A Client First

Something has dawned on me today that has really shed new light on SCoPEd and raised new questions about its reason for being. It has been staring me in the face, yet I have overlooked it. I have spent months examining how SCoPEd is unethical/flawed/wrong, but I have paid little attention to why these three professional bodies might get together and create a piece of research that is so lacking in rigour, and so out-of-touch with the realities of practice.

I cannot pretend to know for certain the motivations of the organisations behind SCoPEd, however, I can highlight potential conflicts of interest in the research that should be at the forefront of our attention.

The SCoPEd framework places UKCP and BPC courses at the upper end of the competency continuum. It places competencies such as “Ability to assess and formulate when working with chronic and enduring mental health conditions” (2.1b); “Ability to demonstrate the skills and critical awareness of unconscious process and ethical understanding, to work therapeutically with ruptures and difficulties within the relationship” (3.10) and “Ability to evidence reflexivity, self-awareness and the therapeutic use of self to work at depth in the therapeutic relationship and the therapeutic process” (5.1c) solely in the column describing those who enter the profession through a UKCP or BPC course.

An employer reading this is likely to want to hire somebody with a UKCP or BPC membership, since they can do anything a counsellor can do and more. A client reading this might look for a therapist with a UKCP or BPC membership. And somebody wishing to train is likely to want to do a course which will grant them UKCP or BPC membership because they want to be attractive to employers.

So therapists, aware of the scarcity of paying jobs in the profession, are likely to feel more inclined to pay UKCP/BPC training establishments to train them, and pay the two organisations to accredit them for years to come. This illustrates a potential financial benefit on the parts of UKCP and BPC to reach the findings presented in the SCoPEd framework.

Should organisations be carrying out research where there is a potential financial conflict of interest for them? The BACP’s Research Ethics Guidelines (2018) says:

“Researchers should be particularly alive to the risk of a conflict arising between the best interests of the participants and the personal interests of the researcher or the organisation for whom the researcher works. Personal or work interests (such as financial considerations) should never be allowed to override the researcher’s duties and obligations to the participants and such conflicts of interest must be identified, declared and addressed immediately in order to avoid poor practice or potential misconduct.”

Neither the SCoPEd framework document nor the SCoPEd methodology document declare or address the potential conflict of interest outlined above.

The World Health Organisation, in their 2009 document Research ethics committees: Basic concepts for capacity-building raise particular concern about the potential of financial conflicts of interest to influence the findings of research. They say:

“Financial interests may threaten the integrity of the research process. They may influence the design of the study, the way it is conducted, the interpretation of research data and the presentation of the final results.
Empirical studies have established a statistically significant link between source of funding and research outcome. Industry-sponsored research is more likely than non-commercially-sponsored research to lead to a conclusion that a new therapy is better than the standard therapy. There is systematic evidence of under-reporting of negative studies. There is also evidence of conscious manipulation of research questions and dissemination of results. Unfortunately, financial interests have also led academic researchers to put their name on publications written by specialist agencies working directly for the sponsor of the study.”

I am sure that these organisations would deny that their motivation for SCoPEd is one of financial gain. And I’m sure that the BACP would deny my suspicion that there is a political motivation for aligning themselves with these organisations. However, no matter what their motivations are, it is not good practice to fail to declare conflicts of interest in research, and the BACP’s own research ethics guidelines say so in black and white. Coupled with the undeclared bias in research methodology which I have already spoken about, the SCoPEd project is looking on really, really shaky ethical ground to me.

In the April edition of Therapy Today, the BACP tell us: “The SCoPEd project is looking at entry points to the professions. […] SCoPEd will not limit or devalue your individual journey. This draft framework is not designed to look at therapists beyond entry point. ”

So according to BACP, these are entry-points, and perhaps through some unspecified advancement, counsellors may progress to become psychotherapists (though where this leaves those who possess the skills attributed to a psychotherapist, yet wish to remain a counsellor, we are yet to discover).

But now at least, we know that the terms refer to entry-points. Clarity at last? I’m not so sure. Looking again at training routes into the profession through the SCoPEd lens, I can clearly see a door marked “counsellor” – it is the door I entered through, with my Level 7 postgraduate diploma in ‘Counselling and Psychotherapy’, which is BACP accredited. I can also see a door marked “psychotherapist” – the UKCP website lists a range of level 7 courses which meet their requirement of 4 years minimum training and 450 client hours (see below – image taken from SCoPEd Competency Framework) But where is the door marked “advanced counsellor”? As you can see, in the table below, advanced counsellor is split into two sections – “accredited counsellor” and “psychotherapeutic counsellor”. So let’s look at both of those.

