Thursday 31 May 2012

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

Wednesday 30 May 2012

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