Is Having Therapy an Admission of Weakness?

Some clients have avoided coming to therapy for a long time fearing that to do so would be an admission of weakness. In this week’s blog I challenge this notion.

Perhaps it is a residue left from our cultural history of keeping a stiff upper lip, where any display of emotion was seen as demonstrating a lack of moral fibre. It was almost as if you were supposed to process your emotions on your own. Things have moved on since then.  Psychological health is now viewed as being comfortable finding appropriate expression for our emotions.  Most often, problems occur because there hasn’t been an appropriate outlet for our emotions. This sometimes leads to depression as we cut ourselves off to varying degrees from the vitality of our feelings. We are social beings, needing emotional contact with others for our physical and emotional wellbeing and development.

Brene Brown gives an enjoyable and engaging talk on vulnerability :- https://www.ted.com/talks/brene_brown_on_vulnerability.html

She makes a compelling argument for the importance of daring to be vulnerable as part of our psychological well-being. Thus, therapy provides a safe space in which you can dare to engage with your vulnerabilities.

Another mistaken view of therapy can be that you are giving control of yourself to someone else. Actually, the reverse is true.  I see it as my job to empower my clients to take control of their own lives. I often ask in the very first session, how the client will know when our work is done. So, from the very beginning, I am encouraging the client to be in charge of how they use their time with me and to decide when they are happy to leave.

I truly believe that it is a strength to be able to engage with your vulnerabilities. If that is not happening in your life, then engaging with them in therapy is also a strength.

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

What’s the difference between a counsellor, psychotherapist, therapist, psychologist, psychiatrist?

With so many different titles to choose from, it can be hard to know which type of professional is right for you in the your particular circumstances. This week’s blog gives specifies the different roles of the titles and some ideas about which may be best for you.

Currently, there are no definitions which are agreed upon across the profession that separate counsellors from psychotherapists. However, virtually everyone has their own views as to what the differences might be. I can only offer my personal view here.

Counsellor – someone helping you to address personal issues through listening, support & exploration.

Psychotherapist – as above, but may be more focused on the person’s way of relating to others, themselves and the world in general. They have tended to train for longer and be more open ended in their work with clients looking at underlying patterns of relating.

Therapist – is a generic term covering anyone treating clients. Often used as an umbrella term for both counsellors and psychotherapists. It may also refer to a wide range of complementary therapies which may or may not be relevant to your problems.

Psychologist – someone who studies the mind and behaviour, but may apply their studies in a wide variety of ways with differing specialities e.g. occupational, clinical, educational, child. Psychologists would be used to provide treatment under a private medical insurance plan.

Psychiatrist – They are the only ones to have trained in medicine and therefore are the only ones who are able to prescribe drugs. They tend to work with the more extreme end of the mental health spectrum, although it is standard practice that anyone seeking treatment through their private medical insurance would need an assessment via a psychiatrist.

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

“How Will Just Talking Help?”

I have often heard concerns that therapy cannot help as they are unable to change their circumstances and so feel they cannot be helped. In this week’s blog, I address this concern head-on with various ways in which talking can and has helped many of my clients.

It can be a huge relief to simply tell someone else. Sometimes, in addition, there can be feelings of shame associated with admitting feeling hurt and upset. This may link to a sense of weakness for not being able to deal with your circumstances impassively on your own. Being listened to by someone who is not judging you and who is actively helping you explore your feelings and where you come from can help you develop a more compassionate understanding for yourself.

With more clients than I can count, by talking through their experience of their situation, they changed how they experienced the situation even when the situation didn’t change.  Bereavement counselling cannot bring back the person who was lost, but it very frequently helps you deal with your experience of that loss.

Some clients have had difficult relationships with their parents. They felt hooked by the pattern of relationship which had been present since childhood. They felt trapped in a cycle of resentment and guilt. By talking through these feelings, whilst the parents remained the same, the clients felt greater freedom to love and relate to their parents as they wished.

With trauma, there are safe and relaxing techniques which can allow panic reactions to be uncoupled from their triggering memories.

For some clients the very fact that someone can understand their experience helps them realise that they are understandable, and are therefore, not “losing it”.

Sometimes it is the very reactions themselves that use up all the client’s emotional resources, so they remain unable to process their experience by themselves. Gently unpicking the various threads of these experiences can gradually help the client to fully comprehend what’s happening within themselves and regain control.

There is even neuroscientific evidence to support the efficacy of listening.  Being heard and understood without judgement elicits the production of neuropeptides (oxytocin) in the brain. These chemicals help us feel good - an important evolutionary factor to help us co-operate as social animals.

Just talking can help you too.

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

“That’s Just the Way I Am”

Some people feel that therapy will not be helpful to them as they feel that their patterns in relationship are simply an unchangeable expression of the way they are.  In this week’s blog, I challenge this notion.

Developments in neuroscience have shown that the brain is continuously adapting to the environment, thus we can continue throughout our lives to learn new things.  New learning is embedded in the brain by new connections and new pathways between the brain’s nerve cells. The more attention we give something or the more we repeat an action, the stronger the link is along these pathways.  Similarly, the less attention we give to things the weaker the connection will be over time.

Patterns of relating are nearly always formed in early childhood. Thereafter, the way in which we understand relationships is viewed through the prism of these early patterns. In this way, almost whatever happens tends to reinforce that early pattern.

For example, a child can learn that the world is a dangerous place. Think of parents’ understandable concerns for their children which can become anxiety provoking for a child if overplayed as part of an anxious style of relating “don’t do that”, “be careful”, or even anger (covering their own fears) when the child is trying to develop their own sense of mastery, exploring their environment. Having learnt that pattern without necessarily being aware of it, new experiences are likely to be seen as holding a potential threat, thus reinforcing the brain’s neural pathways that encode that pattern.

Now consider a child for whom exploration was supported. New experiences will be viewed as holding the potential for interesting stimuli. Thus the same new experience will reinforce completely different patterns in the two children.

