A Poem on Therapy

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

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

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

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

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

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

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

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

 

Possible client concerns:

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

 

Possible therapist concerns:

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

 

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

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

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

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

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

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

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

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

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

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

 

 

 

The Value of Resistance

From both therapists and clients, I have heard therapeutic resistance spoken about as though it were an obstacle to therapy, or an indication that therapy will not be effective for the ‘resistant client’. The word itself appears to have a value judgement attached to it, and I think this is particularly true in the ear of the client. It is regularly heard as a criticism, a label, or perhaps even a confirmation of the hopelessness and futility which is felt internally.

If we are to define resistance in this context as an apparent unwillingness or inability to engage with therapy, it is not surprising that a therapist might feel frustrated or impatient. After all, most therapists are motivated by a genuine desire to help;  spending an hour with a client who might be saying “I don’t know”, “I know this won’t help” and “nothing works” challenges the therapist’s innermost belief that client change is inevitable when, as Carl Rogers posits, certain therapeutic conditions are offered.

I wonder what a client is feeling in this situation. Fear perhaps? Despondency? Dread that the hopelessness which consumes them will again lead to rejection and loss? It really could be any of these and a myriad of other conscious and unconscious processes which paralyse the client’s psychological movement and make contact between the client and the therapist a much slower and more meticulous process than the therapist might usually experience.

As frustrating as it might feel for a therapist, I would argue that this very response from the client is a rich and fertile hotbed of information about the relationship and the client’s process which is likely to be central to therapeutic change. I see the therapist’s role at this stage of the process as one of holding and encouragement. To communicate to the client, through consistency and unconditional positive regard, the messages: “I will not reject you.” and “I trust you.”. Only when these sentiments have been demonstrated in the relationship, will the despondent client feel safe enough to explore the possibility of change.

It is my sense that everything which emerges from this period of therapy is valuable. The client’s verbal responses, physical communication  and attitude to coming to therapy are all likely to provide clues about what is happening in the relationship which can be noted and brought into the room in a sensitive way. Even the therapist’s frustration and impatience may provide valuable data about the relationship, and much for the therapist to reflect on: How much of these feelings are from my own desire for deeper contact? How might they reflect the dynamics of other relationships in the client’s life, past or present? To me, this is a wonderful exploration, and fascinating!

Sometimes, a client might choose not to engage and leave counselling having made little or no progress with the issues they brought to therapy. I find myself asking whether the therapist in this situation might be left with some of the residual hopelessness or skepticism which the client brought into the room. It is certainly not easy for somebody in a helping role to feel they have not helped. As well as feeling a sense of responsibility towards the client, the therapist might feel that something of their own identity or purpose is called into question, at least internally. John Rowan (2016) reminds us to avoid becoming too focused on curing or finding a solution for a client. Not only is it not our responsibility to ‘solve’ the client’s issues, but also, as the client is the person in the best position to seek their own answers, attempting to overlay our own solutions on the process is counterproductive and seeks to meet our own needs.

When a client does leave therapy, whether or not they have chosen to engage, it is important  to acknowledge that we are only the client’s journey companion for a tiny portion of their life. This is where they are now, and we cannot pretend to know where they will be ten, five, two years, or even a month from now. Perhaps they will reenter therapy at a time when they are ready to engage. Perhaps they will never reenter therapy but find other means and support to make changes in their life, or find meaning in the incomprehensible. We must respect that process and the autonomy of the client to find their own way.

 

Ref:

Rowan, J. (2016) The Reality Game. 3rd ed. Routledge: Oxon.

Power in Therapy

Person-centred therapy serves to help the client to develop an internal locus of evaluation – to convey a trust which the client can internalise and begin to trust themselves.

So, while counselling from this humanistic perspective aims to empower, it seems important to ask: What power imbalances inevitably exist within the counselling relationship? and: Are we adequately aware of how they present in the room?

As well as the client and therapist’s perception of their respective societal and professional statuses, their preconceptions about each other and the mandatory reporting responsibilities of the therapist – which are all likely to contribute to the therapist being perceived as holding a role of authority – it seems to me that there is a unique relational power dynamic which affects the relationship and the work in a number of ways. Here are what I feel are some of its contributing factors:

Trust in the therapist: Often a client enters therapy with no experience of counselling or knowledge of what to expect from the therapist. In the introductory session a client is usually given some information by the therapist. In person-centred counselling his might be as simple as “I am not the expert; in therapy we will explore what is troubling you together in order to facilitate the changes you are looking for.”. Whatever boundaries are suggested by the therapist are likely to be accepted by the inexperienced client. If the therapist decides it is okay for the session to run over by ten or fifteen minutes, a client may not object. If a therapist decides to copiously self-disclose, the client may have no frame of reference as to whether this is appropriate in the context of counselling. The therapist has the benefit of supervision to check whether the counselling being delivered is appropriate, however the client often has nobody with whom to check. Which leads me to…

