A Client First

Last week, I wrote a blog post titled The Vulnerable Therapist, exploring the inevitability and value of vulnerability in a therapist, and how this is expressed  in the therapeutic encounter.

In this post I would like to explore resilience as a counterbalance to vulnerability. If our vulnerability is to be managed in the counselling room, I believe that our resilience provides us with the strength and courage necessary for the job.

So what is resilience? The BACP describe it as: “the capacity to work with the client’s concerns without being personally diminished.” (BACP, 2016) and as I browse the internet I find it variously defined as the ability to get up after a fall, and the confidence that we have the ability to deal with challenges should they head our way.

I like the latter definition most of all. It seems to me that our vulnerability becomes something we can embrace rather than fear when we trust ourselves to deal with whatever challenges may arise. To develop this inner-confidence, we must of course have adequate support in place for ourselves – a reliable network which we know we can call upon should we need to. In my work as a counsellor, supervision is central to this. I would also count my therapist, university tutors, peers and family among those who contribute to my resilience in different ways.

I do not think resilience can truly be present without self-care. Breaks, creativity, fun, rest and attending to our own needs strengthen and enrich us. If we are approaching burnout we are becoming personally diminished, and therefore our resilience is diminished too.

So while I am celebrating vulnerability, I also want to give a little shout out to resilience. These fraternal twins of wellbeing are essential parts of who we are as therapists, and as people.

Reference:

 BACP Ethical Framework. (2016). [pdf] Leicestershire: BACP. Available at:  https://www.bacp.co.uk/docs/pdf/15595_ethical_framework.pdf. [Accessed 16 Jan. 2018].

Vulnerability is an inevitability in human relationships, and the therapeutic relationship is no exception. If relational depth is to be achieved in therapy, both parties must bring something of themselves to the relationship – to put trust in each other and the process – to become vulnerable.

As well as being a building block of relational depth, therapist vulnerability can also model an acceptance of feelings, and a sense that it is possible to meet one’s own needs. I remember an occasion when my therapist said to me “I felt vulnerable. But that’s okay. I like that I can be vulnerable, and I can take care of myself.”. Here was somebody sitting in front of me expressing vulnerability and I did not have to rescue or protect them – this was a big moment of learning for me and has changed the way I view vulnerability, in myself and others. It was a huge step on my journey towards acceptance of all feelings.

Recently though, I felt jarred by hearing from a tutor “I am a vulnerable practitioner; if the client doesn’t want a vulnerable practitioner, they can find another therapist.”. For me there are a few questionable things about this statement. Primarily, I do not believe there is such a thing as an invulnerable practitioner, and I think this hypothetical client would probably spend the rest of their lives searching for such a person. I believe the tutor was really referring to the means by which he expresses his vulnerability to the client. The statement in question came as part of a debate about self-disclosure, and self-disclosure is one means by which a therapist may express their vulnerability to a client. The tutor did point out that he wouldn’t self-disclose to every client and he would make a judgement in the moment, which seems to me to show a willingness to adapt to the needs of the client. I believe that if the therapist is willing to put the needs of the client first and to express their vulnerabilities in ways which do not unsettle, antagonise or trigger a vulnerable client, then the need to find the mystical invulnerable therapist should never arise.

Some therapeutic relationships may be very delicately balanced, and if copious expression of therapist vulnerability in any way threatens the safety of the relationship from the client’s perspective, I would argue such exploration is better reserved for supervision and personal therapy, at least until the client’s needs have shifted. My first question, as I consider the appropriateness of any intervention, is always: “Who does this serve?”.

But I do want to celebrate vulnerability. It is what makes us human, it is the seed from which empathy and compassion can grow. It nourishes all of our most intimate human relationships. To love vulnerability is to love ourselves – it is a part of myself I would not wish to be without.

Whether it is your first time seeking therapy or you are changing or restarting, looking for a new therapist is a daunting task. You are likely to have pressing difficulties in your life and the last thing you want to do is to spend time figuring out which therapist and approach is right for you. In this post I intend to focus on some considerations which may be important to you when looking for a therapist.