Now imagine an adult, who has been relating to the world via a pattern of relating of which they remain unaware. This pattern has been reinforced for decades with hardly a second thought. Of course, this individual feels that this is just part of who they are.  It has been going on for the whole of their lives so feel their pattern of relating is unchangeable.

On top of that, they are likely to have chosen (without being aware of it) a partner whose patterns of relating reinforce theirs. They may be similar or complementary. Thus someone who has little confidence in their abilities may choose a partner who wants to take responsibility for both of them. Thus, the partner lacking confidence may feel more comfortable now that someone else is taking responsibility for them, but they are not put in a position to develop their own confidence. Thus their relating patterns are reinforced over and over again.

Like any long established habit. It may take some time to change. Further, their current relationships may expect them to behave in certain ways. It can be threatening to their loved ones when an individual starts to change. In the example above, the partner may feel that his control is being undermined, or simply that he is no longer needed if she starts to develop the confidence to do things for herself.  In such circumstances, the partner, usually unconsciously, may try to undermine her attempts at independence. The spectrum may vary from teasing, to derogatory comments, to expressions of anxiety, to outright anger and threats – all trying to get them to conform to the pattern they expect.

NB. Whilst I have used the terms “she” for the client and “he” for the partner in this example, the roles are just as applicable with male clients and female partners and in same sex relationships.

Perhaps the most extreme example of this kind of pattern is the abusive relationship.  All of the clients I have seen and spoken to involved in this pattern have stated that the emotional abuse is worse than the physical abuse. Whilst it is particularly hard for this client group to break free from their patterns of allowing others to dominate them, with the right support, they may be able to develop the strength to gain confidence in themselves.

Therapy is conducted in 50 minute sessions once a week. The historic pattern tends to be reinforced for the whole of the rest of the week. In the face of this, it can be a long, slow and sometimes painful process to develop new ways of relating.  However, change is possible. I have worked with many clients who have made significant changes through my therapeutic relationship with them.

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Your Concerns?

The intention of this blog is to give people who are considering therapy information about therapy so they may make a more informed decision about whether and how to enter therapy.  The topics I have written about come from my clients who expressed their concerns when considering therapy and what had got in the way for them.  Each individual has their own concerns. So, if there is a topic you would like me to write about in this blog, please feel free to contact me.  If you would rather talk about it, I would happily discuss any concerns you may have about therapy, without obligation.

There are several ways in which you can contact me. You can place a comment on my blog. Or you can contact me via my website: www.garycooktherapy.co.uk

On the website are all the contact details for me or you can email me directly via the website. I look forward to hearing from you.

Client Stories - "Superwoman"

In today’s society, women have taken up the mantle of full time employment, but often without relinquishing much of their traditional, and also full time role in looking after their children and house-keeping. This week’s blog is the story of a type of client with whom I have had many dealings. This is not the story of any one person, but a composite based on many clients with similar issues.

She is used to being the strong one in the relationship, has always worked hard, both at home and in paid employment and has been successful in both.  Other people come to her with their problems and she is happy to take on this role and is good at being there for others. She has good relationships with her partner and family who are supportive. However, over many months, pressure at work has been building progressively and she finds she is struggling to cope.  Despite being desperately tired, her sleep is disrupted with her waking up early and being unable to get back to sleep worrying about work and not feeling rested in the morning.

The final straw came when a colleague had criticised her work.  She burst into tears and withdrew to the toilets. She was not used to crying, let alone in front of others, and even worse, at work, so she went home early, feeling ashamed, confused and overwhelmed.

She contacted me seeking help to “get back to my normal self as this just isn’t me”. In the first session, she told me her story as above and a bit about her background. When talking about the situation at work, she became tearful for which she apologised. When I said that she didn’t need to apologise for expressing her feelings and that it was important for our work together that I heard and acknowledged her feelings, she started to cry but quickly stopped. I wondered with her how she felt about crying. She said that she felt stupid & weak, which she hated. I asked her where she had learnt this, but she didn’t know. I asked her how she would feel if her daughter cried. She recognised that she didn’t think her daughter was stupid or weak when she cried and would comfort her.  I wondered with her about why it was different for her than her daughter. We agreed that we would continue with the sessions in an open ended contract to help her cope with the pressures she faced.

Over the course of several sessions, we explored various aspects of her life in relation to her current situation & feelings.  Having initially talked about how her childhood had been “fine”, as we explored the way the current situation resonated with her past, she began to realise that any tears when she was growing up were “shushed” and she was told not to be so silly.  She had quickly learnt that such expressions of hurt would not be heard or acknowledged in her family, so it was better to “toughen up” and “get on with it” – this isn’t about blaming her parents, but developing a compassionate understanding for her experience as a child. 

Ignoring her difficult emotions had worked well for her until recently when she had become overloaded, so now a new way of dealing with them was needed. She had forgotten that she had needs, having for so long prioritised her family’s needs and those of her employers. She realised that she had not allowed time for herself for ages.

Whilst she understood her need to pay attention to her emotions intellectually, the habit of ignoring them had been learnt unconsciously in childhood and unwittingly reinforced throughout her life. Thus, it took some time for her to start to practice paying attention to, and finding expression for, her emotions in our sessions, through my questions exploring her experience. 

After so long ignoring her needs, she had felt like a passenger in the car of her life, allowing her direction to be chosen by the circumstances of the moment without really being aware of it.  As she began to notice her own wants and needs, she spent progressively more time in the driving seat of her life which enhanced her growing self-confidence. She decided to take some time each week in an activity she had loved earlier in her life but had been phased out whilst focusing on her family.

She discussed her workload with her manager. Whilst the pressure of market forces remained intense, she agreed with her manager a process by which she could feed back to him when her workload was becoming too much.  They could then re-prioritise her workload, identifying what might be delayed or shortcut with the least impact. In the past she had spent time, both in and out of work, worrying about how to manage her workload. The recognition from her manager implied in this process freed her up to be more productive.  Now she was worrying less, her sleep became less disrupted and she felt more rested in the morning. 