It’s difficult to argue that ‘accredited counsellor’ is an entry point. The BACP themselves stipulate that at least 150 of the hours submitted for accreditation are accrued “post-qualification”. I’m not sure what it is even doing in a framework purporting to map entry-points to the profession.

What about psychotherapeutic counsellor? Looking at the training requirements for this ‘entry-point’, we need to find a three-year-long (at least 450 face-to-face taught hours), level six course, which requires 450 client hours. I’ve done some digging around, and I haven’t yet found a course that meets these requirements at the point of qualification. The closest courses I can find are the CPCAB diploma in psychotherapeutic counselling, which is a level 5 course (I wonder if the students on these courses are aware they will not meet the requirements set out in SCoPEd to call themselves a psychotherapeutic counsellor) and select few other courses, including a course at the Scarborough training centre, SCPTI, which offers a level 6 advanced diploma, however this only requires 250 client hours, still not meeting the SCoPEd requirements for this entry-point. It seems an extra 200 hours are required by UKCP post-qualification, so again, not an entry point.

I invite anyone who knows of a course that meets the below requirements to point me in the right direction – I genuinely wish to understand how and why advanced counsellor is considered an entry-point into the profession, and whether this is an accessible entry-point for trainees. I feel quite sure that those on BACP accredited courses will not meet the requirements for psychotherapeutic counsellor or psychotherapist (even if the BACP accredited course bears the name ‘psychotherapy’), and that is confusing to say the least.

I think this inconsistency between the public message and what is presented in the framework is important to highlight. To say “it is not designed to look at therapists beyond entry point.” just is not true, otherwise “accredited counsellor” would not feature in the framework at all. So it seems to me like ‘advanced counsellor’ is not an entry-point.

I would really like to see some clarity from the professional bodies about the purpose of SCoPEd. Is it really to map entry-points? If so, why any mention of this middle, seemingly unattainable tier?

This framework will affect therapists, it will affect our practices, and most importantly, it will affect clients. That’s the reason I keep chipping away at this stone. I don’t trust this framework to do clients any good, and I don’t think any project with these kinds of mixed-messages and inconsistencies can be a sound basis for policy change.

If I were in the upper echelons of the BACP right now, I would seek to directly address the rumbles of mistrust and scepticism which reverberate in its membership. I would acknowledge the undeniable rupture that is forming between the professional body and a large portion of its registered counsellors. I would hope to demonstrate the skills and critical awareness of ethical understanding to work with these difficulties in the relationship. I would also be addressing issues of power inherent in the process of SCoPEd. You know, like a qualified counsellor can’t.

What we have seen from the BACP is something quite different. It seems as though they feel that by spinning the results of the consultation so hard they are in danger of flying away, the large number of concerned and horrified members will forget what they feel, and those who have yet to engage with the nitty gritty of what SCoPEd means won’t bother, because the BACP seem to have shouted “EVERYTHING IS ROSY” so loudly that “Erm…what about the flawed and biased methodology?” doesn’t even register.

I became a therapist because I experienced the therapeutic relationship as beyond duplicity and hubris. Because I found a place for myself which chimed with my values. To witness apparent political manoeuvring so incongruent with those values so soon into my career is deeply troubling, and I can do nothing other than contest it in the strongest possible terms.

A couple of weeks ago I spoke on the phone to someone who wishes for me to call them “a BACP spokesperson” (which was not pre-agreed, but requested afterwards). I feel this title omits important information about who the person was, but I will acquiesce. I am not going to go into detail about what was said – mostly because there was absolutely no new information or departure from what has already been said by the BACP – but probably the most interesting part was that I was offered an opportunity to speak about SCoPEd in Therapy Today as part of a “multi-faceted discussion”. I said I would be happy to.

