Therapy Today

Therapy Today November 2010, Vol. 21 Issue 9
Therapy
Today
For counselling
and psychotherapy
professionals
November 2010
Vol. 21 / Issue 9
www.therapytoday.net
Towards a new pluralism
Hope: the neglected common factor
Prison reform: working therapeutically with offenders

November
2010
Volume 21
Issue 9
Therapy Today is published by the
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Contents
Sarah Browne
Editor
For several years now I have been of the view
that when it comes to creating psychological
change or emotional wellbeing, some things
work for some people some of the time: this
could be psychoanalysis, group therapy, a
self-help website or a walk in the countryside.
Arguing over which single therapy is the most
effective in general seems ridiculous and futile.
This is the gist of what Mick Cooper and
John McLeod are saying in their new book
on the pluralistic approach to counselling
and psychotherapy. As they describe in their
article in this issue, ‘CBT can be helpful, and
person-centred therapy can be helpful, and
psychodynamic therapy can be helpful’ – a
both/and as opposed to an either/or approach.
One crucial distinction between the
pluralistic approach and the integrative or
eclectic approach seems to be that the former
is much more client centred, ie the decision
as to what will best help the client will emerge
from consultation with that client. Cooper and
McLeod also distinguish between pluralistic
practice and a pluralistic perspective and
suggest that we can hold a pluralistic
perspective whilst still practising a single
or specialised orientation. Here the pluralist
approach again differs from the integrative
in not considering multi-orientation ways
of working as necessarily superior to singleorientation
approaches.
I was intrigued by Denis O’Hara’s
exploration of hope in therapy, which seems
particularly poignant in our present economic
climate. We know that it is one of the four
common factors across approaches which
contribute to therapeutic change, but of all
these factors, hope is the least researched
and the least understood. What is the nature
of hope and how do therapists help clients
rediscover it? O’Hara argues for practitioners
to make hope a focus of discussion and
research, and even a topic in its own right
in counselling training.
Features
Regulars
BACP
10 Pluralism: towards a new paradigm
for therapy
Is it time to move beyond schoolism?
How a pluralistic approach could provide
therapists with a greater appreciation of
all potentialities.
16 Hope – the neglected common factor
An essential ingredient in therapeutic
change, hope nevertheless figures least
prominently amongst the four common
factors in research and training.
3 Editorial
4 News
7 Columns
Kevin Chandler
Orla Murray
Alex Erskine
15 Questionnaire
Jeremy Clarke
28 Day in the life
Jacqueline Ullmann
41 BACP news
42 Professional standards
44 Research
46 Professional conduct
20 Becoming a counsellor
How does professional training ‘change’
trainee therapists? The results of a study.
24 A therapeutic prison service?
The Government’s changing stance
towards the rehabilitation of offenders.
26 The frame is the therapy
Boundaries and our internalised sense of
the counselling and psychotherapy frame.
Cover illustration by Geoff Grandfield
31 Dilemmas
The counselling-coaching interface
34 Letters
37 Reviews
49 Noticeboard
52 Classified
52 Mini ads
54 Recruitment
56 CPD
November 2010/www.therapytoday.net/Therapy Today 3

News
Parents’ drinking
is damaging
millions of children
Parents’ drinking puts around 2.6m children at serious risk of neglect
Heavy drinking by parents
is doing so much damage
to children that a national
inquiry into the scale of the
problem is needed, according
to a new report from the
Children’s Society and
Alcohol Concern. Around
2.6m children in the UK
live in a household where at
least one parent’s drinking
puts them at serious risk
of neglect. More than 100
children, some aged just five,
call Childline every week with
concerns about a parent’s
alcohol or drug abuse.
‘It’s shocking that, in spite
of the worrying numbers of
children affected by parents’
heavy drinking and domestic
abuse, so little is being done
to address this,’ said Don
Shenker, Alcohol Concern’s
chief executive. ‘The whole
system sweeps the problem
under the carpet.’
Shenker said because
of the secrecy and stigma
involved, millions of
children are simply left to
do their best in incredibly
difficult circumstances: ‘A
government inquiry must
look at all aspects of parental
alcohol misuse so that we can
improve outcomes for these
children.’
Anne Milton, the public
health minister, said the study
‘paints a shocking picture,
which is why we must identify
early on children and families
that need support’. Bob
Reitemeier, chief executive
of the Children’s Society,
said: ‘We are calling on the
Government to make sure
that everyone who needs
either training or education
to deal with parental
substance abuse is given
the appropriate assistance.’
The Guardian
One in five still waiting
over a year to access
psychological therapies
US study suggests repeated
viewing of violent images
‘boosts teenage aggression’
© iStockphoto/thinkstock
A new report released by
Mind for the ‘We need to
talk’ coalition (of which
BACP is a member) has
called on the Government
to fulfil its promise to make
psychological therapies
available across the country
to people who need them.
The report found that
the Improving Access to
Psychological Therapies
(IAPT) scheme has had
a dramatic impact on
waiting times for people
with depression and
anxiety. However, across
England one in five people
are still waiting over a year
to access psychological
therapies such as CBT
or counselling. Access
to psychological therapies
for children and for people
with severe mental illnesses
remains limited despite
good evidence of its
effectiveness.
Mind’s research found
that one in five people
are waiting over one year
between asking for help
and receiving treatment,
one in 10 people have to
wait over two years, and
68 per cent of people are
not offered any choice of
therapy. The Government
has made a commitment
to choice in its health
White Paper, and a promise
to improve access to
talking therapies.
Mind
Repeated viewing of violent
scenes in films, television
or video games could make
teenagers behave more
aggressively, US research
suggests. The National
Institutes of Health study
of 22 boys aged 14 to 17
found that showing dozens
of violent clips appeared
to blunt brain responses.
The US study, published
in the journal Social Cognitive
& Affective Neuroscience,
involved 60 violent scenes
from videos mostly involving
street brawling and fist
fights. The violence was
ranked ‘low’, ‘mild’ or
‘moderate’, and there were
no ‘extreme’ scenes. The
boys were asked to rate
whether they thought
each clip was more or less
aggressive than the one
which preceded it, and
were brain scanned using
functional magnetic
resonance imaging, which
shows in real time which
areas of the brain are active.
The longer the boys watched
videos, particularly the
mild or moderate ones,
the less they responded to
the violence within them.
In particular, an area of the
brain known as the lateral
orbitofrontal cortex, thought
to be involved in emotional
processing, showed less
activity to each clip as
time went on.
BBC
4 Therapy Today/www.therapytoday.net/November 2010

Mental health groups
praise government plans
UK’s £100bn
mental health
crisis
© jupiter images/comstock/Getty images/thinkstock
Some of the UK’s most
influential mental health
organisations have publicly
given their support to what
the Coalition Government
has achieved during its first
100 days. The Future Vision
Coalition – which includes
Mind, Rethink, Together,
the Mental Health
Foundation and the Royal
College of Psychiatrists –
says it is ‘greatly encouraging’
that the Government is
looking to promote good
Mid-life crisis
arriving earlier
Increasing work hassles,
money worries and loneliness
mean people aged 35 to 44
are the unhappiest in society,
a study by Relate says. The
age group came out worst
in a series of measures, with
40 per cent saying they had
been cheated on by a partner
and 21 per cent complaining
of loneliness a lot of the time.
Relate CEO Claire Tyler
said her counsellors see
more 35 to 44 year olds
than any other age group.
‘Traditionally we associate
the mid-life crisis with people
in their late 40s to 50s, but
the report reveals that this
period could be reaching
people earlier. It’s when
life gets really hard – you’re
starting a family, pressure
at work can be immense,
and increasingly money
worries can be crippling.
We cannot afford to sit back
and watch this happen.’
The Independent
mental health, and focus
on prevention and early
intervention.
Despite the looming deep
cuts across most government
departments, the Future
Vision Coalition’s new report,
Opportunities For A New
Mental Health Strategy, praises
the Government on a number
of fronts. These include the
establishment of a childhood
and families task force and an
independent commission into
early intervention in order
to prevent young people
developing mental health
problems; a commitment
to serve members of the
armed forces and veterans;
a commitment to explore
alternative forms of
secure, treatment-based
accommodation for mentally
ill and drugs offenders; and
a commitment to continue
the roll-out of the Improving
Access to Psychological
Therapies programme.
Psychminded
It’s good to gossip – but be nice!
Gossiping has some positive
benefits – at least for the
person doing the gossiping.
Gossipers feel more supported
and positive gossip (praising
somebody) may lead to a shortterm
boost in gossipers’ selfesteem.
These are the findings
of research conducted by Dr
Jennifer Cole and Hannah
Scrivener from Staffordshire
University. Although not
associated with self-esteem or
life satisfaction, higher levels
of gossiping were associated
with feelings of greater social
support. In a follow-up study,
140 participants were asked to
talk about a fictional person
positively or negatively.
Those who described the
fictional character positively
felt greater self-esteem than
those asked to talk about
them negatively.
British Psychological Society
Higher levels of gossiping linked with feelings of greater social support
Mental illness in England
cost the nation more than
£100bn last year, highlighting
some of the most serious
emotional and psychological
problems in Europe. More
than £21bn was spent on
such health treatments as
antidepressants and social
care such as befriending
services, an increase of 75
per cent since 2003.
Experts warned that the
figure is likely to rise as
government cuts to public
services start to have an
impact. The statistics,
released by the Centre for
Mental Health, show mental
health-related sick leave
and unemployment cost the
economy more than £30bn.
The true impact is likely to
be much higher, as the costs
of underperformance and
poor productivity are not
included. The cost of the
less tangible human toll of
mental illness is calculated
to be £50bn: this figure takes
into account the negative
impact that conditions
such as depression, anxiety,
psychoses and bipolar
disorder have on quality
of life and life expectancy,
as well as the costs of
providing informal care.
The numbers are likely
to trouble members of the
Coalition Government
as it struggles to curb an
annual deficit of £157bn
by slashing departmental
budgets. Mental health
campaigners insist that
all of the money being
spent is essential but say
that it should be diverted
towards prevention.
The Independent
November 2010/www.therapytoday.net/Therapy Today 5

News
Treatments for postnatal
depression assessed
Giving women with postnatal
depression antidepressants
early in the course of the
illness is likely to result in
the greatest improvement
in symptoms, according to
new research funded by the
National Institute for Health
Research, Health Technology
Assessment (NIHR HTA)
programme. The team, led
by Professor Deborah Sharp
from the University of Bristol,
compared the effectiveness
and cost-effectiveness of
antidepressants with a
community-based psychosocial
intervention. A total
of 254 women were recruited
from 77 general practices in
England to receive either an
antidepressant prescribed
by their GP or counselling
from a specially trained
research health visitor.
The results show that in
the population studied where
the prevalence of postnatal
depression was just under
10 per cent, antidepressants
were significantly superior
to general supportive care at
four weeks. There was a lack
of evidence for a significant
difference between
antidepressant therapy and
listening visits at 18 weeks
as the trial design allowed
women to switch groups,
or add the alternative
intervention at any time
after four weeks.
‘Although many women –
at least initially – revealed a
preference for listening visits,
it would appear that starting
women on antidepressants
early in the course of illness is
Antidepressants found to be more effective than supportive care
likely to result in the greatest
improvement in symptoms,’
says Professor Sharp. ‘There
is an urgent need for GPs and
health visitors to agree the
care pathway for women
who suffer from postnatal
depression, not only for the
benefit of the mother, but
also the child.’
The National Institute for
Health Research
Antidepressant prescribed over 13 years in
the UK is ineffective and potentially harmful
© hemera/thinkstock
An antidepressant prescribed
in the UK over the last 13
years is ineffective and
potentially harmful,
according to a damning
new study published in
the British Medical Journal.
The drug, reboxetine,
which is known in the
UK under the trade name
Edronax, works no better
than a placebo, or dummy
pill, say scientists, who
accuse the manufacturer,
Pfizer, of failing to disclose
the results of trials which
show its inadequacies.
The revelations come
from the German Institute
for Quality and Efficiency
in Health Care. Its
independent scientists
decided to scrutinise the
data on reboxetine because
of doubts that have been
raised about its effectiveness
and the fact that the US
licensing authority, the
Food and Drugs
Administration (FDA)
refused it a licence in 2001.
Individual trials that have
been published and reviews
of the data in the public
domain have all shown the
drug to be effective. But the
German institute’s scientists
found that eight out of 13
significant trials had not
seen the light of day.
The institute accuses the
manufacturers of publishing
only positive results for the
drug. ‘Data on 74 per cent
of the patients included in
our analysis was unpublished,
indicating that the published
evidence on reboxetine so
far has been severely affected
by publication bias,’ the
authors write.
Beate Wieseler, deputy head
of the institute’s department
of drug assessment, and
colleagues call for changes
in European law to make it
mandatory for all clinical
trial results to be published.
They argue that all trial data
should be disclosed – even
when the trials fail and the
drug is not approved.
Dr Fiona Godlee, editor
of the BMJ, and colleague
Dr Elizabeth Loder say that
‘the medical evidence base
is distorted by missing
clinical trial data’ and call
for urgent action to restore
trust in existing evidence.
‘Full information about
previously conducted
clinical trials involving
drugs, devices and other
treatments is vital to clinical
decision-making,’ they said.
‘It is time to demonstrate
a shared commitment to
set the record straight.’
The Guardian
6 Therapy Today/www.therapytoday.net/November 2010

In practice
Words
and labels
Kevin Chandler
Words matter. They not only
describe a thing, but define it.
Imagine being described as
‘wheelchair-bound’, or a
‘wheelchair user’. In the former,
the wheelchair is the active
party, limiting the freedom
of its passive incumbent; in
the latter, the disabled driver
breathes life into the otherwise
inert wheelchair.
For a profession that is
meant to be comfortable with
silence, therapy sure relies a
lot on words. Rightly so, for
words and their meanings
are our stock-in-trade, and we
pay our clients’ language close
attention. An anorexic client
who constantly denies herself,
mentions being repeatedly
told as a child that she was
‘too much’ for her mother; her
counsellor finds herself filling
more of the space than usual
in sessions, as if trying to feed
her deprived client a large
nourishing helping. A male
client tells of his fury at being
‘shut out’ of his holiday home
by his partner; two weeks
later, he turns up for his third
appointment a day early, and
his counsellor doesn’t let
him in.
‘Too much’ and ‘shut
out’: simple expressions,
yet powerful and complex
meanings for the people
concerned. The first client’s
response was to make herself
increasingly invisible. The
second’s was to pound on
the caravan door. Thankfully,
he was more respectful of
the counsellor’s door, but
underneath, I imagine his
wound was much the same.
But it isn’t just clients who
coin phrases; we therapists
have a jargon all our own,
and the freezer-full of therapyspeak
carries an assortment of
flavours. The psychodynamic
therapist will readily get their
tongue around the lollipops
of projective-identifications,
internal objects and the
reflection process whilst in
the person-centred drawer
you’ll find plenty of selfactualisation,
advanced
accurate empathy and nondirective
cornets and wafers.
In other compartments,
you’ll find a variety of
solution-focused tubs, CBT
choc-ices, or family packs
rippled with reflexivity and
the co-ordinated management
of meaning. Of course, such
labels are not intended for
client consumption, other
than perhaps to remind them
(and kid ourselves) that it is
only we professionals who
hold the keys to the knowledge
of human relationships. Such
jargon is our shorthand code,
the telltale scent-marks that
indicate to other practitioners
whether we’re of the same clan
as themselves or members of
some foreign tribe, and I have
little time for it.
Of course, it was not
always so. There was a time
I delighted in trying out my
command of such new-found
concepts in Case Discussion
Group, showing off that I was
no stranger to notions of
positive reframing, symptom
carriers, countertransference,
or Henry Dicks’ Three Levels
of Marital Fit.
Language is deeply wrapped
up with identity. I knew of a
man who refused to accept his
wife’s decision to change her
first name; ‘I married Mary
23 years ago,’ he said, ‘I can’t
suddenly start calling her
something entirely different!’
They divorced over it.
Names matter. All the
‘We therapists have
a jargon all our own,
and the freezer-full
of therapy-speak
carries an assortment
of flavours’
more so now regulation of
our profession is galloping/
creeping over the horizon,
and the arguments have
begun about what we can,
and cannot, call ourselves.
I tend to take labels with
a pinch of salt. A prospective
supervisee boldly introduces
themself as someone who
‘works psychodynamically’.
An hour and a half later the
supervisor has found no
evidence of any such thing,
unless you believe gathering
a few morsels of information
about a client’s childhood
to be synonymous with
psychodynamic enquiry
and practice.
Perhaps things are best
identified by what they do
rather than what it says on
the label. I used to refer to
myself as a counsellor, but
increasingly describe what
I do as therapy. Yet, when I
meet a stranger who asks
what I do for a living, I
often as not reply that I’m
a paid listener. It oils the
conversation, is unpretentious,
and pretty close to the truth.
Keen-eyed readers will have
noticed a name change to
this column, from ‘Therapist
column’ to ‘In practice’ when
I took it on earlier this year. ‘In
practice’ describes something
common to us all, whether
we are students-in-training,
newly qualified graduates, or
old stagers who think they’ve
seen and heard it all before.
Each one of us is engaged in
practising our art/craft/trade
– if not to ‘get it right,’ then
at least in an attempt to do it
a little better, whatever the
thing itself is actually called.
Kevin Chandler is a therapist,
supervisor and author of Fifty-
Minute Hour, a novella about
a man dragged along to Relate
(in the collection 8 Hours), and
the novel Listening In: A Novel
of Therapy and Real Life.
November 2010/www.therapytoday.net/Therapy Today 7

In the client’s chair
Left behind
Orla Murray
I’m writing this at the
beginning of a break from
therapy, because my therapist
has abandoned me. Or gone
on holiday, depending on
how you look at it. I miss him.
At least I think it’s him I
miss and not just the
experience of therapy. Can he
mean something to me, over
and above the therapy, or am
I making that up? I don’t know
anything about him and if I
don’t know him, then can I
be missing him? I suppose I
do know how he is with me,
the way he relates to me. Is
that the same as knowing him
– a little bit? Is that part of
who he is, or is it just a façade,
performing a duty?
I don’t like the idea of missing
what I get out of him, rather
than missing him in his own
right. It seems so transactional.
He’s a person after all, not
some sort of therapy vending
machine. Whilst therapy could
exist without him – there are
other therapists – it wouldn’t
be the same therapy that I’m
missing now. I couldn’t just
pick up from here with
someone else. I suppose that
what I get out of him is the
relationship with him, so he’s
inseparable from what he gives
me and then takes away again
when he goes on holiday.
When I began therapy I
read quite a bit about it, partly
because I was interested but
probably also because I was
trying to figure out what I
should be doing. From this I
gleaned that breaks were meant
to be significant. The first
few holiday periods came and
went, whilst I waited to feel
something in relation to them.
I did miss having 50 minutes in
the week that I had protected
from work, but I didn’t seem
to be that upset by his absence.
He would sometimes refer
to a break having happened,
as though it mattered. I would
feel a passing irritation that
‘I had an inkling that
when he announced
a holiday, I was so
quick to manage
away the feelings
provoked that I
barely had time to
see what they were’
my experience was diverging
from the theory and that he
was following the theory
rather than me. In
reality he was probably
just acknowledging the
interruption, in the absence
of any comment from me.
So I didn’t mind the breaks,
but... As time went on, I
noticed that the mention of
a forthcoming holiday stirred
a vague but insistent sense of
wanting him to stop talking
about it. I had an inkling that
when he announced a holiday,
I was so quick to manage
away the feelings provoked
that I barely had time to see
what they were. I thought that
perhaps I caught a fleeting
glimpse of disappointment,
but it would go to ground
before I could be sure. And
I would find myself thinking
reassuringly that it would be
OK, I could do something else
with the time, or that it would
save money, or that it wasn’t
for that long, with no firm
idea of why I might need to
comfort myself this way.
More recently, the
disappointment at him going
away has been coming through
loud and clear – I can’t avoid
it. Or maybe something’s
changing and I have less
need to avoid it. This time
around, I’ve also found myself
expressing irritation to friends,
albeit it only in the safety
of a joke. I feel completely
unreasonable not wanting him
to go away. I know that to do
this job well he needs to look
after himself, and that to rest
properly he needs to leave
work behind. But if he leaves
work behind, what does he
do with me?
Even without a break, I
have trouble believing that
he would bother himself
with thoughts of me between
sessions. This makes it hard
to re-establish a connection
the following week – I never
have any faith there will be
anything to connect to. If
there has been nothing in
between, there can be
nothing for me to get hold
of or to pick up – I have to
create it all over again.
During one especially long
break, caused by our holidays
running consecutively, I read
a whole stack of books about
therapy. Not, for a change,
to understand how it was
meant to work, but to try and
discover what I might mean
to him. I knew that a book by
another therapist couldn’t tell
me definitively what I meant
to him, but I just wanted to
know what the possibilities
might be – what did other
clients mean to other
therapists?
This break has passed now.
During the second week I
began to get excited about
seeing him again. Then, a few
days away from our session,
I started to feel anxious. I
couldn’t think about being in
the room; my mind refused to
settle on it, because it felt like
there would be nothing there,
like I would have nothing of
value to say, that I would find
myself alone, with someone
opposite who I couldn’t reach,
unable to trust that he might
reach me. Being lonely in
therapy intensifies the feeling
because it’s the wrong way
around. It’s not meant to
happen like that.
Orla Murray is a pseudonym.
8 Therapy Today/www.therapytoday.net/November 2010