She realised that through stress she had become tetchy with the children when they misbehaved. She now felt differently in her relationship with them. She spent more time playing with them and clearly, she and they enjoyed this time together. They behaved more calmly as a result. They still had their moments, but even then she was able to manage their crises without feeling stretched.  Following open discussions with her partner, they decided to regularly spend some time with just the two of them away from the children.  Just the act of deciding together to do this re-established the strength of their relationship and more explicitly expressed loving feelings between them.

Her thoughts now moved towards her future and what she wanted from her career and life in general. She was considering various options including reducing her working hours & specialising in an aspect of her current career. She also started thinking about what they might do once the children had left home.

By this time, she felt she had got what she wanted from the therapy and was ready to leave.  The changes had crept up on her incrementally. So, when reviewing her progress in our work together, as part of the usual work of ending therapy, she found it hard to imagine herself as she had been prior to starting the sessions.  

She recognised that there was potentially yet more we could work with, but felt that what had been achieved was enough for now and would take some time to consolidate these benefits on her own.  She was aware of the warning signs and knew what to do if she started to feel stressed at work. However, she strongly felt that having got back in the driving seat of her life, and with all the supportive mechanisms she had put in place, she was unlikely to let that happen again.

She had valued our relationship, appreciating what she had learnt about herself in the process, and was sad that it was ending. She felt that if she needed to, she would imagine discussing things with me and find her own way forward. 

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Head and Heart

Many clients have a clear understanding of their issues, but find themselves behaving in ways that they know are inappropriate or unhelpful to them and can’t seem to stop themselves. In this week’s blog we will be looking at how therapy can help with this dilemma.

I use a simplified concept of head and heart to represent these two aspects of a person. This does not relate to the physical organs. It is merely a way of helping the client to understand that they hold within them two perspectives which disagree. This is most often a thought process versus one based primarily in the emotions. E.g. “I want to eat more even though I know I've had enough”.

In my experience, the emotions have their own logic – what I term crudely as “heart logic”. This may be more subtle and harder to uncover than “head logic”.  At its core, “heart logic” usually has an underlying message. All emotions may be thought of as messages from ourselves, to ourselves. For example, anger is a prompt to action, hence we get all fired up in readiness for that action.  Fear is a prompt to take defensive action in anticipation of some threat.

Babies need their caregivers, usually their parents, to help them learn how to manage their emotions.  No parent is perfect, so there can be issues for the child in this learning process. For example, anger or sadness, crying or complaining may be seen as “negative emotions”. The implication is that such emotions are not desirable. The child may infer from this that such emotions threaten their relationship with their parents on whom they are dependent for survival. This can make it a matter of life and death. Little wonder they try to swallow their anger, or feel ashamed if they are sad. “There must be something wrong with me”.  All of this typically happens outside of their awareness. In addition, Western society privileges an objective stance, which typically means logical thinking without emotions.  Thus, the emotions may be seen as irrational. 

Once the client has learnt that emotions are irrational, unhelpful, to be suppressed, kept within a particular range (no outbursts), then they are likely to respect their head logic at the expense of their heart. This means that the messages of their emotions are not being received. When they are not received, then those emotions try again and again to find a way to be heard.  It is at this point that the dilemma is born. As an adult, the client is not under the same threat as they were as a child, but now the “heart logic” has been buried in the unconscious, they don’t know that. So when a desire surfaces the client has no idea why it is so powerful.

Helping the client develop a compassionate understanding of the underlying logic of their emotions is an important part of the process of therapy. For example, they may realise that they hold a profound shame about some aspect of themselves that they are unloveable, too sensitive, too much, too needy, spoilt. They yearn to soothe this deep wound by any means. If the values in which they were brought up associated food with caring, then perhaps overeating is the heart’s “logical” response.  The next step is for the client’s compassionate understanding of their heart logic to enable them to work with processing the difficult emotions which prompted its necessity. When the emotional wound is healed through a loving relationship towards themselves, the message of the historically unacknowledged emotion is finally delivered. That emotion is satisfied and can now withdraw. Thus, the heart logic becomes redundant, resolving the dilemma.

This sounds all very straightforward. However, it can take time in establishing the therapeutic relationship to such a depth that a lifetime of unconscious and subtle defences dare to relax. Then they can start experimenting with expressing their most vulnerable parts of themselves. In becoming open to their whole being (head and heart) they can become more fully engaged with others.

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Bottling up Feelings

Many clients experience difficulties managing their feelings. Frequently they have learnt to bottle up their feelings as a way of dealing with them, then find themselves struggling to cope when faced with the mounting pressures of living.  When they first come for therapy they may or may not be aware that this is what they are doing.  This week’s blog explores how we learn to bottle up our feelings and how therapy can help.

As babies we don’t know how to manage our feelings.  We are dependent on our caregivers, usually our parents, over the course of our upbringing to help us:-

1.  Identify each of our emotions
2. Learn to express our emotions appropriately
3. Learn that we are still loveable and acceptable when we express our full range of emotions.

Parents are not perfect.  This leaves many clients remaining stuck with some aspects of this learning. There are many ways in which such problems may manifest.  Bottling up emotions is just one of these.  

If parents are uncomfortable with their emotions in some way, it can be very difficult for them to remain relaxed when their child is expressing forcefully some very intense emotions. Most often, it is anger that is seen as a “negative” emotion, although in some clients it is joy that has been inhibited. Thus it may be discouraged, consciously or otherwise.  The child then learns it is not safe to express that emotion which is when the strategy of bottling feelings appears to be protective and useful. 

Over the years, more and more of these angry feelings remain unexpressed with nowhere to be heard and understood.  Sooner or later, such feelings either leak out, or perhaps the individual learns that they are powerless to express themselves successfully.  These are the seeds of depression.  Such individuals sometimes “self-medicate” using alcohol as a means of managing their emotions which only adds to their problems in the long run.

