A Client First

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.

I chose the image above because I like the idea that a gap in something can be a window to something else. I think this can be true with therapeutic ruptures – a gap in understanding can illuminate areas which had been outside of awareness both for the therapist and the client, as well as in the relational dynamic.

When I think of ruptures in the therapeutic relationship, I am thinking of any point during the therapeutic process when the client and therapist encounter difficulties in their working alliance, whether it by through a miscommunication, therapist error, an incongruence between client expectations and therapist boundaries, or whatever else.

Such occurrence in therapy can be a source of great anxiety for client and therapist alike. Sometimes a rupture will be unresolved, and the client will choose to leave the relationship, sometimes there will be an unsuccessful attempt to repair the relationship, and very often ruptures can be worked through and resolved successfully.

I know from experience that repairing a rupture in the therapeutic alliance can actually have a strengthening effect on the relationship, and I think this is probably particularly true where the client’s previous experience of conflict has been scary, dangerous or unresolvable. When approached with acceptance and care, there can often be potential for growth and healing.

If we accept as an inevitability that ruptures may occur in the therapeutic relationship, we need to think carefully about what comes next. Obviously a lot will depend on the nature of the rupture, but I think some broad notions are worth keeping in awareness:

• The client’s feelings are valid – No matter whether the therapist agrees with the client’s perspective about what has happened, it’s really important not to lose sight that the client is still entitled to it. I know it sounds obvious, but it is possible to become focused on our own frame of reference when our work is challenged. It’s a human response and we are all vulnerable to becoming defensive when we feel attacked. A defensive response towards the client is unlikely to have a therapeutic outcome.
• It is a part of the work – From my relational perspective of psychotherapy, ruptures are a part of the work. As a client, they have taught me new ways to be ‘in relationship’ and the confidence I have gained in expressing my needs is helpful for all my relationships. Equally, the trust I have gained in my therapist allows for greater relational depth in the work. It’s a part of my process, and something would have been lost, I think, if my therapist and I had not worked together to resolve issues when they arose.
• Boundaries are important – Issues around boundaries are sometimes a catalyst for ruptures in the therapeutic relationship, and they can also be instrumental in resolving them. It is important to have clear boundaries which create a sense of safety in the relationship, and being clear about where those boundaries lie may make boundary-related ruptures less likely. When ruptures do occur, therapeutic boundaries provide the frame and the space to resolve whatever issues are occurring. I would argue that while the alliance is fragile, altering therapeutic boundaries could cause additional strains or difficulties in the work.

Sometimes ruptures do go unresolved, and I think it’s important to retain perspective when this happens. It goes without saying that the therapist has an ethical responsibility to examine what has happened, and whether anything might have been done differently, – supervision provides a space for this important work. There will be occasions when ruptures arise due to the nature of the work (such as in the emergence of transference) and the client will leave before there has been any opportunity to work with the emerging material. It is so important in those instances, in my view, for the therapist to treat themselves kindly, and also to value client autonomy and trust them as the holders of their own process.

To me, ruptures are not about ascribing blame, but they are about taking responsibility – the willingness and ability to work non-defensively and reflexively are hugely important. I believe that modelling this way of being as a practitioner gives the best possible opportunity for positive therapeutic outcomes.

I am due to qualify this summer. I have one shortish assignment left to write and 19 counselling hours left to get in order to have fulfilled all the requirements of my course.

I’m hearing a lot about finish lines, and ‘finally theres’ but it doesn’t feel that way to me. Of course a few things will change overnight when I get that piece of paper – my BACP membership will become a full membership, I can apply for paid positions if I wish to, I can remove the word ‘trainee’ from this blog.

I think there is likely to be an emotional shift too. It’s difficult for me to predict how that will feel; I imagine there will be a sense of accomplishment as well as trepidation; university has provided me with a valuable support network and I will have to adjust to no longer having that weekly connection with friends, peers and tutors. I plan to top my PG Diploma up to a masters next year and I think a small part of my motivation for doing so relates to my attachment to the academic element of my learning as well as a desire to continue to touch base with the university.

But in a strange way, during my learning journey I have already become so accustomed to ongoing change that qualification does not seem like the huge shift that I thought it might. Almost every week my perceptions about myself and about psychotherapy have been influenced and shifted by some aspect of my learning, whether that be client work, personal therapy, supervision or university. I am constantly discovering, and I don’t anticipate that will ever stop. I feel that I am in this process for life.