• Therapeutic approach This may or may not be something you consider when searching through the wide variety of counsellors and psychotherapists registered with the popular internet directories. Thinking back to my own initial search for a therapist, I did not know one approach from another, and the modality of the therapist barely crossed my mind. What I have learned from my own journey, is that the quality of the therapeutic relationship is key to positive outcomes in therapy, and research has shown this is a more influential factor than the therapist’s theoretical approach. Broadly speaking, some modalities may be more beneficial for certain people or difficulties, and more information about therapeutic modalities can be found here.
• The right therapist There is no easy way to tell from a directory listing or website whether you will work well with a particular therapist. You may have preferences around age, gender, location or price. You may prefer a therapist with a particular area of interest, such as working with LGBTQ clients or religious issues. Those preferences may provide a helpful foundation for your search. It is often useful to read carefully through what the therapist has written about the way they work and their philosophies. Does anything resonate? Is there anything you don’t agree with? When you meet with a therapist for the first time, it is important to remember that you are both exploring whether you will work well together. You are not committing to working with this therapist; you are essentially interviewing them – deciding if you want to hire them. If at all possible, I recommend meeting with more than one therapist to get a feel for different styles and personalities before you make your choice. Many therapists offer a free initial consultation or phone call – take advantage of that.
• Professional Body Membership There is no statutory regulation of counselling and psychotherapy in the UK. This means that therapists and organisations do not have to be a member of a regulatory body to practice, however, in my opinion most reputable therapists are members of a professional body (either personally or organisationally). Membership requires the therapist to keep up-to-date with their training, seek appropriate professional supervision and work to an ethical framework. These things protect clients and promote quality therapy. I recommend that before meeting with a therapist, it is a good idea to make yourself aware of which professional body the therapist is a member of, and check the professional body’s online register to ensure this information is up-to-date. The BACP register can be found here. If you are seeking therapy through an organisation, it is worth checking the organisation’s professional body membership too.
• Is this okay? No matter whom you work with, therapy is likely to be uncomfortable. You are working with difficult and sometimes distressing material and talking with your therapist about how you are experiencing therapy is often an important part of the work. Your therapist should listen to any concerns you raise and seek to address them with you. This is a collaborative process. If you feel that your relationship with your therapist is problematic, and this is not resolved or addressed by discussing the issue with the therapist, you may decide that you would be better served seeking therapy elsewhere. This is okay and your therapist should not pressure you to stay. If you are unsure about any aspect of therapy with a BACP registered therapist, you can contact BACP’s Ask Kathleen service for confidential guidance and advice. Ultimately, I would say trust yourself  – you are the expert on you and best placed to decide whether the relationship is right for you.

Last night I dreamt that a large snake was swallowing a smaller snake. Aghast, I pulled and pulled on the smaller snake to prise it from the larger snake’s jaws. When I finally pulled the snakes apart, they both were dead. 

I ruminated about the meaning of the dream and what the two snakes might represent. I decided that they might represent parts of myself – the larger snake symbolising my present self and the smaller snake a representation of past experiences or former versions of me. In trying to keep those parts of myself away from one another I lost them both. I see this as a powerful reminder that my past experiences serve to nourish the person that I am today. The message I take from this dream is that rather than try to hold areas of my experience in isolation, it is important for my growth to seek to integrate aspects of myself into the self-structure, as Carl Rogers theorised. It feels like a wholly positive and wholesome reminder.

Is this what my unconscious had intended me to take away from this dream? The answer to that is, well, unconscious. But this meaning resonated with me, and it helped me to refocus and reflect. For me, this is the value of dreamwork. Those hidden messages; whether spontaneously existent or emergent in the interpretation, they nourish and inform us. The unconscious is a wondrous place. 

I believe very strongly that clear and consistent boundaries are one of the most fundamental elements of the therapeutic relationship. They contain the relationship, frame it and promote trust. Boundaries don’t just come from the therapist; they are agreed upon within the relationship and the client’s boundaries need to be heard and valued.