In training
Walking
the line
Alex Erskine
Now that we’re back at college
I find myself thinking about
the implications of training,
at the oddest moments – like
last weekend when I was
ankle-deep in mud on a
walking trip in Wales.
Years previously I had
been there as part of a group
expedition: it was fun tagging
along with everyone else and
enjoying the scenery at leisure.
This time, however, we fancied
something a little wilder and
opted for a more out-of-theway
route that required tough
boots, a copy of the local
Ordnance Survey map and
some map-reading skills. The
views were more spectacular
than ever and we hardly saw
a soul. I felt alive. The only
frustration was that I kept
feeling compelled to consult
the damn map to ensure that
we didn’t stray from the
unmarked footpath.
What on earth, you may
ask, does this have to do with
counselling? I wasn’t on some
ecotherapy trip, and moving
though the landscape was,
I wasn’t hoping that nature
would bring me close to my
inner soul. The answer is one
word: boundaries. When you
don’t know they are there, it’s
easy to go about your business
oblivious to the implications
of treading somewhere you
shouldn’t. But, just as the
novice hill walker in me was
worried about losing my way
and trespassing onto private
property, so the novice
counsellor in me is becoming
ever more aware of the
complexity of interpersonal
dynamics and mixing up roles.
The importance of
boundaries – for both client
and counsellor – is one of the
first things we start to learn
about as students (we have
yet to question this received
wisdom in the way encouraged
by Nick Totton in last month’s
Therapy Today!). Their looming
relevance in the practice room
is making me ever more aware
of them in my personal life.
And, like that faded footpath,
it is not always immediately
clear where they should start
and end.
Take the example of a friend
who recently found herself
suddenly plunged into a lifechanging
crisis. We talked at
length about what was going
on, and I suggested that it
might make sense to see a
therapist to start addressing
some of the deeper material.
She duly started seeing a
therapist, who has rapidly
helped her gain some major
insights into her life story. Yet
as she explored these issues,
she wanted to talk about it
with someone, and I proved
a willing pair of ears. That felt
fine, until one day she started
telling me information that I
didn’t need to know, and which,
frankly, was more appropriate
for her therapist. A line had
been crossed. In that moment
I had made the basic error of
allowing myself to switch from
being an old friend to becoming
a surrogate therapist. Mistake.
Around the same time
another friend became
seriously ill. On my visits to
him in hospital we shared some
of the most moving, intimate
moments together we have
ever enjoyed. At times, words
were unnecessary – just being
together was enough. And
yet... And yet when I wasn’t
there I didn’t spend all my time
thinking about him, which in
turn gave me pangs of guilt.
‘The novice counsellor
in me is becoming
ever more aware
of the complexity
of interpersonal
dynamics and
mixing up roles’
That inevitably relates to
my own issues with caring for
others, but it did prompt me
to wonder how I would feel
with future clients. However
much I am able to provide a
safe space for them during a
counselling session, it would
not be healthy for me to carry
their material with me for the
rest of the week. Yet will this
in turn make me feel guilty
if I don’t think about them
between sessions? How easy
will it be to contain what goes
on in the counselling room?
At college the issue of
boundaries is also lurking
in the background. The
experiential part of our
training can involve exploring
very personal material –
as well as experiencing
meaningful shared moments.
Confidentiality dictates that
what happens in a group stays
in the group. But as soon as
an experiential session is
finished and we regroup in
the canteen, not to mention
the pub, do we really put all
that aside as we resume the
student chit-chat? It can feel
a little disorientating to say
the least.
In a sense, ignorance is
bliss. But I recognise that
unboundaried life – let alone
work – is not an option. My
hope is that my emerging
‘internal supervisor’ will
make it easier to navigate
through those shifting
boundaries of interpersonal
experience – and even one day
to achieve ‘boundlessness’,
as Nick Totton puts it. At the
moment it feels rather like I
am embarking on that walk
across the Welsh hills, map
in hand. In time I hope I will
not have to consult it so often:
then truly will I have more
space to experience in full
the humbling majesty of the
views all around me.
Alex Erskine is a pseudonym.
November 2010/www.therapytoday.net/Therapy Today 9

Viewpoint
Pluralism: towards
a new paradigm
for therapy
10 Therapy Today/www.therapytoday.net/November 2010

Increasingly, counsellors and
psychotherapists are becoming
concerned that we are moving towards
a therapeutic ‘monoculture’ in which
cognitive-behavioural therapy (CBT)
dominates; and in which other
therapeutic orientations – such as
psychodynamic, person-centred and
integrative – are marginalised: freelyavailable
only for clients who actively
decline CBT, 1 or in the private and
voluntary sectors.
Yet this current threat can be seen
as just one manifestation of a deeper
trend within the counselling and
psychotherapy world towards splitting
and dividing, and to pitting one school
of therapeutic thought and practice
against another. ‘Over the years,’
write Duncan et al, 2 ‘new schools of
therapy arrived with the regularity
of the Book-of-the-Month Club’s
main selection’. Today it is estimated
that there are more than 400 different
types of therapy, 3 with the majority
of practitioners in the UK tending
to identify with one or other of
these schools. 4
Undoubtedly, such diversification
can foster much growth and creativity
in the field. We are now in a position
where clients have a vast diversity of
practices to choose from, and where
forms of therapy are constantly
developed and refined to be of as much
benefit as possible to clients. And yet,
there is also the danger that the
development of ‘schools’ can lead to
an unproductive ‘schoolism’, in which
adherents of a particular orientation
become entrenched in the ‘rightness’
of their approach; closed to the value,
skills and wisdom of other forms of
therapy. Here, practitioners lose out,
embroiled in a competitive, hostile
and stultifying culture; but, perhaps
more importantly, clients can be
severely disadvantaged: inducted into
therapeutic discourses and practices
that may not be most suited to their
individual, specific needs and wants.
And, indeed, it is clear from the
research that clients do want and
need different things. In a recent trial, 5
primary care patients were given the
option of choosing between nondirective
counselling or CBT. Of those
patients who opted to choose one of
these two therapies, around 40 per cent
chose the non-directive option, while
60 per cent chose CBT. Here, it might
be argued that what clients want is not
necessarily what they need, but a recent
review of the literature found that
clients who get the therapy they want
are likely to do better than those who
get a therapy they do not want, and
are also much less likely to drop out. 6
Furthermore, an emerging body of
evidence suggests that some ‘types’
of clients do better in one kind of
therapy than another. For instance,
clients with high levels of resistance
and an internalising coping style
tend to do better in non-directive
therapies; while those who are judged
to be non-defensive and who have a
predominantly externalising coping
style tend to benefit from more
technique-orientated approaches. 7
How can we move beyond ‘schoolism’ towards
a paradigm that embraces the full diversity of
eective therapeutic methods and perspectives?
Mick Cooper and John McLeod propose a ‘pluralistic’
approach. Illustration by Geo Grandfield
November 2010/www.therapytoday.net/Therapy Today 11

Viewpoint
The development of integrative
and eclectic schools
Since the 1930s, psychotherapists
and counsellors have attempted to
overcome the problems associated
with single orientation therapies by
developing more integrative and
eclectic approaches. Growth in this
field has been particularly marked from
the 1970s onwards, such that it can now
be claimed that an integrative or eclectic
stance is currently the most common
theoretical orientation of Englishspeaking
psychotherapists, with around
25–50 per cent of American clinicians
identifying in this way. 3 Furthermore,
research indicates that practitioners
of all orientations – howsoever they
identify – tend to integrate into their
practice methods from other
orientations. For instance, a US-based
study found that psychodynamic
therapists, on average, strongly endorsed
the CBT practice of challenging
maladaptive beliefs, while the vast
majority of CBT therapists prioritised
the person-centred stance of empathy. 8
In contrast to a schoolist perspective,
integrative and eclectic therapists tend
to hold that no one school has all the
answers, and that different methods
may be of help to different clients.
Arnold Lazarus, 9 for instance, founder
of ‘multimodal therapy’, writes that the
multimodal therapist asks, ‘Who or what
is best for this particular individual?’,
and he describes his approach as both
‘personalistic’ and ‘individualistic,’
flexibly tailoring the therapeutic
method and style of relating to the
individual client.
However, there can be a tendency
for many of these attempts to transcend
singular models of theory and practice
to end up replicating something quite
similar: albeit with elements synthesised
from a variety of sources. Ryle’s 10
cognitive analytic therapy (CAT),
for instance, outlines a very particular
‘The pluralistic approach starts
from the assumption that dierent
things are likely to help dierent
people at dierent points in time’
model of personality functioning; while
Egan’s 11 problem management approach
advocates a highly specified set of
procedures for helping clients overcome
their difficulties. Even multimodal
therapy 9, 12 locates itself within a specific
theoretical framework – social-cognitive
learning theory – and eschews other
understandings.
Moreover, in most of these integrative
and eclectic approaches, the decision
as to which methods or understandings
to use tends to be located very much
in the therapist, with little or no
consultation with the actual client
involved. There is no guarantee,
therefore, that the particular practices
adopted in an integrative or eclectic
approach will be any more tailored to the
client’s particular wants and needs than
any other single orientation approach.
Introduction to a pluralistic approach
Against this background, the two of us
have been working for the past five
years on developing a ‘pluralistic’
approach to therapy, culminating in
the publication of Pluralistic Counselling
and Psychotherapy in November 2010.
This approach is steeped in the
humanistic, person-centred and
postmodern values which underpin
both our approaches, but aims to be
a way of practising, researching and
thinking about therapy which can
embrace, as fully as possible, the whole
range of effective therapeutic methods
and concepts.
The pluralistic approach starts from
the assumption that different things are
likely to help different people at different
points in time, such that it is meaningless
to argue over which is the ‘best’ way
of practising therapy, per se. It can be
summed up as a ‘both/and’ standpoint
– that CBT can be helpful, and personcentred
therapy can be helpful, and
psychodynamic therapy can be helpful –
in contrast to an ‘either/or’ one. As a
corollary of this, the pluralistic approach
also assumes that it is not just therapists
who should decide on the focus and
course of therapy – rather, therapists
should work closely with their clients to
decide on how the work should proceed.
The two basic principles underlying this
approach can be summarised as follows:
(1) Lots of different things can be helpful
to clients; (2) If we want to know what
is most likely to help clients, we should
talk to them about it.
We have come to describe this
approach to therapy as ‘pluralistic’, as
the term seems to describe, very fittingly,
these two core principles. ‘Pluralism’
is a word used in a variety of fields, and
refers to the belief that ‘any substantial
question admits of a variety of plausible
but mutually conflicting responses.’ 13
It is a viewpoint that has become
increasingly prevalent in the field of
philosophy, 14, 15 and which has had a
major role in debates within political
science and sociology. Pluralism can be
contrasted with ‘monism’: the belief that
every question has a single and definitive
answer. In other words, a pluralist holds
that there can be many ‘right’ answers
to scientific, moral or psychological
questions, which are not reducible to
any one, single truth. Central to this
standpoint is also the belief that there
is no one, privileged perspective from
which the ‘truth’ can be known. That
is, neither scientists, philosophers,
psychotherapists nor any other kinds
of people can claim to have a better
vantage point on ‘reality’.
In developing this pluralistic approach
to psychotherapy and counselling, we
have come to find it useful to distinguish
between pluralism as a perspective on
psychotherapy and counselling, and
pluralism as a particular form of
therapeutic practice. A pluralistic
‘perspective’, ‘viewpoint’, or ‘sensibility’
refers to the belief that there is no one
best set of therapeutic methods. It can be
12 Therapy Today/www.therapytoday.net/November 2010

defined as the assumption that different
clients are likely to benefit from different
therapeutic methods at different points
in time, and that therapists should work
collaboratively with clients to help them
identify what they want from therapy
and how they might achieve it. This is
a general definition, which does not
make any specific recommendations
about how a therapist might go about
implementing a pluralistic perspective
in their own practice.
By contrast, ‘pluralistic practice’ or
‘pluralistic therapy’ refers to a specific
form of therapeutic practice which draws
on methods from a range of orientations,
and which is characterised by dialogue
and negotiation over the goals, tasks
and methods of therapy. Making this
distinction is important because,
although pluralistic practice is rooted
in a pluralistic viewpoint, it is also
quite possible for therapists to hold
a pluralistic viewpoint while working
in a non-pluralistic, single orientation
way (what we refer to as ‘specialised’
practices). Unlike integrative and
eclectic approaches, then, the
pluralistic approach does not view
multi-orientation ways of working as
necessarily superior to single-orientation
practices: for some clients at some points
in time, a purely non-directive approach,
or a highly behavioural approach, may
be exactly what they need.
The pluralistic framework: goals,
tasks and methods
If a pluralistic approach strives to
embrace an infinite diversity of
therapies, how does it avoid an ‘anythinggoes
syncretism’: the haphazard,
uncritical and unsystematic combination
of theories and practices? Clearly, there
needs to be some kind of structure,
some focal point for thinking about
therapy and what might be effective.
Coming from a pluralistic philosophical
standpoint with its commitment to
References
1. National Institute for Health and
Clinical Excellence. Depression:
the treatment and management
of depression in adults (update).
London: National Institute for
Health and Clinical Excellence; 2009.
2. Duncan BL, Miller SD, Sparks JA.
The heroic client: a revolutionary
way to improve effectiveness through
client-directed, outcome-informed
therapy. San Fransisco: Jossey-Bass;
2004.
3. Norcross JC. A primer on
psychotherapy integration. In
Norcross JC, Goldfried MR (eds)
Handbook of psychotherapy
integration. New York: Oxford
University; 2005.
prioritising the perspective of the client,
the pluralistic approach suggests that
the focal point for therapy should be,
ultimately, what the client wants from
it. That is, not the client’s diagnosis,
their assessment, or the therapist’s
personal beliefs about what is effective
in therapy, but the client’s own goals
for the therapeutic process. This then
sets the basis for what the client and
therapist see as the tasks of therapy
(ie the different foci, or strategy, of
the therapeutic work) and, from this,
the specific methods (ie the concrete
activities that they will undertake).
For instance, Dave came to therapy
with an overall desire to be happier and
less anxious. More specifically, he wanted
to look at ways in which he could have
better relationships with other people
(goals). In discussing this with his
therapist it became apparent that one
thing he might helpfully do was to look
at ways of changing his behaviour,
so that he might make himself more
available for close friendships (tasks).
To achieve this, Dave and his therapist
talked about the ways that he behaved
in social situations, and what he might
do differently. Dave reflected on how
he might come across to others, and
his therapist gave him feedback on
how he perceived him (methods).
Collaborative dialogue
This goal-task-method framework
provides a means for therapists to think
about what kind of therapeutic practices
may be most helpful to a particular client
and, indeed, whether or not they have
the appropriate methods to help a
particular client reach their goals.
Of equal importance, however, is that
it highlights three key domains in which
collaborative activity can take place
within the therapeutic relationship.
Haruki, for instance, was a student in
his first year at university who suffered
from ‘performance anxiety’ – a crippling
4. Couchman A. Personal
communication; 2006.
5. King M, Sibbald B, Ward E,
Bower P, Lloyd M, Gabbay M et al.
Randomised controlled trial of
non-directive counselling, cognitivebehaviour
therapy and usual general
practitioner care in the management
of depression as well as mixed
anxiety and depression in
primary care. Health Technology
Assessment. 2000; 4(19):1-83.
6. Swift JK, Callahan JL. The impact
of client treatment preferences on
outcome: a meta-analysis. Journal
of Clinical Psychology. 2009;
65(4):368-381.
7. Cooper M. Essential research
findings in counselling and
psychotherapy: the facts are
friendly. London: Sage; 2008.
8. Thoma NC, Cecero JJ. Is
integrative use of techniques in
psychotherapy the exception or the
rule? Results of a national survey
of doctoral-level practitioners.
Psychotherapy. 2009; 46(4):405-417.
9. Lazarus AA. Multimodal therapy.
In Norcross JC, Goldfried MR
(eds) Handbook of psychotherapy
integration. New York: Oxford
University; 2005.
10. Ryle A. Cognitive analytic
therapy: active participation in
change. Chichester: Wiley; 1990.
fear of speaking (or even worse,
presenting a paper) in a tutorial group
or seminar. When he came to see John,
he was clear that his life as a whole was
satisfactory, and that all he wanted from
counselling was to achieve his goal
of ‘being able to take part in seminars’.
After some discussion, it appeared that
there were three main therapeutic tasks
to be tackled for Haruki to achieve his
goal: (a) making sense of why this
pattern had developed – Haruki did not
want a ‘quick fix’, but felt that he needed
to have an understanding of the problem
in order to prevent it re-occurring in
the future; (b) learning how to control
the powerful and debilitating panic
that overcame him in seminars; and
(c) moving beyond just ‘coping’, and
having a positive image of how he might
actually be successful and do well as
a ‘presenter’. As counselling proceeded,
each of these three themes tended to
be focused on in separate sessions.
During one of the early sessions that
focused on the task of dealing with his
panic feelings, John and Haruki talked
about the ways that Haruki thought it
might be possible for them to address
this issue (methods). Haruki began
by saying that the only thing that came
to mind was that he believed he needed
to learn to relax. John asked him if there
were any other situations that were
similar to performing in seminars, but
which he was able to handle more easily.
He told John that he remembered that
he always took the penalties for his
school soccer team, and dealt with his
anxieties by running through in his mind
some advice from his grandfather about
following a fixed routine. John then
asked if he would like to hear some of
John’s suggestions about dealing with
panic. John emphasised that these were
only suggestions, and that it was fine
for him to reject them if they did not
seem useful. John mentioned three
possibilities. One was to look at a model
11. Egan G. The skilled helper: a
problem-management approach
to helping. Belmont, CA: Brooks/
Cole; 1994.
12. Lazarus AA. The practice of
multimodal therapy. Baltimore:
John Hopkins University; 1981.
13. Rescher N. Pluralism: against
the demand for consensus. Oxford:
Oxford University; 1993.
14. Berlin, I. Two concepts of liberty.
In Hardy H (ed) Liberty. Oxford:
Oxford University; 2002.
15. Connolly WE. Pluralism.
Durham: Duke University; 2005.
November 2010/www.therapytoday.net/Therapy Today 13

Viewpoint
of panic as a way of understanding the
process of losing emotional control. The
second was to use a two-chair method
to explore what he was saying to himself
at panic moments. The third was to read
a self-help booklet on overcoming panic.
Haruki thought all of these methods had
potential value for him. Over the next
two sessions, Haruki and John tried
out each method, along with suitable
homework tasks. Haruki fairly quickly
became a lot more confident in seminars.
Conclusion
As a development of integrative and
eclectic perspectives, our hope is that
the pluralistic approach can help the
counselling and psychotherapy field
move towards a greater appreciation
of all our potentialities; such that, as a
community, we can provide therapeutic
interventions that are more closely
tailored to the specific needs and
wants of the clients that we work with.
Our vision is to create a research-,
theory-and-practice-informed ‘open
source’ repository of information – a
‘Wikitherapy’ – which outlines all the
different methods by which clients might
be helped to achieve their goals;
acknowledging that some methods may
be more helpful for more clients more
of the time, but that a vast range of
practices still have the potential to be
of benefit. More than that, we hope that
a pluralistic outlook can help us move
beyond the many false dichotomies that
plague our field: ‘Is it the relationship
that heals?’ ‘Does CBT just provide
a short-term “fix”?’ ‘Do antidepressants
work?’ From a pluralistic standpoint,
these are just the wrong questions to
be asking: it depends on the particular
client at the particular point in time.
Of course, without doubt, there are
already many counsellors and
psychotherapists who think and practise
in pluralistic ways – perhaps the majority
– but they have always tended to be overshadowed
in the literature and research
by more singular, uni-modal thought and
practice. Perhaps that is because of the
human desire for simplicity: the idea
that ‘x is caused by y’ may always be
more appealing than the idea that ‘x is
sometimes caused by y, but sometimes
by z, and w seems to be important some
of the time, but we are not really sure.’
And yet, perhaps now more than ever,
there is a need for those who hold a
pluralistic vision to articulate it as fully
as possible, and to look at how it can be
developed and applied through research,
training, supervision and practice. As
William Connolly, 14 political scientist
and author of Pluralism writes,
‘Tolerance of negotiation, mutual
adjustment, reciprocal folding in, and
relational modesty are, up to a point,
cardinal values of deep pluralism. The
limit point is reached when pluralism
itself is threatened by powerful unitarian
forces that demand the end of pluralism.’
Here, he states, ‘a militant assemblage
of pluralists’ is required to resist such
forces, to ensure that diversity, mutual
respect and an appreciation of each
person’s uniqueness can continue
to flourish.
Mick Cooper is Professor of Counselling
at the University of Strathclyde, and John
McLeod is Emeritus Professor of Counselling
at the University of Abertay. This article
is adapted from Mick Cooper and John
McLeod’s Pluralistic Counselling and
Psychotherapy, published by Sage.
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14 Therapy NDM 2955 Today/www.therapytoday.net/November Cooper and McLeod Advert .indd 20101 3/11/10 10:18:51