At that point in time (a little while before the consultation results were received) I was experiencing SCoPEd-fatigue and decided to take a week or so off reading, writing or thinking about the project. I received an email from their communication team a few days after my initial phone-call, which asked whether I could have a telephone conversation later that day, with somebody for Therapy Today. I asked for more information about what this would entail, what my contribution would look like, and whether I could write my contribution, rather than give it over the telephone. I received no reply to this email and no further communication from the BACP at all*. It feels very much like they wished for this contribution to be on their terms and with their objectives in mind. Thinking about the leading and narrow questions in the consultation, I wonder if I would have been asked similarly restrictive questions had I agreed to a telephone call.

And this has been my experience of the SCoPEd team from the BACP – sporadic and disingenuous. Frustrated and disappointed doesn’t even begin to cover my feelings about it. Meanwhile, the NCS have fully consulted with their membership in a way that I feel upholds the ethical principles of respect and justice, and the BACP have singularly failed to do this.

I would be incredibly disappointed to have to part ways with the BACP. I love the work they are doing around older people, and other important areas too. There are great people doing great work within the organisation. To have that undone by an unethical, unilateral shift in their policies would be a tragedy.

At this point I think we are doing the right thing – we are keeping this issue as much in our consciousness as we can. We are not letting it fade away into the background so that it can be adopted surreptitiously without fanfare or protest. I will not accept SCoPEd now or at any point in the future, and I stand with the many organisations, including the Alliance for Counselling and Psychotherapy, Counsellors UK, the Psychotherapy and Counselling Union, and Psychotherapists and Counsellors for Social Responsibility, in their efforts to reject it on every level – from its origin, to its bias, to its methodology and its claims.

We must ensure that the profession remains congruent with the philosophies which underpin it, at every level and in every action. I feel that the BACP are not achieving this at the moment; it seems to me that they must undergo some serious self-examination, and ask themselves whether they believe in their own values at all.

*Update 18/03/19: Today, two weeks after my email was not replied to, and less than 15 hours after this blog post went live, the BACP replied, apologising for not responding before. Apparently I am still invited to participate, but the deadline for the April issue has been missed.

In November 2018 I went to a morning of workshops and discussion hosted by the BACP, to which I had been invited because of my involvement with the BACP’s Older People Expert Reference Group (OPERG). I greatly value the work the BACP does campaigning for better access to counselling and psychotherapy for older people – a demographic whose engagement with counselling is disproportionately low and I am proud to be a part of it. I was pleased to see that one of the workshops I could choose to attend addressed the SCoPEd framework – something I had been aware of since the spring, and yet had little idea of what it was actually going to look like.

It seemed to me that there could potentially be some benefits for the public in having a clear understanding of what our profession looks like, its diversity and training routes so that clients are able to make informed choices, and have greater awareness of what “qualified” is and isn’t. I had visions of such a framework explaining that a six week online course is insufficient to be recognised as a counsellor by the professional bodies, and to encourage the public to check the membership bodies’ registers to ensure their therapists are appropriately qualified. What I didn’t expect was assertions such as that counsellors are incapable of assessing whether a client is suitable for therapy without first consulting with a supervisor or other professional. It seems to me that careless insinuations like this one will confuse the public further, denigrate the profession and damage public confidence in counsellors and counselling organisations. I’m not sure how to reconcile this with the BACP’s promotion of counselling throughout their history.

When I first sought therapy I looked for a counsellor. I don’t think I even really knew what a psychotherapist was, and I certainly never would have thought to myself “I need psychotherapy”. My therapist calls himself a counsellor and psychotherapist, and states in his literature that he doesn’t make concrete distinctions between the two terms. I’m very glad, because I have no idea where counselling ended and psychotherapy began in my personal therapy. As a client, what I needed to know was that I could trust in him to assess my suitability for counselling and know how to appropriately work with what I was bringing. If I had read this framework, I think I would have been concerned about hiring a counsellor at all.

One of the biggest ethical concerns I have about this framework is that, in my view, it risks misleading the public. If I were a client reading this, I would probably assume that every counsellor, “advanced counsellor” and psychotherapist I could possibly hire must meet the stated criteria, because these authoritative sources seem to say so. But as we know, these titles are not protected, and setting up as a counsellor or psychotherapist after a six week online course (or no course at all) is completely permissible, so clients who believe the framework may feel a false sense of safety hiring somebody using these titles on the basis of what it asserts. Far from providing greater clarity for clients, it seems to me that this obfuscates things further and could potentially have detrimental consequences.