Isolation: There are very few relationships in life which deliver such an intense level of intimacy in complete isolation from all other relationships.  This means that no other person is witnessing the relationship, therefore there can be no objective view on its health and productivity. Even a supervisor is getting a picture of the relationship through the therapist’s filters. As I alluded to above, this means that a client has no sounding board and may not be able to independently ascertain whether the sessions are therapeutic or whether the relationship has become problematic. The BACP’s ‘Ask Kathleen’ service seeks to address this issue, however it is dependent on clients’ awareness that something may not be right and their willingness and ability to seek help. The intimacy of the relationship and the complete focus on the client may also contribute to intense feelings towards the therapist, which could potentially impact on the power dynamics…

Love and attachment: Love and attachment can form an important part of therapy. The therapeutic bond is a vessel for the work and I believe that immense healing can occur when working at relational depth. The emergence of attachment can be a large part of the therapeutic work and many modalities see the client’s attachment to the therapist as extremely valuable to the process.

Love and attachment do, of course, impact on the power dynamic in the room. Attachment towards a therapist often ties into very young feelings and can leave a client vulnerable and sensitive to perceived rejection or inconsistency. To call upon my earlier example of a therapist who allows time to run over regularly, imagine how a vulnerable client may feel if the therapist decides to book clients back-to-back one week and ushers the client out of the room right on time. From an adult perspective, the therapist is doing nothing wrong – last week they had time to go over, and this week they do not, but to a vulnerable inner child, the communication may be that the therapist has had enough of them, or they are no longer good enough or worthy of extra time. Equally with a therapist who habitually self-discloses, what if something occurs that they do not wish to disclose? Perhaps they need to miss a session due to a funeral, or an illness they do not wish to share details of. Of course a therapist does not have to disclose anything they do not wish to, but the disempowerment that a client might feel in such a scenario must not be ignored. 

A client’s feelings of love or attachment to their therapist might also impact on their willingness to make a complaint or seek an opinion on the actions of the therapist. Here lies potential for grooming, gaslighting or abuse, whether conscious or not on the part of the therapist. Additionally, if a therapist were to lose objectivity due to their feelings towards a client, they may discourage the client to leave, thereby not properly respecting the client’s autonomy or even initiate dual relationships.

It is vitally important that we keep all of this in our awareness as practitioners and ensure that we are not using the unavoidable power differences which occur in the relationship in order to meet our own needs.

 

 

A Client First

This is my first foray into blog-writing and in a strange way I feel very at home already. I am in the final year of training to become a counsellor/psychotherapist and I suppose I am already beginning to wonder if the world of the qualified therapist provides the same space for discussion and exploration of ideas that I enjoy weekly at university. Perhaps I am scoping out new territory in which to…well, I’m not sure…express? explore? ignite debate? challenge my preconceptions? Maybe all of these. I tread lightly as I take my first steps into this uncharted terrain and bring with me an open mind and enthusiasm to learn and grow.

The title of this blog alludes to my introduction to psychotherapy, which was (and still is!) to experience therapy as a client. As I move into psychotherapy as a career, I am sometimes uncomfortable with what I describe as an ‘us and them’ attitude I have occasionally experienced from practitioners. At the beginning of my learning, I witnessed a tutor declare to the students “All clients lie!”. As inexperienced as I was at the time, I found this sentiment jarring and frustrating. As a client I felt a real sense of the inherent power imbalance, as though I were stood at the foot of a mountain, vying to be heard by those at its summit.

My experiences in psychotherapy  have not always been positive. My first therapist displayed a disregard for therapeutic boundaries which was not only unhelpful, but actively harmful. When I subsequently sought consultation with an excellent therapist, I noticed that even he sometimes struggled to know how best to work with the fallout from my previous therapist. I have found that almost no literature or research exists on working with clients who have been harmed in therapy and meeting the unique needs of this client group. I hope to be able to contribute in this area; I want the profession to be able to confront this aspect of its shadow and not to shy away from the harm that we can do as practitioners. I want clients who are wary of reentering therapy know that therapists want to help them. That we are by their side, that we want to understand what is happening for them, and that we do not fear working with them. I feel that an open conversation in the profession is essential to achieve this.

So, that’s a little bit about me and my interests. In this blog you can expect my thoughts and comments on all things psychotherapy, a strong leaning towards the rights of clients and the ethical responsibilities of therapists, and probably some poetry here and there too!