Questionnaire
Jeremy Clarke
A national adviser
for IAPT and
founding Chair
of the New Savoy
Partnership,
Jeremy Clarke is
working hard to
broaden the choice
of therapies offered
in IAPT services
What made you decide to
become a psychotherapist?
In 1987 I was teaching history
at Dulwich College, London.
One day I woke up weeping
over a student who was
suffering a personal tragedy,
from which I saw he might
never recover if he didn’t
get help.
What gives your life purpose?
A few years ago I attended
an event at which Richard
Layard and Michael Marmot
were speaking. That was when
it struck me how counsellors
could be in the vanguard of
reinventing the Welfare State.
Years devoted to listening to
the ‘mentally ill’ is not a bad
vantage point from which
to redefine the concepts of
‘wealth’ and the ‘good life’
for the 21st century. This is
what I’ve been trying to tell
everyone that IAPT is really
about ever since.
What is your earliest
memory?
Eating something mashed
up with warm milk, inside
a caravan in the summer
of 1962, shortly before my
first birthday.
What are you passionate
about?
Making the New Savoy
Declaration a reality, and
whatever other meeting
of minds I can help to
engineer that ensures the
work we are all engaged
in is taken more seriously
and given more support.
What has been the lowest
point in your life?
The early 1990s when my
then partner died suddenly
and unexpectedly before
his 30th birthday. Shortly
after this I lost my job as the
director of a small voluntary
sector organisation that
offered a victim support
service. I returned from a
fortnight of compassionate
leave to find they’d changed
the locks on my office door.
How do you relax?
Swimming outdoors at
Tooting Lido.
What makes you angry?
The last time I got seriously
angry was when the NICE
guidelines for depression
and anxiety were published
in 2004, because they didn’t
reflect a fair weighing of the
evidence, because I knew
the consequences would
be significant, and because
most of my colleagues were
so complacent.
Which person has been
the greatest influence on
you professionally?
If you undertake an analysis,
as I have done, for many
years, five times a week,
then your analyst’s influence
stays with you for life, both
for the person they are and
for the person they were
at different times to you in
the transference. I also feel
honoured to tread in the
footsteps of Antony Grey
who did pioneering work
at the Albany Trust in the
1950s.
How do you keep yourself
grounded?
I don’t. I dive in at the deep
end and hope I come out
of the shallow end still
breathing.
Do you fear dying?
No. I fear my partner dying.
What makes you laugh?
My sister’s friend went to
a beauty salon to top up
her tan. Inside the changing
room she took off her
clothes and put on the
protective goggles, which
were so tight she couldn’t
see. She reached down to
where she thought the door
handle was to the sunbed
room and walked through.
A gasp of shock greeted her
on the other side, so she
took off the goggles to find
she’d walked back out into
reception. Statistically, these
things happen more in the
North, which is one thing I
miss from growing up there.
If you could change anything
about society what would
it be?
I was part of the group that
updated the NICE guideline
for depression in 2009, and
with my fellow national
advisers alongside me, we
are now trying to broaden
the choice of therapies we
are offering in IAPT services.
So I’m already working on
some of the things that I
would like to see change.
What is your idea of
perfect happiness?
The sun is shining, it’s
Christmas day, and we are
having a picnic with our
family and friends at
Tooting Lido.
Do you believe in God?
I will do if the cuts ever
threaten to close Tooting
Lido.
What do you consider your
greatest achievement?
The next time I make
my partner laugh out
loud, not just by saying
something funny but by
saying something funny
in Portuguese.
Jeremy Clarke is a national
adviser for IAPT and founding
Chair of the New Savoy
Partnership. He is also a Fellow
of BACP, research and practice
lead for the analytic consortium
that includes the British
Psychoanalytic Council, a
trustee of Albany Trust, and
a senior accredited counsellor
working in the NHS, third sector
and in private practice.
November 2010/www.therapytoday.net/Therapy Today 15

Viewpoint
Hope – the neglected
common factor
Of the four factors
generally accepted
to be common
across all therapeutic
approaches, hope is
the least researched.
Denis O’Hara believes
it’s time for a clearer
exposition of how
we conceptualise
and practise the
work of hope in our
different approaches.
Illustration by
Geo Grandfield
One of the exciting and gratifying aspects
of being a therapist is the fact that therapy
makes a real difference to people’s lives
most of the time. In fact studies have
shown that therapy is around 80 per cent
effective compared to no treatment. 1
This confirms that counselling and
psychotherapy are more successful than
other healing therapies and treatments,
including standard medicine. This fact
has led researchers to ask the question:
What is it about psychotherapy that
facilitates therapeutic change?
We know that therapy works, but how
does it work? The immediate assumption
was that good theory facilitates
therapeutic change: the better the theory,
the greater the likelihood of therapeutic
change. This was an appealing
assumption, but in their search for an
answer to the question, researchers
came across a surprising finding: most
bona fide therapies provide about the
same amount of therapeutic effect. 2, 3
This intriguing finding is now so
well established that it is humorously
referred to as the ‘Dodo bird effect’
after the comment by the Dodo in
Alice’s Adventures in Wonderland:
‘Everybody has won and all must have
prizes.’ The discovery of the Dodo bird
effect led to the realisation that if most
major therapies provide about the
same therapeutic effect, then there
must be something common among
these therapies that is responsible
for producing therapeutic change.
The common factors
In examining the features of therapy that
appear to be common across approaches,
researchers identified four major factors:
••
Extra-therapeutic factors (ie factors
external to therapy, eg relational and
social supports)
••
The therapeutic alliance or relationship
••
The theory of practice
••
Hope and expectancy.
These important factors found across
theories and approaches have become
known simply as the ‘common factors’.
The first of these, extra-therapeutic
factors, is highly significant but is one
that exists whether a person seeks
counselling or not. This is not to say
that capitalising on these various extratherapeutic
factors within therapy,
and encouraging the benefits of such,
is not an important therapeutic task.
However, much of the action of this
factor occurs outside of therapy itself.
Factors two and three have received
the most research attention. The
therapeutic alliance has consistently
been shown to be an active ingredient
in the therapeutic change process.
Factor three, the theory of psychotherapy,
whilst not the central component of
change as once assumed, does play
an important part in orientating the
therapist in the work of therapy. The
fourth factor, hope and expectancy,
has been well acknowledged but is the
factor which has captured the least
research attention. The remainder of
this article explores the significance
of hope and expectancy as an essential
ingredient in therapeutic change.
The necessity of hope
The importance of hope should not
be underestimated. The renowned
psychotherapist Jerome Frank stated,
‘Hopelessness can retard recovery or
even hasten death, while mobilisation
of hope plays an important part in
many forms of healing.’ 5 Hope, it
seems, is essential to life and is
therefore a fundamental human need.
Without hope, despair and depression
take hold with devastating effects.
But what is hope? One simple
definition is that hope is a confident
expectation of a good future. Without
a belief that good things and good
experiences are still available to us,
November 2010/www.therapytoday.net/Therapy Today 17

Viewpoint
References
1. Wampold BE. Psychotherapy:
the humanistic (and effective)
treatment. American Psychologist.
2007; 62(8):855-73.
2. Lambert MJ, Bergin AE. The
effectiveness of psychotherapy.
In Bergin AE, Garfield SL (eds)
Handbook of psychotherapy and
behavior change (4th edition).
New York: Wiley; 1994.
3. Luborsky L. Are common factors
across different psychotherapies
the main explanation for the Dodo
bird verdict that ‘everyone has won
so all shall have prizes’? Clinical
Psychology: Science and Practice.
1995; 2(1):106-109.
4. Lambert MJ. Implications of
outcome research for psychotherapy
integration. In Norcross JC,
Goldstein MR (eds) Handbook of
psychotherapy integration. New
York: Basic Books; 1992.
5. Frank JD. Persuasion and
healing: a comparative study of
psychotherapy (revised edition).
Baltimore, MD: Johns Hopkins
University Press; 1973.
6. Larsen D, Edey W, LeMay
L. Understanding the role of
hope in counselling: exploring
the intentional uses of hope.
Counselling Psychology Quarterly.
2007; 20(4):401-416.
hope is lost and despair sets in. One
of the main reasons that people seek
counselling is because they have become
confused and despondent about whether
their particular situation still has hope.
They come to the counsellor to see if
hope can be recovered. Hope and
expectation are so powerful that
researchers have to actively adjust their
findings to account for the well-known
placebo effect. If people believe that
something is curative, it quite often is.
If hope and expectancy are so
important, why is hope not an essential
topic in our counsellor training
programmes? Apart from being given
a general awareness that hope is one
of the common factors, what specific
training do therapists receive in applying
hope within their therapeutic approach?
How do we as therapists help clients
rediscover hope?
Therapists’ conceptions of hope
How therapists assist clients in
rediscovering hope depends in large part
on how they themselves conceptualise
and experience hope. Researchers from
the Hope Foundation in Alberta,
Canada have identified three different
conceptualisations:
••
Hope as a commodity
••
Hope as a process of discovery
••
Hope as a co-construction. 6
They suggest that all three
conceptualisations are needed to
address the issue of hope within therapy.
The western mind has often
conceptualised hope as a commodity;
as something which exists and can be
given to someone else. Such a view
tends to have hierarchical overtones
supporting the notion of an enlightened
expert holding the knowledge which
the novice seeks to gain. A variant form
of this conceptualisation is that of the
spiritual quest where the seeker receives
hope from God or God’s messenger.
18 Therapy Today/www.therapytoday.net/November 2010
‘What specific training
do therapists receive in
applying hope within their
therapeutic approach?
How do we as therapists
help clients rediscover hope?’
Hope in this view already exists in
principle and therefore can be imparted
and received. Many have been helped
by words of wisdom from ‘the wise’.
Hope does, at times, seem to appear
from outside oneself.
Another view of hope sees it as
something which is always available
but which needs to be sought and
discovered or uncovered. Like the first
conceptualisation, hope is understood
to pre-exist, but rather than being
imparted, it is sought and discovered.
The counsellor’s role here is different:
instead of being the imparter of hope,
the counsellor helps the client unearth
seeds of hope which were always
present in the client’s story, but
unrealised. In this scheme, the
counsellor and client journey together
to discover where hope lies.
A further conceptualisation is that
of hope created. Instead of hope preexisting
as in the first two forms, hope
is largely constructed within the therapy
session. This postmodern view holds
that we create our own reality, our own
meaning in life, both individually and
corporately. The therapist employing
this approach does not impart or search
for a hope which already exists but rather
aids the client in constructing a hope
which makes sense for the client. The
counsellor and client together ‘re-story’
old narratives into new narratives of
hope. In this approach the counsellor
is often an active co-creator of hope.
In addition to these three views, hope
can also be conceived of as being duplex
or dialectical. 7 We often think of the
experience of the human condition as
being either hopeful or hopeless. At any
given time we may think and feel quite
hopeful about life and our prospects
or, alternatively, quite hopeless and
despairing. While we often do seem
to experience life in these more
contradictory frames, it is also true
that we can experience both hope and
hopelessness at the same time. It is
not uncommon to have hope in one
moment and then a few moments later
to seem to have lost it – to feel hopeless
and despondent. This conflicting
experience is in some ways more
confusing. Of course, the client’s
experience of hope and hopelessness
coexisting at relatively the same time
is a challenge for the therapist to engage.
Working with hope in therapy
These various conceptualisations of
hope form the bedrock of therapists’
approaches to addressing hope in therapy.
Each conceptualisation orientates the
therapist in a way of working with clients.
Given these various positions, hope can
potentially be imparted, searched for,
constructed, and held in tension with
hopelessness. The great challenge for
the therapist is to know what to do
within any therapeutic moment. The
last part of this article explores different
approaches to working with clients in
a way that aims to encourage hope.
One overarching frame of reference
for what it is the therapist does in hope
work is the degree of action taken by
the therapist. How much does the
therapist actively employ strategies for
engendering hope? The range of activity
might best be seen as a balance between
a quiet holding of hope and an active
pursual. The notion of the therapist
providing a place of safety and
containment is not a new one. 8, 9

7. Flaskas C. Holding hope
and hopelessness: therapeutic
engagements with the balance of
hope. Journal of Family Therapy.
2007; 29:186-202.
8. Bion WR. Attention and
interpretation. London: Tavistock;
1970.
9. Winnicott DW. Human nature,
London: Free Association Books;
1988.
10. Eliott J, Olver I. The discursive
properties of ‘hope’: a qualitative
analysis of cancer patients’ speech.
Qualitative Health Research. 2002;
12:173-193.
11. Adler A. Understanding human
nature. Random House Publishing;
1927/1981.
12. Dreikurs R. An introduction to
individual psychology. London:
Kegan Paul; 1935.
13. Snyder CR. Hope theory:
rainbows of the mind. Psychological
Inquiry. 2002; 13:249-275.
14. Snyder CR (ed). Handbook
of hope: theory, measures, and
applications. San Diego, CA:
Academic Press; 2000.
Sometimes the best thing the therapist
can do is simply be with another, sharing
and acknowledging their pain. In
recapturing hope we sometimes need
first to be present to hopelessness.
Therapists’ readiness to sit with pain,
to hold hope for others when they cannot
hold it themselves, can be their greatest
service. There exists, however, a dynamic
tension between holding or seeming
inaction, and energised strategic action.
Hope may not always best be
engendered through direct engagement.
That is, even though encouraging hope
may be an intentional aspect of the
therapist’s work, it may not necessarily
be talked about directly. Hope may be
a topic implicitly explored. Many
therapists would argue that their
therapeutic work is about developing
hope in clients, but that they do not
make hope itself a focus of the
therapeutic conversation. The therapist
works within this approach in multiple
ways, sometimes imparting aspects of
hope, searching with the client for seeds
of hope, co-creating hope in a way that
has meaning for the client, or holding
hope quietly for the client when the
client cannot hold it himself.
An explicit discussion of hope as a
topic within therapy can foster a rich
dialogue. One way to begin is to notice
times when hope or hopelessness is
mentioned directly by the client. What
type of language and contexts represent
hope to the client? Is hope referred to as
a pre-existing entity, as something lost
and needing to be found, or something
to be built? Is hope referred to as an
abstract cognitive construct or as a
subjective experience? As experienced
counsellors know, it is essential to work
within the client’s frame of reference
and mode of processing information.
When, for example, hope is referred to as
something existing apart from the client,
it is often seen as something needing to
‘What type of language
represents hope to the
client? Is hope referred
to as a pre-existing entity,
as something lost... or
something to be built?’
be conferred by an expert. 10 In this
context, the client’s orientation towards
hope is passive; he or she is waiting for
some pronouncement or word of
wisdom. When hope is subjectively
experienced, there tends to be a more
active engagement. There exists a greater
sense of personal agency, a drive to hope
without the need for external validation.
Our preferred theories of
psychotherapy have within them implicit
ways of working with hope. The insightbased
therapies inform the therapist’s
capacity to provide the client with
important reflective or interpretative
knowledge about their view of self and
life, and about the existence of hope.
Therapists working from this theoretical
base are trained to support the client by
themselves acting as a container, a holder
of the client’s painful story until such
time as the client is able to hold it himself.
Cognitive and behavioural therapies
provide the therapist with a sense of
certainty that hope already exists and
can be embraced when a balance is
reached between goals and action plans.
The humanistic approaches by nature
tend toward a focus on the subjective
experience of hope, of hoping as a
personal action. The acknowledgement
of a self-actualising drive within the
human makeup orientates the therapist
to aid the client to adjust their search for
that which has been lost or never fully
found. Constructivist therapies equip the
therapist to work together with the client
to co-create new stories of hope, new
meanings of self and of life purpose.
The field of psychotherapy already has
rich ways of working with hope. At the
moment though, these ways of working
are mostly implicit and therefore not
fully shared. It is time for a clearer
exposition of how we conceptualise and
practise the work of hope in our different
approaches of psychotherapy. Until we
engage this topic more fully, our
understanding and capacity to employ
one of the essential active ingredients in
therapy will be unnecessarily restricted.
In summary, we know a few
fundamental things about hope:
••
Hope is necessary for life
••
Engendering hope is one of the
essential tasks of therapy
••
Working with hope is a balancing
act between a passive holding and an
active engaging with clients on the topic
••
Hope can be conceptualised as an
objective entity or commodity, as a
reality which needs to be discovered,
as something to be constructed, as
existing in contradictory either/or
terms or in dialectical both/and forms
••
Therapists can work with hope
implicitly or explicitly.
It is time for this longstanding but
oft neglected common factor to be given
a voice, to move from the background
to the foreground in the discipline of
psychotherapy. We need to know much
more about how hope functions and how
we can best engender it in clients’ lives.
A shift towards a greater focus on hope
and expectancy in our research agenda,
training programmes and practice
will most certainly demonstrate the
enormous benefits of this most
essential of common factors.
Dr Denis O’Hara is Programme Leader
in the MSc in Counselling at the University
of Abertay, Dundee, Scotland and research
supervisor at the Australian Catholic
University Brisbane, Australia.
November 2010/www.therapytoday.net/Therapy Today 19

Training
Becoming
a counsellor
Surprised to learn that little research evidence exists
to support the view that training has any impact on
therapeutic skill, Julie Folkes-Skinner was prompted
to undertake her own. Illustration by Geo Grandfield
Formal training in counselling and
psychotherapy provides a gateway to
practice. Undertaking work with clients
without it would be regarded by most
therapists as unthinkable. Yet, little
research evidence exists to support
the view that training has any impact
on therapeutic skill. With the help of
a BACP Seed Corn grant, I have spent
the past five years engaged in research
which has attempted to begin to bridge
this gap between practice and evidence.
In this article I will provide an overview
of what I have found out about trainees’
experiences of training and the impact
it may have on the development of
therapeutic skill.
I began professional counsellor
training on a BACP accredited course
17 years ago. It not only changed my
career but it also changed me. Many
therapists I have known, and most
of the students I have worked with,
seem to have had a similar experience.
However, training is not just about
personal change. It differs from personal
therapy in one very important respect:
trainee therapists change because they
primarily want to be able to help other
people who are in distress, ie clients.
This is easy to take for granted, but
needs to be regarded as something quite
remarkable. So, at the heart of all training
programmes is this question: How can
we help students to become therapists?
From its inception, training has been
regarded as essential preparation for
practitioners. Consequently, not only
do trainees and trainers invest much
in the notion of training, but so do
clients, professional organisations,
and employers. It is assumed that those
therapists who have completed training
courses will be able to do the job they
have trained to do, competently and
safely. Therapists who fail in this regard
are often offered more training in the
hope that this will solve the problematic
aspects of their practice. Therefore, it
may come as a surprise to learn that
the research evidence in relation to
therapist training is both ‘meagre’
and ‘inconsistent’. 1
Research into training
In 2004, Larry Beutler 2 and his colleagues
reviewed the previous 20 years of training
research and concluded that ‘the overall
findings cast doubt on the idea that
specific training in psychotherapy is
related to therapeutic success or skill’.
More recently, Ronnestad and Ladany 3
have suggested that the belief that
training has no effect on therapist
development is probably unfounded,
not because research evidence exists
that contradicts Beutler’s conclusion,
but because the majority of studies have
often been flawed in their design and so,
therefore, have their findings. They also
state that the researcher who undertakes
work in this area will be met with
‘formidable methodological challenges’.
There are some examples of more
rigorous research into therapist training
but only a few of these have investigated
the impact of professional training on
trainees 4 and even fewer have attempted
to examine the experience of trainees
whilst in training. 5, 6 The absence of
such research prompted me to undertake
my own. I decided to focus on two basic
questions: 1) How do trainee therapists
change? and 2) What helps them to
change?
The study
From the outset it was clear that the only
way to answer these research questions
was to use a variety of methods.
Following a pilot study, the findings
of which have recently been published
in Counselling and Psychotherapy
Research, 7 a nested study design was
20 Therapy Today/www.therapytoday.net/November 2010