What a trick the professional bodies have missed here to support their membership, hold those who meet membership criteria as the gold standard and to properly inform the public about the charlatans who may be practising without professional body membership or adequate skills and experience. Instead they have unfairly dismissed the skills and experience of large sections of their own membership. Wow.

At the workshop I attended in November, a BACP member suggested to me that by having a framework in place, if statutory regulation happens, we will be best placed to put forward the structure for the regulation, and the process will be more on our terms than if we enter those negotiations without a framework. My question would be why does this have to amount to splitting the profession down arbitrary lines dictated by an unrepresentative reference group? (The group evidently consisted of 7 psychoanalytic; 2 integrative (unspecified combination); 1 hypno-psychotherapy; 1 pluralistic (unspecified); and 1 humanistic-integrative therapists). Surely it would have made more sense to focus on who we are as a united profession rather than to divide it.

My relationship with the BACP at this point feels confusing. On the one hand, I value the work they do, I love being a part of the OPERG, and I have met many wonderful, inspiring people working very hard to promote counselling and psychotherapy within the organisation, on the other hand, I feel that the membership and the public have not been at the top of the priority list in the formation of this framework, and this seems to me to be in conflict with the BACP’s own ethical values of justice and respect.

I hear a lot of people expressing a desire to leave the BACP, and I understand this. I did mention at the workshop I attended at the BACP that this may happen, and I was disheartened at the presenter’s apparent lack of concern about members choosing to vote with their feet.

For me, the principles and values of the BACP inspired me to choose counselling and psychotherapy as a career, and I feel that the organisation is a force for good at its core. I want to remain a part of the BACP because I feel I can only effect change when I engage with the elements of the profession I feel do not currently meet the needs of clients or practitioners. I love counselling and psychotherapy, and I believe it is in all of our interests to work on a solution that does not divide those titles or the profession.

This somehow feels like a good moment for a rhyme…

They made a framework,
called it SCoPEd.
It wasn’t quite
what I had hoped.

I find the intangible, cacophonous, fragments of thoughts and feelings that bounce around inside of me both incredibly alluring and a little bit terrifying. I call them my chaos. Through my life I have sought ways to channel, express and contain my chaos, most of the time without even realising I was doing it.

Why is it important to manage our chaos? Well, I think appropriate outlets for internal chaos are crucial, so that it doesn’t overwhelm us. If chaos floods us, it has the potential to emerge in harmful and destructive ways. A completely chaotic life is rarely sustainable, and like an uncontained fire, it may well burn out, leaving a path of destruction in its wake. Equally, if we do not allow the energetic quality of chaos any expressive freedom at all, we are likely to find that too much of our emotional energy is used up in an effort to squash it down. This internal struggle might leave us flat, low in energy and feeling unfulfilled.

Art remains one of my very favourite ways to express and indulge my chaos. Musically, I can listen to the gloriously chaotic lyrics and music of The Pixies and make meanings of it which chime strongly with the intensely passionate internal experiencing which struggles to find resonance in most areas of my life. My chaos feels validated by Black Francis’s impassioned screams, and the contrast of quiet and loud, soft and harsh in his music.

The literary cut-up technique of creating poetry and prose, popularised by William S. Burroughs offers my chaos a kind of linguistic means of expression. I feel that my personal chaos does not have words, as such, therefore to express itself in words it must find, select and recreate meaning in them. Similarly, visual collage allows me to express ideas and images which are too abstract for me to draw or describe, yet through selecting and reordering existing images, my chaos finds its way onto the page. I’ve carefully selected an example of this from my own work, to illustrate how this works for me. Below is an image I created using magazines, and without too much conscious thought, selecting words from the magazines which jumped out at me. I then used the words to create the poem. It was a satisfying exercise, and I feel that it allowed my chaos a place in the world. It provided a real container for that internal energy.

Crime novel justice, the hammering surrounds 
Intriguing concrete on the grass-green mounds.
The aesthetic potential of the white-grey day
And the open use of acid smearing it away.
Snake mother breakdown lovingly transformed,
Repeated patterns, artfully performed.
Surgical treatments set the heart free.
Thinking something scary and drinking weak tea.

Medieval characters remember gruesome hearts
Horrible implements fling the broken parts.
Morbid and emotional, the atmospheric war
Military snickets – a path worth lying for. 
Timorous adventurers alone in their minds
Looking out for products to help them unwind
The eponymous crumbled leaf from cultivated tree
Gripped by something scary and drinking weak tea.

