Masculinity

The ‘Fells & Dales’ network of accredited counsellors met on 10th Sept. to reflect on the subject of gender and particularly male-ness and masculinity.  A catalyst for our discussions was Catherine Jackson’s article entitled ‘Sometimes it’s hard to be a man’ in Therapy Today (July/August 2021, Vol. 32, Issue 6), and Chapter 8 ‘Discovering our emotional needs’ in John Gray’s classic text ‘Men are from Mars, Women are from Venus’ (Harper Collins 1992).

We shared something of our own upbringings and experiences of being expected to comply with the stereotypical societal roles assigned to men/boys and women/girls, and noted how perceptions have changed within the past generation  –  how much more accepting people generally are today, of feminine qualities in men and vice versa, and of diversity of sexuality.

We spoke of the difficulties some male clients have in accessing and naming feelings, and of the need for therapists to work with ‘what is’ but maybe to find another language that is meaningful to men, but which still enables them to contact emotion and to feel safe enough to be vulnerable.  As quoted in the TT article, ‘emotions… exist so we can connect with what we need.’  It was noted that there can be an ambivalence around men seeking counselling, in that they are often looking for solutions, or tools to ‘fix’ their problem, and yet they might need to believe that they achieved what they came for but without any help from us!  We also noted the predominance of male compared with female suicides, and the association with shame, e.g. the belief that “I’m not man enough to survive.”

We spent some time debating the sensitivities associated with pronouns, and the risks of quite unknowingly causing offence in the current ‘non-binary’ world.

For further reading: James O’Brien’s ‘How not to be wrong – The art of changing your mind’ (Penguin, 2020)

In chapter 1 O’Brien describes how he grew up with, and fully believed, ‘‘It never did me any harm” (corporal punishment etc.), until he allowed himself to ask “Or did it?!”

Masculinity

Reflection on Spirituality

The Therapeutic Process and Relationship and reflection on Spirituality (with reference to Mind and Consciousness) was a discussion led by Peter Bowes.

The paper given for reference was Exploring the God Question – a presentation made by Peter Bowes to a Grasping the Nettle audience and now available from that website.

Two diverse books, A Theory of Everything by Brian Greene, (String Theory discoverer and mathematician), and The Devil You Know by Gwen Adshead and Eileen Horne et al (a reflection on working with the minds of violent criminals that reveals profound consequences for human nature and society at large), were mentioned during discussion. The reference arose because both authors have a reference to ‘soul’ in the very last paragraph in their referenced books. The observation seemed relevant as the group grappled with finding understanding of ‘spirituality’ and its meaning for therapists and therapy.

It can surely be stated that human beings in all societies in the world seem to need a word to capture experiences common to all. ‘Soul’ appears to point to a capacity of the human mind to feel that there is part of us that seeks expression and whose meaning relates to a seeking within or without us,  a relationship to that which is somehow always beyond us. Spirituality is intended perhaps to be the envelope into which many different expressions of that capacity are located. Peter offered that his current summary definition of ‘spirituality’ was related to the capacity of consciousness that needs to make meaning. Sadly religion, with which spirituality is frequently confused, is more related to human beings attempts to define and control that experience. The orthodoxy (right teaching) that emerges seems more about the power and control which is evident in history or religions.

Group members related life changing experiences involving awe and wonder that were also found occasionally in our relationships with our clients. These are of a profound awareness, somehow known by both therapist and client, of something taking place which might also be of dimensions beyond the normal, involving awe and wonder and invoking deep emotion and usually without cognitive understanding.

A reference to our dying and the return of our atoms to the pool of particles in the Universe that sustains us, permitted a reference to the current conundrum that in each of us these particles somehow produce consciousness and the legacy of many such as Jung that there may exist a collective and even archetypal consciousness ‘out there’. Peter noted that his interest lay certainly in the metaphor of ‘soul seeking’ and how it occurs and what it implies for human beings. Is evolution a chance happening or by design is a decision that each of us might be invited to consider. Our response does matter since our values and our survival as humans depend on our answer.