So what I see ahead is a checkpoint. An important checkpoint certainly, but not a finish line – it is a continuation of a journey which I feel began when I first walked into a therapy room as a client.

As I reach graduation, I will take time to celebrate my achievements, and reflect on my learning and growth so far. I am proud of what I have achieved over the last few years and grateful for the friends and mentors I have met along the way.

And at the same time, I will also celebrate what is to come – the unknown future paths of this remarkable journey.

It strikes me that I did not elaborate on erotic transference in my recent blog post about transference. It seems to me that sexual feelings towards a therapist are often some of the most uncomfortable and difficult feelings that can emerge within the relationship. Often such feelings come as a complete shock to a client, especially when the therapist is not the client’s ‘usual type’ or even preferred gender.

As I talk about erotic transference, I want to confess some ambivalence about the term. It seems to me that these feelings can extend beyond the erotic, to romantic feelings, infatuation or feeling in love with a therapist. Having said that, a more all-encompassing term does not immediately present itself (answers on a postcard) so for the purposes of this blog post, erotic transference will be assumed to include any feelings of a romantic nature, including feeling in love and any sexual feelings towards the therapist too.

The emergence of erotic transference within the therapeutic relationship

Disclosing erotic feelings to a therapist can be a terrifying proposition. How will the therapist respond? Will they change boundaries? Will they feel disgusted? These are common concerns I hear expressed about the prospect of discussing erotic transference with a therapist.

I think it is important that therapists consider how they might respond to such a disclosure. Do they feel able to be accepting of whatever feelings emerge? To hear details of sexual fantasies, or desire for a romantic relationship, from any client who might express them? And how confident is the therapist in ethically managing erotic countertransference in this scenario? Physical sensations or reciprocal feelings could be very unsettling for a therapist and it is important that the client’s exploration of the emerging material is not undermined by the therapist’s uncertainty in the work. Supervision is vital of course, and an understanding of the nature of transference is very important to working ethically with these feelings and retaining a sense of perspective in the work.

So how are the feelings worked through? Accepting the feelings just as they are is huge. Listening with an open curiosity and without judgement, and crucially, never pushing the client for details which they do not wish to disclose. It’s really important that, as therapists we are examining our motivations for interventions as we work, because a client may feel very vulnerable when discussing erotic transference, and the potential for harm is present.

It is my personal feeling that boundary changes as a result of a disclosure of erotic transference (in fact, disclosure of any feelings towards a therapist) can be received as punitive, and should be avoided. As an example, any sudden changes to boundaries such as out of session contact or therapeutic use of touch because of a disclosure of erotic transference may feel like rejection, and reinforce conditions of worth which would be counterproductive to the therapeutic process.

One foot in the past

Erotic transference, like all other feelings towards the therapist, is likely to be rooted in a mixture of here-and-now feelings and feelings which originate in past relationships. So there may be here-and-now attraction (or not), but if these feelings are characterised by an unusual intensity, I think that this provides a clue that some element of the feelings may be historical. This could be around past romantic relationships, or quite often related to relationships from childhood.

Clients sometimes describe experiencing a mixture of erotic and maternal transference or erotic and paternal transference towards their therapist. It is not surprising that in some cases the emergence of strong attachment feelings last felt in childhood might be associated with eroticism in the adult brain. After all, the passion with which we loved our parents and needed our parents’ love and touch as infants is not usually paralleled in adult life, other than in romantic relationships. I feel it is possible that erotic feelings can sometimes be a way of consciously making sense of powerful unconscious feelings which are stirred from infancy.

I could get carried away with theory at this point, so I am consciously reining myself in. There are lots of useful books offering varied perspectives on erotic transference and love in the therapy room, and I would encourage anybody who is interested to explore the literature.

Why work through it?

I am a firm believer that the therapeutic relationship is a vessel to growth and change. If we ignore the emergence of any feeling, including erotic transference, we are potentially missing opportunities for movement in the relationship and important clues about the client’s process.

It needs to be handled with care and understanding, and the therapist must be aware of the delicacy of the work and attuned to the client’s needs (an in-depth exploration of the past will not be appropriate for a client in crisis, for example). However, feelings around erotic transference are simply feelings, and I feel, should be accepted and valued in the therapeutic process the same as any other.