When clients don’t know where the therapist stands on particular boundary issues, not only can this be very anxiety-provoking, but tripping over the therapist’s unspoken boundaries can be tremendously painful too. I once saw this described on an internet forum as akin to stepping on an invisible electric fence, and this elegant metaphor provides the title for my blog post.

Aside from the obvious ethical violations, there are few clear-cut answers about how we manage boundaries in our practice. There seems to be a lot of differing opinions, and I feel that our ethics, learning and experience provide a frame for making our own best judgements (alongside the honest and open use of supervision) about working in the interests of our clients.

I will say a little bit about some of the most commonly discussed boundaries in the therapeutic relationship:

Time boundaries: I still struggle to understand it when clients report regular therapist lateness; to me this is a straightforward issue of fulfilling the contract. If I have agreed to meet a client at a specific time and place it is my duty to fulfill that. Habitual lateness by the therapist can be very problematic for a client; I have spoken with clients who report high levels of anxiety due to a therapist’s unpredictability. I would argue that this type of inconsistency could trigger feelings relating to childhood trauma or abandonment. It can and should be avoided. Running over time in sessions also may have its pitfalls. A distressed client may appreciate some flexibility about extending the length of a session, and I think it’s important that there is an open discussion about the purpose of that, and when and if the client might expect something similar to be offered in the future. It is also important to pay attention to how the client feels about the extra time. It’s easy to assume that the client is happy to have a longer session, however they could be holding some anxiety about the inconsistency or may feel indebted to the therapist and more reluctant to bring up any problems that arise in the relationship. It is so important to check in with the client about any changes to the session frame.

Self-disclosure: We self-disclose just by being. Our gender, age, race, clothing, body type, accent are all apparent before the relationship has even begun, and it’s really important to be mindful of how we are being received by our clients. I am also aware that my presence on social media is a form of self-disclosure and I pay careful attention to what I post and how I approach my online relationships. my personal social media accounts are also restricted. I feel this is helpful both to myself – I am in pursuit of a healthy work/life balance – and also to my clients – I feel it is important to be mindful of how it might feel for some clients to see me in non-therapeutic roles and relationships. So what about self-disclosure in the therapy room? Congruence, or genuineness is, I believe, fundamental to the efficacy of the therapeutic encounter. If I am not me, then the relationship cannot be real, and as a humanistic therapist, I believe that the relationship is of paramount importance. So how much of myself, and what of myself do I share? These are difficult decisions which take place in-the-moment. There are relationship-specific contexts and multiple therapeutic factors to take into account. As I write this part of the post, I find myself thinking that self-disclosure really deserves its own post. There is so much to consider. Will the disclosure enhance the relationship? Is it the best way to illustrate a point? Are there any risks associated with it? What is the therapeutic purpose? Could it be received as minimising or dismissing the client’s experience? And not to mention: Is the therapist comfortable with revealing this part of themselves? As I so often say, it is essential to ask the question “Who does this serve?”. If the answer is not “the client” then I would suggest that it is not appropriate to disclose. I would also urge caution when faced with an uncomfortable personal question. It seems important that the therapist gives themselves time to reflect on their feelings about the question and the potential impact of giving an answer, rather than feeling pressured into a response.

Out of session contact – It seems to me that the therapist’s out of session contact policy is something that should be decided upon and communicated to the client at the start of the relationship. I don’t think there is any one right way to approach such a policy but I do think it is crucial that whatever the therapist offers, they can deliver on it. As we all know, we need to make time for self-care in order to avoid burnout and I think we have to be really honest about what we are willing to offer, and what we can offer. I think it’s important to avoid a situation where the client uses the out of session contact as it was offered, only for the therapist to feel overwhelmed and suddenly change the boundary. This can be experienced as shaming, rejecting and can be incredibly painful. It goes back to the analogy of the invisible electric fence – the client does not know where the fence is, but it doesn’t half hurt when they tread on it. If the therapist does need to adjust what they are offering a client, I think this has to be handled very sensitively to avoid inadvertent hurt.