“So what does this all have to do with therapy?” I hear you cry.

When I discovered therapy as a client, I realised there could be no greater validation for my chaos than to invite somebody into its wilderness, and witness them understand, value and embrace it. Receiving the message that my chaos really was a valuable part of me did wondrous things for my experience of self.

When clients attend therapy, often thoughts and feelings are fragmented, muddled and unclear. When we have no sense of the okayness of being muddled, our desire to make sense of everything can become extremely anxiety provoking. We can want our internal experience to be as clear and rule-abiding as the constructed society we live in.

Carl Rogers’s wonderful quote “The curious paradox is that when I accept myself just as I am, then I can change.” springs to mind, and I think a similar sentiment applies to chaos – It may seem paradoxical, but when we accept that some things just don’t make sense, and we value the incomprehensible within us, things start to make a lot more sense! Sure, it’s a different sense than the one we were looking for, but I would argue it is a greater sense, because it is authentic.

For me, therapy is a place you can sit in front of another person and say whatever you want, and it doesn’t matter a jot whether it makes sense or not. You don’t have to make the other person understand, you don’t have to paint an accurate picture, you just have to experience what you are experiencing and trust that the therapist will bear witness to that, to sit beside you in the uncertainty and confusion it creates. It is from this place, I believe, that our chaos has a remarkable opportunity to thrive.

It can be argued that transference and countertransference are ubiquitous phenomena in the therapeutic relationship, and much of the time the multi-layered relational responses that occur for both therapist and client either do not dominate the therapeutic work or become a fertile and productive means of gaining relational understanding and effecting therapeutic growth. In my work as a therapist, my understanding of the feelings and interactions which transpire between myself and a client play a crucial role in how I make sense of the therapeutic process and my client’s way of being in the world.

I believe wholeheartedly that transference and countertransference can hold great value in the therapeutic process (from my experiences as a client as much as anything else) so  how do I understand the significant prevalence of transference being cited as a cause of harm in books, articles, internet forums and in blogs, most frequently cited first-hand by the people who have experienced harm in therapy?

Often, when people experience difficulties in their feelings towards their therapist, they Google it. That’s what I did, and it’s also how I make sense of the fact my blog posts on transference, countertransference, and particularly, erotic transference receive more worldwide hits than any of my other posts.  When clients type ‘feelings towards my therapist’ into Google, they receive access to thousands upon thousands of resources and online discussions on transference. They will probably read that it’s important to talk to their therapist about how they are feeling, and those who feel able to, might attend their next session ready to tell their therapist about their understanding of transference and desire to talk about it. What happens next can vary widely.

In her 2016 article for Therapy Today, Dawn Devereux writes “The risk of AIT [adverse idealising transference] can also be reduced by responding appropriately when clients bring up transference concerns, as AIT is much more likely to occur if the first indications are ignored.”.

I would posit that the transference is far more likely to have a long-term adverse effect (distinct from here-and-now discomfort) if the therapist shows discomfort, rejection or denial towards the client’s feelings. Devereux continues “We have observed that therapists whose clients develop AIT are unlikely to discuss transference, and are dismissive or hostile when clients suggest it. Clients also describe therapists becoming irritated, defensive and rejecting in response to discussion about the adverse effects on the client’s life.”.

What is happening for therapists here? It is tempting to say “What terrible therapists; how dare they respond in such a way to a client!” however I think the uncomfortable truth is that any therapist could be vulnerable to responding in a hurtful way to their client and when we ‘other’ the harmful response, we avoid the necessary self-reflection for safe and ethical practice. I really want to take a look at why therapists might respond in this way and how the risks of such a harmful (and potentially retraumatising) response can be reduced.

I have experienced some mixed responses from therapists about my interest in harm in therapy, and I sometimes wonder when I receive confrontational correspondence whether this might relate in part to a reluctance on the therapist’s part to acknowledge their own potentiality to do harm (in fact I recall that this sense was once freely admitted to me). When I hear of therapists’ dismissive or rejecting responses to a discussion of transference, I wonder whether a similar avoidance occurs. It’s almost as though we can, as therapists, bask in our sense of doing good, yet have trouble reconciling ourselves with the inevitable shadow of our virtue. So how can we manage that response as therapists? I would argue that the only way we can reconcile this shadow, is by facing it head-on. I often retweet Carl Jung quotes, because he professes it so boldly and so unequivocally: “People will do anything, no matter how absurd, in order to avoid facing their own soul.”. If we find ourselves shaming and invalidating our clients in order to avoid facing our own soul, we do ourselves, our profession, and crucially, our clients, a terrible disservice.

