A Client First

Colleagues at the British Psychological Society’s Psychotherapy Section have offered me an exciting opportunity to collaborate and work alongside the BPS Psychotherapy Section, helping to guide and contribute to their position on SCoPEd. The prospect of working with BPS psychotherapy section is particularly attractive to me because of their commitment to the values I believe therapy must continue to embody – diversity, respect, equality and the value of relationship. Held in London on 18th October 2019, The BPS Psychotherapy Section’s 2019 conference “The Outsider: Inclusion and Exclusion in the Therapeutic Relationship” offers a number of £20 reduced-price tickets, both to students and to people who self-identify as belonging to marginalised groups. I think this is a fantastic way to honour the philosophy of the conference, promote inclusivity, and provide an opportunity for the voices of a diverse group of colleagues to be heard.Additionally, 10 FREE tickets are being offered to students who wish to present a poster on any topic relating to psychotherapy. I love that students are being encouraged to share their work and passions in this way!Please read the information on the conference below, which has been written by the BPS Psychotherapy section chair-elect Dr Phil Cox, and get involved! Hope to see you there!

Psychotherapy Section’s 2019 Annual Conference

Welcome to the Psychotherapy Section’s exciting and innovative 2019 Annual Conference, entitled: The Outsider: Inclusion and Exclusion in the Therapeutic Relationship. Join us in a day of exploration with the Psychotherapy Section during which we seek to deepen our understanding of the complexity of the therapeutic relationship and the unconscious barriers that exclude outsider and marginalised groups.To remain philosophically aligned with the conference topic, there are reduced price tickets to just £20.00 for those who self-identify as belonging to marginalised groups, and a number of students. 18 October 2019 9:00 am – 4:30 pm, BPS Offices, 30 Tabernacle Street, London, EC2A 4UE https://www.bps.org.uk/events/outsider-inclusion-and-exclusion-therapeutic-relationship

Free conference entry for 10 poster presenters

We are giving away up to 10 conference free entry tickets to people who would like to present a poster about any topic linked to psychotherapy. Posters can be for any stage of the research process. I (Phil) can offer support and guidance on how to prepare or present a poster. Students on any counselling/psychotherapy or psychology course are particularly welcome – we are not looking for a work of art, just to support you. You’ll have the opportunity to stand by your poster during breaks and answer questions – it’s a great way to develop how to explain your research and ideas – it’s also great exam/viva voce practice. Feel free to contact me PsycheLetter@bps.org.uk

Dr Philip Cox (D.Psych, CPsychol, EuroPsy)

HC

PC reg, BACP (Snr Accred)

BPS Register of Applied Psychology Practice Supervisors

BPS Psychotherapy Section Chair-elect

BPS Psychotherapy Section e-letter editor & Facebook co-editor

Psychotherapy & Counselling Union consultant for professional complaints

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.