Touch – There are many schools of thought on touch, and I think it is pretty much universally agreed that touch should never be forced upon a client, nor does any sexual touching ever have a place in the therapy room. Personally, I believe that any touch should be client-led and client-initiated, and I also feel that the use of touch in the therapy room should happen alongside discussion about therapeutic purpose and the client’s response. It seems to me that like any aspect of the relationship, an ongoing dialogue is really important to the work.

So these are a few of the potential electric fences as I see them. There are plenty of other boundary issues I have not been able to cover in this post – gifts and dual relationships both spring to mind, and it is probably not the last time I will look at boundaries in this blog.

As I began by saying, the boundaries of the relationship are essential, they are what makes it safe. They are what makes it therapy. We can’t (and shouldn’t) take away the safety of the boundaries, but what we can do is make those boundaries as visible and clear as possible, so nobody has to trip over an electric fence.

I have written poems for a number of years and have found poetry provides a frame for an intense and focused kind of journaling. The compact nature of the form forces me to go directly to my feelings, and helps me to create imagery which adds colour and depth to my experiences. If I were so inclined, I could probably produce several anthologies of poetry I have written during my own therapy. As my writing has developed I also find myself writing nonsense poetry and children’s rhymes – finding fun and silliness in the meaningless and absurd.

These are not poems intended for publication, but for myself; sometimes I share my writing with friends and family, or a writing group I attend, but essentially I write for me. It is a part of my self-care. I take great joy in the craft of poetry and reading the work of others. I particularly adore the poetry of Spike Milligan. As well as his famous nonsense children’s verse, Spike wrote movingly about his deep struggles with his mental health. Below is perhaps one of the most poignant poems I have ever read on the subject of mental health:

Manic depression 

The pain is too much
A thousand grim winters
   grow in my head
In my ears
    the sound of the
    coming dead.
All Seasons
All Sane
All Living
All Pain.
No opiate to lock still
     my senses
Only left,
   The body locked tenses.

Spike Milligan, St Luke’s Hospital, Psychiatric Wing, 1953/54

The words of this poem have always stuck with me, evoking as they do a torturous struggle and an intense loneliness which feels ever starker in the poem’s sparsity.

An increasing number of therapeutic practitioners are actively using therapeutic writing in their practice. I have recently become a member of Lapidus, a writing for wellbeing organisation, and I see the subject gaining traction both in literature and in practice. I have attended workshops both to participate and to learn more about the benefits and uses of writing in a therapeutic setting. The network is growing and that’s really pleasing to see.

Poetry also allows me to connect with the therapeutic world at an experiential level, digging below theory and practicalities and exploring the personal meanings which emerge for me in becoming a therapist. Earlier this year, I was honoured to see my poetry poster win the McGraw Hill prize for ‘Inspirational Poster’ at the 9th Annual Conference for Psychological Therapies and Mental Health at Leeds Beckett University.

The connection and depth of feeling which can be communicated in poetry is one of the reasons I believe creative writing can provide such a powerful tool for communication in the counselling room, particularly when working with clients who find verbal disclosure and exploration of feelings overwhelming. The use of metaphor, as with art therapy, can also contribute to making exploration feel safer.

I wish to learn more about the benefits of writing therapy for vulnerable client groups, in different settings and therapeutic contexts, individually, in groups and more. I feel that this burgeoning branch of therapy can only continue to blossom and seed.

 

 

Yesterday evening I watched an hour-long Skype conversation between John Wilson and Philip Cox in the Onlinevents library (a UK based online learning platform). The topic of the conversation was ‘Exploring Unintended Harm in Psychotherapy’ and the discussion raised many interesting talking points, some of which I’d like to discuss in this blog post.

Firstly, Philip presents the following definition of harm, which will also be the definition I will adopt for the purposes of this blog post:  “Harm must be relatively lasting i.e. this definition excludes transient effects, such as in-session anxiety or between session sadness, and must be directly attributable to the quality of the therapeutic experience or intervention”.

With this definition in mind, Philip points to recent research suggesting that the figure for clients who feel they were harmed in therapy is as high as 10%, and that these figures become substantially higher when looking at clients from minority groups and clients who are therapists themselves. I have to confess that I am not surprised by these statistics at all. My feeling is that the more we listen to the experiences of clients, the more we will come to understand the scale of, and reasons behind this high level of harm.