Hostility as a response to idealising transference is an interesting one; it seems counter-intuitive to meet positive feelings in an ill-disposed manner, particularly as therapists. It seems to me that the therapist who acts with hostility (and quite possibly those who act with defensiveness and rejection too) are likely to be chin-deep in countertransference without the first idea about it. After all, I think it unlikely that any therapist would say it’s okay to act in a hostile and rejecting way to a client expressing such feelings, so if it’s happening, something may well be occurring for the therapist outside of awareness.

My supervisor said to me recently “Awareness is key, and always in the service of the client”. With that in mind, I would say, awareness, reflection, robust scrutiny, and a crucial container for all of these processes: supervision, each have a role to play in managing our own responses to our clients’ feelings in a way that reduces the risk of adverse effects when transference and countertransference emerge in the therapy room.

I don’t think this is by any means a comprehensive exploration of this huge and under-researched area, however I have tried to touch on some of the ways in which we might work to mitigate harm and engage positively with this fascinating and valuable area of the relational dynamic.

I have begun researching literature for my master’s research into harm in therapy. I am reading reams and reams of accounts of harmful experiences as well as many cynical , even disparaging articles about the therapeutic process and the profession as a whole.

As I read all of this, I am reminded of a question I have been asked on more than one occasion – How can you claim to love the profession when you focus on the harm it could do?

This question can come from two angles –

Some might wonder how I can still love therapy, given that I have experienced harm as a client, conversed with many others who have experienced harm, and immersed myself in narratives of harm and sceptical viewpoints.

Others might wonder why, if I claim to love the profession so much, would I highlight its harmful elements, rather than focus on the great contribution it makes to healing and wellbeing in society. Do I wish to damage the profession in some way?

Well, of course I don’t wish to damage the profession. It would be counter-intuitive to spend years training, to laud the profession, to work with dedication with clients, and to endeavour to engage with all elements of theory and practice if that were my intent. It is my belief that, because harm undoubtedly exists in counselling and psychotherapy, engaging with it is our responsibility, as well as being important if we are to honour our integrity as individuals and as a united profession.

Like our individual shadows, if we ignore what lurks in the shadows of the profession, it is likely to pose a greater risk than if we seek to engage with it and address it.

So how about the trickier question of how I can still love this profession, given the energy that I put into exploring its harmful elements? Well, starting with my own experiences as a client, good therapy has had a transformative effect on my self-concept, my self-compassion, my relationships and my outlook on life. I am fully aware that this was made possible by being ‘in relationship’. By being fully accepted, to the point where I no longer needed to fear verbalising my internal experiences, and could hear them for the first time, without judgement or risk of being shamed. To me, that experience is magical. The healing and growth which I know can occur when those necessary and sufficient conditions are met tells me categorically that this is a worthwhile endeavour for me and that the therapeutic relationship is a very special thing indeed.

How do I begin to offset that sense against harm, and place value judgements on the benefits and the risks? I can’t. Not for anyone else but myself (it is for this reason that I believe a client’s autonomy is of paramount importance in the work.). For me, the journey so far has not only been worthwhile, but has been life-changing, and this has to be where my frame of reference grows from.

Of course, my frame of reference is ever-growing. As a therapist,  my work with clients informs my view of psychotherapy as do my conversations with other therapists, with clients, many of whom are my friends, acquaintances or colleagues. The literature I read and my online engagement with therapists and clients alike all form part of this great tapestry that forms in my mind when I think of the role of psychotherapy, both for individuals and for wider society too.

Right now I am brimming with enthusiasm for the future of psychotherapy. I feel that the internet has provided a way for therapists at all levels of training and experience, as well as clients and interested members of the public to get involved with conversations around therapy, and I think that this growing dialogue can only help to improve transparency and credibility of the profession. After all, if we are to help clients to become their authentic selves, we must too demonstrate authenticity, and not shy away from the shadow.