Therapy offers a safe environment in which a relationship based on trust can aid the client to find more appropriate ways of managing their emotions.  Together, the client and their therapist, can explore how they learnt to bottle up their feelings. Through this, the client can develop a more compassionate understanding of themselves. In the safety of the therapeutic relationship, the client can begin to dare to express their full range of emotions, and experience the sense of release and their own power in doing so, knowing that the therapist accepts them as they are.

They learn that these feelings, far from being toxic, are there for their benefit, empowering them to express themselves and potentially move towards outcomes they desire. The final step in the process is when they can apply this to their relationships outside the therapy.  When the client can do this for themselves, they are usually ready to leave therapy.

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Breaks

Sooner or later in all but the shortest therapy, there will come a time when either you or the therapist will be unable to attend the weekly session due to holidays or illness.  The feelings that accompany the break can be very informative. This week’s blog looks at the sorts of feelings that may be elicited and why therapists are likely to ask you about them.

The most beneficial element in therapy is the relationship between the client and the therapist. Often, feelings experienced by the client before, during and after a break, can give a useful window on the nature of that relationship from the client’s perspective.  These feelings can express the pattern of relating that the client learnt in their formative years.  This pattern is most often not held consciously, “that’s just how it is” can be the client’s response if you only scratch the surface around this topic.

For clients who have learnt to be anxious about their relationships, a break can feel like a threat, particularly where it is the therapist who is not available for a session.  Some such clients may try to sustain contact over the break by emails or texts.  Others may subconsciously “punish” the therapist by not attending the session after the break or by turning up late.  It may also show up in the nature of the material spoken of in the sessions.  Underlying themes of abandonment and loss may emerge here even where it is not about the therapist.

For clients who have learnt to protect themselves from the vulnerability associated with relationships, a break can merely reinforce what they anticipated anyway.  Subconsciously, there can be a sense that “I knew they couldn’t be trusted”.   For some, this feeling is so strong that they may not return to therapy after the break, sometimes without any contact.

For these reasons, I find it important to explore with the client what their feelings are around breaks.  I would try to give at least 3 weeks notice of any holiday that I am to have and request the client to give me as much notice as possible before their holidays. This way, we have a chance to explore these potentially sensitive issues, so the client has the chance to gain a conscious awareness of how their patterns may be impacting their experiences of breaks.

Thus, if they find they are feeling hurt prior to a break, they can begin to recognise their pattern of relating which is the first step towards taking conscious control and beginning, through the trust developed in the therapeutic relationship, to learn new patterns of relating.  In the new pattern, they can begin to trust that they are loveable, are not about to be rejected, and can bear a gap in the support from loved ones without anxiety or hurt.

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Time

Time has a significance within therapy which may not be apparent to you if you have not had therapy before. So, in this week’s blog we will be exploring some aspects of time which are particularly relevant to therapy.

Often, therapists in private practice see clients in their own home and therefore do not have the luxury of a receptionist & waiting room to accommodate them if they are early.  Even practice clinics or agencies may not have such facilities although they are much more common.  Thus, you will be asked to wait until the agreed time before knocking on the door for your session.  Imagine how you would feel if at the end of your session, which may or may not have been very emotional, to have to walk past a stranger as you leave. I normally allow 10 minutes between sessions which gives time for one client to leave well before the next client is due to arrive.

If you are late, then the session still ends at the agreed time, 50 minutes after the scheduled start time.  It avoids one client having to meet the next client as mentioned above.  More importantly, it is one of the many ways in which therapists demonstrate their reliability in providing support for the client.  By repeatedly being on time for the start and the end of each session, over many sessions the client can feel at a gut level that here is a pattern of support on which they may rely, even when the client themselves may be irregular in the timings of their attendance.  For clients whose formative experiences when young were of care-givers who were unreliable in their responsiveness this can be an important aspect of the support offered.

It is often enlightening to explore with a client what happened and how they felt about being late. It can often be a window onto how they manage their world and their expectations of it. This is especially true if there is more than one non-attendance and/or lateness. Do they view therapy as an indulgence, therefore not to be prioritised in the face of regular traffic problems? Do they not prioritise themselves and therefore the therapy? Are they trying to impress upon you just how busy they are? The list of possible reasons is endless. What is important, is to try to understand what is going on for the client when this happens. This is all part of the work of therapy.

Sometimes, clients will be full of things to say during the session, and only in the last few minutes engage more fully with their emotions.  There may be many reasons for this.  Often, it is an unconscious strategy to avoid having to stay with difficult emotions for long. Once they recognise this pattern they soon get frustrated as they realise they are getting in the way of helping themselves move forward.  Some clients can feel hurt by the seeming coldness of the therapist in ending a session whilst the client is in the middle of some intense feelings. Different therapists work with this in different ways. Personally, I monitor the intensity of the client’s feelings in the last few minutes of the session, offering them a choice as to whether they wish to go that deep so close to the end of the session. Even so, at times the client may be profoundly emotional in the last minutes, in which case I would allow the client a minute or so to compose themselves before facing the outside world.

Clients can think of things to say just as the session is ending. At that point, there is no possibility of exploring what the meaning is for the client of this story.  Thus, it may be better to ask the client to bring it next time if they wish.  It would be particularly important to address this, if it were a pattern. What is the meaning of the pattern?  To avoid the ending?  To avoid having to stay with difficult emotions that might be evoked by the story? All useful information about how the client relates to their world.

Through all of these issues around time, the client can experience the therapist’s questions around it as criticism for being early, late or whatever. However, the work of therapy is always to try to understand what meanings these events and patterns might have for the client and how they experience, & relate to, the world.  It is an exploration not a judgement.

If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Confidentiality

For therapy to be effective, the client needs to feel free to talk about their issues.  These issues often arise because of the sense of shame which prevents the client from talking them through with others. Thus the client needs to know that whatever is disclosed in therapy remains confidential.  For this very reason therapists are rightly very protective of their clients’ confidentiality. There are however a few exceptions to this rule. This week’s blog explores the limits of our confidentiality.