I do not wish to make any assumptions about why minority groups and therapists report greater harm, but I find the fact that ethnic minorities, people with disabilities, and those who identify as LGBTQ+ are reporting higher rates of harm in therapy particularly concerning. Unless we begin to face up to these challenges and address them, I feel we are not fulfilling our ethical responsibilities of non-maleficence and justice as a profession.

Philip made a great point about therapist flexibility as a vehicle for positive therapy experiences and outcomes; as he explored, this is likely to be particularly important when meeting with a client with a different cultural frame of reference. When the therapist sticks rigidly to a paradigm which doesn’t meet the client where they are, they risk alienating the client, and ultimately damaging the relationship. Those statistics leave me with a renewed awareness of the importance of endevouring to understand the client’s frame of reference, and retaining a dialogue with each client about the relationship throughout the process. By having conversations with the client and checking in with their experience of counselling, I would hope that any issues could be caught and resolved more readily, reducing the risk of harm.

Philip highlighted the importance of the therapist’s openness to feedback. I would like to shout this point from the rooftops. My personal experience of therapy has shown me that when a therapist is willing to hear their client’s concerns and accept feedback non-defensively, the relationship can become stronger and more trusting as a result. It sounds obvious, however I think it can be difficult to keep that notion in our consciousness when faced with clients who may challenge us. For me, it is important to remember that I am, as a therapist, in service of the client; whether or not I recognise what the client is feeding back to me, it is my duty to reflect, both upon my actions, and the significance of what is occurring in the relationship in the context of the work. This can be explored in supervision and, where appropriate, brought into the counselling room. Philip described co-creating a relationship strong enough to withstand therapist errors, and I think a non-defensive attitude towards feedback is essential in creating the level of trust required for this kind of work.

John mentioned the idea of having a “fresh pair of eyes” on the relationship, which supervision offers us. Philip rightly pointed out that this objective input serves both the therapist and the client, and when issues occur, the Counselling and Psychotherapy Union can also offer non-judgmental support for therapists. These are undoubtedly excellent resources which benefit all parties, including the therapist’s caseload of other clients, whose counselling could be potentially affected by an unsupported practitioner going through the process of a disciplinary proceeding, for example.

Unsurprisingly, I find myself wanting to borrow the idea of a ‘fresh pair of eyes’ and make a shift of emphasis to what might be happening for a client in a difficult situation. Therapy can be an isolating experience for a client, as well as a practitioner, and as I have mentioned before, clients do not have the benefit of supervision or any objective voice which might be able to point it out if things go awry. How is a client even to know that things aren’t right?

Happily, there are more resources available today than there used to be. As I have previously discussed, the BACP offers a free and confidential advisory service for clients who are concerned about any aspect of their therapy. The international organisation Therapy Exploitation Link Line (TELL) also offers support, resources and advice for those who have been in exploitative or abusive therapy. In addition, online peer support forums and chatrooms exist where clients can check in with others about aspects of their therapy, usually anonymously, and hear different perspectives. I don’t think these resources are to be feared; it seems to me beneficial to the integrity of the profession that we welcome scrutiny and offer transparency.

I am encouraged and impressed by the way Philip has sought to address the problem of unintended harm in therapy. It seems vital that we as practitioners are having these kinds of discussions and looking at ways to reduce those worrying statistics.

So alongside working to avoid causing harm in therapy, for me the next logical step is looking at how we can best support those who have experienced harm. I feel it is important to acknowledge the fear that many clients are likely to experience around returning to therapy and becoming vulnerable again in a therapeutic relationship.

How can we meet these clients’ needs in a new therapeutic relationship? Perhaps more therapy won’t be the way forward for all clients – what do they need? What support do clients need when going through a complaints procedure? Are we doing enough? These are all questions which I feel require much more investigation. I am excited by the good work already happening, and I feel confident that client experiences will inevitably improve as long as we remain curious, and keep these conversations alive within the profession.

Reference:

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.