Last week I went to the first meeting of the small group undertaking a research master’s in psychotherapy at Leeds Beckett this year. My research idea is still in the planning stage, but I am essentially interested in what happens for therapists when a client comes to them wishing to talk about a previous distressing, harmful or traumatic experience of therapy. One reason I am interested in researching this topic is that it appears to me to be a common presenting issue in therapy, yet I cannot find a single thing written for therapists who work with therapeutic harm (I live in hope that this will change as my research deepens!).

In terms of my research, I don’t want to say anything more until the wheels are in motion, but I do want to talk broadly about what it can be like to experience harm in therapy, because among those who have never experienced it, I imagine it could be difficult for some to appreciate the nuances of this particular issue.

I have touched on the definition of harm in therapy before in this blog, so I won’t dwell on it here, except to say that as an integrative, person-centred practitioner, I believe the phenomenological perspective of the client is of paramount importance, therefore, if a client comes to me saying they have been harmed in therapy, then, as far as I am concerned, they have been harmed in therapy.

Here are some of the themes I have been aware of when in conversation with people who have returned to therapy after a previous harmful experience:

Grief: If a client comes to therapy to discuss harm in therapy, more often than not, this client will have been through a painful termination with their previous therapist. I have heard people in this position speak of carrying the great pain of this disenfranchised grief, and feeling as though those around them see the loss as little different to changing dentist or optician. Carrying this grief alone can be a weighty burden, even accompanied by a sense of shame and ‘unworthiness’ as a result of invalidation from a society that rarely acknowledges the depth and significance of the therapeutic relationship from the perspective of the client. While, of course, the therapeutic relationship does not hold tremendous significance to every client, for many, the relationship is not only central to the work, but also holds a significant, often reparative role in the client’s wider relational landscape. In my experience, it is often (though not always) clients for whom the relationship itself holds greatest significance, who are most vulnerable to experiencing harm in therapy.

Vulnerability: At the root of harm in therapy, as all iatrogenic harm (harm which occurs via contact with the helping professions – therapist, doctor, dentist, surgeon etc)  is vulnerability. When we go into surgery, when we see a doctor, when we meet with a psychotherapist, we inevitably make ourselves vulnerable to some degree. We must trust that the person in front of us wishes to do us good, not harm, and that they will do us good, not harm. When we experience harm in this vulnerable state, whether intentional or, as in most instances, purely accidental, it is shocking and very scary. I can only liken it to the reliance a child has on their caregivers – children are necessarily vulnerable; they rely on those around them to ensure their safety and security. To be in this situation as an adult and for it to backfire is an acute pain indeed.

Fear of a repeat performance: Clients are likely to return to therapy with their defences fortified. I certainly spent the first year or so telling my therapist that I didn’t have any feelings towards him one way or the other and that if I never saw him again, that would be fine by me. I look back on that wondering who I was trying to convince – myself, I am sure. I suspect it was my way of ensuring I was the guardian of my own vulnerability.  As I reflect on what was happening outside of my awareness, I actually praise the wisdom of my unconscious, and I am grateful to my inner world for the way in which it worked to protect me. When this particular defence realised it was safe to step down, it did, and the next phase of therapy could begin, but I learnt much about myself from its presence and the love I showed myself at this time.

I think, when a client returns to therapy after a harmful experience, it’s important that every feeling, even the kind I describe above, which might appear to be a barrier to relating, are recognised and treated as part of the process. In my view, defences are not a barrier to relating, they are a means of relating. As my supervisor says, the unconscious just does it’s thing, and it knows what it’s doing. It shifts as it receives new information, and in my view, there is no more healing a new experience than an unconditionally accepting, patient and trusting relationship.

* If you are a UK-based therapist who has worked with clients who have been harmed in counselling or psychotherapy and you would like to express an interest in participating in my research, please drop me an email at erinstevenscounselling@gmail.com . The research is likely to involve exploring your experiences and responses to working with clients who have been harmed in therapy. The focus of the research will be on your experiences and feelings, and not details of your client’s experience of harm in therapy, and will be anonymised. At the moment, the research is in the early stages of planning and I will not be officially recruiting participants until after Christmas. At this stage you would be expressing interest only. Thanks!

I’m sure many therapists can relate to those internal “me too!” moments where a client speaks about a thought, an attitude or an experience that the therapist can relate to on a profound level. Perhaps things  emerge which we might think are improbable, bizarre or inexplicable, which leave us gesticulating in supervision as we emphasise just how incomprehensible the parallels seem.