Supervision:– The therapist will identify the client by a first name only, and give enough detail about the client’s life to help the supervisor understand the background to the process unfolding between the therapist & the client. The supervisor is also bound by their professional code of ethics to maintain confidentiality.  See the earlier blog entry on Supervision for more details.

Risk:- If I have concerns about the safety of the client or of those around them, I may, if the circumstances are appropriate breach confidentiality by expressing my concerns with the client’s GP. This is a last resort and even then, the only information disclosed would be the minimum sufficient to advise the GP of the nature & degree of risk involved, so they are best placed to manage that risk.  If at all possible, I would encourage the client to seek help directly themselves to manage their risk, e.g. take themselves to the Accident and Emergency Department of their local hospital, contact their local GP or out of hours service.  If I felt that the client was unable, unwilling or unlikely to do this, then I would seek their permission to contact their GP on their behalf.  If that permission were denied and I was seriously concerned for their immediate safety I would then contact their GP. This is never undertaken lightly and in practice is quite rare. See the earlier blog entry on Managing Risk for more details.

Legal Requirements:- There are a number of laws which may require the therapist to breach confidentiality. This may be around disclosures of impending terrorist activity or of an ongoing child protection issue. My first reaction would be to encourage the individual to report the matter to the appropriate authorities e.g. the police or social services. Only if they were unwilling to do so would I seek their permission to disclose the information on their behalf, and failing that advise them that I will be breaching confidentiality in the interests of safety. It is also possible (albeit extremely remote) that a therapist’s client notes will be subject to a subpoena from the courts. For this reason, client notes are usually limited to recording brief details of what the client disclosed and no conjecture about the client by the therapist.

In summary, breaches of confidentiality are rare and in the best interests of the client. Therapists are highly protective of their clients' confidentiality as it is the basis of trust in the relationship.


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Managing Risk

It can feel daunting to open up to a stranger especially when there are issues around the safety of the client which may require the therapist to breach confidentiality. In this week’s blog I want to explore how risk is managed in therapy. As with almost any aspect of therapy, this will vary between individual therapists. I can only speak for myself in how I manage risk, although some features of what I will be explaining will be common to most therapists.

In the initial session, I ask the client whether they have had any thoughts of suicide or self-harm. If so, I would then ask further questions to ascertain the degree of risk that they represent to themselves. A great many people have suicidal thoughts at some point in their lives. This does not, of itself, mean that emergency procedures need to be carried out. However, if they state that they have an immediate intention to self-harm then I would feel an ethical duty to take that seriously. If they felt unwilling or unable to contact their GP or get themselves to their local Accident & Emergency Department, then I would seek their permission for me to contact their GP on their behalf. If the individual declined that permission but were expressing serious intent to self-harm then I would inform them that I would be contacting their GP anyway. In any case, I would want to stay with the individual’s feelings of hurt, despair & anger so they may feel heard, understood, valued & connected. Sometimes, the experience of having someone stay engaged with them despite what feels to them as overwhelming, can of itself offer some sense that their feelings are containable, and through that, gain some sense that a future can be bearable. 

It is important that the individual feels heard. Subsequently, the risk questions can be raised & if necessary, ways of managing extreme risks can then be established.

If the individual is expressing anger towards others, then the limits of this need to be elicited. In the extreme situation of the client stating a clear intention to harm another, then there is an ethical duty on the part of the therapist to manage this risk to the other person. As a last resort this may involve breaching confidentiality to the police. This is very rare.

Also in the initial session, I check out with the individual their pattern of intake of alcohol & non-prescribed drugs, e.g. drugs used for recreation. Where there is heavy use, this may or may not suggest that the individual is using these substances as a means of managing difficult feelings. Given that therapy is often about helping clients find a way of healthily managing difficult feelings, the use of substances may prevent the client from facing the full intensity of their experience. Thus, it is important for the client to be aware that they need to be free from the effects of these substances (sober) when attending the sessions. Any client attending a session under the influence of a non-prescribed substance would be asked to leave & to return at a subsequently agreed date/time when they are sober. 

It would be a matter of some concern to me if the individual felt little motivation to address their heavy use of alcohol or drugs. Whilst I would normally encourage the client to be leading the direction of their therapy, in such circumstances, I would draw their focus back to their substance use wherever possible, trying to help them develop a compassionate understanding for such self-abusive behaviour. This is a delicate balance to maintain. On the one hand it would be easy to collude with their avoidance of the issue & on the other it would be easy to add to their sense of shame. By providing a non-judgemental relationship which keeps a caring focus on the issue being played out by the use of these substances, the individual may develop a stronger sense of self that is therefore more able to face issues without the need to “self-medicate”.


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Supervision

You may have seen the term "supervision" on therapist's websites but maybe don't know what this means. In this week's blog I give a simple overview of this topic.

Why? - It is a matter of good practice and a requirement of professional bodies like BACP & UKCP that all therapists should be in ongoing supervision. The object of supervision is to ensure that the therapist is offering the best treatment possible to their clients. 

What? - Supervision is a regular meeting between a therapist and their supervisor to discuss the therapist’s work with their clients and ongoing professional development. The therapist will explore with the supervisor their understanding of the process which is unfolding in the therapy. The supervisor may offer alternative ways of viewing the process to help the therapist best support the client. It should be noted that the discussion of clients does not involve a judgement of the client. The focus is on the process between the therapist & the client and how this might best be facilitated for the benefit of the client.

Who? The supervisor is a qualified practitioner & so is also bound by a code of ethics which ensures the client’s confidentiality is paramount. 


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

What Will Be Expected Of Me As A Client?

I have written an earlier entry on what you can expect as a client of the therapist when you set up an initial appointment. In this week’s blog entry I want to help you understand what might be expected of you at a therapy session.