As therapists, it seems we are united in holding onto high valuing of our clients and in having the motivation to seek what is best for each of them. What then comes to the fore is that as therapists we ‘see’ in each person a core that we love and respect. Furthermore we catch an awareness that this that we love is beyond, and perhaps before, reason and cognitive belief. We learn to be aware of what our most primitive emotions tell us. Sometimes we catch our bodies, our guts, speaking before our cognitive processes take over. The awe and wonder that prompts our love and glimpses of the potential of the other is surely at the core of what drives us therapists. If so, that renders that experience, potentially, as one of the highest pursuits of humanity and one which, if its values and behaviours were more widely expressed, might save our planet ….and our souls?

Reflection on Spirituality

Long Covid

This session opened with a short 5 News  documentary on long covid to start with called “What is long covid COVID 19  Ruth Liptrott” Minutes :  2:30-9:50 and we continued to explore our own experiences of long covid in those that we know and also with our clients along with the impact on us. We learnt about the research into long covid being linked to an auto immune response to the infection and raised some questions about the observations we have of clients struggling to cognitively process and remember along with fatigue.

There was an observation where conditions such as ME often have a psychological link to them where as there does not seem to be any such link with COVID.

We recognised the comment from a participant on the video who said “I’m not the person I used to be” along with the comments about feeling frightened and lost as  a result and how bereavement is a recurring feature in therapy.

We recognised the link of trauma to COVID and how the effect of trauma is held in the whole of our bodies.

We reviewed the article in Therapy Today   (Jan 2021)  “Inside the long COVID Maze” by Karen Rawden.

This article opened a discussion about the authors continuing journey with covid herself and the suggestion that “witnessing my fallibility invited my clients to see and honour their own”. The risks of over disclosing issues of self were raised and the question askes “who is this disclosure for”  led to highlighting a risk of role reversal and the client taking care of the therapist. It was recognised that self awareness is generally a private process and as therapists we take the internal moment after connecting with a congruent response to consider who benefit is disclosure for before making it.

However it was recognised that the article did accept that there may come a point to withdraw from counselling as the most appropriate and ethical response to personal COVID.

An article in the current Therapy today “Generation Covid” (May 2021)

https://www.bacp.co.uk/bacp-journals/therapy-today/2021/may-2021/the-big-issue/ on the effects of COVID 19 on children and how counselling can help looked at the question of if we are storing up distress in our children to come out another day. Children are seen as generally resiliant and if they have a supportive home environment then then are likely to do well but it was recognised that not all children benefit from this.  We looked at the recommendation in the article that counsellors should be placed in all schools with enhanced training in counselling for depression and the opposing view of this may not be necessary if enough funding and training were  to be put into teachers so that they have the time to listen would probably be more effective.

Long Covid

Anorexia – a hospital and school combined

We welcomed Ellie Curtis who works as a teacher at a hospital and school for young people with eating disorders, primarily anorexia. It was a very stimulating and lively talk from someone clearly  very thoughtful about her work. She outlined the children’s experience of being hospitalised (and usually sectioned under the mental health act), with particular emphasis on the unwelcome but crucial restraints that have to be imposed to prevent them dying  without food. We heard the disturbing lengths that these patients go to in order to avoid food and the medical interventions that have to be imposed.  The children see their anorexia as the solution to their problems and are therefore not motivated to recover. ‘No one with anorexia wants to get better’. There is a dilemma that the child is necessarily  the centre of attention of an impressive group of professionals. This makes them feel important and might be an incentive to hold on to the illness. Children are hospitalised here for at least several months and often for many years. Happily there have been no deaths at this hospital and there is a high success rate – most children eventually becoming well enough to function outside again. Leaving  is a milestone which is deliberately celebrated .

We discussed the theory that feelings are so deeply buried that the anorexia serves as a way of keeping feelings repressed. The control the patients exert over their eating ironically means that the anorexia ends up controlling them. Anorexia was described as a mental illness which manifests itself as a drawn out suicide attempt and this lead to a discussion about the ethics of preventing death in adults with anorexia .

