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Cruse is also piloting a new ‘Understanding Your Bereavement’ intervention that aims to empower bereaved people to help themselves and each other. Says Langford: ‘We are taking a more psychosocial approach. Bereaved people can register with us and attend an online group where an experienced volunteer will talk with them about what they can expect from the experience of grief and options for how to help themselves and others. They can then progress to breakout groups for small-group discussions. We are finding there is a desire for support but also a desire to gain more understanding about how people can support themselves and each other. We’ve had a very positive response, with the majority of participants saying they didn’t feel they needed any further support – they’d got what they needed.
If we ask you to provide us with any written client or other third-party consent, this should be done via one of the secure methods above. We will delete the consent from our system once we have seen them. My mum was suffering from dementia. She was diagnosed in 2017 and we had to move her into residential care in December 2019. Then COVID came and I couldn’t visit daily, as I’d been doing. Then I got a call saying they’d got COVID in the home, and I knew it was a matter of when not if Mum got it. They called me on Friday 10 April to say she’d got a cough and they’d called 111 and been advised to treat it as COVID. Many others struggled with relationships and compulsive sex. It seemed drugs were omnipresent on the gay scene. At Attitude, I noticed a pattern of staff taking Mondays off. I found one asleep on his desk. Then the gay brother of our advertising manager, someone who worked with us for a while, who had struggled with drink and drugs, took his own life. If we receive a written complaint of plagiarism, we will raise the complaint with the author or authors. One of the key problems for LGBT people, especially those living outside big cities, is the difficulty of being able to easily connect with people with the same experience. Sometimes when they do, because that community is made up of many traumatised people, often drinking and partying, it can sometimes not be the most welcoming place. The need for authentic connection is vitally important. For some of the men who have attended A Change of Scene, a monthly discussion group for gay and bi men facilitated by Simon Marks, it’s their first experience of sitting with a group of other gay men and discussing their lives, even though they have been out for 20 or 30 years. Marks also runs group therapy for his clients, which he believes can particularly help gay and bi men connect. He believes one upside of the pandemic may be that more support has become available online. ‘A Change of Scene, as well as many 12-step LGBT meetings, are now being held on Zoom,’ he says, ‘which means people from across the country can access them who might not have been able to before. I hope this continues when the pandemic is over.’
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It’s clear that there is still work to be done for the LGBT community to feel comfortable in therapy – and also for therapists to understand the complexities of working with LGBT people. The good news is that there are signs of positive change. Pink Therapy has a database of therapists of all sexualities and gender identities who work with gender and sexual diversity clients across the LGBT spectrum from a non-judgmental standpoint. BACP has published a Good Practice across the Counselling Professions resource for members, Gender, Sexual and Relationship Diversity. 5 She died a week later. The home had told me I could go and see her just for five minutes to say goodbye before she died and I donned all my own PPE – cagoule, waterproof trousers, goggles, dust mask – I didn’t want to use up the PPE at the care home. I think she knew I was in the room, but she was very heavily sedated. I just stood at a distance and spoke to her and said goodbye and came away. I didn’t touch her, I didn’t know if I could do that. And she died the following evening. I was told she wasn’t on her own when she died, which was some comfort. And the result is widespread anxiety and sadness. But, she stresses, ‘anxiety and sadness are normal reactions to abnormal situations – and we have had an abnormal situation for going on three years now. And the treatment for such sadness is human connection.’ US family therapist, academic and writer Dr Pauline Boss is taking a different approach. Originator of the concept of ‘ambiguous loss’, after years of writing, teaching and training practitioners, she has written her latest book, The Myth of Closure, 9 for the general public (reviewed in this issue). ‘Ambiguous loss’ may be physical or psychological. Physical ambiguous loss refers to deaths where there is no verification of the death itself – no body, no death certificate, for example. It can also apply to other losses, such as a job, money, and even the ability to mourn together, as happened in the time of COVID. ‘Psychological losses are amorphous and much harder to identify and quantify,’ Boss says. ‘For example, they could be loss of trust in the world as a safe place, loss in trust that your friends are safe enough to be physically near you, loss of feeling secure about going to buy groceries, of being able to go about your daily routine, go out of your house and feel safe. It is a really long list.