If you arranged to see the therapist at an agreed date & time, then you will be expected to show up as agreed. You may need to check beforehand whether the therapist has a waiting room. If not, then it is important you do not knock on the door before the appointment time as they may be still with another client. Think of how you would feel if someone knocked on the door during your session or was standing there at the door as you were leaving your session. 

If you are unable to attend or know that you are going to be late, then as a matter of courtesy, it is important to advise the therapist with as much notice as possible. This could save you money on paying for a missed session as therapists charge for missed sessions, but may waive that if they have had sufficient notice. It depends on the therapist: for some it may be 24 hours, others 1 week, others would charge anyway.

Once you are through the door, then the expectations of you are very few. Obviously violence and abuse would be unacceptable, but this is extremely rare in my experience. However you present, and whatever you do say or don’t say, this will always be grist to the mill. You can’t get it wrong or be a “bad client”. If you talk about things that are inconsequential to your issues, I would wonder about that with you. Why? This may prove to be a fruitful exploration of your pattern of relating.

If you sit in silence, that is ok. Silences can vary, from a safe space enabling an internal exploration to, at the other extreme, one of escalating anxiety. If I thought it were in the latter part of the spectrum, I would check out with you if you are ok. If you are ok, then I would honour the silence. If not, then I might ask what is going on for you so you know that you don’t have to face the silence alone, and what that might mean for you.

This is my way of working. Other therapists may choose to leave any silence unbroken. This is not wrong, or right, it is just a different way of working.

If you don’t know what to say, that’s ok too. In the first few sessions it can be difficult to know how to start, where to start, how to convey a complex situation which may span many years. Clients sometimes ask me to help them by asking them questions. Whilst I might offer hints to start with, such clients usually develop confidence in their ability to find a way to express themselves without prompting from me. 

It is common for clients to want to know more about their therapist. It can feel strange to share your deepest feelings of vulnerability, shame & intimacy with someone about whom you know very little, creating a pull to know more about them. It is not wrong to ask whatever question interests you, however, the therapist is unlikely to disclose much to you as this is unlikely to be in your interests. This can feel excruciatingly frustrating, almost a blight on the relationship which is central to the work. However, knowing where your therapist went on holiday, what they feel about some topical matter, is unlikely to be of use in your therapy. It would be more beneficial to explore with them why you want to know, what it feels like when the therapist doesn’t disclose this information. Disclosure is a topic of some debate between therapists working in different ways.

Thus, any behaviour is useful & interesting, as it expresses something about how you relate with others which is core to the work of exploring your experience of living.

I am giving you permission (just in case you feel you need it) to be whoever, however, and say whatever you want to and know that I will meet you with my acceptance, understanding, warmth & engagement.


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Dealing with Conflict in Therapy

If you are considering therapy but wary of entering into a relationship because you don’t know what’s involved, this blog is aimed at trying to help you get some sense of what therapy is to reduce your concerns. There can be a fear that the therapist holds all the power in the relationship, leaving you feeling vulnerable, especially in the face of conflict. This week’s entry focuses on how you might deal with a conflict if that were to arise.

First, it is important to acknowledge that you are not powerless in this relationship. You may feel vulnerable, but ultimately it is your decision as to whether you continue with your sessions. There are plenty of other therapists so if you don’t feel happy with your therapist you don’t have to stay.

That said, it is usually more in your interests to try to resolve the conflict as a first port of call. I have certainly spoken to clients who did not feel they were getting what they wanted from their therapy or had some issue. I told each of them to at least try and resolve the matter through discussion with their therapist. In many cases, this resolved the issue to the clients’ satisfaction. Further, for some clients the resolution of the conflict proved to be therapeutic of itself, allowing the client to gain some felt sense of their own power, to feel heard, respected, and strong enough to deal with conflict.

Patterns of relationship formed in childhood are usually invoked during therapy. Conflicts from the past can subtly be re-enacted with the therapist. That offers the opportunity for reparation not just of that conflict but of that whole pattern of relating regarding conflict. Thus, hanging in there during a conflict with your therapist can be extremely fruitful. But how do you know if this very familiar pattern is being worked on, or whether, less helpfully it is merely being replayed? Ask yourself these questions :- Is the process of the conflict the focus of our work or is it being ignored? Are you talking about what its like being in conflict or is the conflict and its impact on you being minimised by the therapist? If you feel it is being ignored or minimised, have you told the therapist how you feel? If you still feel ignored or minimised then perhaps it is time to consider your alternatives.

There is no training course for therapists that includes Mind Reading. We may develop a skill at reading subtle signs of emotions. We may even develop a hunch for why clients behave the way they do, but these can only be generalities. The therapist cannot know the client’s unique and individual experience. For that we need the client to tell us. TV representations of experts who “know” just by looking at someone what their past has been or what they are experiencing, whilst enticing are unhelpful as they raise unrealistic expectations of therapy. It can be a seductive idea that a therapist will just know your unique experience of the world without having to be told. It’s a small step from there to hoping that they will apply a similar magic to “fix” you. No effort. No pain. Just a quick fix.

There is no magic in therapy. It’s a relationship which requires the full participation of both parties. There are no short cuts. Further, I don’t believe that the clients who come to me are broken so “fixing” them is not appropriate. I have yet to meet a client whose experience didn’t make perfect sense once we had understood the full complexity of their lives. Thus their anxiety, distress, depression, anger or whatever feelings they have don’t need fixing, but compassionate understanding so the individual can find their own way forward.

Therapists are not perfect. We are fallible human beings like anyone else. This can lead to conflict. As mentioned above, that can be an opportunity to develop the therapeutic relationship further.

If you feel that the therapist has acted inappropriately, not just an error, but in a way that is unethical, then you may consider raising a complaint with the professional body with whom the therapist is registered e.g. BACP, UKCP, BPS. This is one reason that it is important that you check that your therapist is registered with a professional body. It may be reassuring to note that only a small percentage of clients raise complaints in any year. 