There is no incentive to get better, anorexia to the sufferer is the answer not the problem. Although there is frequently a history of trauma, exploration of feelings  in therapy is generally unwelcome and we noted how rarely adult clients present with anorexia. Ellie’s experience is that most of the children do not engage with therapists. Touchingly she talked of the joys of breakthroughs when children begin to relate to her as a teacher.

Relationships between the children are sometimes intense and sometimes there is harsh competition to be the thinnest, the most successful at being anorexic. There is a danger that the children teach each other ingenious ways of avoiding food or burning calories, many exercise compulsively.  In terms of family dynamics, Ellie reluctantly admitted that the children in her care very often have problematic relationships with their parents, mothers in particular. Mothers have often had their own experience with anorexia. Fathers are typically left feeling helpless. She also mentioned in passing that they care for a disproportionate number of twins, hypothesising that anorexia could be an unconscious response to competition or comparison between them.

Relationships with the helping adults in the hospital are not always straightforward either. We talked about deceit which is a necessary part of being a successful anorexic. Ellie mentioned the discomfort of feeling suspicious that every positive gesture from a student is likely to be disingenuous. She was so honest about her natural feeling of wanting to be liked by her students whilst knowing that she is probably being manipulated much of the time.

Finally we heard a case study of a student with the very rare condition Pervasive Arousal Withdrawal  Syndrome (PAWS) where the child had withdrawn from all physical activity including eating, speaking, moving. In this case, the person was detached for several years before slowly reengaging.

Anorexia – a hospital and school combined

The Therapy Square

We met as the Fells and Dales group of therapists on Friday, April 9th, 2021 and the focus of our discussion was an article from “Therapy Today”, July 2020, entitled “The Therapy Square” by Anthony Prendergast. This article offers an interesting model and hence a  tool to potentially use with clients – a laminated sheet which has 4 quadrants. It  invites a client to identify and write down inhibiting emotions such as shame, guilt, fear or anxiety and the inhibiting messages conveyed by these feelings. It also includes “Human potential” which Prendergast believes we are born with but then , due to social conditioning (including internalised messages from parents), we “end up in blocked potential”. The goal of therapy is then to help us “get back to our full human potential”.

The author digresses to examine Malan’s triangle of conflict with the hypothesis of a Defence existing in reaction to Anxiety which is rooted in Hidden feelings which then need to be made conscious and worked through psychodynamically. Prendergast’s model adds 2 new concepts: the concept of Injunctions leading to inhibiting messages. He states that “Inhibiting messages are the crucial missing element driving internal conflict because without such messages there would be no inhibiting emotion to enforce it and , as a result, no blocked potential, internal conflict or transference”.

In the ensuing discussion, we gave clinical examples from clients of evidence of blocked potential and inhibiting messages and felt these were useful concepts to encapsulate some issues that clients bring.

An interesting image was discussed by one of us, who had worked with a client with autism, of a tree with many leaves- this arose when the therapist spoke to the client about the trunk of the tree as a kind of solid central core and the client said he could not relate to this since, for him, all parts of the tree had equal weight and importance and he couldn’t differentiate between them. We all felt this was a useful piece of learning in shedding light on the different ways our minds work and process information and feelings.

We all felt that it was valuable to know about different models of counselling and to ask ourselves “ Do I understand the model and how do I apply it?”. There was, however, a cautionary note about using a model with a client in the sense that it would be more likely to be effective and appropriate if the presentation of a model by the therapist arose spontaneously in the course of a session. For example, one of us recalled a colleague presenting a client who had suffered from trauma with a drawing done there and then of the window of tolerance and how this had worked well.

We also discussed how we might use transference in a session and whether it is effective to directly name it in the here-and-now with the client by looking at the relationship between you both.

Reference was made here to Malan’s 2 triangles which explore transference and counter-transference and the unconscious dynamics involved. Some of us felt that raising this question could be confusing or alienating for the client and needed to be handled sensitively if at all.

All in all, it was a stimulating and enriching meeting as is usually the case.

Rosemary Pitt

The Therapy Square

Where Do Ethics Come From?