Training
‘Each trainee’s ability to change is likely
to have more impact on the outcome
of training than the training itself’
adopted, as this would enable the same
group of trainees to be investigated in
a number of different ways, in the hope
that this would capture the complexity
of their experience. Four professional
counsellor training courses agreed to
take part in the study. Two offered a
two-year part-time psychodynamic
training and two were person-centred
programmes, one of which was full-time.
All four courses were BACP accredited.
Study one: the early effects of
counselling training study
Prior to beginning work with clients,
trainees completed three questionnaires
during the first term of their training.
These were:
••
The Development of Psychotherapists
Common Core Questionnaire (Trainee
Version) – a version of a well-established
instrument that has been used to
investigate the development of
psychotherapists for the past 20 years,
it gathers data on the background of
therapists, current work with clients,
coping strategies and the influence
of training
••
The Core Outcome Routine Evaluation
Measure (CORE-OM (34) – a well-known
counselling and psychotherapy outcome
measure that provides information on
levels of distress and clinical cut-off
scores
••
The Strathclyde Inventory (SI) –
this is based on Rogers’ notion of the
fully functioning person and aims to
measure levels of congruence or incongruence.
This is also described in
terms of experiential fluidity or rigidity.
It is a clinical outcome measure and
also aims to evaluate levels of distress.
In addition to the questionnaires,
seven students took part in individual
semi-structured interviews using the
trainee version of the Change Interview
Schedule (the details of which have
recently been published 6 ), three weeks
prior to the end of term one.
Study two: the impact of training –
how trainee therapists change
This investigation involved one cohort
of trainees who completed the same
22 Therapy Today/www.therapytoday.net/November 2010
three questionnaires used in study one.
These were completed during the first
term of their training and again during
the last three weeks of the taught part
of their course. In addition, one trainee
counsellor from a different course took
part in a qualitative case study where she
was interviewed every six weeks during
her full-time training programme.
The findings
Sixty-three trainees took part in the
first study, and included in this sample
were the 21 trainees who took part in the
second. Therefore, the details that follow
relate to the overall sample. Eighty-seven
per cent (55) of trainees were female.
They ranged in age from 23 to 64 years,
with an average age of 41. Around 22
per cent (14) of the trainees identified
as members of a religious, social, or
cultural minority. Most trainees (63
per cent) were either married or living
with a partner, and half of the group
had children. The majority of trainees
had siblings and grew up in families
with parents who did not divorce.
Although most felt well cared for in
childhood, moderate levels of trauma
and abuse were reported, along with
low to moderate levels of psychological
and emotional functioning in their
families of origin.
The majority of trainees (63 per cent)
had experience of personal therapy.
But most of these had been in therapy
for less than a year. At the start of their
training, 17 per cent (10) were engaged
in therapy. With regards to mental
wellbeing, the trainees in the study had
low levels of distress and incongruence,
moderate levels of stress, and high
levels of experiential fluidity and life
satisfaction. A minority of trainees (three
per cent) had scores that were within
the clinical range on the CORE-OM(34),
ie might be in need of psychological help
or treatment, with scores that indicated
mild to moderate levels of distress.
How do trainees change?
By the end of their first term, trainees
felt they were making much progress,
had a deeper understanding of therapy,
and were more enthusiastic about
doing therapy. They reported having
experienced moderate change in their
level of therapeutic skill. The essence
of the trainee experience during the
early months of training was ‘altruistic
reflexivity’. Trainees demonstrated not
only ‘radical reflexivity’ (ie the ability
to observe their own self-awareness 7 )
but they were also concerned with
self-awareness for the sake of others,
ie future clients. This was characterised
by intense self-scrutiny that had the
conscious aim of constructing a
therapist-self worthy of future clients.
Trainees aspired to embody the core
philosophy of their chosen programme,
not only to guide their professional
practice, but also as a way for living
their lives. They were primarily
concerned with change, and evaluated
their training on the basis of how far
it assisted or hindered change.
Three main drivers for change at
the start of training were identified:
••
Trainee motivation – they arrived
in a state of change and with the desire
for more
••
The prospect of real clients
••
The course as a gateway to practice:
a testing environment in which change
was evaluated, facilitated and accelerated.
What helps trainees to change at the
start of training?
The most helpful aspect of training at
this stage was personal development
groupwork. This seemed to help by
facilitating real encounters with the
self, the core theory and other group
members. Role-play and meaningful
feedback were identified as the next
most helpful aspect of training because
role-play presented opportunities to
begin to learn how to be a therapist
and develop existing skills and also
to deepen understanding of therapy
process and theory.
The sharing of therapy experiences
between students and of clinical
examples by staff, who were all
experienced therapists, was also
regarded as helpful. As was the way
tutors modelled the core philosophy

‘Trainees were primarily concerned with
change, and evaluated their training on the
basis of how far it assisted or hindered change’
of the course through their interactions
with each other and with the students.
Tutor openness and transparency were
also felt to encourage trainee honesty.
In addition, reading books and journals,
attending courses and seminars, and
case discussions, were all ranked as
moderately helpful at this stage.
Unhelpful experiences
The most unhelpful aspect of the
course at the beginning of training
was negative groupwork experiences,
in particular accounts of feeling
overlooked and unsupported or
frustrated by other group members.
These were not just difficult emotional
experiences but were primarily
regarded as unhelpful because they
were seen as obstacles to individual
growth. By the end of training, however,
the students in the second study
reported significantly higher levels of
therapeutic skill and greater satisfaction
in their work with clients. They coped
better with the demands of being a
therapist, were much less anxious, and
were working in more sophisticated
ways with their clients. There was also
an increase in experiences of boredom
with clients and, to a lesser extent,
difficulties in practice.
How did trainees change?
The single case study, which formed
part of the second study, revealed
processes similar to those of clients
engaged in therapy. Training requires
personal change and therefore creates
problematic emotional experiences for
trainees. In contrast, unlike for many
clients, most trainees do not undertake
training because they are in distress or
in need of help. It is the training that
creates personal problems for trainees.
The case study revealed that initially
the demands placed on trainees may
be fiercely defended against, with
theory often used as a weapon, ie
providing reasons not to change or to
create an emotional distance from other
group members and members of staff.
But over the period of training, as these
problematic aspects of the self were
encountered and then assimilated
(largely through personal development
work), the trainee became more
resourceful with regards to her work with
clients but also better able to develop
more meaningful relationships with
her fellow students and in her personal
life. In short, her ability to become a
therapist was closely related to greater
self-awareness and self-acceptance.
Also revealed in the study was the
fact that, like clients, trainees are likely
to be emotionally vulnerable during this
process of change, but also more likely to
have high levels of emotional wellbeing
and low levels of distress and so in this
respect are able to manage these difficult
emotions in ways that distinguish them
from the clinical population.
Summary of findings
••
Trainees begin training in a state
of change and with a desire for more
••
Unhelpful aspects of training were
processes that became obstacles to change,
eg negative group work experiences
••
The most helpful aspects of training
were personal development groupwork,
observed role-play and feedback, tutor
modelling of the core philosophy, real
examples from tutor practice, work
with clients, and supervision
••
Training has a dramatic impact on
trainees and this is translated into
greater self-awareness, therapeutic
skill, and confidence, and lower levels
of incongruence
••
The process of training may be similar
to that of change processes experienced
by clients in therapy. The assimilation
of problematic experiences encountered
in training are likely to result in
greater congruence and emotional
resourcefulness
••
Most trainees experience painful
emotions during training but maintain
low levels of distress and high levels
of emotional functioning throughout.
Conclusion
The notion that training has little impact
on trainees or on their therapeutic skill
is contradicted by the findings presented
above. However, these results do rely on
trainee perspectives of their training
and their practice and therefore more
research is needed where the
development of therapeutic skill, in
particular, is studied through observing
trainees work with real clients.
What seems clear is that training to
become a therapist requires ‘intra-psychic
adaptation’ 4 on the part of each trainee.
Therefore, training courses do not ‘train
people’ in the same way that therapists
do not ‘do’ therapy. In both cases,
what takes place is the provision of a
supportive and challenging environment
in which change can take place. Thus,
each trainee’s ability to change is likely
to have more impact on the outcome
of training than the training itself.
Julie Folkes-Skinner is a lecturer in
psychodynamic counselling at the
University of Leicester, Director of the
University of Leicester Counselling and
Psychotherapy Research Clinic, and a
BACP accredited therapist and a supervisor.
References
1. Ronnestad MH, Ladany N. The impact of
psychotherapy training: introduction to the
special section. Psychotherapy Research. 2006;
16(3):261-267.
2. Beutler LE, Malik M, Alimohame S, Harwood
TM, Talebi H, Noble S et al. Therapist variables.
In Lambert MJ (ed) Handbook of psychotherapy
and behavior change (5th edition). New York:
Wiley; 2004.
3. Bischoff RJ, Barton M, Thober J, Hawley
R. Events and experiences impacting the
development of clinical self confidence: a study
of the first year of client contact. Journal of
Marital & Family Therapy. 2007; 28(3):371-382.
4. Howard EE, Inman AG, Altman AN. Critical
incidents among novice counselor trainees.
Counselor Education and Supervision. 2006;
46(2):88-102.
5. De Stefano J, D’Iuso N, Blake E, Fitzpatrick
M, Drapeau M, Chamodraka M. Trainees’
experiences of impasses in counselling and the
impact of group supervision on their resolution:
a pilot study. Counselling & Psychotherapy
Research. 2007; 7(1):42-47.
6. Folkes-Skinner J, Elliott R, Wheeler S. ‘A
baptism of fire’: a qualitative investigation of
a trainee counsellor’s experience at the start of
training. Counselling & Psychotherapy Research.
2010; 10(2):83-92.
7. Rennie DL. Radical reflexivity: rationale for
an experiential person-centered approach to
counseling and psychotherapy. Person-Centered
and Experiential Psychotherapies. 2006; 5(2):
114-126.
November 2010/www.therapytoday.net/Therapy Today 23

Society
A therapeutic
prison service?
The Government’s attitude to the rehabilitation of prisoners
is changing. Re-education based on the notions of behavioural
and cognitive change has recently come under the ministerial
spotlight. By Alan Dunnett and Peter Jones
The new coalition may not seem the
most obvious place from which to expect
pronouncements on social justice or the
common good. That one of the longestserving
members of the Conservative
front bench should have put forward
radical ideas on such matters may come
as even more of a surprise. Ken Clarke’s
speech to the audience on 30 June 2010
at King’s College, London, on the future
of the prison service ruffled plenty of
political feathers – disturbing especially
the plumage of many of his own party
members. For the cynical observer, the
speech was no more than a money-saving
ploy. The less cynical were able to read
the underlying question, throwing back
the comfortable certainty of Michael
Howard’s assertion that ‘prison works’.
Returning to ministerial office after
years on the opposition benches, the
new Justice Secretary has taken time
to study afresh the evidence for success
and failure. The prison population has
doubled since Clarke was last in office
in 1993. At 85,000, it is far larger than
the comparative figures for our European
partners. Overcrowding is common.
Morale in the prison service reflects the
dissatisfaction widely felt. Recidivism
rates show no sign of falling. Some 50
per cent of short-term offenders will
be re-convicted within a year of their
release; and more than 60 per cent will
re-offend. Taken overall, the notion that
prisons can be institutions which restore
and repair damaged or failing human
beings is hard to sustain.
For the minister, the two justifications
for a custodial sentence lie in retribution
and re-education. Moralists can argue
about the social need for the first of these
– a process by which the community
claims an individual’s freedom in
24 Therapy Today/www.therapytoday.net/November 2010
compensation for what has been taken
from it. There is less debate about the
now revived concept of restorative
justice: in a process widely used in other
European countries, whereby offenders
make reparation directly with those
harmed by the offence.
Re-education, predicated on notions
of behavioural and cognitive change,
is what has currently fallen under the
ministerial microscope. It is partly, for
sure, with an accountant’s eye that the
Justice Minister is reviewing the balance
sheet from the last administration. It
has been widely quoted that the cost
of maintaining an offender in prison
exceeds that of sending a child to Eton,
yet the educative impact of prison seems,
in the majority of cases, to be negligible
or worse. On the subject of short-term
sentences, another voice has been added
to the chorus of disapproval – that of
Phil Wheatley, former Director General
of the National Offender Management
Service. According to him, short-term
imprisonment ‘does not work’ and ‘does
not have a therapeutic effect’. Wheatley’s
remarks (cited in The Independent, 2.6.10)
feed directly in to those of the Minister
when he highlights that those who do
community sentences fare better than
expected, whilst short-term prisoners
fare worse.
The statements by Clarke and
Wheatley coincided with a less
publicised, but potentially significant
contribution to the lives of those affected
by the debate on the prison service. In
June 2010 the third Annual Conference
of the Counselling in Prisons Network
published its 5-Year Strategy, Promoting
Excellence in Therapy in Prisons. This
ground-breaking document provides
a clear and workable framework within
which therapeutic (in ministerial terms:
re-educative) work can take place. Its
premise is that many or most offenders
will import into the prison setting a
history of trauma, imported distress or
abuse. The strategy therefore aims to:
• Raise awareness amongst criminal
justice personnel
• Create a constructive and therapeutic
regime within which trauma and
imported distress can be safely disclosed
and responded to
• Identify clear pathways for support
and intervention both inside and outside
prisons.
Members of the Counselling in Prisons
Network and all those working with this
population will be under no illusions
about the enormity of the task if the
Justice Minister’s ambitions are to be
fulfilled. Currently, counsellors in
prisons and young offender institutions
work with a very restricted resource
base, sometimes as lone workers or
in small teams in large secure units.
Therapeutic work can be fragmented or
difficult to arrange or liable to premature
termination through removal of an
inmate. There are major challenges in
practical and ethical terms. The needs
of the institution have to be attended to
every bit as much as the counsellor’s own
professional code. Learning to operate
effectively in the prison environment
involves working with the grain of the
institution and accepting necessary
compromises. Until now there have
been too few relevant research studies
and too few opportunities for networking
and sharing best practice. The 5-Year
Strategy seeks to work productively
alongside whatever structures develop
under Clarke’s proposals. Six major
components will be developed:

© hans neleman/the image bank/getty images
• Specialist training and development
for work with offenders
• A Code of Ethics for specific use with
this population and in this context
• Enhancement and sharing of best
practice
• Promotion of relationships – with
service users and across the range of
providers
• Constructive interactions with the
regime (Home Office, prison service,
institution)
• Extension of the evidence base.
It was notable that a recent edition
of the BBC’s Any Questions featured a
question on the issue of prison reform.
The questioner was the mayor of the
town hosting the live broadcast – a
person who, it emerged, had been in
prison as a young man for drugs offences.
His story was that it was support from
others which turned his life around.
There are plenty of similar narratives
to be found. Mark Johnson, founder
of the rehabilitation charity Uservoice,
argues equally strongly for support for
offenders – and for recognition that
this is needed inside prison – not just
on release.
What is sure is that if the Justice
Secretary’s statements are to mean
anything, they will imply a significantly
increased input from individuals willing
to work therapeutically with offenders.
The questions about how posts are
created, funded and maintained remain
to be answered. Without doubt, some
of the work will need to be done by an
expanded volunteer sector. It is likely
that many counsellors will be working
with those on community-based
sentences.
What is clear is that the policies of
the previous administration have been
radically called into question. There is
reason to hope that a more differentiated
system of penal care and offender
management could emerge – one where
notions of re-education and change are
more central than they have ever been
in this country. If this concept can be
allowed to develop, then it is obvious
that those most in contact in supporting
change processes with individual
offenders will play a critical role.
Alan Dunnett and Peter Jones have
co-facilitated annual conferences of the
Counselling in Prisons Network since 2008.
Enquiries about the Network or the 5-Year
Strategy should be addressed to Peter Jones,
Chair of the Counselling in Prisons Network,
at Jonesp@bournemouth.ac.uk. Peter Jones
is a Fellow of BACP.
November 2010/www.therapytoday.net/Therapy Today 25

Debate
The frame
is the
therapy
In response to last month’s article by Nick Totton,
‘Boundaries and boundlessness’, Toby Ingham
argues that well-observed boundaries are the
life-blood of therapy
I found Nick Totton’s article on
boundaries in psychotherapy
(‘Boundaries and boundlessness’, Therapy
Today, October 2010) rather unhelpful.
I think it might serve to confuse readers
and I would like to offer a reply.
Totton’s idea that the ‘therapy police’
are ‘installed in practitioners through
an insufficiently examined notion of
boundaries’ is a questionable statement
that deserves consideration. To my
mind one of the key aims of training is
to enable the practitioner to internalise
their own subjective understanding
of the psychotherapy and counselling
frame. That is, to develop a sense of
one’s own therapeutic identity and an
understanding of what the frame means
to each of us. It is less about thinking
we should behave in line with what is
expected of us by an external authority
or regulator (be that BACP, UKCP, BPC
or HPC), and more about how we are
able to internalise and develop our own
sense of authority based around our
assimilation of ethical codes. To my
mind training should enable us to
fundamentally address and examine
our notions of boundaries. This should
not be an insufficiently examined area
in our trainings.
The facts of the frame
The idea that psychotherapy boundaries
are in place particularly to protect the
client from sexual abuse is far too
reductive. Of course psychotherapy
clients should be protected from sexual
and ethical violations, but in my view
such protection is more likely to be
provided if the therapist’s training has
specifically focussed on the importance
of being able to work within boundaries.
I think Totton’s article confuses (a) the
capacity to adapt to the uniqueness of
each client, with (b) boundary violation.
Adaptation is essential, but so are
boundaries. The idea that such
boundaries are in place to meet a
defensive need in the therapist is, I
think again, overly reductive. Observing
boundaries is a much more involved
business than should be summed up as
‘risk management’. Furthermore, I think
we have to be careful with notions like
‘authenticity’; whatever we think we
mean by such words deserves careful
clarification. The beauty of observing
the facts of the frame is that it really can
be observed. We can for instance be clear
about whether a session has overrun or
not, in a way in which we cannot as
regards what we mean by ‘authenticity’.
I am entirely committed to
maintaining appropriate boundaries in
26 Therapy Today/www.therapytoday.net/November 2010

my work. This is not because I am overly
concerned by the fear of misconduct
hearings but rather because in the
course of my experience as a patient,
a trainee and a therapist, I have come
to the conclusion that well observed
boundaries are the life-blood of therapy.
It is all very well to get drawn into ideas
from ordinary human relationships
about common kindness, care, empathy
and human warmth. But psychotherapy
is not an ordinary relationship, it is an
extraordinary relationship, and what
preserves that is the psychotherapist’s
ability to maintain boundaries.
If we think of ordinary conditions of
unhappiness that may lead an individual
to seek our help, we might think of a
client who approaches psychotherapy
or counselling because they never had
a reliable enough experience of care.
A client, for example, whose mother
or father always impinged too much on
them in their early days. A parent who
was agitated by their baby and instilled
agitation into their child. Or a parent
who was too knowing, persecuting,
demanding, bullying and disturbing.
Our attempts to practise a reliable,
predictable frame are based on the idea
that the therapist/patient (or client)
relationship offers quite possibly the
only opportunity an individual will ever
have to work through these examples
of psychic disturbance and to start
again from scratch. Aside from notions
of disturbances in the individual’s
development, we might think of the
client who comes to therapy because
of failures in the frames of their current
experience. Perhaps they are bereaved,
divorced, have been made redundant;
these again are cases where a predictable
part of their experience has failed,
undermining their confidence.
Holding and containing
You could argue that there are occasions
where we should respond differently,
where we should follow our hearts,
where we should follow the ideas that
spring from the unconscious. I think
more is gained from being able to think
at such moments about what it is in this
relationship that provokes us to want
to do this. What is making itself present
at this moment? It is better that we are
able to notice the spontaneous idea that
emerges within us and be able to reflect
on it. In time we develop the capacity
to hold and contain such experiences
for the client, and the art of feeding
them into the therapy in careful ways.
Psychotherapy and counselling, I
believe, provide the place where the
patient/client should get one thing as a
given: the frame. In my analytic training,
the principle of maintaining a consistent
frame was key. I have come to the
opinion that the thing that is most
valuable about what we offer is a fixed
frame. The frame is more important
than making interpretations. In many
ways the frame is the therapy. Some
people might not like that; they might
stop coming; they might find me too
rigid and inflexible; but I put being a
guardian of the frame above bending this
way or that. I know I have limitations.
In my experience people who object
to the frame are often the ones who are
most in need of the secure and consistent
environment it offers. In my view we do
our best work when, like the DIY
commercial, we do exactly what it says
on the tin: we are clear about times of
sessions, fees, we signpost holidays
clearly. To confuse psychotherapy with
any other kind of human relationship
is mistaken.
We will always be met with very
persuasive reasons for why we should
deviate from this position. Our challenge
is at those most difficult moments to
find a way to keep the line, to reach deep
into ourselves and be able to think about
the impulse that is making itself felt.
These are the moments when we might
say for example, ‘Thank you for your
offer of healing tea; I think you don’t like
finding me ill and you want to make me
better; I thank you for that. I won’t take
the tea, but thank you.’ I think the terms
Totton quotes, for example that Jodie
Messler Davies was aware of becoming
‘mesmerised’, is revealing, and as the
described scene plays out it seems Davies
had no way of managing this experience
other than to go along with it. In
psychodynamic language we might think
of this as something that was acted out.
It was not an event whose symbolic
dimensions could be thought about.
I don’t think an ‘incredible
interpretation’ was necessary at the
point Jodie Messler Davies was offered
the tea. I think all that was necessary
was that the therapist maintained a
frame, a practice of working within a
fixed boundary. The case is described
in a warm tone but I hold that doing
things because they feel like a good idea
is the first step on the path towards a
more serious violation of the therapeutic
position. Better to be able to reflect on
the wish that is making itself present.
I find the notion of ‘undefensive
practice’ unhelpful; it is too vague;
it contains too much opportunity to
legitimise all sorts of actions. I think
this is an example of acting out.
When you train as a therapist you
never know whether you will suit the
training or vice versa. I was fortunate
that my second training was with the
Association of Independent
Psychotherapists, an analytic training
which is particularly focussed upon
training therapists for the demands
of private practice. The AIP training
fundamentally understands the value
of maintaining a frame.
The idea that therapists are boundary
ruled should be true, but this is less to
do with the therapist being overly
restricted in a wilful spirit of deprivation
and more to do with an attempt to
provide a predictable experience of care.
By attending to boundaries in this way
the client may develop confidence that
we are prepared to reflect on all of their
experience. By doing so we pave the way
for them being able to do so themselves.
DW Winnicott’s paper ‘The use of
an object and relating through
identifications’ (DW Winnicott, Playing
and Reality, 1971) is salutary reading.
Amongst other things, this elegant
essay argues that a therapist should be
able to maintain a predictable boundary
despite the provocations deployed by
the patient. Winnicott demonstrates that
ultimately what the patient finds helpful
and which thus leads to progression and
a mutative encounter (the therapeutic
relationship that Totton aims at) is that
the patient comes to realise that the
therapist has survived despite the
patient’s attempts to undermine the
therapy. This proves that the patient
cannot be so bad. To Winnicott’s mind,
this brings a new possibility of care and
love to the therapeutic relationship and
thus to the client’s life. The client gets
the chance to start again from scratch.
So as a rule of thumb I say refuse all
healing beverages and stick resolutely
to the frame. Put the frame first. This
does not mean that there will not be
occasions when a spontaneous thought,
feeling or gesture will not join the
therapy, but that we commit to reflecting
on it when it does. It is being able to work
to these principles that make us useful.
Toby Ingham is a UKCP registered
psychodynamic psychotherapist, counsellor
and supervisor working in private practice
in Beaconsfield, Buckinghamshire. He
supervises on both the Association of
Independent Psychotherapists and the
Manor House Centre for Psychotherapy
and Counselling trainings. He trained as
a supervisor with the Society of Analytical
Psychology. Email toby@tobyingham.com
November 2010/www.therapytoday.net/Therapy Today 27