I do appreciate that having dared to share your vulnerabilities with someone it can be daunting to consider having to go through it all again with someone new. However, even this can be an investment in your wellbeing. 


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Ending

In this week’s blog entry I want to discuss the ending of therapy. A good ending to the therapy can facilitate many benefits for the client. Sometimes, clients may feel significantly better than when they first started and decide to leave straight away, feeling that the work is done. In most cases, it would be useful for them to work through an ending even if that is for only one session. Where the therapy has been going on for a number of months or years, more sessions may be useful to work through the ending fully. 

The duration of the ending is something that would be negotiated with the client, e.g. a final review session agreed at the beginning of treatment, or when the client in an open-ended contract starts to consider ending our work together, we would at that point agree how many sessions might be required. Ultimately, as the client, it is up to you when you leave. If you are leaving abruptly, i.e. without the chance of working through the ending, then this may suggest some conflict with the therapist. Next week’s blog will explore ways of dealing with such conflicts.

A properly worked through ending helps consolidate the gains made in therapy by putting the whole process of therapy into perspective – what benefits have been gained, what has yet to be achieved, what was helpful and what was not, what will it be like for the client not to be coming to see the therapist. 

It can also enhance the client’s resilience to issues in the future by:-
- being more aware of the early warning signs of issues, 
- developing support networks so they are better able to maintain their well-being preventing potential future difficulties
- developing good practice in psychological wellbeing maintenance via:-
--- regular exercise
--- a healthy diet
--- improved ongoing self-awareness
--- improved self-soothing: yoga, meditation, relaxation & breathing techniques
--- clearer focus on the client’s own priorities
--- better able to maintain their work/life balance.

Subtle forces may be in play during an ending, whereby the client does not want to acknowledge the importance that their relationship with the therapist has acquired. This may lead the client to request going down to fortnightly or monthly sessions, or a review session at some point in the future. Sometimes this is a denial of the ending, (often unconscious), by fading away, getting used to less frequent sessions. It is much more likely to be helpful to the client to take some time to work through the ending maintaining weekly sessions, facing it explicitly as this can stimulate some fruitful work. An ending can resonate with other endings in the client’s life or with difficult relationship patterns. By being able to work through the ending consciously, directly, a different experience of ending and thus of relationship can be realised.

Clients may feel re-assured by the knowledge that they will be welcome back for whatever reason should they so decide.

The benefits of therapy don’t stop just because the therapy has stopped. Research indicates that many clients continue on their path of increased self-awareness & improved sense of well-being beyond the end of therapy. Therapy may be a platform from which the client develops more fully afterwards.


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

What will Happen in Therapy?

If you have not had therapy before, it can be quite daunting to put yourself in front of a stranger just at the time when you feel most vulnerable, often with an issue about which you feel ashamed. Not knowing what to expect when you do go for therapy can add to these concerns. This week’s blog entry is designed to allay some of those understandable concerns by letting you know what will and will not happen.

What will NOT happen in therapy

Ignore all comic representations of therapy, even many drama based representations of therapy.

I will NOT:- 
- shout at you/belittle you (Local Hero, Anger Management), 
- have sex with you (Prince of Tides). 
- enter into a social relationship with you, 
- tell you what you should do or how to live your life, 
- judge you, 
- ignore you, 
- tell you my problems (various TV comedies), 
- try to change your sexual preferences (a small number of therapists recently believed 
this to be acceptable, however the vast majority of the profession are against it and 
sanctions are now in place to prevent such behaviour), 
- try to change your religious/secular/philosophical/political beliefs.

NB. The BACP Framework for Good Practice provides a code of ethics by which our work is evaluated. Breaches of this practice which are not resolvable directly with your therapist can be addressed by raising a complaint with the BACP (provided the therapist is a member of the BACP). Before starting therapy, find out with which body the therapist is registered. Under proposed legislation soon to be implemented there will be registers (“Assured Voluntary Registers”) for any practising therapist to ensure all are operating within an agreed code of ethics. It is reassuring to note that not many complaints are made each year and most clients find therapy beneficial.

Each client will have their own individual way of presenting, influenced by their normal patterns of relating, the current circumstances & how the therapist is with the client. Thus, it is not possible to exactly say how things will be. Some clients need space to be witnessed, unjudged, & calmly contained in their silence, others may feel the need to offload the pressure of things they want to talk about & feel heard. There is no prescriptive right or wrong way of being for the client in therapy. However you present, you will be saying (not necessarily verbally) something about yourself and that is what we will be working with.

What will happen in therapy?

In the way that I personally practice, the initial session is different from all later sessions. I usually offer to start by outlining my service (weekly, 50-minute, individual sessions), how I handle holidays & illnesses, the limits of confidentiality, agreements on payment. This normally takes around 5 minutes. 

I then offer the space up for the individual to tell me a bit about why they are here? I may ask several questions to try to understand how the issues they bring sit within the bigger picture of their life as a whole. I may ask questions about the degree of risk that the individual represents to themselves or others e.g. self-harming/suicidal thoughts or behaviour, drug & alcohol use, any psychiatric history. I usually try to give the individual some sense of what it will be like to be in therapy with me. Thus, I will endeavour to offer a reflection on my experience of being with the individual (how I resonate as a “tuning fork”). 

In the last 5 minutes, I would invite the individual to tell me how the session has gone for them, whether they wish to continue our sessions, on what basis (open ended, short term), and if so to agree a set time and day of the week for our sessions. I usually ask, “How will you know when you are ready to end our sessions”? For differing individuals this may be easy or difficult to answer and may change over time, but nevertheless it is an important question to keep in mind, so we can hold some focus for the work. 

If the nature of the issue is one for which I feel would be better addressed by a specialist agency I would try to provide the appropriate contact details, e.g. issues around adoption legally require specific training and qualifications, similarly children under 16 require specialist support.

