure how we would know) that mitigating this risk is not worth the risk to the wider profession. I feel that, if there is an identified risk to clients that we can mitigate, then we need to mitigate that risk. If any clients at all face this avoidable situation, we are failing them.

I am still confident that we can find some common ground. That we can work together to achieve something positive. I don’t want a split in the profession, and I don’t think anybody really wants a split in the profession. It will take hard work and respectful dialogue from all sides, but I see no reason why we can’t develop a way forward which both protects clients, and protects psychotherapy, in all of its diverse and creative forms.

In my recent blog on Googling therapists, I touched on the subject of the therapist’s responsibility to manage their own online activity. In this blog post I would like to expand on that and highlight some ways in which therapists can ensure their online activity meets the standards of ethical conduct we all aspire to.

I was heartened and inspired by Cathy Knibbs’s recent blog post raising the issue of therapists posting about clients online. It is something I have witnessed on a number of occasions, mostly in Facebook groups and on Twitter. As Cathy Knibbs points out, even that which seems anonymous can be narrowed down, and can even become identifiable information, especially when combined with the poster’s Facebook page details, in the many instances that the therapist’s workplace is listed on their profile. Supervision exists to ethically discuss client work, and posting about it on social media, for whatever reason is very difficult to justify in my opinion.

I think a large part of the problem is that therapists are not always as aware as they perhaps should be of how their online presence can impact on clients. As a relatively tame example, I was once searching for a supervisor, and as part of my process of narrowing down potential supervisors I looked to see if any of my shortlist had social media profiles. One supervisor did, and had written in a public post about how glad they were that it was the weekend because being at work was such a bore! I thought about how their therapeutic clients in particular might have felt if they had read this. I imagine it could be quite hurtful and potentially damaging to the therapeutic alliance. In addition, due to the feelings of shame which can emerge for clients around searching online for their therapists, this hurt may never be brought into the room and never be addressed in the relationship. All of this potential risk of harm to client relationships could have been avoided if the therapist had simply altered their Facebook privacy settings more appropriately, and/or anonymised their personal Facebook account. (This supervisor was promptly crossed off my shortlist).

I feel that any therapist using social media needs to feel confident that they are able to manage their content ethically and safely. If not, there are many resources to help. From online tutorials to help with managing Facebook privacy, to ethical blogging workshops and social media coaching, help is out there and we are each responsible for any gaps in our competency.

I was recently at an event where online conduct and ethics were debated. It seems to me that dilemmas such as “What do I do if a client sends a friend request?” are easily resolved by the presence of a social media policy, which can be made available to the client at the contracting stage outlining what the therapist’s boundaries are around online activity. Hazel Hill has an excellent example of this on her website. Like any boundary consideration, clarity, consistency and dialogue are crucial for avoiding harm. Think ahead and remove the need for reactionary social media policy, which could be received as shaming by any client involved in its creation.

As I have written before, I am aware that by engaging with social media, I am allowing my clients access to thoughts, opinions and areas of my experience which would not be presented in the therapy room. I am self-disclosing with every tweet and blog post. I am mindful of how my words could be received by clients, and I have brought this part of my professional activity to my supervision in order to ensure I am properly reflecting on it.

To me, social media is a valuable platform, both on a personal and a professional level. I love to blog, and to read blogs; I find engagement with other therapists enriching and I feel the knowledge I gain from other bloggers and social media users (including therapists, other professionals and therapy-users too) contributes to my awareness in counselling practice and also in research and professional issues.

The ethics of social media use is a subject gaining traction, I think, and I am hopeful that our awareness will continue to grow. The latest BACP ethical framework requires that “reasonable care is taken to separate and maintain a distinction between our personal and professional presence on social media where this could result in harmful dual relationships with clients”. I feel a significant expansion on this area of ethical conduct would be beneficial for its members and their clients going forward.

People have asked me whether engaging with the topic of harm in therapy has led me to feel jaded or cynical about the the profession I am entering. I have reflected on this question a lot, and I have concluded that the answer is an unequivocal “no”. On the contrary, I feel that engagement with this topic makes the profession more robust, and the positive response I have received from therapists since I have started this blog assures me that the profession as a whole cares deeply about ethical practice and client responses to therapy. I am also encouraged by, and in admiration of, those therapists already speaking out about harm in therapy, such as Philip Cox and Amanda Williamson.

 

I was motivated to begin blogging about harm primarily because I just couldn’t hear the voices of those who have had negative experiences in therapy, even though statistics tell us that they are out there in large numbers. There’s something terribly disempowering about having a harmful experience and then not being heard.

Over the years I have engaged with online communities where people have supported each other through harmful experiences in therapy and I have also been involved with online forums for therapists. I wondered, where do I exist in all of this? Where is the bridge that connects these experiences and viewpoints? I feel like I belong at the place where those worlds meet, and honestly, I feel like we all belong in that place – we are all learners and teachers.

Somebody recently asked me who this blog is intended for. When I write, I am aware that I will be read by a mixture of therapists, clients, trainees and other people with an interest in the subjects I discuss. It is important to me that we are all able to engage in dialogue together. I am always learning from the comments on this blog from clients and therapists, and also from my engagement on twitter, which I initially saw as a means to promote my blog, but which has actually become a real platform for learning and exploration for me.