So how do we explain such experiences?

Synchronicity:

Carl Jung introduced us to the term Synchronicity – meaningful coincidences which, far from being random, are connected by their meaning and without obvious causality. I find this explanation for some of the parallels which have emerged in my own therapy very intriguing. It feels good to imagine a mystical and intangible influence in my choice of therapist, whom I now know to be rather similar to me in unexpected and charming ways. The party-poopingly rational part of me, however, won’t allow me to fully indulge in the pleasure of imagining this explanation to be so (though I do not intend to dismiss the potential existence and influence of synchronicity out of hand).

Unconscious Knowing:

As I have developed a deeper understanding of unconscious processes through my own therapy, my studies, and my work with clients, I have become increasingly interested in the role of our unconscious in our lives and the way in which we form relationships. It is my feeling that unconscious knowing plays a significant role in the way therapeutic relationships are selected and formed, and that our unconscious creates opportunities for parallels to emerge in our awareness.

My therapist once said to me that sometimes it seems as though our unconsciouses are having an entire conversation that we know nothing about. I feel that this is a likely explanation for  many of the feelings that sometimes occur in therapy which appear inconsistent with what I am aware of happening in the room.

My supervisor, quite delightfully, prefers to refer to the unconscious as the “greater mind”, finding the term unconscious does not do justice to its role, its significance and its value to us as organisms. While a large function of my therapy continues to be a process of allowing unconscious material to become conscious, I am also learning that my unconscious knows what it’s doing – that I can trust it, and my ability and willingness to listen to my intuition is growing all the time.

So to what extent do these unconscious conversations influence the way in which we form relationships? I am certain that my unconscious knew that my therapist is as introverted as I am, long before I was consciously aware of it. I am equally certain my unconscious picks up on certain cues from him,  seeking out our similar processes, and that I say things that resonate because my unconscious wants to nurture the connection between us. In my view, this relational process is likely to echo the way in which an infant seeks attunement with their caregiver.

Equally, I have sat in the therapist’s chair and thought that emerging parallels, and the way they are emphasised in my client’s narrative, are likely to be more than mere coincidence.

Coincidence:

Coincidences, of course do happen. One day I showed my therapist a photo on my phone. His response was muted and I noticed. I asked him what was wrong. I watched as he considered whether a disclosure was appropriate, and clearly he came to the conclusion that I had noticed something was up, and he had better tell me rather than risk falsely invalidating my experience of him. “Have you got a new phone cover?” he asked. Indeed, I had a new phone cover, and apparently it was identical to one he had just bought for himself (which I had never seen). As far as I am concerned, it was clearly a coincidence (though it’s still fun to imagine that it has a quality of synchronicity). We enjoyed the curiosity of the situation, and I think my therapist was relieved when I told him he had definitely not seen my phone case before; the notion that his choice had been unconsciously influenced by my phone case would give rise to some interesting reflection in his supervision, no doubt!

Disclosure:

On that occasion, my therapist chose to disclose the parallel between us. In my view there had been a clear therapeutic purpose to doing so, as I have described. This leads me to wonder, how do we go about ascertaining therapeutic purpose when making decisions about whether to disclose similarities between ourselves and our clients?

I imagine there are a number of reasons why it might be helpful to disclose when similarities emerge – validating client experience (as in the case described above), building relational depth, normalising feelings, perhaps even helping to model a way of being. And I suppose there are reasons to be cautious too – there could be a risk of invalidating a client’s experience, taking up too much space in the relationship, assuming to understand the client’s experience, and missing the client’s frame of reference by imposing our own meanings and value to parallels in the work. I think, as with all self-disclosure, it’s a case of being mindful of the client’s process, and having a clear therapeutic purpose.

I like Val Wosket’s ideas, described in her book The Therapeutic Use of Self, where she highlights relational self-disclosure (disclosure about the therapist’s experience of the relationship, and things that are directly pertinent to the relationship) as often having more value to the therapeutic relationship than a biographical self-disclosure. With self-disclosure, I would say: the experiential learning in the here-and-now is usually more valuable than the anecdotal learning from the there-and-then. I feel this is likely to be equally true when parallels emerge in therapy.

Reference :

Wosket, V. (2016) The Therapeutic Use of Self: Counselling practice, research and supervision. 2nd ed. Oxon: Routledge.

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.