Day in the life
Giving people
space
Jacqueline Ullmann
divides her time between
her family life, private
practice and her role as
a cancer counsellor at
the Royal Free Hospital
in London.
Interview by John Daniel.
Photographs by Phil Sayer
28 Therapy Today/www.therapytoday.net/November 2010
The alarm wakes me at 6.30am and I try
to sneak in another five minutes of sleep.
Sometimes five minutes become 20
and I have to rush. When the children
were at home, we always had a family
breakfast. Now my husband and I have
breakfast together.
In addition to my private practice,
I work two and a half days a week as
a cancer counsellor at the Royal Free
Hospital in London. I’m lucky because
it only takes 30 minutes to travel from
my home to the hospital. I arrive just
before 9am and the first things I do are
to switch on the computer and check
the message book. I job share with a
colleague. We work alternate days and
overlap one day a week, when we meet
to discuss various departmental matters
and other issues.
I see inpatients and outpatients and
their relatives, and cover all cancers
except for the lymphomas and
leukaemias. There are a further two
counsellors for blood cancers, as the
work is different because the patients
go through different experiences. For
example, the blood cancer patients spend
a lot more time in hospital as inpatients.
The counselling service is very much
part of the whole team and works closely
with the consultants, the medical teams
and the nurses. A few weeks following
diagnosis, if the medical team feels a
patient or a relative is struggling to cope,
they call us in. We invariably insist that
they obtain the client’s agreement first.
People can also self-refer and we see them
at any time during their cancer journey.
I am person-centred and start from
where the client wishes to start. I use
some psychodynamic and systemic theory
and a little CBT. I explain this to clients in
the first session. On an average day I will
see five clients for a 50-minute session
and possibly another one or two just
to say hello and introduce the service.
Some clients come for only one session
– it might not be what they want or they
just need to know that they’re reacting
normally. Other clients access the
service long term.
Obviously, cancer happens to real
people and there may already have been
all sorts of problems in their lives before
diagnosis, and now they just can’t cope.
One week they might want to talk about
the worries they have about their disease,
and the next week they might be angry
that parking was a struggle. I meet them
where they are at, we explore their
feelings and often themes arise.
There are some common themes in
the work. First of all, there’s the fear
of recurrence – how to live with that.
Then there is what I would call ‘other
people’ – the patient has a diagnosis
of cancer and outsiders can’t cope
with it, it freaks them out and they
have ‘crossing the road’ syndrome –
they just want to avoid the patient.
There’s another category of people
who are overwhelmingly helpful and
this is also too much for the patient.
Every day I show my face in the
inpatient ward. There is often a nurse
who needs to tell me about a patient
who is not coping or one who is dying.
I always say I am available to the family
if they want it, but I remind the nurse
that I cannot do magic: the patient is
dying and the family is going to be
upset; that’s normal. Often somebody
says they want to speak to me because
they’ve done so much crying with each
other that they need an outsider. This
is why I am here – to care, support,
listen and give people space.

November 2010/www.therapytoday.net/Therapy Today 29

Day in the life
‘Often somebody says
they want to speak
to me because they’ve
done so much crying
with each other
that they need an
outsider. This is why
I am here – to care,
support, listen and
give people space’
30 Therapy Today/www.therapytoday.net/November 2010
Clients frequently want to know
if I’ve had cancer. I say, ‘Everybody
nowadays has had some experience of
somebody close to them who has had
cancer.’ We leave it at that and they all
understand. Once when a client asked
me that question, she stopped, looked
at me sideways, and said, ‘I can see
you’ve suffered.’ Afterwards, I went to
my colleague and said, ‘Do I look so bad?’
and we had a good laugh.
I used to have lunch at my desk with
one hand on the computer, but my
husband advised me to go to another
room for at least 10 minutes. Now I go to
the counselling room and take The Times
crossword or sudoku with me. I don’t
do the clever crossword; I do the concise
one. My husband is very good at it and
we exchange notes in the evening. It’s
a lovely diversion.
In the afternoon I may have more
meetings to attend. Each different
medical team has its own weekly meeting.
There are many teams – the brain team,
the urology team, the breast team, the
ward team and many more. I don’t deal
with them all. I also do a lot of training
and support with the medical and nursing
staff, and supervise a palliative care nurse.
People in palliative care see end-of-life
only and it can be very heavy and difficult
to bear emotionally.
I have seen a lot of improvements in
cancer treatment in the 10 years I’ve
worked here. We’re not quite as good
as the rest of Europe, and definitely not
as good as the United States, but we are
better than we were. People are diagnosed
earlier because there is so much more
awareness in the population at large, and
amongst GPs. For example, 15 years ago,
if a 25-year-old woman went to her doctor
with a lump in her breast, the average GP
would have said, ‘Don’t worry; it’s the
time of the month.’ Whereas now the
average GP will say, ‘I don’t know what
it is. It’s probably nothing, but let’s
check.’ Also treatments have become
very much more refined and are not
as horrendous as they were.
I usually finish work at 5pm and go
straight home. I have a cup of coffee and
chat with my husband, who is retired and
does a lot of charity work. In the evening,
we spend time together. We both love
classical music and go to concerts.
Sometimes we’ll go out for a walk. We
have a married daughter who lives round
the corner with her husband. They have
a little boy who brings us a lot of joy.
If I am having an evening in I might
do the ironing whilst listening to
Radio 4 – I’m an avid fan. I also like to
read. At the moment I’m reading Julian
Barnes’s Arthur and George, which I find
intriguing. Because I was not educated
in this country – I was born in France
and came to England in my early 20s –
I decided to catch up on quite a lot of the
classics. I also love chatting to friends on
the phone and ring my mother most days.
Bedtime is after 11pm and nothing
much keeps me awake at night. I love my
work; it’s never boring or repetitive. It is
often very sad, but often it’s not. I meet
some amazing people: patients, carers
and relatives. The dedication of the
nursing and medical staff is unbelievable.
I am the first one to admit the NHS is
not perfect, but oh boy, they give so
much. For each ‘scandal’ you read in
the newspaper, there have been hundreds
of good interventions which are never
mentioned, that save and lengthen lives
and improve the quality of people’s lives
dramatically. It is a privilege to be part
of it.

Dilemmas
The counselling-coaching interface
This month’s
dilemma explores
the interface
between counselling
and coaching. Is it
ethical to counsel
a client at the same
time as coaching
his brother, against
the advice of your
supervisor?
This month’s dilemma
Lucy is a counsellor who is
just completing a two-year
diploma in personal
coaching. Martin, one of her
private counselling clients,
has asked her if she will see
his brother Alex. Alex has
been made redundant and
wants some ‘confidence and
career coaching’. Alex knows
Coaching has been an
emerging discipline within
its own right for many years,
with a theoretical base and
ethical structure that is similar
to, but also different from,
counselling. With the launch
of the BACP Coaching division,
it seems timely to consider the
interface between counselling
and coaching, and in particular
the dilemmas faced when those
differences and similarities
present in clinical work.
Like many practitioners in
the coaching field, Lucy is
both a counsellor and a newly
that Martin has been having
counselling for the past
year to help him overcome
depression following a messy
divorce. Lucy’s supervisor
Estelle has cautioned Lucy
about seeing a relative of a
client, whatever the service
being offered, because of
the potential boundary
issues and effects on the
qualified coach; for her, one
framework will influence and
inform the other. The ethical
imperative is for her to hold
the boundaries between the
two. Martin’s request that
Lucy sees his brother Alex for
coaching presents her with a
difficult dilemma. Additionally,
how the interface between
the two activities is managed
in supervision is also brought
into view. The concerns of
Estelle, Lucy’s supervisor,
appear to be made irrelevant
by Lucy because Estelle is not
a coach. Yet, perhaps Estelle
relationship she has with
Martin. However, Lucy
believes that as she’s
offering coaching it will be
a very different relationship
with Alex, that the issues are
just not the same, and that
Estelle doesn’t understand
as she doesn’t coach herself.
What should Lucy do? And
what should Estelle do?
has something important
to say here. The responses
below hopefully tease these
issues out. I am also keen to
receive your responses for
the next dilemma, outlined
on page 33. The December
dilemma not only raises
issues about confidentiality
and responsibility, but about
how the interface between
employer, employee and
counsellor is managed.
Please send your responses
before 29 November to
andrew.reeves @bacp.co.uk
Andrew Reeves
Mary-Jane Kingsland
(mentor and coach)
A coaching approach is well
suited to the type of situation
that Alex finds himself in, and
it is apparent Lucy feels well
qualified to start work with
him. However, for Lucy to
start unravelling this ethical
dilemma, she should ask
herself why, against the advice
of her supervisor Estelle,
she feels that she is the right
person to coach Alex.
Although Lucy may feel
capable of adopting a pure
coaching relationship
with Alex, her year-long
counselling of Martin will,
undoubtedly, inform her
assessment of Alex and
his situation. As Martin’s
counsellor, Lucy will have
discussed Martin’s familial
relationships in the context
of his ‘messy divorce’ – and
as such she is unlikely to
regard Alex and the very
different challenges he faces
with complete impartiality.
A coaching relationship
requires a different skills set
from counselling, and I think
Lucy will find it difficult to
‘switch hats’. There is a real
danger that Lucy will lapse
into counselling with Alex –
particularly if she encounters
apparently familiar ground.
Equally, there is every
likelihood that Lucy’s ongoing
professional relationship
with Martin will be marred
once she starts work with
his brother. It can also be
anticipated that Martin may
subsequently regret offering
Lucy’s services, as he may
feel that the one-to-one
relationship that he has with
Lucy is no longer special but
‘shared’ with Alex. When
Lucy is examining her own
motivations for wanting to
coach Alex, she should also
consider why Martin would
suggest it in the first place?
Estelle will have identified
that no matter how
professional Lucy strives to
be, by delivering counselling
to one brother and coaching
to another, the brothers
may confuse the help they
are getting from the same
practitioner. The implied
nuances of both are not
widely understood outside
of the profession. Lucy
may find that despite her
own professionalism, the
brothers will compare their
time with her and draw their
own conclusions – possibly
damaging their relationship.
Before making any
decisions, Lucy must reflect
upon her relationship with
Estelle and ask herself if
her ego is influencing her
November 2010/www.therapytoday.net/Therapy Today 31

Dilemmas
view of the supervisor’s
role. I would also suggest
that Lucy consider whether
she is best placed to offer
coaching on the specific
topics of confidence and
career coaching, in any
event. Lucy has the academic
qualification to coach, and
one assumes some practical
experience, but coaching for
confidence is a specialist
area, as is coaching for
career advancement, and
the challenges of both should
not be underestimated.
Coaching is not a ‘one size
fits all’ solution, and Lucy
should always consider her
suitability to coach before
taking any coaching work
that is offered to her.
I would suggest that Estelle
review her supervisor’s role in
view of Lucy’s rejection of her
expressed need for caution
and apparent dismissal of her
professional view. Together
they can explore Lucy’s
motivations, but the outcome
depends upon whether Lucy
is prepared to place her
client’s needs before her own.
Linda Aspey (Chair,
BACP Coaching division)
Learning new approaches
and skills is exciting, and
I’m sure that many readers
will resonate with Lucy’s
enthusiasm for putting
her coach training into
practice and recouping her
investment. However, this
might be blinding her to the
potential dangers, and it’s
her role as the professional
to set and hold the
boundaries; she must stay
grounded in her therapeutic
training and principles.
Is Lucy being dismissive
towards Estelle, feeling
superior, or genuinely
misunderstood? Or is she
feeling defensive about
her wish to take Alex on,
when her own ‘internal
supervisor’ is speaking to
her but she doesn’t want to
listen? This needs exploring.
To foster mutual respect
and encourage curiosity,
Estelle should suggest
taking a learning perspective,
looking together at the
BACP Ethical Framework for
Good Practice in Counselling
and Psychotherapy for support.
Additionally, they could draw
upon the BACP Information
Sheet P4 – Guidance for ethical
decision making: a suggested
model for practitioners and use
the Socratic ‘What if’ process
to aid their discussion. They
need to consider Martin
and Lucy’s relationship, in
particular his motives for
referring Alex to Lucy, and
her responses to that request.
Whilst his intentions may
be well meaning, his true
motives may be unconscious
– is this a gift, a test of loyalty
or trust, a sharing of her, or
has he idealised Lucy? And
how does she feel – flattered,
seduced, pressurised or eager
to please? Perhaps he thinks
he’s helping; if so, why does
he think she needs his help?
How is the drama triangle
being played out here; who
could become the victim
or the persecutor or the
rescuer? (Lucy and Estelle
could consider this drama
in relation to their own
dynamic too).
They should explore what
Lucy already knows about
the fraternal relationship;
why is Martin finding a
coach for Alex and what
might happen if the coaching
doesn’t ‘work’ for Alex or if
he doesn’t share Martin’s
admiration of Lucy’s work?
And critically, what might she
do with information gained
from either party about the
other that could affect the
coaching or counselling
work, and what might cause
either of them to become
anxious about sharing their
thoughts? Martin has already
said that Alex needs help
with ‘confidence’, so if that is
the case, what might that say
about Alex’s vulnerability too?
It’s highly likely that
there are parallel processes
between Martin and Lucy’s
relationship and his former
marital one. Is it possible
that this could end up in
a messy divorce too?
Lucy and Estelle should
consider which of these issues
and questions (and others
that are bound to arise) can
usefully be addressed in
the therapeutic work with
Martin. There is certainly
value in him understanding
his motivations and the
wider, systemic implications.
At the end of the day it is
imperative that Lucy keeps
trust with Martin; to do
otherwise could be highly
detrimental. I hope that in
following these steps, Lucy
will feel that taking Alex on
as a coaching client would not
be in anyone’s best interests.
If it’s appropriate, she could
signpost Martin to other
sources of coaching for Alex.
Finally, Lucy might be
at least partially correct in
saying that Estelle ‘doesn’t
understand’ if she’s not
had training in supervising
coaches. Estelle should talk
with her own supervisor
about this and explore her
professional development
needs if she plans to supervise
coaching work too. Both
need to be clear about the
supervision contract and
Lucy may need to have
different arrangements in
place in order to manage
coaching and counselling
work going forward, unless
they are confident that the
two can be properly held here.
32 Therapy Today/www.therapytoday.net/November 2010

Kate Cunnion (counsellor,
supervisor and trainer)
On first reading this dilemma,
I was left with a sense of
confusion and lack of clarity.
Although I was aware of
hearing within myself a very
definite negative response
to the counsellor/coach’s
proposed action, I also knew
that it would be important
for me, or any supervisor,
to explore and tease out
certain aspects of this
situation before coming to
a conclusion and being able
to make an explicit response
with any confidence.
I would like to think that
in any new supervisory
relationship where the
parties involved are from
different training modalities,
time and effort would be
given to addressing the sort
of circumstances described,
so that reference can be made
to such contractual points,
if required. Such would be
the case now with Estelle
and Lucy.
An important circumstance
to bear in mind is that
Lucy was trained first as a
counsellor before undertaking
this, as yet incomplete,
training as a coach. From
that counselling perspective,
it is regarded as unethical to
counsel a close relative of an
existing client. Again from the
counselling angle, whilst Lucy
was counselling Martin, to
what degree was she aware
of the ‘presence’ of his brother
within the room? How much
was she aware of the effects
on either herself or Martin
of triangular relationships?
Another point which is not
too clear in the described
dilemma, but known to
counsellors (and possibly
to coaches) is that anyone
wanting to be counselled,
such as Alex, must make that
first appointment him/herself.
It’s worth Lucy reflecting on
just why she would expect it
to be acceptable for her to
take the word of her client
that his brother wanted an
appointment.
In my opinion what we
know so far does not give us
much to endorse Lucy’s plan
to work with Alex. To be fair
to her, I would suggest taking
the focus now to the coaching
perspective on this dilemma,
for, like Estelle, I know
little enough of what it is
comprised. A proposal I
would put to Estelle would
be that she ask, even require,
Lucy to make as strong and
convincing a case as she can
as to why she should work
with Alex, especially in the
light of the above arguments
against it.
Now I move to the word
‘caution’ as used in the
description of the dilemma.
I can almost see Estelle’s
wagging finger, hear the
critical tone in her voice.
In relation to that, there
goes Lucy, in my mind’s
eye, skipping off to do her
own thing, regardless of her
supervisor’s injunction. Am
I alone in thinking that this
relationship has gone askew?
Perhaps I have
misconstrued the whole
thing. Putting myself in
Estelle’s place, I would
be assertive, own my own
authority and set up a review
of my working alliance and
arrangements with Lucy in
order to ascertain just how
healthy our relationship is.
In the meantime, I would
also suggest that Estelle make
an appointment with her
own consultant supervisor
in order to look at these
developments in some
personal depth. As for Lucy,
at least some reflection,
maybe a piece of writing,
on what is going on for her
as she participates in this
coaching course vis-à-vis the
learning on the subject of its
relationship with counselling.
What of this might be
contributing to a blurring
of the boundaries between
them? My recommendation
to Lucy would be for her not
to work with Alex, at least
until her counselling with
Martin has been finished
for some time, and with the
approval of her supervisor.
December’s dilemma
You are employed as a
counsellor by an employee
assistance programme
(EAP) for a large haulage
company. The EAP funds
six sessions of counselling,
following an initial
assessment. Your client,
John, is an HGV driver for
the company and you have
seen him for four sessions.
He discloses in the fifth
session that he is drinking
heavily – up to a bottle of
vodka in the evening – and
having an occasional drink
at work. John says that he
is ‘sorting this out’ by seeing
you and asks you to keep
the information confidential
for the time being so that
he doesn’t risk losing his
job. You believe John is
making progress and view
his disclosure as an
important statement of
trust, but remain unsure
about what to do.
Please keep your
responses to 500 words or
less. It is important that you
outline your response to the
dilemma, and make your
thinking as transparent as
possible. A small selection of
answers will be published in
December’s Therapy Today,
with others appearing online
(see www.therapytoday.net).
Email your response to
andrew.reeves@bacp.co.uk
before 29 November.
November 2010/www.therapytoday.net/Therapy Today 33

Letters
Male
counsellors
must
protect
themselves
Contact us
We welcome your letters.
Letters not published in
Therapy Today may be
published on our website
(www.therapytoday.net)
subject to editorial discretion.
Email your letter to the Editor
at therapytoday@bacp.co.uk or
post it to the address on page 2.
In the May 2010 issue of
Therapy Today, James Hennah
wrote a letter raising three
issues: one highly context
specific; the personal; the
final, his response to both.
The first issue was about
the difficulties he experienced
as a man working with
children and young people.
The second, drawing on the
first, was about his anger at
being discriminated against:
he wrote about how he
experiences women
practitioners as both socially
and numerically advantaged
in the world of counselling
and psychotherapy relative
to their male colleagues. In
the third he drew upon the
ideas of Stephen Biddulph
(2008) 1 to call for male
counsellors in children’s
work to unite specifically for
working with boys and young
men. Perhaps because of the
specialist aspects of the first
issue, the replies to date have
focused upon the second and
third: the nature and the
polemic of gender politics
are easier and more generally
stimulating to discuss than
the professional and
corresponding personal
difficulties of a colleague.
As a man who has
counselled children in
schools for 10 years, I
recognise what Mr Hennah
writes about. I have been
viewed with suspicion by
parents, staff and colleagues.
I have learned to hesitate
about exploring difficult and
uncomfortable transferences
and counter-transferences
in some supervisory contexts.
I have experienced being
forbidden to work with a
vulnerable female client
following a sexual abuse
disclosure, not because of a
fear that I might contaminate
the evidence in a criminal trial
but because of the school’s
fear that the child might make
‘I have learned to
hesitate about
exploring difficult
and uncomfortable
transferences in
some supervisory
contexts’
an allegation about me. On
these occasions, it seems as
if for a girl or young woman
to engage therapeutically with
a man makes her something
dangerous in the eyes of
the school, a danger that
generally disperses when
she is referred on to a female
therapist.
I am not sure what to
make of Mr Hennah’s remarks
about women and physical
contact with young clients.
I have a formal policy that
with children and young
people I do not touch my
client: despite being aware
of the well-argued case for
the contractual use of
therapeutic holding when
working with children
(Sunderland, 2006). 2 I believe
that such an intervention,
however well intended in
therapeutic terms, is open to
misinterpretation by others.
I do not know the extent to
which other practitioners
of either sex adopt a similar
approach; I would however
suggest to any that have not
formalised their policy one
way or the other on physical
contact with young clients, to
do so with their supervisors
and with those who are
responsible for the welfare
of the children. The scenario
I used to inform my decision
was to wonder what account
I could give for my actions
if a child client said of me,
‘He touched me and I did
not want him to do it.’
Frankly, I think that in
such a situation, my gender
would not be in my favour.
This all reflects the
territory of children’s work
and I think that men, in
particular, just have to deal
with it. Men have to accept
the reality that in society
they are seen as dangerous
and women not: the existence
of data to the contrary seems
to make little or no difference
and men working with
children can have to think
and behave more defensively
than women. This seems to
me to be the most important
implication of the issue that
Mr Hennah raises: in the
context of children’s work,
male therapists have to
compromise their
effectiveness by working in
ways that protect themselves
and their employers even
when it is against the
therapeutic interests of
their clients. This should
be a matter of concern for
all practitioners regardless
of gender. I cannot see a
solution to the problem in
Mr Hennah’s call for men
to come together to form
a ‘Biddulphian’ source 1 of
fathering to lost boys: any
children can benefit from
contact with boundaried,
containing men. What
seems more appropriate
to me is to engage in
reflection and dialogue
with my peers, like this
one that Mr Hennah has
so courageously started.
When this does not happen,
all that may be left are
misattunement, hurt and
risk to therapist and client.
In reflection, sadly now
well after the event, I wonder
what the thoughts and
feelings were of a female
former colleague in a
supervision group some years
ago. I had talked about the
warm counter-transference
feelings I had for a 16-year-old
34 Therapy Today/www.therapytoday.net/November 2010

female client and was seeking
support both to manage
these and to understand
what they meant. My
colleague had two responses
to what I brought. The first
was that she was glad I was
talking about my feelings in
the group, as by doing so it
might make it harder for
me to act on them. Secondly
she thought that perhaps
it would be best if I stop
working with the young
woman in both her
interests and mine. I felt
judged and unsupported
as a professional; more
significantly I felt rejected
and rejecting and I resolved
to be far more circumspect
around where I took such
sensitive issues in the future.
I was tempted to shut up
about my relationship with
my client, but recognising
that secrecy and furtiveness
were greater dangers than
any feelings I may have
been holding about her, I
eventually took the issue
to the supervisor I saw for
my adult work. She, perhaps
because she was less impacted
by the cultural implications
of what I brought, was able
to offer a containing yet still
challenging response. Whilst
I think that may have been
the wise move at the time,
with the benefits of
experience and hindsight I
am now wondering whether
my colleague was scared of
me and what I was bringing;
I wish that I could revisit that
moment to re-explore what
was going on for both of us.
Perhaps she did see me
primarily as a potentially
abusive man and her
supervision as the best she
could do to keep my client
from harm. I want to think
that her fear was more to
do with us both being out
of our depth around my
strong, worrying and
unfamiliar feelings towards
a young woman. Again,
continuing my reflection,
I am not even sure that my
colleague’s gender is relevant
in this discussion: I can easily
imagine getting a similar
response from another man.
Perhaps the experiences of
Mr Hennah and I are due to
the fact that there are many
more women than men in this
business and that statistically
we are more likely to have
such an experience of being
judged with a female
colleague than a male one.
I seek to be nonjudgemental
in my work and
I think that there would be
few in this profession who
would not say the same.
But it amazes me how
insidious my own
judgemental fantasies can
be, particularly in the grey,
often sexual areas where
love, desire and developing
adulthood mix and merge
with the black and white
certainties of the Children’s
Act and the popular press.
Notwithstanding all I have
said, I am continually
surprised by how easy it can
be for me to become caught
up in and go along with the
social process which, with
some support from history,
polarises men and the rest
of society into abuser and
abused.
I am a counsellor and
psychotherapist not an
amateur historian, a police
officer or a gender politician.
Within the bounds of the
need to keep clients safe,
my interest is ultimately
about what happens between
two people, be they client
and therapist or, as in Mr
Hennah’s case, a passing
stranger and a teacher,
anxious not to lose her job
and be pilloried in the local
paper, as the woman who
allowed an abusive man to
get near her primary
school charges.
John Drouot
Diploma Humanistic
Counselling; Diploma
Management Studies;
MBACP (Accred)
references:
1. Biddulph S. Raising boys: why
boys are different – and how to
help them become happy and
well-balanced men (2nd ed).
Berkeley, California: Celestial
Arts; 2008.
2. Sunderland M. The science
of parenting. London: Dorling
Kindersley; 2006.
Observing
strict
boundaries
I found the article
‘Boundaries and
boundlessness’ (Therapy
Today, October 2010) very
interesting, in particular
the part about well-known
counsellors having taken
risks and kept quiet. I would
agree with Nick Totton that
a barrier to taking practice
forward is the perceived
need for ‘defensive practice’
and perhaps also ‘defensive
reporting’ in order to avoid
vulnerability to misconduct
hearings.
After a ‘near miss’ myself
some years ago, several
things about the spectre of
professional conduct hearings
have become very clear to
me. Any complaint about
improper behaviour made
by a woman will have a man
defending himself at a
disadvantage, on the back
foot, as it were. There is no
likelihood of me allowing
boundaries to become
relaxed, to permit ‘boundary
crossings’ as described in the
article, however much in the
client’s interest I believed
that might be; showing that
strict boundaries had been
maintained would be a
cornerstone of any imagined
defence I might need to make.
Also, I find myself very
careful when assessing
prospective female clients.
I no longer accept female
clients with abuse issues,
or who are or have been
involved in complaints issues
or litigation. This is in case
there are repeating patterns
of behaviour involved, which
would make a complaint
against me much more likely
whatever I had or had not
done to provoke one (Kearns,
2007) 1 . Obviously the very
fact that I have this concern
would also mean that it would
not be ethical for me to work
with the issues those clients
are bringing.
The dilemma in the
same issue (October 2010)
described a situation
concerning boundaries,
where the question arose
as to whether a counsellor
should be reported to the
Professional Conduct
Committee, in order to
receive an educational and
developmental sanction.
Within BACP this is a quasilegal
procedure, and
the use of professional
advocates and lengthy
submissions is commonplace,
at a huge emotional cost
(and a significant financial
cost) to the member.
None of the respondents
mentioned the destabilising
effect that such a referral
could be expected to have on
the counsellor’s relationship
with his other existing clients,
and his past clients, and the
cost to those clients in terms
of uncertainty and confusion
at what they might consider
the ‘naming and shaming’
(Kearns, 2007) 1 of their
counsellor by his/her own
professional body.
November 2010/www.therapytoday.net/Therapy Today 35

Letters
I find myself realising
that under no circumstances
whatsoever would I refer a
fellow member (and their
clients) to such an ordeal,
short of being convinced
that membership should
be immediately withdrawn.
In fact I would agree with
Kearns 1 that the current
policy of publically naming
those who have been judged
to need merely an improving
sanction, brings BACP
perilously close to breaching
its own Ethical Framework
(in respect of malfeasance,
justice and self-respect).
David Solomon
MA; MBACP (Accred)
reference:
1. Kearns A. The mirror crack’d:
when good enough therapy goes
wrong and other cautionary tales.
Karnac; 2007.
Understanding
IAPT’s
progress
I am trying to make sense
of IAPT’s own review
of its progress. 1 The detailed
analysis of the effects of the
implementation of the IAPT
programme (Glover et al,
2010) concludes that: ‘...the
collection of such a large
outcome dataset is in itself
a remarkable achievement
for the services’ (p40).
However, to my untrained
eye, it does little to establish
the effectiveness or
otherwise of the treatments
offered to patients. The
treatment offered to patients
at the 32 sites varied greatly:
‘Of the 18,308 patients with
finished episodes receiving
some high intensity therapy,
57.8 per cent received CBT
and 50.1 per cent counselling,
with 1.3 per cent and 0.6 per
cent receiving IPT and couple
therapy respectively’ (p21).
Efficacy of the high level
interventions (of which
CBT and counselling were
the main offerings) varied
greatly and the data reported
seem (to me at least) very
confusing. This seems to
be backed by the authors:
‘It is important to stress
that this cannot be seen as
a test of the comparative
efficacy of the different
treatment approaches, as
patients were not assigned
randomly, but to the
approach which appeared
most suitable in the light
of initial assessment and
locally available resources.
The table makes it clear that
the different approaches
were used selectively for
different problems. As the
programmes included a
substantial element of
training for CBT therapists,
it is also likely that a
substantial proportion of
the staff providing CBT
were inexperienced or
trainees, whilst those
employed to provide
counselling were probably
mainly already trained and
experienced’ (p30).
I have also failed to find
a meaningful definition of
counselling in the document,
which seems to me to be a
glaring omission.
Whilst I cannot fault the
review conclusions about
the tremendous success in
gathering (and indeed its
ability to process) data, the
study does little to support
the theory that CBT is the
best option for the treatment
of a whole host of mental
illnesses and that counselling
is less efficacious; this theory
is actually based on other
randomised clinical trials
which have been previously
reported on CBT in a highly
controlled and scientific
manner (counselling being
less well evidenced; not less
efficacious!). Therefore,
IAPT evidence does not
(yet) support the theory
that ‘CBT is best’ in vivo!
I am now wondering if it
is possible that the data that
IAPT has made available
could be re-evaluated by
BACP, such that people like
myself might be able to make
better sense of the real role
counselling has played in
the IAPT programme so far.
Mark Smith
MBACP
reference:
1. Glover G, Webb M, Evison F.
Improving access to psychological
therapies: a review of the progress
made by sites in the first rollout
year. July 2010. http://www.iapt.
nhs.uk/wp-content/uploads/iaptyear-one-sites-data-review-finalreport.pdf
Supervision
intervention
It is interesting that the
dilemma (‘Managing
boundaries’, October 2010,
Therapy Today) is presented
in the second person. This
perspective forces the
responder to make a choice.
One option is to discuss the
shortcomings of the supervisor
as if they were one’s own; the
other is to reply in the third
person and disown the
supervisor’s work. Naturally
I would prefer to take the
latter stand: the supervisor
isn’t me; I hope I would
never work this way with
a supervisee. But in the
interests of trying on this
supervisor’s person I will
accept the invitation to reply
in the first person.
While I have noted that
I have ‘challenged’ Jason
on the succession of issues
I am concerned about, there
is a glaring absence of
information in this scenario
about how I have been
addressing the apparently
increasing unprofessionalism
of his work. This suggests
that I may not have carefully
planned out or implemented
a method of effectively
helping Jason address these
issues or indeed to see them
as problematic in the way
that I do. Jason’s defence
structure is such that he does
not react to ‘challenging’, so
another style of intervention
should now be attempted.
I don’t seem to be
experienced in dealing with
supervisees who break the
rules, which may suit Jason
perfectly if he is genuinely
unwilling to undertake
further training. It would
appear that in fact it is I who
may need further training,
particularly in how to deliver
appropriate feedback to
enable ethical practice.
It is good news that I have
been taking my concerns
about Jason’s work to my
peer supervision group, but
it is worrying that of all the
feedback given by the group,
the suggestions to either
dump or report Jason are
the ones I am considering.
Both of these courses of
action sidestep my
responsibility to provide
Jason with a suitably robust
supervisory approach.
Additionally, both are
unnecessarily punitive,
humiliating and potentially
damaging to Jason under
the circumstances. After
all, it was I who said ‘none
[of the issues of concern]
have warranted immediate
action’. Am I harbouring
an unacknowledged wish
to be rid of Jason, or worse,
to punish him for not being
a well-behaved and easy
supervisee?
Caroline Vermes
MEd, MBACP (Accred)
36 Therapy Today/www.therapytoday.net/November 2010

Reviews
Evidence
for the
economic
value of
therapy
Psychotherapy is worth it:
a comprehensive review
of its cost-effectiveness
Susan G Lazar (ed)
American Psychiatric
Publishing 2010, £40
ISBN 978-0873182457
Reviewed by Colin Feltham
This is an important,
authoritative and persuasive
contribution to the
explication and promotion
of psychotherapy. British
readers who are counsellors
and psychotherapists will
note that it is decidedly
psychiatric and American in
style and orientation. It opens
with considerations of mental
illnesses, their costs to society
and the contributions of
psychotherapy. Its chapters
examine clinical outcomes
and cost-effectiveness
relating to schizophrenia,
borderline personality
disorder, PTSD, anxiety
disorders, depression,
substance abuse, ‘medical
conditions’, and children
and adolescents. It concludes
with a favourable examination
of long-term intensive
(psychodynamic)
psychotherapy.
The book sets ‘mental
illness’ (standard psychiatric
terminology is used
throughout) in a global
context as the leading cause
of disability but most of its
examples and statistics are
associated with the US
experience. Looked at starkly,
the incidence of all kinds of
psychological distress and
their costs to society proves
both interesting and ‘useful’
as a base from which to argue
for the benefits, indeed
necessity, of psychotherapy.
Contributing authors
review all relevant literature
for their topics and a major
strength of the book is its
scholarly thoroughness. It
seeks to provide (presumably
to fund-holding sceptics)
almost irrefutable evidence
of clinical effectiveness and
the economic wisdom of
utilising psychotherapy.
Tables of published evidence
are supplied, case studies
vividly demonstrate
effectiveness and authors
fairly critique the various
research methodologies
underpinning the evidence
presented in each domain,
although the ‘gold standard
double-blind randomized
control study’ still appears to
have the edge here. There is a
mass of comparative research
and data that should to some
extent be generalisable in
the UK context.
One of the disappointing
(but not surprising) aspects
of the book, to my mind, is
its emphasis on CBT and
psychoanalytic therapies.
Curiously, it actually asserts
that ‘there are several [my
emphasis] theoretical
approaches to psychotherapy,
chief among them cognitivebehavioural
and
psychodynamic’ (p9).
Cognitive analytic therapy
(CAT) and dialectic behaviour
therapy (DBT) do appear but
humanistic therapies do not.
‘Counselling’ is mentioned
in the context of alcoholism
and depression and there
is a very brief review of
‘non-directive counselling’
compared (with uncertain
results) with GP care. Some
European examples have been
given but no links are made
with, say, Layard’s work on
the economic benefits of CBT
in the UK. The book certainly
offers no critique of American
society vis-â-vis the aetiology
of mental distress but it does
in places include relevant
culturally specific data.
This book champions
psychotherapy as a clinically
productive and probably costeffective
intervention. In spite
of its presumably unintended
biases and limitations, it is a
welcome addition to the
debate in the UK about the
economic value of therapy.
Colin Feltham is Emeritus
Professor of Critical Counselling
Studies at Sheffield Hallam
University
Risks of group
interaction
Difficult topics in group
psychotherapy: my journey
from shame to courage
Jerome S Gans
Karnac 2010, £22.99
ISBN 978-1855757691
Reviewed by Chris Rose
This is a collection of
articles first published in the
International Journal of Group
Psychotherapy, dating from
1989 to 2008, introduced
with some personal reflection
upon each topic. Jerome S
Gans is a Distinguished
Fellow of various American
institutions, with many years’
experience of working with
groups privately and within
the American medical system.
Both patients and
therapists take the journey
he describes from ‘shame to
courage’. Shame refers to a
global sense of inadequacy,
of being ‘no good’, which,
according to Gans, we
defend against in myriad
ways, including indifference,
depression, perfectionism
and compulsive caretaking.
He talks of an internalised
ideal therapist who is wise,
compassionate, and able
to make a positive impact.
The constant failure to realise
this ideal in the real word of
helplessness, incompetence
and sometimes hatred can
generate feelings of shame,
which distort our practice
and prevent us from looking
clearly at various issues.
In a similar way, the
patient’s profound sense of
November 2010/www.therapytoday.net/Therapy Today 37

Reviews
failure as a person obscures
other realities from view.
Their courage lies in
committing themselves to
the risks of group interaction,
saying the unsayable, returning
after difficult sessions, and
so forth. As Gans says, ‘most
patients are doing the best
they can’. Group therapists
display courage in various
ways also, depending on
their personal sense of fear.
For some, it might be deviating
from their model, for example,
or openly confronting their
own mistakes.
The journey travels via
issues of hostility, money,
silence, difficult patients,
indirect communication,
combined group and individual
therapy, and the missed
session. In all these areas
Gans has thoughtful things to
say. His personal comments
provide the most engaging
sections, testifying to his
recognition that the
facilitator’s issues are always in
the group. Otherwise, although
the most recent chapters are
only a few years old, it felt to
be a book from my past.
The issues Gans raises are
interesting, but they are not
for me the difficult questions
in group psychotherapy in
2010. Lacking a critical
engagement with its own
social, historical and political
context, the book presents a
world in which conventions
can be challenged but
underlying structures are
unquestioned. For example,
the authority of the therapist
is not seen in the context of
class, gender, sexuality, age,
race, ethnicity, disability or
age. These are the powerful
structural divisions that
shape the self, and present
for me the really difficult
topics in group psychotherapy.
Chris Rose is a psychotherapist,
writer and Associate Editor for
groupwork for Therapy Today
38 Therapy Today/www.therapytoday.net/November 2010
Managing
difficult people
Dealing with difficult
people: from rookie
to expert in a week
Kay Frances
Marshall Cavendish, £9.99
ISBN 978-0462099781
Reviewed by Val W Allen
Aimed at the professional
working within organisations,
perhaps with some
management responsibilities,
this is a practical self-help
book. It provides a focused
description of the hazards of
working life, outlining typically
difficult workplace situations
and people. It aims to help
professionals improve
relationships at work by
providing strategies for dealing
with some of those difficulties.
Counsellors working in
workplace or employee
assistance programme (EAP)
settings may find it useful
to recommend to clients.
The book gives clear
categories of the types
of people who may be
encountered, combined
with some simple tactics
for managing them. Broadly,
this means using emotional
intelligence to understand
difficult colleagues, providing
strategies to turn them into
allies. It also includes
techniques for communicating
and negotiating, problem
solving and managing
confrontation. Although
some therapists will find this
manipulative, others will find
the sketches of characters and
situations helpful for clients
suffering work-based stress.
It uses simple, clear English
in a format that is easy to dip
into. It is well structured and
organised, including tips and
notes for coaches. Although
some tips, such as ‘Keep away
from bad news and depressed
people’, can seem simplistic,
they lead on to practical
techniques for dealing with
situations and people.
Not tackled specifically in
the book are problems arising
from difficult and/or bullying
managers or superiors. Nor
is there much recognition
of the long-term difficulties
that can arise from making
use of grievance procedures,
especially when the culprit
is a senior colleague.
Val W Allen is a counsellor,
psychotherapist and supervisor
Pros and cons
of humanistic
therapies
The problem with
humanistic therapies
Nick Totton
Karnac 2010, £12.99
ISBN 978-1855756632
Reviewed by Louise Guy
This is part of a series of books
that aim to ‘set out the stall
for different kinds of therapies
and treatments, and then
demonstrate that, whatever
the proposed solutions, they
are not necessarily a cure-all,
and can be accompanied by
a series of potentially
intractable problems’.
Nick Totton attempts what
is probably an impossible task
and, inevitably, what has been
produced in a book of only
four chapters and 79 pages
is a severely limited look at
humanistic therapies. This is,
however, balanced by a wideranging
list of 140 references,
many of which are the seminal
works in their fields.
Totton takes Transactional
Analysis, Gestalt and Rogerian
therapy as his ‘big three’
humanistic therapies, although
he does make passing
reference to others. The series
is tightly structured. Chapter
one is entitled ‘What are the
humanistic therapies?’
Chapter two addresses the
‘strengths’ of humanistic
therapies through the 10
distinguishing features that
Totton identifies. These he
balances in chapter three by
examining 10 ‘weaknesses’.
The final chapter considers
how to move forward.
As might be expected from
this author, he tackles the
social and political aspects
of the subject, and the book
is topical as it addresses the
likely regulation of counsellors
and psychotherapists by the
Health Professions Council,
identifying some particular
problems humanistic
therapies might have with
statutory regulation. Oddly,
there is no mention of the
major role played by employee
assistance programmes in the
commissioning of counselling
and psychotherapy in the UK.
I have not read the other
books in the series. If this
book was read in conjunction
with the others, I suspect
that a broad overview of the
current state of therapy in the
UK would emerge. However,
on its own, it is not obvious
which type of reader is being
addressed. This book is a
curiosity but worth a look.
Louise Guy is a senior accredited
counsellor in private practice
in central Scotland

Co-creating
therapeutic
conversations
Reflexivity in therapeutic
practice
Fran Hedges
Palgrave Macmillan 2010,
£21.99
ISBN 978-0230553088
Reviewed by Richard House
Few, if any, specifically
counselling/psychotherapy
books have been written on
reflexivity per se. Several
books have been published
on reflective practice, and
on therapists’ use of self;
however, the distinction
between ‘reflexive’ and
‘reflective’ might be one that
needs more attention. In the
introduction we’re usefully
told that ‘reflexive’ is defined
as ‘capable of turning or
bending back… directed
back upon the mind itself’
[my italics] (p2).
Writing a book on
reflexivity is by no means
straightforward, and Hedges’
approach is perhaps as good
as any. Following Vernon
Cronen’s lengthy
contextualising foreword,
chapter one explores the
ways in which our own
biographical stories influence
our therapeutic conversations.
Thus, ‘when we meet a client...
our identities intermingle...
we are literally entangled in
stories at the interpersonal
level... and we... influence
each other’s self-descriptions,
developing... “we-identities”’
(p15). The author’s socialconstructionist,
postmodern
predilections (which I largely
share) are clearly apparent
throughout. Chapter two
looks at the central role of the
emotions in reflexivity, and
chapter three looks at how
language (a favourite theme
in postmodern thinking)
influences our assumptions
and prejudices. Chapter four
looks, interestingly, at how
stories of time influence
conversations, and chapter
five explores transparency
and self-disclosure. Chapter
six considers bodily responses,
and chapters seven and eight
look, respectively, at further
ideas/resources for practice
and supervision.
The book has an engagingly
non-mystifying readability
that never lapses into
theoretical obscurantism or
superficiality. Hedges renders
challenging postmodern
ideas in a comprehensible
way, weaving in case study
material that is always
stimulating and thoughtful.
I do, however, have several
concerns. The term ‘made
me feel’ recurs throughout
the book. This is a problematic
notion, suggesting a kind of
determinism that most
therapy modalities would
reject; and it surely has no
place in a reflexive discourse
that privileges co-creation.
There are also points in the
practice examples with which
some therapeutic modalities
would take issue: for example,
extensive self-disclosure,
inviting the relatives of clients
to come to therapy sessions,
etc. But these practices do
serve the goal of encouraging
readers to look again at the
often taken-for-granted
therapeutic ‘regimes of truth’
within which we work, and to
question their assumptions.
This is an excellent book
for any student/trainee
wanting a readable and
engaging introduction to
systemically informed,
postmodern approaches
to co-creating effective
therapeutic conversations.
Richard House is Senior
Lecturer in Psychotherapy
and Counselling at Roehampton
University and the author of
Therapy Beyond Modernity
and Against and for CBT
The impact of
domestic abuse
Rebuilding lives after
domestic violence:
understanding long-term
outcomes
Hilary Abrahams
Jessica Kingsley 2010, £18.99
ISBN 978-1843109617
Reviewed by Cath Fuller
This is a longitudinal study
of the effects of domestic
violence and abuse on the
lives of 12 women. They were
interviewed first when they
were in refuges, then six
months later, then a few years
after that. This is the book’s
unique selling point, as most
studies cover a much shorter
timescale. Working with the
women over this extended
timescale, Abrahams was able
to gain their trust, and they
report they found the research
process a validating and
positive experience in itself.
The author’s respectful,
acceptant and honest approach
models the guiding principles
of working with women whose
self-esteem and sense of
safety have been shattered by
domestic violence and abuse.
It is the author’s aim to assist
today’s policy makers
and service-providers in
developing appropriate,
targeted and cost-effective
services.
This is a really useful
resource for inexperienced
and trainee counsellors. It
is written in clear and direct
language and is well
structured, with bulletpointed
summaries at the
end of each chapter and
a useful list of organisations
and their websites in an
appendix. Counsellors who
are more experienced in this
field may not be surprised
by the book’s conclusions,
but they are likely to gain
a richer and deeper
understanding of the
problems and impact of
domestic violence from
these women’s stories.
With evidence that 30
per cent of a larger group
of women surveyed either
started or returned to abusive
relationships after leaving
the refuge, emotional
loneliness is identified here
as one of the major hurdles
to be negotiated. The reader
learns that the gradual
process of leaving and
returning to an abuser ‘may
ultimately increase a woman’s
confidence in her ability to
manage alone, or… to
recognise that she is repeating
old and outworn patterns of
behaviour and eventually gain
the strength to take a stand
against the abuse’.
It can feel frustrating and
overwhelming to counsel
these clients. The closing
chapters of the book – in
which the women look
forward to brighter futures
– powerfully validate the
work of services which do
not give up on those who live
with domestic violence and
abuse, difficult and draining
as the work may be.
Cath Fuller is a psychotherapist
November 2010/www.therapytoday.net/Therapy Today 39

Reviews
Reasons
for lying
Why we lie: the source
of our disasters
Dorothy Rowe
Fourth Estate 2010, £18.99
ISBN 978-0007278855
Reviewed by Gertrud Mander
This is an amazing book with
a snappy title that at first made
me expect a morality tract.
In fact, the author does not
plead for more telling of the
truth, but rather for a thorough
examination of how ‘ubiquitous
lying is in human life and how
we construct reality’. She uses
her vast psychological
knowledge to reveal what
complicates our perception,
confirming Freud’s discovery
of the unconscious: ‘We cannot
see reality directly, but only the
constructions our brain devises
from our past experience. Most
of what we know lies in our
unconscious.’ But she is no
Freudian and is quite critical
of the ‘lurid connotations of
psychoanalysis’ (p39). Her own
approach is pragmatic, as she
believes that consciousness is
quite a small part of what goes
on in our brain: ‘the fear of
being annihilated as a person
is far worse than the fear of
death... This is why we lie’ (p50).
This lively book is brimful of
interesting thoughts, theories
and questions, and contains
fascinating information on how
we construct reality. There
are interesting stories about
celebrities, quotes from the
writer’s extensive reading, from
her vast knowledge of history,
politics, of crooked presentday
events, and the affairs of
famous people like Hemingway,
Sartre and Simone de Beauvoir.
Confirming that ‘lying is
necessary’, Rowe goes on to
describe how we learn to lie,
and how we lie because we
have reason to lie, and are
afraid of chaos. Yet we are also
shown how dangerous it is to
be obedient, how important
fantasies are, how they are
shared with others, and that
we are constantly drawn into
other people’s mad conspiracy
theories, eg the delusions of
politicians like Hitler, Stalin,
or, dare I say it, Gordon Brown.
There are interesting asides
on climate change, churches,
scientists, Holocaust deniers,
pet hates like Blair, Cheney,
Bush, and high finance horror
stories like Enron and RBS.
Last but not least, politicians,
bankers and people who are
lying for the Government tell
us about how we are lied to
by the newspapers.
I highly recommend this
book. The only thing that was
missing for me is a bibliography.
Gertrud Mander is a
psychodynamic psychotherapist
Challenging
bullies in the
workplace
Managing workplace bullying:
how to identify, respond
to and manage bullying
behaviour in the workplace
Aryanne Oade
Palgrave Macmillan 2009, £25
ISBN 978-0230228085
Reviewed by Vee Howard-
Jones
This book does exactly what
it says in the title. The reader
is given practical step-by-step
information and instructions
on how to manage a myriad
of situations that involve
workplace bullying. Its author
is a seasoned chartered
psychologist, who runs her
own coaching and development
business and has delivered
workshops and training events
to businesses in the public and
private sector. She draws on
the experiences of her clients
to produce some helpful case
studies which give the reader
opportunities to gauge how
they might respond in a
number of given circumstances.
In this way the book is rather
like a self-help learning tool.
The text is aimed at four
groups: those with experience
(current or past) of being
bullied; those who linemanage
someone who
bullies; people who are
close to someone who is
being bullied; and those who
witness bullying behaviour.
The reader is left in no
doubt regarding Oade’s
opinions of bullies in the
workplace or otherwise.
Whilst there is a helpful
section that looks at the
psychological motivations
of bullying behaviour, there
is little consideration for how
bullies become who they are.
Empathy for the bully and
the bullied is a key ingredient
if any kind of mediation and
resolution of difficulties is
going to occur.
Having said this, Oade
aims to empower those who
are experiencing bullying
behaviour. She does this
with crystal clear rhetoric
and carefully considered
potential outcomes.
Enhancing self-esteem
through confronting the
bully is sensitively discussed.
The book is a practical,
well-structured, logical and
pragmatic approach to the
subject, which helps to
affirm and normalise the
experiences of those on the
receiving end of bullying
behaviour.
Vee Howard-Jones is Associate
Director of Psychology,
Counselling and Psychotherapy
at the University of Salford
Visit www.bacp.co.uk/shop for great books at great prices!
Browse the BACP online bookshop for the full range of BACP
publications including: training & legal resources, directories, research
reviews, information sheets and more.
Now available: Essential law for counsellors & psychotherapists – this third
book in the series provides a user-friendly guide to the law for all those practising
and training in the counselling profession, by Barbara Mitchels & Tim Bond.
40 Therapy Today/www.therapytoday.net/November 2010

News
From the Chair
How are developments in the political
and economic arena impacting BACP
and counselling and psychotherapy?
By Lynne Gabriel
The Government’s
comprehensive spending
review (CSR) has been
uppermost in many minds
recently. The review is now
in the public domain and
there are economic
challenges ahead that will
touch us all. On a positive
note, the CSR makes clear
that psychological therapies
will continue to receive
government funding.
Continuing government
commitment to talking
therapies is excellent news
and BACP is working with
others to ensure that clients
and patients have access
to a range of psychological
therapies. Through the ‘We
need to talk’ coalition, which
represents mental health
organisations, professional
associations and groups who
place high priority on client
choice and access to a range
of psychological therapies,
BACP is working to influence
client/patient access to a
range of evidence-based
psychological therapies.
BACP was represented at
a recent high-profile mental
health summit, organised
through Mind and the
Coalition. Paul Burstow,
Minister of State (Care
Services), attended the
meeting to discuss key
matters and conveyed the
Government’s continuing
commitment to mental health
and wellbeing. The ‘We need
to talk’ coalition will
continue to influence the
Government’s mental health
strategy in positive and
proactive ways.
Some of us have also
been awaiting Lord Browne’s
report on securing a
sustainable future for higher
education. For those who
offer counselling and
psychotherapy training
within a university setting,
there are significant
implications. The Browne
report proposes the removal
of the Higher Education
Funding Council for
England(HEFCE),
recommending that the
current cap on fees of
£3,290 is removed, thereby
allowing universities to set
fees to reflect the quality of
the course or programme.
It is likely that universities
will charge annual fees of at
least £6-7,000 per year for
undergraduate programmes.
The creation of a free market
in the HE sector will bring
challenges – and
opportunities – for
counselling and
psychotherapy training in
higher education settings.
Watch this space.
In relation to dialogues
and contact with members,
in BACP’s ‘Making
Connections’ events, we often
have questions and comments
from members about
regulation, but by far the most
common concerns are about
jobs and workforce matters.
With that in mind, it is good
to see the Government’s
commitment to psychological
therapies in the CSR – we
look forward to more detail
on the planned investment
and expect that client/patient
choice of a range of therapies
will be a priority. Counselling
and psychotherapy already
has a skilled workforce,
enabling swift ‘up-skilling’ of
practitioners for specific work
contexts. It is inevitable that
austere times increase mental
health and wellbeing issues
in the general population,
necessitating even better
access to psychological
therapies. Given the growing
evidence of the efficacy of
talking therapies for mental
and emotional distress, we
expect to see greater
provision of counselling
within and alongside IAPT
(Improving Access to
Psychological Therapies).
On the regulation front,
the work of the Health
Profession Council’s (HPC)
Professional Liaison Group
(PLG) continues. The PLG’s
November meeting was
rescheduled to enable two
working groups to convene –
one to devise Standards of
Proficiency (SoPs) for
psychotherapy, led by
Peter Fonagy; the other to
formulate Standards for
counselling, led by Sally
Aldridge, BACP’s Director
of Regulatory Policy. We will
keep you updated on how
this work progresses.
Finally, I wanted to let
members and other readers
know that a new BACP
committee will soon be in
action. The committee –
Professional Ethics and
Quality Standards – will
replace the Professional and
Ethical Practice Committee
(PEPC) and the Professional
Standards Committee (PSC).
I want to say a very warm
thank you to Mary Berry
(PSC Chair) and Pat Siddons
(PEPC Acting Chair), for
their chairing roles and
contributions to their
committees, which are in
the process of standing down.
Mary and Pat, and their
committee colleagues,
worked well to design and
implement a committee
structure that best reflected
current policy, ethics,
standards and training
issues in BACP, as well as
within the counselling and
psychotherapy field. My
thanks to all of the PEPC
and PSC committee members
for your time, commitment
and contributions to BACP.
Volunteer work with BACP
makes a key and crucial
input to the continuing
development of the
Association.
Lynne Gabriel
BACP Chair
November 2010/www.therapytoday.net/Therapy Today 41

News/Professional standards
Policy and public affairs
Following a question asked
in Parliament about the
regulation of counselling
and psychotherapy, BACP’s
Director of Regulatory Policy,
Sally Aldridge, wrote to
Middlesbrough South and East
Cleveland MP, Tom Blenkinsop.
The letter expressed the view
that whilst the issue of
regulation remains unresolved
by the Government, BACP
urges members of the public
who are seeking support to use
BACP members, who are all
bound by the Ethical Framework
and conduct procedures.
The ‘We need to talk’
coalition, of which BACP is a
member, published its report
on ‘Getting the right therapy
at the right time’. Of particular
interest to members is the
section on ‘The impact on
therapists’, which states:
‘The recent developments in
psychological therapy provision
over the last few years have had
a mixed impact on therapists.
Psychological therapy training
is now available on the NHS
with IAPT funding 3,600 new
therapists. This is a fantastic
opportunity for the profession.
However, research by the
British Association for
Counselling and Psychotherapy
has found that, where areas
implement IAPT in a way
that reduces funding for other
services, therapists not trained
in IAPT modalities, particularly
CBT, are losing their jobs. For
example, many in-house GP
surgery counsellors are being
let go, depriving services of the
local knowledge and valued
relationships with service
users that these counsellors
have built up over the years.
Underusing an existing
trained workforce is simply
not practical, particularly in
the current financial climate.
‘In discussions with service
providers we were also told
that many IAPT therapists
are experiencing stress as a
result of having to work with
complex problems they are
not trained for, due to
inappropriate referrals. This
has led to some therapists
leaving the IAPT programme.’
The full report can be found
at http://www.bacp.co.uk/
campaigns/index.php?news
Id=1967&count=4&start=0&
filter=&cat=46&year
BACP has been working
closely with NHS Choices to
assist in the development of
an emotional support directory.
The aim of this directory is to
allow users to find services
providing short and mediumterm
interventions for
emotional health. We now
have over 200 listings of BACP
accredited services or members
in the directory. For further
information, please see
http://www.nhs.uk/service
directories/Pages/Service
SearchAdditional.aspx?
ServiceType=Mentalhealth
The Department of Health
has consulted on a range of
elements of the NHS White
Paper, ‘Equity and Excellence:
Liberating the NHS’, which
sets out the Government’s
long-term vision for the future
of the NHS. BACP responded
to all four consultations:
••
Local democratic legitimacy
in health
••
Transparency in outcomes
••
Regulating healthcare
providers
••
Commissioning for patients.
BACP’s comments on all
consultations can be found at
http://www.bacp.co.uk/policy/
previous_consultations.php
BACP responded to the
Education Select Committee
enquiry on ‘Behaviour and
discipline in schools’. We
provided evidence showing
that counselling in schools
can significantly improve
young people’s challenging
behaviour, support them
with their emotional
difficulties and help them
manage their anger.
BACP welcomed revisions
to the generic standards of
proficiency consulted on
by the Health Professions
Council and believes they
will enable a wider range of
professions to see the HPC
as an appropriate regulator,
if this is the policy pursued
by the Coalition Government.
BACP also responded to
the following consultations:
••
Regulation of independent
healthcare in Scotland,
Scottish Government
••
Depression quality
standards, National
Institute for Health and
Clinical Excellence
••
New learning and
development qualifications
in England, Wales and
Northern Ireland, Lifelong
Learning UK.
Finally, BACP was
represented at the Annual
Party Conferences of the
Conservative Party, Labour
Party and Liberal Democrats.
For further details, please
contact policy@bacp.co.uk
Kooth.com clarification
In the October 2010 issue
of Therapy Today, it was
stated in the ‘Day in the life’
interview with Aaron Sefi
(titled ‘Online disinhibition’)
that Aaron ‘counsels young
people all over the country
from his house on the
Cornish coast.’
Kooth.com have asked
us to clarify that although
their counsellors are based
nationally, they are unable
42 Therapy Today/www.therapytoday.net/November 2010
to offer a service to young
people from ‘all over the
country’.
Kooth.com is funded
by local authorities, and
therefore is only able to
offer a service to young
people who live within
specific local authorities.
For further information
about Kooth.com, please
visit the website http://
www.xenzone.com
Newly accredited
counsellors/
psychotherapists
We would like to congratulate
the following members on
achieving their BACP
accredited status:
Lynn Ash
Emma Atherden
Julia Bailey
Jill Barry
Erica Brunner
Mary Carr
Janette Caunt
Jacqueline Chamberlain
Sheila Cole
Julie Colling
Olivier Cormier-Otaño
Helen Cotter
Jo Donoghue
June Edney
Janet Edwards
Beth Forster
Bob Froud
Anne Glynn
Helen Goddard
Cecilia Gregory
Lynne Harmon
Rosemary Hawes
Amanda Haynes
Julie Hewings

Could you write an information sheet for
the BACP Information Services department?
The information sheets have
become a valuable resource
for members seeking
guidance on best practice in
a wide variety of settings and
topics. We now have a library
of more than 45 of these
sheets and we are hoping
to commission a number of
new sheets. The Information
Services Editorial Board
(ISEB) has suggested some
of the essential elements
that need to be included.
BACP members are invited
to submit a synopsis for an
information sheet on any
of the following topics.
Risk assessment in
counselling and
psychotherapy
How to identify and assess
risk (eg potential physical or
other harm) to the counsellor
(eg attack, stalking, etc) and
to the client (including selfharm
and/or harm to others).
Ethical considerations
for counsellors and
psychotherapists when
thinking of working in a
client’s own home
The issues that a therapist
would need to take into
consideration when working
in a client’s own home, both
on a practical and ethical
level. For example, risk
assessment of the situation
for therapist and client,
factors that may impact
on therapy, etc.
If things go wrong with
clients – prevention,
management, recognition
How might therapists develop
their awareness of the client’s
perception of therapy and
whether it is progressing well?
How to foresee and prevent
things going wrong. Regular
review procedures with clients
and in supervision. Ways to
recognise and acknowledge
appropriately those situations
when clients are not happy
with their therapy. Possible
ways of coming to a
resolution of conflict.
Working with clients
with dementia and/or
Alzheimer’s disease
The recognition of dementia
and Alzheimer’s, and the
challenges and issues relevant
to working with clients with
these conditions. For those
in residential care, issues of
administration, and practical
arrangements for provision
of appropriate therapy.
Appropriate therapeutic
modalities and skills.
Please note that information
sheets need to link with the
BACP Ethical Framework for
Good Practice in Counselling
and Psychotherapy, current
published research and other
relevant information sheets.
Guidance on ‘house style’
and the overall requirements
regarding writing an
information sheet can be
found in the Information
Sheet A1 in the members’
area on the BACP website,
and information packs are
available on request, which
include a pro forma for your
sypnosis. The deadline for
submission of the above
information sheets is
Monday 20 December.
ISEB will select one
synopsis and author for each
of the above information
sheets, from those submitted.
The author will then need to
enter into a ‘commissioning
contract’ with BACP and an
author’s fee of £200 is payable
for each information sheet
agreed and published. This
is paid in two instalments
of £100 each, the first on
receipt of the first draft and
the second on publication
of the information sheet.
For further information,
please email Denise
Chaytor (Information
Services Manager) at
denise.chaytor@bacp.co.uk
or call 01455 883315.
The Information Services
team is very keen to meet
the needs of our membership
and of those seeking
counselling, and we would
be very pleased to receive
suggestions for useful
information sheets for either
group. Please email Denise at
denise.chaytor@bacp.co.uk
All information sheets are
available to download from
the members’ area of the
BACP website, or they can
be purchased in hardcopy
format for £2 (members)
and £3 (non-members) from
the online BACP Shop.
Denise Chaytor
Information Services Manager
Christine Hildersley
Tracey Hughes
Elizabeth James
Alison Jenkins
Jennifer Jones
Dalvir Kaur
Malcolm Kennedy
Beate Lippik
Paula Mallinson-Roberts
Thomas Marron
Debbie Miller
Lynne Nowell
Lois Pearce
Lyn Powell
Caroline Reeves
Andy Rickford
Sharon Robinson
Margaret Russo
Lisa Shapter
Elizabeth Shipp
Alison Slinn
William Smith
Sonia St John-James
Liz Stephen
Anastasia Sullivan
Aelie Symons
Gail Thompson
Pauline Thrower
Sean Turner
Cynthia Wassall
Marie-Louise Whitehead
Sandra Whyman
Mike Wibberley
Yvonne Wildi
Lyn Willcox
Patricia Willoughby
Newly accredited
counselling/psychotherapy
supervisor of individuals
and groups
Terry Shevlin
Newly accredited
counselling/psychotherapy
supervisors of individuals
Myles Donnan
Maureen Perkins
Hazel Stevenson
Ann Vodden
Newly accredited
counselling/psychotherapy
service
Colchester Mind
Successful counselling/
psychotherapy service
re-accreditations
Young Concern Trust
(YCT)
All details listed are correct
at the time of going to print.
November 2010/www.therapytoday.net/Therapy Today 43

Research
Research using routine outcome
measures may enable individual
needs to be considered
Research within counselling
and psychotherapy often
raises concerns amongst
therapists. Some of the
concerns are highlighted in
a recent paper by Professor
Mick Cooper, published in the
September 2010 issue of CPR,
‘The challenge of counselling
and psychotherapy research’
(10(3):183-191). One of the
primary concerns raised by
therapists is with regards
to research ‘dehumanising’
clients, through generalising
findings, when therapists
often want to focus on an
individual’s experience of
therapy. However, research
in counselling and
psychotherapy doesn’t
necessarily mean the
therapist cannot allow their
client to be an individual,
or to treat them as such.
There are many different
formats in which to conduct
research in counselling and
psychotherapy. A recent
NHS White Paper ‘Liberating
the NHS: Transparency in
Outcomes’ discussed the
need for Patient Reported
Outcome Measures (PROMS)
in both physical and mental
health services. PROMS are
something that have been
utilised within mental health
services for many years.
They are essentially any kind
of questionnaire that a client
completes (eg CORE, SDQ),
rather than a therapist or
practitioner reporting on
the client’s progress. The
benefits of using PROMS
for both clients and therapists
are great, although many
therapists still object to
using these for the purposes
of research. The three main
benefits for using routine
outcome measures are:
1. They have the potential
to focus therapy towards
an individual’s needs.
2. They enable therapists
to provide evidence for the
effectiveness of their work.
3. They can be used for
reflective practice.
The use of routine outcome
measures for the purposes
of research may enable
therapists to gain a greater
understanding of what works
for whom. Within counselling
and psychotherapy, not to
mention other mental health
services, there is a wide range
of therapeutic approaches
and presenting problems for
which clients attend therapy
(eg depression, anxiety,
PTSD, eating disorders,
bereavement etc). Therapists
are often concerned with
focusing on an individual’s
needs and experiences of
therapy and the routine use
of outcome measures can
actually aid therapists in
understanding the individual
rather than generalising and
‘dehumanising’ clients. Many
referrals to counsellors and
psychotherapists are made
by general practitioners and
are often based on clinical
judgement and the availability
of therapists. However, if
routine measures are used
for the purpose of research,
these could be used to inform
GPs of what may be the most
appropriate mode of therapy,
or type of therapist, for their
patient. Outcome measures
will not simply generalise
clients on the basis of
diagnosis (eg that everyone
presenting with depression
is best dealt with through
a specific type of therapy).
By gathering information
on a client’s diagnosis,
demographic information,
previous experience of
therapy and client
preferences, alongside
outcome measures, an
understanding of what works
for whom at the client level
could be developed.
Further reading
Cooper M. The challenge of
counselling and psychotherapy
research. Counselling and
Psychotherapy Research.
Lutterworth: BACP. 2010; 10(3):
183-191.
Roth T. BACP Information sheet
R4. Using measures and thinking
about outcomes. Lutterworth:
BACP; 2006.
2011 CPR New Researcher prize
Are you currently doing
research for your degree?
Or have you completed
a research project within
the last 24 months?
The BACP Research
department and the editorial
board of Counselling and
Psychotherapy Research
(CPR) would like to
encourage you to submit
an account of an empirical
44 Therapy Today/www.therapytoday.net/November 2010
research project for the
2011 CPR New Researcher
prize. The winning entry
will receive £200 worth of
book tokens plus £200 cash.
This prize is sponsored by
Routledge, part of the Taylor
& Francis Group. Submissions
should not exceed 4,000
words (excluding references)
and should be accompanied
by an abstract of no more
than 350 words, with a list of
keywords below. Submissions
can be either qualitative or
quantitative, and must
adhere to the academic
conventions of CPR (visit
the CPR website for further
details: www.cprjournal.com).
Please send submissions to
angela.couchman@bacp.co.uk
by 5pm on Friday 10
December 2010.
Next research
surgery date
The next research surgery is
on 9 December from 2-4pm
(30-minute slots for each
session). Book early to avoid
disappointment; please email
joanne.pybis@bacp.co.uk or
call 01455 206359. Along with
your briefing, you will need to
forward a telephone number
where you can be contacted.

Case Study Research in Counselling
and Psychotherapy: a foreword
Case study research
in counselling and
psychotherapy
John McLeod
Sage 2010, £21.99
ISBN 978-1849208055
Foreword by Daniel B Fishman
Many of the major ideas and
theories associated with
psychotherapy have been
created and empirically
demonstrated through case
study research. Immediate
examples that come to mind
in psychoanalysis are Sigmund
Freud’s cases of ‘Dora’ and
‘Little Hans’; in behaviour
therapy, JB Watson’s case of
‘Little Albert’ and BF Skinner’s
insistence that behavioural
principles of learning be
studied one organism at a
time; in cognitive therapy,
Aaron Beck and colleagues’
book, Cognitive Therapy in
Clinical Practice: An Illustrative
Casebook; in client-centred
therapy, Virginia Axline’s case
of ‘Dibbs’; and in existential
therapy, Irvin Yalom’s book
of cases, Love’s Executioner &
Other Tales of Psychotherapy.
However, in spite of the
case study’s impressive
contributions to psychotherapy
theory and practice, starting in
the 1920s and gaining strength
and going forward until
recently the view was that case
studies were by their nature
unscientifically journalistic
and subjectively biased, and
they became marginalised in
psychotherapy research. The
major source of this negative
view of case studies was the
domination in psychology –
psychotherapy’s main research
discipline – of a positivistically
inspired research paradigm.
This paradigm privileges the
deductive search for general,
context-independent
knowledge by the quantitative,
experimental comparison of
groups, dealing with
statistically simplified
individuals.
In contrast, practitioners
know that therapy knowledge
always starts with the
contextually specific,
qualitatively rich case that is
naturalistically situated, that
deals with real persons (not
statistical composites), and
that generalises via induction
from the specific. Case-based
knowledge is thus the polar
opposite of knowledge based
on group experiments – that
is, qualitative vs quantitative,
naturalistic vs experimental,
context-dependent vs contextindependent,
inductive vs
deductive, and individual-based
vs group-based, respectively.
These dramatic differences in
the epistemology of traditional
researchers and practitioners
have created tensions between
these two groups, with each
frequently dismissing the other
for being off-base in advancing
our understanding and the
effectiveness of psychotherapy.
In recent years, with the rise
in psychology of a postmodern
alternative to positivistic
epistemology, there has been
a re-emergence of interest in
the case study as a credible
and useful vehicle for therapy
research, complementing
experimental group studies.
However, this re-emergence
has been quite fragmented
geographically, conceptually,
and methodologically, and it
has been hidden from the view
of many academic researchers
and practising therapists.
John McLeod’s book, Case
Study Research in Counselling
and Psychotherapy, does a
brilliant job of pulling these
fragments together into a
persuasive and coherent whole.
Using accessible and engaging
language, concepts, and
examples, McLeod provides
clarity and insight as he guides
the reader through challenging
clinical and epistemological
terrains, along the way
showing how the researcher–
clinician divide can be bridged.
McLeod accomplishes these
goals in three ways.
First, in chapters one to
three, and 12, McLeod describes
in detail the historical
development of case study
research towards methods that
create systematic, observationbased,
rigorous, critically
interpreted information –
that is, ‘scientific’ knowledge
in the usual sense of the word.
This type of information
links the experiences of the
practitioner to the general
scientific knowledge base
of the field, at the same time
providing credibility for casebased
knowledge in the eyes
of traditional psychotherapy
researchers.
Second, McLeod lays out and
discusses specific methods and
considerations in conducting
systematic and rigorous case
studies, including ethical issues
around ensuring the privacy
of the clients being studied
(chapter 4) and how to collect
and analyse case study data
about the process and outcome
of therapy (chapters 5 and 11).
McLeod pays particular
attention to procedures for
clinicians – not just academic
researchers – to conduct
systematic case studies
that can contribute to the
discipline’s knowledge base.
Finally, McLeod catalogues
and describes the ways in
which the case study field has
differentiated into five distinct,
complementary models of
systematic and rigorous case
study research. Each model has
a distinct purpose, method of
data design and collection, and
strategy for data summary and
interpretation. And each model
has unique value in expanding
the field’s knowledge base,
both practical and theoretical.
The models include an
emphasis upon the use of case
studies as exemplars of best
clinical practice (chapter 6);
as settings for single-case
experiments (chapter 7);
as vehicles for intensively
evaluating efficacy via multiple
types of data as analysed by
multiple judges (chapter 8);
as a means for theory-building
(chapter 9); and as a way to
explore the narrative meaning
of the therapy experience
for both client and clinician
(chapter 10).
In short, McLeod’s
accomplishment is
extraordinary. He has cogently
and persuasively pulled the
separated strands of the
multifaceted field of case
study research in counselling
and therapy into an intricate,
integrated tapestry that lays
out a detailed and effective,
stellar road map for future
goals in the field, and
pathways for getting there.
Daniel B Fishman, PhD,
Graduate School of Applied
and Professional Psychology,
Rutgers University.
November 2010/www.therapytoday.net/Therapy Today 45

Research/Professional conduct
BACP’s annual research conference co-host: the SPR
‘Research and Practice’ –
6 and 7 May 2011, Liverpool
BACP is delighted to welcome
the Society for Psychotherapy
Research (SPR) as its co-host
for the conference next May.
SPR (UK) is an international
organisation which brings
together researchers and
practitioners from different
backgrounds and traditions.
Like BACP, SPR membership
draws on and contributes to
a wide range of international
psychotherapy research.
The SPR has hosted its
own annual conferences
for 25 years and its aims are
in line with those of BACP;
to foster a climate of open
inquiry, where new
researchers, practitioners and
acknowledged leaders in the
field come together and share
their common enthusiasm for
learning and their desire to
discover how practice can be
improved. We are delighted
to have this opportunity to
work collaboratively with
SPR and look forward to a
broad and varied programme
with research presented by
both SPR and BACP members
(non-members are of course
invited to submit for the
conference also). Professor
Thomas Schroder, President
of SPR (UK) will present
the Saturday keynote at
the conference, entitled
‘Researching therapists
and their practice – a shift
of perspective’. Professor
Michael Barkham, from the
University of Sheffield, will
present Friday’s keynote,
entitled ‘Re-privileging
practitioners at the heart
of practice-based evidence’.
The theme of the next
conference, to be held on 6
and 7 May 2011 in Liverpool,
is ‘Research and Practice,’
which is relevant to the
interests of both BACP and
SPR. We welcome SPR to cohost
the research conference
with us and look forward to
meeting new colleagues,
learning from others and
broadening the forum for
discussion. Visit our
webpages for updates, as and
when they become available:
http://www.bacp.co.uk/
research/conf2011/index.php
BACP Professional
Conduct Hearing
Findings, decision
and sanction
Frances Nicola Cooper
(aka Niki Cooper)
Reference No 528909
London N8
The complaint against the
above individual member
was taken to Adjudication
in line with the Professional
Conduct Procedure.
The complaint was heard
under BACP Professional
Conduct Procedure, and the
Panel considered the alleged
breaches of the BACP Ethical
Framework for Good Practice in
Counselling and Psychotherapy.
The focus of the complaint,
as summarised by the Pre-
Hearing Assessment Panel,
is that in September 2008,
the complainant registered
on a two-year Postgraduate
Diploma in Counselling
Children in Schools. Ms
Cooper was the programme
leader and tutor. From early
on, the complainant alleges
that she was bullied by other
students on the course. At
a residential weekend in
February 2009 she alleges
that another student shouted
at her, ‘Stay away from me,
don’t speak to me, don’t look
at me, don’t come anywhere
near me.’ Ms Cooper was
not present in the room but
the complainant allegedly
informed Ms Cooper of
what had occurred. The
complainant alleges that
Ms Cooper’s advice was to
stay away from the student
in question, therefore failing
to take appropriate action.
In the second year of the
course in November 2009,
another residential weekend
took place, facilitated by
two body psychotherapists.
The complainant alleges that
fellow students, including
the student that she alleged
had previously bullied her,
behaved in a hostile and
intimidating way towards
her. The complainant further
alleges that although Ms
Cooper was present while
some of the incidents took
place, Ms Cooper failed to
intervene. In another alleged
incident of intimidation
on 3 November 2009, the
complainant alleges that
Ms Cooper again failed to
take appropriate action.
The complainant alleges
that following this, Ms
Cooper invited her to a
meeting on 9 November
2009. At this meeting the
complainant alleges that
Ms Cooper informed her that
she was suspended under a
Suitability Procedure, which
was handed to her there and
then. The complainant alleges
that three errors occurred:
firstly, she had allegedly not
been handed a copy of the
Suitability Procedure prior
to this; allegedly it had simply
been posted on a notice board
at the beginning of the
academic year (second year
in the complainant’s case);
secondly, Stage Two of the
procedure had allegedly been
invoked, omitting Stage One;
thirdly, there was allegedly
no mention of the sanction
of suspension within the
Suitability Procedure. The
complainant alleges that
Ms Cooper suspended her
unfairly without informing
her of the allegations against
her and did not follow the
procedures concerning her
correctly. The complainant
further alleges that Ms
Cooper ignored two emails
concerning the allegations
against her dated 15 and
16 November 2009
(wrongly dated in the
complaint as 2010).
The Pre-Hearing
Assessment Panel, in
accepting this complaint
was concerned with the
allegations made within
the complaint suggesting
contravention of the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy (2009), and
those in particular as follows:
••
Ms Cooper allegedly failed
to make the complainant
aware of the Suitability
Procedure prior to
implementing it, nor provided
her with an opportunity to
have its meaning clarified
prior to implementation
••
Ms Cooper allegedly failed
to implement the Suitability
Procedure correctly in that
she allegedly invoked Stage
Two of the Procedures,
omitting Stage One. Further,
Ms Cooper allegedly invoked
a suspension, a sanction
which is not documented in
Stage Two of the Procedure
••
Ms Cooper allegedly failed
to demonstrate the requisite
46 Therapy Today/www.therapytoday.net/November 2010

skills and attitudes as a tutor
to manage group dynamics
appropriately, to the
detriment of the complainant.
Findings
On balance, having fully
considered the above, the
Panel made the following
findings:
••
The complainant should
have been made aware of
the existence of the
Suitability Procedure prior
to its implementation on 9
November 2009. She should
also have been given the
opportunity to have the
meaning of this procedure
clarified before the meeting
on 9 November 2009.
However, the Panel found
that Ms Cooper was not
solely responsible for
these significant lapses
in communication
••
Ms Cooper made a
decision, having consulted
appropriately, to implement
the Suitability Procedure at
Stage Two, rather than at
Stage One, which was allowed
••
The Panel found that Ms
Cooper, as programme leader,
did suspend the complainant
from the course, using a
sanction which was not
permitted under the
Suitability Procedure at Stage
Two. When questioned, Ms
Cooper admitted frankly that
she should not have done so
••
The Panel found that Ms
Cooper’s level of skills and
her attitudes as a tutor to
manage group dynamics
during the course did not fall
below the standards that may
reasonably be expected from
a practitioner exercising
reasonable care and skill.
Decision
Accordingly, the Panel was
unanimous in its decision
that these findings amounted
to professional malpractice
in that Ms Cooper unfairly
suspended the complainant,
and was partly at fault in not
providing information about
the Suitability Procedure
prior to its implementation.
In these instances, Ms
Cooper’s behaviour fell
below the standards expected
of a practitioner exercising
reasonable care and skill.
Mitigation
Ms Cooper conveyed
openness and sincerity to
the Panel, and demonstrated
that she had since considered
and addressed the issues
arising from the complaint.
The flawed Suitability
Procedure was withdrawn
and Ms Cooper participated
in efforts to facilitate the
return of the complainant
to the course. The Panel
was satisfied that Ms Cooper
had already demonstrated
significant learning from
these events, both in her
own statements at the
hearing, and also when
questioned by the Panel.
Sanction
Consequently, the Panel
did not impose a sanction.
Withdrawal of membership
Pennie Aston
Reference No 545827
London N3 3DR
During the course of a
Professional Conduct
Hearing, information came
to light which was sufficient
to refer for consideration
under Article 4.6 of the
Memorandum and Articles
of Association.
The summary of the
information, together with
the allegations as notified
to Ms Aston, were as follows.
During the course of a
Hearing where Ms Aston
was a complainant, evidence
came to the attention of the
Adjudication Panel regarding
a statement supplied by
her from Ms A, a witness.
The evidence suggested
that Ms Aston had
substantially altered Ms A’s
statement about Ms B, the
member complained against,
which was very much to the
detriment of the latter. It is
further alleged that Ms Aston
had knowingly and
deliberately falsified evidence.
Ms Aston allegedly admitted
that she had substantially
altered Ms A’s statement with
the intention of undermining
Ms B in the Hearing, for
which she apologised.
The Panel viewed this
matter very seriously and
raised it as a separate matter
with Ms Aston at the Hearing.
Allegedly, Ms Aston could
not provide any rational
explanation for her actions
and accepted any
consequences that may
arise from it.
Despite her apology,
the Panel remained very
concerned about the matter
and referred it, formally, to
be considered under Article
4.6 of the Memorandum
and Articles of Association.
Ms Aston was sent a copy
of the information received
from herself, Ms A, Ms B and
the Professional Conduct
Panel, together with a copy
of the Ethical Framework for
Good Practice in Counselling
and Psychotherapy and the
procedure for Article 4.6.
The nature of the information
raised questions about the
suitability of Ms Aston’s
continuing membership of
the Association and suggested
that she had brought, or may
yet bring, not only the
Association, but also the
reputations of counselling/
psychotherapy into disrepute.
The information further
suggested that there may
have been serious breaches
of the Ethical Framework for
Good Practice in Counselling
and Psychotherapy and it
raised concerns about the
following, in particular:
••
Allegedly, Ms Aston
dishonestly, deceitfully
and deliberately altered and
falsified a witness statement.
Further, Ms Aston submitted
it as evidence under the
Professional Conduct
Procedure to be considered
in a complaint that she had
made against another BACP
member, with the alleged
intention of undermining
the member complained
against in the Hearing and
causing her detriment
••
Ms Aston’s alleged lack of
respect for Ms A in altering
her statement without her
consent or knowledge
••
The information suggests
that Ms Aston’s alleged
behaviour is incompatible
with the values and
principles of counselling
and psychotherapy and is
lacking in the personal
moral qualities of integrity,
sincerity, respect, fairness,
and wisdom to which
counsellors and
psychotherapists are strongly
encouraged to aspire. It also
suggests that Ms Aston
failed to treat colleagues
respectfully and to exercise
probity. Further it suggests
that Ms Aston failed in her
responsibility both as a
member and provider of
information to participate
appropriately and honestly
in the Professional Conduct
Procedure of this Association.
The member was invited
to send in a written response,
and made a response.
The Article 4.6 Panel
decided to implement Article
4.6 of the Memorandum and
Articles of Association and
withdraw BACP membership
from Ms Aston to take effect
28 days from notification
of this decision. The reasons
November 2010/www.therapytoday.net/Therapy Today 47

Professional conduct
for its decision are as follows:
••
The Panel was not satisfied
that Ms Aston had given a
good and sufficient
explanation for altering the
letter without Ms A’s consent
or knowledge
••
Furthermore Ms Aston
allegedly failed to take any
steps after she submitted
the altered letter to BACP
to reflect on her conduct
and to contact Ms A to tell
her what she had done,
failing to show her respect
and acting to her detriment
••
Ms Aston dishonestly,
deceitfully and deliberately
altered and falsified a witness
statement. Further, Ms Aston
submitted it as evidence
under the Professional
Conduct Procedure to be
considered in a complaint
that she had made against
another BACP member, with
the intention of bolstering
her case and undermining
the member complained
against in the Hearing and
causing her detriment
••
The information suggested
that Ms Aston lacked integrity
and that her behaviour was
incompatible with the values
and principles of counselling
and psychotherapy
••
The nature of the
information was evidence
that she had brought, or
may yet bring, not only the
Association, but also the
reputations of counselling/
psychotherapy into disrepute
were the public to be aware
of all the facts.
Ms Aston appealed against
the Article 4.6 Panel’s
decision to invoke Article 4.6,
believing that it was unjust
and unreasonable in all the
circumstances to implement
Article 4.6.
The Appeal Panel, in
addition to the information
considered by the Article
4.6 Panel was provided with
Ms Aston’s appeal against
the decision to withdraw
membership, as well as
further supporting
information received from
Ms Aston, Ms B and Ms A.
All of the preceding
information, including the
oral evidence given on the
day, was carefully considered
by the Appeal Panel.
Decision
It was the duty of the Article
4.6 Appeal Panel to decide
whether the decision of
the Article 4.6 Panel to
implement Article 4.6 was
just and reasonable in all the
circumstances and then to
decide whether an appeal
should be allowed or denied.
The Appeal Panel viewed
the matter of falsifying a
witness statement and
submitting it to a Professional
Conduct Hearing as a very
grave matter. The Appeal
Panel was satisfied that her
actions involved a train of
events including the actual
falsifying of the written
statement, the subsequent
submission of it to a BACP
Professional Conduct Panel
and failing to take adequate
steps to contact the witness.
Ms Aston had indicated to
the Article 4.6 panel that she
had no rational defence for
her professional behaviour
and lack of judgement. She
also provided some
information with regard to
mitigation, including learning.
In her appeal Ms Aston
contended that the sanction
was disproportionate. The
Appeal Panel considered
whether the decision of the
Article 4.6 Panel had been
proportionate and found, in
view of the gravity and serious
nature of Ms Aston’s actions,
that the Article 4.6 Panel was
proportionate in reaching
the decision at that time.
The Appeal Panel
considered further details
of mitigation submitted by
Ms Aston at her appeal.
While Ms Aston admitted
what she did was wrong and
inappropriate, the Panel was
not satisfied that she fully
accepted the gravity and
seriousness of her actions,
nor fully understood the
consequences and the adverse
impacts of her actions on the
informants and their
professional practice.
Ms Aston described the
circumstances and the
emotional effects of matters
in her private and
professional life at the time
of these events. Ms Aston
also described actions she
had since taken together
with her learning. The Appeal
Panel was not satisfied that
Ms Aston had provided a
justification for the
falsification of a witness
statement and its submission
to a Professional Conduct
Hearing nor that she had
demonstrated adequate
learning.
Despite the mitigation
provided by Ms Aston and
carefully considered by the
Appeal Panel, the Panel
was deeply concerned by
the serious nature of her
actions and considered
that the public’s trust in
the profession and the
Association might reasonably
be undermined if they were
accurately informed of all the
circumstances in this case.
The Appeal Panel was
unanimous in finding that
the decision of the Article
4.6 Panel in invoking Article
4.6 was just and reasonable
in the circumstances and
denied the appeal.
Consequently, Ms Aston’s
membership of BACP is
withdrawn with immediate
effect.
Any future re-application
for membership will be
considered under Article 4.3
of the Memorandum and
Articles of the Association.
48 Therapy Today/www.therapytoday.net/November 2010