It is my feeling (and my personal experience of therapy supports this) that harm in therapy can, in some cases, be mitigated by a positive re-engagement with therapy. Quite likely, this is not always true, and it is important, in my view, to trust a client’s own self-determination when deciding their best way forward after a harmful experience.

It seems crucial, when a client presents with a story of an unethical or careless therapist, or an otherwise harmful situation, that the new therapist is able to be with them on that journey, just like with any other presenting issue or traumatic experience. It is important to be aware of our own personal investment in the profession, how it challenges our objectivity and how this might impact on our empathy. Awareness, as always, is key, and in creating a healthy collective consciousness of  harm in therapy, I feel as though the profession is moving in the right direction.

In short, yes it is okay.

There are a number of reasons why you may Google a therapist – it may be as part of a screening process as you are selecting a therapist, it may be out of curiosity about your counsellor, or it might be part of a desire for connection between sessions, especially where attachment is a consideration. All of these feelings are okay, and a therapist should not shame or blame you for searching for them on the internet.

Googling a therapist can raise feelings of guilt for some clients, and I think that it is useful in therapy to discuss the relationship as openly as you feel able. I would suggest that having a conversation with your therapist around your internet search could be a great opportunity for good work in therapy. While it is fine to look your therapist up online, sometimes doing so can cause discomfort or even distress and if you find you are experiencing negative effects, I think it is especially important to discuss that with your therapist, and to consider whether the behaviour is unhelpful to your process.

As a therapist I am mindful about my internet presence, and work reflexively to ensure the content I produce online both keeps me feeling safe, and is unlikely to negatively impact my relationships with clients. Were a client to read any of my publications or public social media content, I would encourage discussion around that in the therapy room; I don’t wish for my online activity to become an obstacle to therapy for any client, therefore when it emerges in the relationship it feels really important that a client can be honest with me about the impact my activity has. That which presents itself in the relationship is inevitably part of the work.

I believe that the responsibility for managing online presence lies squarely with the therapist. Training exists to help therapists to ethically manage their social media activity and I strongly urge any therapist who is unsure about managing the public or private side of their social media content to take up these training opportunities.

These are relatively new ethical considerations, but in my view, absolutely vital ones for all therapists who engage with social media.

So why do I use social media? Well, essentially I wanted to blog. I felt like I wanted to be part of a conversation, and particularly to raise the profile of the topic of harm in therapy. I felt (and still feel) that in order to support the integrity of the profession, this discussion needs to be more present in our awareness than it feels at the moment. If I can be a part of that, then great. To do that I have to feel secure that I am not putting my clients at risk of harm, and for this reason I continue to engage with online training content, read and listen to the experiences of other therapists who blog and engage with the online community in what is hopefully a mutually supportive way.

I have thought carefully about what I do and do not disclose publically, and while I believe therapists have the right and responsibility to make their own best decisions about this, for me, I prefer not to disclose many details of my journey or my therapeutic process. This is both to ensure that I retain a sense of safety online, and also out of consideration of the potential impact of such disclosures on clients.

Lastly, another ethical question comes to mind: Is it okay for therapists to Google their clients? I will answer with my own personal view of this, which is an offer and not an undebatable truth. I have never, and will not Google my clients. This is my personal and professional boundary. The reason for this is that I am interested in the client who presents themselves in the therapy room. If there are parts of my client’s life that they do not wish to share with me, I feel it is important to respect their choice and their autonomy.

I find snow completely paradoxical.

It is deliciously soft, yet it hurts my hands. Each flake is unique, yet together they create a blank canvas. It is so very solid, yet so readily it melts away. It brings us into the street to play together, yet it cuts us off from one another. It is beautiful yet I dismay when I see it.

This week I have an appointment with my rurally-situated therapist which looks unlikely to go ahead. As I reflect on the interruption to the continuity of the work, I think about the fragility of our routines, how easily they may be disrupted, and the resilience required to adapt creatively to unpredictable external events.

There is likely to be a great many therapy sessions, supervision sessions, coaching sessions, and so on, cancelled throughout the UK this week. Each has meaning; each represents the loss of an encounter for both parties, and perhaps the gain of something too. For the clients, supervisees, therapists, supervisors and coaches whose week is altered by the snow, there is an opportunity for reflection – we can contemplate what each encounter means for us, what meaning each relationship holds. I will reflect on the different feelings which emerge with different types of cancellations. I made it to my supervision this week – how would it have felt to have been disconnected from that? How did it feel to go?

We also have an opportunity to connect with nature differently – to get outside in the crisp, cold air and experience and connect with our altered environment.

As barriers to relating go, the ‘Beast from the East’ feels like a pretty relentless one right now, but just as it came, it will pass. And as we resume our connections which have been put on hold, we may make new discoveries about how we manage changes to our routine, and how it feels to reconnect after an unplanned disruption.

For now, I think a warm drink and some time to appreciate the gentle beauty of a snowy day are in order. I can already see the crocuses peeking their heads above the snow.