The fells & Dales group of counsellors/psychotherapists met on 12th March, when we considered the questions, “Where do ethics come from? What give us our sense of right and wrong?”

The pre-reading was Ch 6 ‘Working ethically as a counsellor or psychotherapist’ in Peter Jenkins:  ‘Professional Practice in Counselling & Psychotherapy’ and the paper ‘What is Ethics?’- BBC Ethics Guide 2014

We  began by each of us sharing where our own sense of ‘right and wrong’ came from. Ideas included our parents, siblings, extended family, religious faith, the 10 Commandments and social mores.  We debated the extent to which ‘ethics’ are innate/hereditary or acquired, how they are learned through observation of others, and how they have evolved over time.  We noted the strong sense of (in)justice that even young children can experience.  It was pointed out that ethical values are socially construed, meaning some could develop in different ways in different cultures, while others might be universally understood and applied.  We spoke of resistance to externally imposed regulations (“rules are to be broken!”).

We considered the BACP Ethical Framework based on ethical principles, and noted the significance of it having moved away from the previous Code of Conduct with its lists of rules (especially what not to do).  A number of ethical issues arising from present-day circumstances were tackled, e.g. what to do if a client refuses to be vaccinated, or if a client discloses that they are infected but not self-isolating?

We also raised the issue of ‘mistakes’ in therapy, the duty of candour, and the differing possible interpretations of having ‘got it wrong’.  The conclusion we reached was the importance of having a rationale with which to justify and account for our decisions, and if our practice is ever scrutinised, hoping we would be judged by those with similar standards to our own!

Where Do Ethics Come From?

The Brain and the Inner World

Peter had made available Chapter 9 of The Brain and the Inner World by Marc Solms, Karnac Books, 2002, which focuses on ‘neuroscience and the talking cure’. The chapter summarised a little of the current knowledge of the Self, and how the Mind works; the understanding of awareness and consciousness with reference to the internal and external world. Solms reviewed current understanding (from Jaak Panksepp in particular) of basic primary instinctive emotions and the manner in which self-object relationships are encoded in the brain both for the automatic responses necessary for survival. This activity is at first unconscious. Then memory of interaction with objects experienced as ‘good’ and ‘bad’ are laid down in memory systems which in turn act unconsciously on further experience of the world of objects. This sounds like a more or less passive mechanism.
However, there is a difference between the inner and the outer perspectives of the mind which is experienced as having an active agency which is synonymous with the sense of self we all have perceived, of course, subjectively. This SELF (the capitals are used by Panksepp to denote emotional and primary instinct different from our conscious acknowledgment of an emotion) guides action on the basis of evaluation without however free will at first.
“Free will” is understood from a neuroscience perspective as the capacity of the prefontlal lobes to inhibit what is otherwise what Freud called “repetition compulsion” of triggered motor programmes. And this ‘choice’  and “agency”is regarded as being at the core of our humanity as homo sapiens. The developed potential for delay in “motor responses” is thus in the interests of “thinking”. This capacity develops early and is heavily dependent on child life experience of what parents do and what parents say.Critical to this process is the language which becomes “inner speech” whereby as Solms says, prohibitions for example become inhibitions which is one of the processes by which humans develop their pathology whereby ‘”knowing is dissociated from doing, a diminution of the ability to regulate behaviour verbally. 
The “talking cure” which Freud described as strengthening the “ego” meant extending the sphere of influence of the “ego” over the “id”. but he abandoned his early distinction between the conscious and unconscious parts of the mind and saw also the core capacity of the ego was for “inhibition”. Thus repression is an unconstrained primary process and the inhibitory constraints a secondary one. The aim of the talking therapy is to bring to bear on the repressed inhibitory constraints of this secondary process and bring them “under the flexible control of the ego/SELF/free will.
So, anything which is not under the control of the prefrontal lobes is ‘repressed. Talking therapy aims to  extend that sphere of influence. To do so it uses language which is the means by which, at a higher level abstract connections between perception and memory are ‘named,’ and allow then behaviour to be subordinated  to “programs of activity”.  But, teasingly, Solsm suggests that we ‘know’ that  such internalised and unconscious connections are ‘rekindled’ by transference in the therapeutic relationship being that which is repressed to consciousness.  But, he says, of this “we know virtually nothing! So Solms avoids adroitly false claims for the “talking cure”
Discussion properly focused on the experience of clients observed and felt by members of the group. We were able to contrast approaches along the spectrum from cognitive and analytical to person centred, directive to non-directive. The value of full body relaxation experience for noting the existence of emotions and their location in the body was appreciated. This would appear to be a process of allowing something of the unconscious connections and control to be acknowledged and, if named, then able to be within conscious reach allowing some aspect of the executive function of the prefrontal lobes to allow ‘space’ for alternate behaviour.
The value of transitional objects in childhood was recognised, but the relationship of this phenomena to an adult life encounter with a therapist required thought. The teddy bear may be torn apart but the desire to do that to the therapist is perhaps unlikely to be owned unless named by the therapist?
A number of the group ‘have to’ work short term with clients and the application of the processes of the ‘talking cure’ needed elaboration and exploration. Working intensely to establish a therapeutic alliance that acknowledged the power of relationship to effect awareness and potential change, might be one response. Attending carefully to the client’s understanding of the goal of being in therapy might be another. 
Perhaps learning from neuroscience about brain processes and what is unconscious and what is consciousness might help therapists to use deliberately the value of the human relationship for ameliorative change. The current stage of neuroscience awareness has yet to be able to define and understand “consciousness’ so therapists’ experience now is vital information for future understanding of what brings about change therapeutically. 

The Brain and the Inner World

Resilience

We discussed the notion of resilience today where Dominic opened with a quote from The Making Of A Therapist by Louis Cozolino “A risk of private practice is that you are God in a universe of your own creation. Like priests , movie stars, and kindergarten teachers, therapists can suffer  from having too much power over too many people. The lack of balanced relationships in private practice  can contribute to reality drift and make the therapist  dependant on his or her clients for human contact. If you choose private practice , make sure you have colleagues you can tell anything to , while maintaining confidentiality. Talk honestly with them about clients , and continue to get accurate and compassionate  peer supervision and feedback when ever possible.”

This led to a discussion on power in the relationship and how this can be seductive  and even enriching. One down side is when we do not see progress and feel powerless. We looked at examples of how this can relate to various client groups in particular couples and how we feel when therapy is unsuccessful. The effects of this seem more immediate in couple work than in individual work where clients seem to be looking for a “fix”. Couple  work is seen as more demanding than individual work and this led to look at resilience in relation to self care and client load.

We looked at resilience as a facet of internal  supervision and when we feel helpless who does that belong to . We touched on external supervision as being an essential part of monitoring and helping supervisees to grow along with the role of challenge in that relationship. For example asking the supervisee “now what have you not brought to supervision from your client work”

We also looked at using supervision to help replenish our internal level of resilience.

The idea of how inadequate supervision may come from a lack of resilience within the supervisor was discussed and how , if at all, this is monitored by the profession.  We also looked at the risk of supervisors falling into the role of second counsellor thereby making the supervisee feeling inadequate and how to avoid that.

We looked at how some clients seem to try to “tough it out” and how conversely this can lead to a loss of resilience in the individual. This led to a discussion of the paper by Roebuck and Reid (Coun Phychother Res. 2020:20:545-555) which looked at how trainee therapists experience resilience: An interpretative phenomenological analysis where students observed the need to feel vulnerable as a an important part of resilience development and learning from failure (P549).

The notion of “you are allowed to be ill” was discussed as was how we tolerate failure and how we have to be careful of avoiding collusion leading to a misuse of the therapeutic power dynamic.

We moved onto the role of empathy and congruence in the therapeutic relationship  and how we use the impact of supervisee  content on us to support the supervisee. How do we allow the impact of clients on us to be useful in the therapy space and how we encourage students to take that nanosecond to pause before using a congruent reply to ensure we are assessing whose benefit is this disclosure for.

Resilience

Money

Stimuli were ‘ The Culture of Affluence:Psychological Costs of Material Wealth ‘ by S S Luthar ; Financial Times article Sep 2020 ‘Wealth:Mental Health Series ‘ Financial Therapists Helping Wealthy People Cope With Change’; The Guardian article Oct 2015 ‘Wealth Therapy Tackles Woes of The Rich

Today’s theme was the uncomfortable subject of money and our relationship with it. We shared personal experience and unsurprisingly found that our adult attitudes to money were influenced by the introjects of our childhoods – the fear of not having enough ,attitudes to spending money on unnecessary things, insecurities around social class.

We touched on our reactions to the very wealthy. Some of us had experience of being treated badly by wealthy clients, some felt the otherness of the wealthy. We also found compassion for the isolation reported by the children of the very wealthy and their tendency towards destructive behaviours. The same isolation might account for the observation that wealthy people often give proportionally less money to charity. It was suggested that the comparative generosity of the poor is connected with the greater intimacy of their childhoods allowing for a more empathic attitude to others.

It was noticed that there is some pride in coming from a poorer background and shame in admitting to wealth. Connected to this, the idea of adopting a ‘poverty mentality’ when people present themselves as less well off than they really are.

We touched on the seductive power of money and the naïve idea that our sense of status and success can be measured by accumulation of money. This ties in with the questionable belief that happiness comes from extrinsic rather than intrinsic values. Research consistently confirms that a basic annual income is correlated with happiness, but beyond that, more money does not make more happiness. Money does act as a passport to opportunity and for at least one of our clients, allowed a safe departure into a new life, released from the grind of acquiring ever more money.

We were pretty irritated by the articles which talked about specialised counselling for extremely wealthy clients, we could not see why the counselling on offer would differ. There may be particular personal challenges for the therapist, but no extra knowledge or skill seemed necessary. There may be recurring themes for rich people, but the same range of human suffering will be theirs too.

Finally we talked about the exchange of money for therapy, in particular the thorny question of being paid for what might be thought of as ’merely’ compassion. In my opinion, describing therapy as just compassion is definitely under valuing ourselves. It was posited that being paid for therapy is critical to the contract and sets boundaries of commitment on both sides. Holding the boundary is more difficult if the client is not paying or pays a concessionary rate. We acknowledged the potential for shame in the therapist for taking money for something that is a basic human need   (to be heard with compassion) and shame in a client for needing therapy from a stranger.

Money

Shame and Guilt

We discussed a paper published by CambridgeCore entitled

“Working with guilt and shame”.

We all agreed on the important distinction between guilt and shame being that guilt is about what I do to others whereas shame is who I am. Both need to be normalised by the therapist through an attitude of acceptance.

The etymology of both terms is interesting: guilt deriving from the German word GELD which means money or debt, thus leading to a sense of having to pay a debt or repair something and shame deriving from the Indo-european word SKEM which means cover, thus leading to a sense of needing to hide an aspect of ourselves as in some way we feel we have fallen short in the eyes of others and in our own eyes. As an example again, the parent induces guilt by saying “what you did was naughty” whereas shame comes from the parent saying “ you are a naughty child”. Also a person who experiences shame expects to be abandoned,whereas a person with guilt expects to be punished.

Guilt is usually felt by the client in their mind so the therapist needs initially to have an intellectual understanding of what is going on, whereas shame is felt more in the body and can be embedded and so emerges more slowly in the therapeutic process. The therapist needs to show compassion so the client feels safe enough to share this exposing feeling.

We discussed how shame can be healthy, perhaps as in a sacred part of ourselves that we need to protect, or toxic when associated with more negative feelings about the self.

Likewise Guilt can be healthy when it contributes to a sense of cohesion in the community and so has a social aspect as in obeying laws. Reference was made here to a book by Rurger Bregman entitled “Humankind” which posits the notion that humans are basically kind.

We also discussed the link with guilt and shame in addictive behavior and a book was recommended entitled  “the booze battle”.

The paper proved to be a rich source of ideas and stimulated lively debate.

Rosemary Pitt, 24/11/2020

Shame and Guilt