Subsequent sessions are not structured by me. Having welcomed you to the session, I leave it for the individual to express themselves in whatever way they wish and I will work with that. Some individuals find this a challenge and so I would support them through that challenge encouraging them over time to trust themselves. This in itself would be part of our work. Whilst I will ask questions in subsequent sessions, these will be very much to aid in the exploration of whatever the individual brings rather than me directing the individual.


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Giving Advice

In this week’s blog I want to explore my views on counselling and where it stands in relation to giving advice.

It is curious to note that the telephone directories categorise therapy under either “psychotherapy” or “counselling and advice”. This reinforces the notion that counselling is in some way about giving advice. Whilst some counsellors in some situations may give advice, this is not the essence of what counselling is about. Many clients are actively seeking advice. This may or may not be appropriate.

Some of the more clear cut cases for giving advice are where the client simply lacks the information needed, e.g. what resources of support may be available for care of the elderly, people with mental health issues or disabilities; information around child protection issues. If I do choose to give advice, I would hope to offer it tentatively as a suggestion that the client may or may not choose to take up.

Some of the more clear cut cases for not giving advice are where the client is struggling with the process of decision making, e.g. should I stay with my partner/job?, how do I stop feeling like this?

The problem with giving advice is that it is merely one person’s view of what to do and not the client’s view. It is not absolute truth. Therapists are trained to listen, engage with and help clients explore their experience of their world. Therapists are not all-knowing sages who know what is right for you. The danger of the therapist giving advice is that then takes away from the client, their chance to figure it out for themselves (with the therapists help through exploration), and that way empower themselves. Giving advice can deny the client the opportunity of learning to trust themselves in making decisions.

Edward DeBono, the great proponent of lateral thinking, outlined various stages for the process of decision making, including:-
- information gathering; 
- exploring all the possible, even seemingly irrational solutions; 
- evaluating all solutions; 
- choosing one; 
- taking action to implement that solution. 

Clients may have issues around any of these stages. I have never had a client who lacked the cognitive ability to perform these tasks. Usually, issues occur around the emotional aspects of these tasks:-
- “As soon as I am faced with a decision, I just can’t think”, 
- “I don’t know how I feel about these options”, 
- “What if I get it wrong”, 
- “I just want someone to reassure me that my decision is ok”.

There are lots of ways of working with these issues, but all are based in developing a trusting relationship with the therapist, so the client can dare to challenge themselves to try out something different in a safe environment.

Different therapists work in different ways. These lead to differing views on advice giving. I do not seek to make this a statement of what is right for everybody. Even where I have stated that something is clear cut – an experienced therapist may choose to give advice in a particular instance with a particular client as there may be other, more pressing, processes which call for it. 

If I gave advice to a client it might suggest that I don’t trust the client to be able to figure it out for themselves. That would tend to say more about my anxiety than the client’s, which is usually (but not always) enough to stop me giving advice. 

Thus, when a client is having difficulty in decision making, I would tend to explore the pros & cons of the options they perceive as available around the current situation. Ask them to evaluate how strong they feel about each of the pros & cons (e.g. score out of 10),compare scores and then come to a conclusion. Where I feel the options presented appear only to show the extremes, I may offer a middle-road option for them to evaluate. If I notice an emotional block in this process, I would then explore with the client what underlies that block. 

For example, if the decision making process is blocked by “What if I get it wrong?” we may find an underlying fear of failure & under that may be a fear from childhood (especially where the fear of failure has been lifelong). Along with the increasing awareness of their emotional blocks, we can propose an alternative process e.g. imagining a parent wishing them well. More subtly, the nurturing relationship I develop with the client helps them see themselves in a more positive, more powerful light, without the client necessarily being aware that this is going on.

This is merely one way of working with one kind of issue (which many clients have) but each client is unique and so I respond like a tuning fork, resonating with the way in which each client presents to me.


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk

Choosing a Private Therapist

This blog is designed to help people who are considering having therapy of some kind but are not sure how to do that, or whether therapy is right for them at this time. 


In this first entry I want to help those who have decided they want private therapy but don't know who to ask:-

1. Go to the BACP (British Association for Counselling & Psychotherapy) website: www.bacp.co.uk
2. Click on the "Seeking a Therapist" button on the right hand side of the home page.
3. Enter your postcode in the box where prompted. There are other search criteria you can enter if you are clear about what you want, but if you don't then its fine to leave them blank.
4. Click on the "Search Now" button at the bottom. This should display a list of therapists in your area starting with those nearest to you.
5. Select the ones you are interested in, say, between 3 & 5 options, by clicking on the box next to each entry. If you are not sure, just choose those nearest to you. As a form of "kite mark" I would recommend you choose only therapists who have listed next to their Profile: BACP accredited and/or UKCP registered as they are the 2 foremost organisations for the profession.
6. When you have selected those you are interested in, click on the "View Selected Profiles" button at the top or bottom of the page. This will give you the contact details for the therapists you have selected. 
7. Make a note of their telephone numbers. Some people prefer to contact the therapist by email and the option is there for you to click a button and do that directly if you wish. 
8. I recommend that you talk to each of the therapists you have selected on the phone as that will give you important information to help you choose YOUR preferred therapist. Feel free to ask them questions about the therapy they offer, what experience they have of dealing with your kind of issue, ease of parking etc. Let them know that you are shopping around at this stage before making up your mind. You are under no commitment to attend or pay at this stage.
9. Trust your gut feelings as to whom you would feel most comfortable opening up to about the most difficult feelings you have. If your gut feel is that none of the options are right for you, extend your search to take in more options. If you remain undecided, consider having an initial session with more than one therapist - do let them know that is what you are doing. It can be difficult to decide from several possible options even after speaking to them. In that case, I would recommend you choose the most convenient one for you as they are both likely to be able to be of use to you.
10. Contact your preferred therapist to arrange your sessions.

Sometimes, it can feel too daunting to pick up the phone and talk to a stranger. Remember, if they answer in a manner which is not to your liking for whatever reason, you are perfectly free to choose another therapist. 


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk