Amanda Williamson Coaching and Counselling Service in Exeter, Devon

I recently attended a workshop "Working at Relational Depth", hosted by the Person Centred Approach South West, an association which I am a member of. The workshop was facilitated/held by Professor Mick Cooper who co-authored the excellent Working at Relational Depth in Counselling and Psychotherapy with Dave Mearns. This book was very influential on me during my training. I had some minor struggles with the classic, Carl Rogers' person-centred approach (person-centred being a major influence on my approach) and Mearns and Cooper gave me "permission" to be more progressive in my person-centred-ness. The emphasis is less on being strictly non-directive and more on achieving a deep level of relationship with the client. More about Rogers and the person-centred approach can be found here.

I have the deepest respect for what Carl Rogers contributed to the world of psychotherapy. He introduced a humanistic outlook that changed the face of the world of therapy. His seminal books were written in the 50's and 60's and although still very important and influential, it is thanks to the likes of Dave Mearns and Mick Cooper that the person-centred approach has been brought into the 21st century. The book Working at Relational Depth in particular, breathed fresh air and cutting edge perspective into a well-established therapeutic approach.

And so there was a full day workshop listening to Mick explore this concept of relational depth, incorporating some experiential learning and discussion. Some of the salient points of which I share below:

• The connections we have with other people are more indicative of a better outcome than smoking and health
• There are issues around whether it is possible to "capture" relational depth, but if we don't try then it remains an elusive concept

What is relational depth?

There was an exercise where we paired up and discussed "what does deep connection feel like?" We had to describe it and try and draw it (yikes). Afterwards the words and pictures were shared and the following words are just some of those used to describe deep connection between two people:

• openness
• relaxed
• safe
• relief
• sense of self 
• lack of self consciousness
• speaking without words
• on the same wavelength
• cutting through the small talk
• lack of judgement
• in the moment
• knowing without the need for explanation

our attempt to capture relational depth

There were also descriptions of changes in perceptions, of time disappearing, differing visual or audio experiences.

Mick shared some slides showing research into people's experiences of relational depth in the therapeutic relationship:

• Intrapersonal (how one feels in oneself) - alive, immersed, authentic, okay with self
• Experience of other - open
• In relation to other - closeness, union, mutuality (the therapist's willingness to be open to change)
• Atmosphere - timelessness, altered states of consciousness

The I/Thou relationship

Martin Buber is a philosopher who focused on deep and meaningful connection in the book "I-Thou". Although the book is short I found it took quite a long time to get through it and really understand the intricacies of the differences in the differing ways of relating, to self and others.

Briefly speaking - I/Thou is where two individuals meet with no objectification of the other, in an authentic and open dialogue, experiencing the other rather than evaluating. I/It is the majority of human interaction whereby we apply previous judgements to our encounter. These two differing modes also apply to how we relate to ourselves; I/I being the honest and nonjudgmental accepting of ourselves and I/Me being the evaluating, judging way of relating to self.

The Client's perception of Relational Depth/The Person-Centred Approach

It was interesting to hear that the non-directivity of the person-centred approach can be perceived by some clients as being cold. If the non-directivity is taken as a dogmatic must, then yes, I can see how a client could feel a lack of holding and care from somebody that doesn't prompt the start of the session with a question, or that provides no guidance whatsoever. Especially at the beginning of the relationship when the client perhaps has no idea what to expect or whether they're "doing it right" (no such thing, by the way).

A fascinating discussion also took place here where it was asked whether the client's and therapist's experience of relational depth correlated. I have wondered this right from the start of my training, when we would do practice sessions on other students. A small group of us regularly mused on this and would ask each other if they, as a client, had felt that level of intensity at the same time as us, as a therapist. There often was a correlation but that could because we knew each other so well.

What is this intensity? What are we talking about here?

Everybody has such a different experience of it, and I shall share some aspects of my experience of feeling very connected with another on whom my attention  is focused. Visuals wise, the nearest thing I can compare it to is when during a movie the camera tracks back and zooms in on a person's face at the same time, so the size of the face remains the same but there is an intensity created by this camera technique. One of my peers happened to be experienced in film making so he could tell me that it has a name. You can read more about the Dolly Zoom effect here, and you may have a clearer idea of what I am trying to describe. In the Wikipedia entry it describes the purpose of this trick; "seeing a perspective change without a size change is a highly unsettling effect, often with strong emotional impact". I must add here that I don't find my experience unsettling at all.

There are other sensory distortions that I experience that tell me that I am "in the zone". This happens with clients, it happens with my therapist and it happens with loved ones. 

According to the research that Mick shared with us, there is only a correlation of the perception of relational depth between therapist and client 30% of the time. This surprised me. 

Is Relational Depth important in the therapeutic relationship?

Mick shared that the research on relational depth and the person-centred approach is in it's infancy but that which has been done so far has been well received and correlates well with the research on the therapeutic alliance (which indicates that the therapeutic alliance may be a better predictor of outcome than technique or approach).

We saw some slides that showed the effects of relational depth in counselling:

• Immediate effects - empowering, catalytic, lessened painful feelings
• Effects on the client's process - greater trust, being able to "go back there"
• Long term effects - greater self-knowledge, self-acceptance, being "real self", improved relationship with others.

I did wonder how this research tied in with the latest in neuroscientific research. I suspect that there would be a correlation. I am thinking specifically here of the book Why Love Matters by Sue Gerhardt (which I briefly reviewed here).

Disconnection

Then we looked at disconnection, and had some time to discuss in pairs what having no connections would feel like. 

My first personal responses were that I would feel bereft, grief-stricken and experience absolute loneliness. Further, that I would rather die and be at one with the universe than be at one with nothing. Interestingly, there were different reactions to this with some people actually finding the prospect quite comforting.

My partner (Tina) and I looked at differing circumstances of having no connection:

1. Being on a desert island
2. Being surrounded by people devoid of the capacity to connect

Which would be worse? We decided that 1) would be okay, if we were okay in ourselves, and that we could create transitional objects and our own reality. We thought of Tom Hanks in Cast Away and his friend Wilson the volleyball). 2) would be harder - the isolation would be more pronounced than if we were simply on our own.

The distress of disconnection

Apparently this is the primary source of psychological distress.  Without connection we become nothing. Whom am I? - we become instincts only. Life becomes meaningless, with a lack of direction.

However, connection is risky and some take the stance that it is easier and safer to stay disconnected. from this place it is easier to see the disadvantages of connection.


Are you getting your 5 a day?

But connection is one of the 5 psychological needs:

1. Connectedness/relatedness
2. Exercise/physical activities
3. Taking notice/being mindful
4. Giving to others
5. Continuing to learn                                 (I cannot find reference to these on the internet)

• loneliness
• depression
• anxiety
• interpersonal problems
• impeding of PTSD recovery (post traumatic stress disorder)

How do we make sure we are attaining relational depth with our clients?

What gets in the way of Relational Depth?

From Non-Directivity to Dialogue -  Pluralistic Counselling and Psychotherapy

Meeting the needs of the clients - things for therapists to consider

Finally

Time to buy this book now... Pluralistic Counselling Psychotherapy by Mick Cooper and John MacLeod

I was loaned this book by a fellow therapist. I told her of a situation that I had been in, where a therapist had abused my trust, and that of other women, and I was struggling with the concept of how somebody can do that. She told me that my situation reminded her of this book.

It is probably the seminal publication on the subject of abuse of power in therapeutic/mentoring relationships. The blurb on the back (on this 1990 edition) states:

"In this moving and controversial book on sexual psychology, Peter Rutter explores the epidemic of sexual relations between men in authority and the women that they are meant to help."

Reviews of the book state:

"This is a landmark book. It explores the dynamics of power in male-female interactions and the tragic consequences when those with power betray their trust. It should be read by physicians, therapists, teachers, clergy and lawyers." Carol C Nadelson MD

and

"The depth and truth of Dr Rutter's insights into erotically charged relationships will challenge and empower both men and women to make choices that matter greatly. Sex in the Forbidden Zone should be read by everyone in the helping and mentoring professions" Jean Shinoda Bolen MD

Our cultural attitudes towards abuse are changing. Just because it is horrifying and reflective of a part of humanity we'd rather didn't exist, doesn't mean that it doesn't exist. In fact, I believe that this aspect of ourselves, our sexual side, our more animalistic tendencies, are part of our collective shadow (in the Jungian sense - click here for some info). The taboo around frank sexual discussion could well have contributed towards our inability to deal with dysfunctional sexual relations when they arise. Instead, what society allows to leak out is pornography and the media portrayal of women as being "available" and in some parts of the world a huge anti-gay culture (with remnants here in the UK too, sadly). This doesn't seem healthy to me.

By the way, I'm a feminist and a masculist.

I digress (and for further digression along this tangent read this article on sexual assault and the chain of command: http://thefeministwire.com/2013/05/are-men-to-be-trusted-thoughts-on-sexual-assault-and-the-chain-of-command/

Power in the therapeutic relationship

Back to the book. I do agree that it is essential reading for anybody working therapeutically in a position of power. I have a personal dislike of the use of the word power in the therapeutic relationship. I don't see myself as having power over my clients. I don't want to have power over my clients - I see us as being equal. But the fact is, when we open up to a therapist, we are trusting them, and anybody we trust has some power over us, because they can abuse their position. Our therapist has intimate knowledge about us, but we don't have the same knowledge of them. I don't like it, but it's there. It is something I cherish greatly, this privilege of being entrusted. As Yalom states, we are "cradlers of secrets".

Rutter states that any sexual contact between a therapist and client is an abuse of position of trust because of the nature of the relationship, because the therapist often becomes a parental figure to the client. With this, the sexual exploitation is tantamount to incest, and the repercussions for the victim can be as devastating. It is interesting to note, that when I told the therapist (the one who abused my trust) that he was kind of like a father figure for me, he looked horrified and said "I do hope not". Another male therapist with whom I saw in a fatherly way was touched when I told him. Such a stark contrast.

"Because the forbidden zone reawakens these childlike parts within us, acquiescence to sex under these emotional circumstances can hardly be equated with adult consent. In the light of these underlying dynamics there can be no such thing as consent in the adult sense, to a sexual act by a woman with a man who has power over her in the forbidden zone. A man of this position of trust and authority becomes unavoidably a parent figure and is charged with ethical responsibilities of the parenting role. Violations of these boundaries are, psychologically speaking... acts of incest."

So, like any profession out there, there are a few rotten apples. There are some who are called to the caring professions because their shadow side takes them there. The statistics are worrying. The book refers to research on sexual exploitation by psychotherapists. The study looked at therapists who had treated patients who had a sexual relationship with a previous therapist. 70% of therapists reported at least one patient who had had such a relationship, 96% of these previous therapists were male. The book also looks at sexual exploitation between clergymen-parishioner and teacher/student relationships but my focus is on psychotherapy as this is the field in which I am familiar (although I have awareness of a clergyman abusing his position of trust with at least two parishioners, sadly, and of course the papers abound with stories about the church and abuse).

Like I have mentioned before, I cannot believe that counselling and psychotherapy are unregulated professions in the UK. It won't stop abusive therapists but will help make them accountable and give a course of action for people to take if they are affected by somebody's inappropriate behaviour (sexual or otherwise - breach of confidentiality, amongst other things, is also an abuse of trust).

I earmarked a few pages of this book as they really spoke to me and reached the part of me that was in an abusive situation with somebody I trusted, and the part of me that is in touch with and has heard the many stories of other people (male and female) who have been abused in one way or another. When I read articles on the internet with comments from the public such as "how could she be so stupid" or comments regarding Savile's victims saying "she must be lying - how can she have gone on all this time without saying anything" I feel immense frustration. I have been on the receiving end of such tripe. This is utter nonsense. Anybody who has an ounce of empathy will know that being on the receiving end of an abuse of trust has an extremely complex response to the abuse. It can take victims years to speak up, if ever. To speak up is unfathomably hard. And usually it is only one person's word against a manipulative, powerful individual. Such attitudes perpetuate abuse.

Rutter has a chapter illustrating the snapshot of a man who crosses the boundary. There are warning signs. Clinical supervision is an ethical necessity for therapists and erotic feelings towards clients should be explored professionally. Bury them and they'll pop out again somewhere and you'll have little control over them, is the message.

This paragraph stood out as particularly interesting:

"Success itself puts a man at higher risk for feeling that he can make his own rules and that his word (or his fabrications) will be believed against the words of a woman who challenges him. In most of the case histories I gathered for this book, the man who had a sexual relationship in the forbidden zone had been considered an outstanding member of his profession."

Power rears it's head again. The higher the position of power the more likely the propensity to abuse trust. Remember that quote? "Power corrupts, absolute power corrupts absolutely".

Give me humility over power any day.

[This book has also been reviewed in January 2015 by Phil Dore in his Not So Big Society blog]

Our Mortal Wound refers to our knowledge that we humans have, that ultimately, we will die. This book examines our fear of death, conscious and unconscious, and the ways we find to deal with that fear, in particular through therapeutic exploration.

When I first heard about this book, when it was released in 2008, I was very keen to read it. However, due to my being in the middle of counselling training, I decided that I wanted to get a better grip on my own relationship with death before I explored Yalom's work. I wanted to make my own journey and come to my own conclusions, rather than taking on somebody else's construct.

So, a few years later and I have completed counselling training, had extensive personal therapy, life events and a particular confrontation with the concept of the ceasing of my own existence, and I feel in a good place to read Staring at the Sun. I read Yalom's Existential Psychotherapy a month or so prior (my review for which can be found here) which had a huge section on Death Anxiety.

I was ready for the full weight of a book dedicated to facing the fear of death, written by somebody who at (then) age 70 was facing his own fear of death.

I needn't have stressed. I actually found the book quite untraumatic compared to my personal explorations. It was probably something to do with reading Existential Psychotherapy beforehand and I think that, ideally, the best order would be to read Staring at the Sun first.

Rather than review the book I would like to share some snippets that I bookmarked whilst reading. These are useful to me as a therapist and resonate with my way of being in the therapy room.

Chapter 1 - The Mortal Wound

"Death, however, does itch. It itches all the time; it is always with us, scratching at some inner door, whirring softly, barely audibly, just under the membrane of consciousness. Hidden and disguised, leaking out in a variety of symptoms, it is the wellspring of many of our worries, stresses, and conflicts."

"I feel strongly - as a man who will himself die one day in the not-too-distant future and as a psychiatrist who has spent decades dealing with death anxiety - that confronting death allows us, not to open some noisome Pandora's box, but to reenter life in a richer, more compassionate manner."

Chapter 4 - The Power of Ideas

On Schopenhauer's triplet of essays: What a Man Is, What a Man Has, What a Man Represents:

"1. What we have. Material goods are a will-o'-the-wisp. Schopenhauer argues elegantly that the accumulation of wealth and goods is endless and unsatisfying; the more we possess, the more our claims multiply. Wealth is like seawater: the more we drink, the thirstier we become. In the end, we don't have our goods - they have us.

2. What we represent in the eyes of others. Reputation is as evanescent as material wealth. Schopenhauer writes "Half our worries and anxieties have arisen from our concern about the opinions of others...we must extract this thorn from our flesh."....Opinions hang by a thread and make us slaves to what others think or, worse, to what they appear to think - for we can never know what they actually think.

3. What we are. It is only what we are that truly matters. A good conscience, Schopenhauer says, means more than a good reputation....Inner equanimity stems from knowing that it is not things that disturb us, but our interpretations of things."

Chapter 5 - Overcoming Death  Terror Through Connection

"The task, then, is not to offer answers, but to find a way to help others discover their own answers. The same principle operated in the treatment of Julia, a psychotherapist and painter, whose death anxiety stemmed from her not having fully realized herself and neglecting her art in order to compete with her husband in earning money. I applied the same strategy in our work when I asked her to assume a distant perspective by suggesting she imagine how she'd respond to a client who behaved as she did. Julia's instantaneous comment - "I'd say to her, you are living a life of absurdity!" - signalled that she needed only the slightest guidance to discover her own wisdom. Therapists have always operated under the assumption that the truth that one discovers for oneself has far greater power than a truth delivered by others."

Chapter 6 - Death Awareness: A Memoir

"In my practice, I've worked with several psychotherapists who, having just finished a graduate program consisting almost entirely of cognitive-behavioural therapy, feel despair at the prospect of working mechanically with patients in a behavioural prescriptive mode. And I wonder, too, where therapists trained to treat patients in this impersonal behavioural mode will turn when they themselves need help. Not to colleagues of their own school, I would wager."

Chapter 7 - Addressing Death Anxiety

"Terence's Maxim and Therapist Self-Disclosure - Terence, a second-century Roman playwright, offers an aphorism that is extraordinarily important in the inner work of a therapist: 



Beginning therapists would do well to use Terence's axiom as a mantra, helping them to empathise with their patients by locating their own similar experiences. This aphorism is particulalry apt to work in patients with death anxiety. If you are to be truly present with such patients, you must be open yourself to your own death anxiety...no training program prepares therapists for this type of work."

"...why is the here and now important? A fundamental catechism of psychotherapy training is that the therapy situation is a social microcosm; that is, patients will sooner or later exhibit in the therapy situation the same behaviour they exhibit in the life outside.....This is the first step in helping a patient assume responsibility for his or her life predicament."

"...the positive therapeutic alliance is a prerequisite for the effectiveness of any therapy. It is not the end, but a means to an end. A major internal shift can occur when patients form a genuine, trusting relationship with the therapist, disclose everything and still be accepted and supported. Such pateints experience new parts of themselves, parts previously denied or distorted. They begin to value themselves and their own perceptions rather than over-valuing the perceptions of others....The intimacy with the therapist serves as an internal reference point. Knowing that they have the ability to form relationships they develop the confidence and willingness to form similarly good relationships in the future."

"I never tire of telling student therapists that their most vital instrument is their own self, and that, consequently, the instrument must be finely honed. Therapists must have a great deal of self-knowledge, must trust their observations, and must relate to their clients in a caring and professional manner. It is precisely for this reason that personal therapy is (or should be) at the core of every therapy training program...they should return to therapy as they progress through life."

These selected snippets do not reflect the content of this book, more, my ideals on the therapeutic relationship.

The book itself is a useful accompaniment to a personal journey in exploring one's relationship with death. However, I already had gone deeper and further than this book took me, and I wish I had read it earlier. It is ideal for those dabbling with the concept, and wondering about therapy's place in such a journey. Referring to my fears expressed above before reading this book, there are no "constructs" to take on. Staring at the Sun is respectful of all the ways we find to deal with our mortal wounds.

Amanda Williamson is a registered BACP Senior Accredited counsellor and EMCC Senior Accredited Coach with a thriving private practice in central Exeter, Devon.

I have come to realise that many members of the general public are not aware that counsellors and psychotherapists are in an unregulated profession. I think that may partially be because we supposedly live in an age of litigation and accountability, and it is taken for granted that those with whom we entrust our deepest, darkest secrets would have somebody to answer to if they acted in an unethical way towards their clients.

Look at this typical response from somebody when I tell them that therapists aren't accountable:

"Lack of regulation seems like a recipe for a lot of abuse and misconduct. Who couldn't recognize all the potential hazards considering how vulnerable people are when they seek treatment?"

I CHOOSE TO BE ACCOUNTABLE. I am a member of the British Association of Counselling and Psychotherapy - the UK's largest professional body for counsellors. I attended a BACP accredited course because it made sense to me to start off my career as I meant to go on. The Iron Mill Institute's counselling courses are accredited by the BACP which means, according to the BACP website:

"...that (the course) has been assessed by BACP against the criteria for course accreditation as detailed by the BACP public Accreditation of Training Courses (BACP 2002) and awarded accreditation...that they can offer quality training to a high standard, which is recognised by employers, colleagues and prospective clients."

So it was part of the training from Certificate level (the preliminary training) that we were made aware of the BACP Ethical Framework for Good Practice in Counselling. This is actually a very well written document and far from constraining the profession, I think that it gives a lot of leeway for creativity. Note that it is framework, not a list of rules and regulations. It is very sensible and really, I would be worried if anybody counselling out there had a problem with adhering to the principles set therein as they correlate with the qualities and ethics of any decent person.

I could see from the start the clear advantages to being a member of a professional body, for the therapist and for the client. I have struggled to understand the opposing view - that regulation would restrict the profession such that the service we supply would be impaired. This struggle has increased as a result of my falling victim to unethical practice. I am unable to divulge much about the actual situation and have been threatened with being "put in a cardboard box" (yes by another counsellor, who has recently resigned from the BACP...) if I publish details of who this person is.

I'm happy with that, not the cardboard box bit, but I do understand that official procedures are needed at times like this. It's all very well when counselling and psychotherapy goes well, and everybody behaves and acts professionally, but like doctors, policemen, teachers, priests...every single profession in fact, there are a few rotten apples. So we have the inconvenient issue of, how do we deal with those rotten apples? Well, if they have acted in an illegal way then it is a matter for the police. We all know that this is not foolproof and without overwhelming evidence, and because of the stress of going through the legal system, many people don't bother or give up part of the way through.

Now, unfortunately, the therapist whom I fell victim to chooses not to be a member of a regulatory organisation so, apart from complaining against the organisation which he owns and works for, he is personally unaccountable. He can hide behind the organisation and carry on his private, unethical practice. I assume it will continue to be unethical because he refuses to see that anything he has done is wrong. I think he knows it must be wrong because he is completely denying the truth and is attacking from as many angles as possible anybody who is trying to raise awareness of his behaviour.

If this therapist were a member of a professional body then a formal complaints process could be had and he and the victims would have the opportunity to provide evidence and cross-examine and the body could make a decision on whether it was unethical or not. I know in theory that at least 18 paragraphs of the BACP Ethical Framework for Good Practice in Counselling have been contravened, in my case. It would just be a case of proving it, and given that there are several women who are prepared to write statements of their experiences it should be fairly cut and dry. Except that he isn't accountable. So he can carry on, and the public need not know anything.

I want potential clients to know that this is what can happen if you choose to see a therapist who chooses NOT to be accountable.

Of course no system is faultless and there is the risk of therapists slipping through and of being falsely accused. This is part of parcel of the medical profession so why not the therapy industry? Do we throw the baby out with the bathwater because there might be an unfair sanction? Shall we abolish the whole justice system so that we don't make the mistake of incarcerating an innocent? Of course not. Surely it's possible to have a system that protects clients from unethical practice, and no it won't stop it completely (Harold Shipman keeps getting mentioned in these arguments), but it will provide a process, a safety net, for those that would like to raise awareness of potential unethical practice because they have been on the receiving end of it. And maybe, just maybe, they will receive the validation they need in the face of having had their trust abused.

I would not like to have to go through the complaints process myself, but in doing so, I would be confident that I do run my counselling by the guidelines suggested, I do check out my own motives and my own blindspots regularly, and if it was ever found that I had acted unethically I would want to do the right thing, alter my practice if needs be, and apologise to the person who was on the receiving end of it. This is the very opposite of what I am getting. I do not want anybody else to be in this position.

Here's what the BACP say on this matter: http://www.bacp.co.uk/media/index.php?newsId=1769