Is there a significant message here for the counselling profession? There is, says Cooper, an understandable wariness among person-centred counsellors about questioning Rogers’ six conditions and the fundamental client-led ethos of the person-centred approach. But, he argues, the research tells us this may not be what some clients want or find useful, and ethical practice demands that we listen to what clients say they want. ‘It is often assumed as a fixed position that it is the relationship that heals, but that’s not what the evidence always shows. It’s great if a therapist wants to be non-directive and work from a wholly relational stance, and there is evidence that it can really help some clients, but those practitioners need to be clear that it may not suit all clients, just as CBT doesn’t suit all clients. One man told me about his positive experience of working with a straight counsellor. ‘I’ve spoken in great detail about the specific challenges that gay men may face, as well as my other intersections, such as living with HIV and living in a rural area. She has followed my lead, developed a professional awareness of these issues and responded in an attuned and empathic way. It’s almost become her niche now.’Of course, it is likely some of the healthcare providers mentioned in this survey were therapists. We can’t be naive or complacent – there will be incidences when therapists get it wrong, either intentionally or inadvertently. And, through legislation, education and awareness, we have to ensure that anyone who is LGBTQ+ (or wondering if they may be) can access therapy without fear of judgment or that they will be pressured to change a fundamental aspect of who they are. If you're writing about a piece of research, present it as a narrative, not in the style of an academic essay. Engage the reader with a lively opening paragraph setting out your argument. Case studies Her aim with this book is to encourage people to recognise that they are resilient, they are able to come through such losses, by drawing on their own and others’ strengths and support. ‘The counselling profession is very much needed for people who have depression and are suicidal and so on. But for the rest of us, what we need is psychoeducation,’ Boss says. ‘I believe it’s information that will help people to cope with the natural stress that comes out of an unnatural situation. There are long waiting lists for professionals and we need to know that not the entire population needs to go into a therapy room. There aren’t enough therapists to do one-to-one therapy and nor can many people afford it, so you need to give out psychoeducational material so they can help themselves and each other.’ King’s College London is a partner in a large-scale data collection initiative across the higher education sector called SCORE (Student Counselling Outcomes Research and Evaluation), which is supported by both BACP and UKCP and is amassing and publishing outcomes data from several student counselling services. Turner’s professional experience is that outcome measures are a helpful addition to her work and to the higher and further education sector. For her, collecting and pooling outcome data are essential for individual professional development and the development and status of the profession. ‘Large datasets ensure counselling services are fit for purpose. The data can help services strategically align themselves better to student need and practitioners shape their interventions to make them more useful and viable. I think studies like PRaCTICED and ETHOS are a huge opportunity for practitioners to look outside their own clinical practice and maintain our professional development in the way key stakeholders expect us to. These studies offer evidence of our value as a specialist service and that what we are doing is valuable from a more externalised measure.’ The key mechanism in people’s recovery is the exchange of stories. People can’t make sense of the death – because they weren’t there, they had to rely on reports from healthcare staff, they’ve been denied the eulogies and conversations after the funeral – it’s delayed grief and, as the research has found, people aren’t recovering. But we have been monitoring participants in our Zoom groups that we’ve also been running, using an Assimilation of Grief Experiences Scale that we developed to measure how well participants are beginning to accommodate their loss into their lives, and it’s clear that, even when the rest of their lives are still difficult, and they may be struggling with their anxiety and depression as shown on the PHQ and GAD scales, their relationship with the deceased and making sense of the death steadily improve. We are seeing changes and adaptation in the people in our groups.’
There is a generation of gay men still alive today who were criminalised and imprisoned. Being gay is still illegal in 70 countries and subject to the death penalty in around 11, and thousands of gay people still come to London from across the world for sanctuary. Even in the UK, it’s only in the past 20 years that legal inequalities have begun to significantly improve. And while we can eliminate laws, the shame and trauma inflicted on people over generations are not so easy to erase. Although young people today are growing up in a very different world to that experienced by previous generations, it is still hard to be different. When I read Marina’s words I immediately hear Judith Butler’s voice: 12 ‘The boundary of who I am is the boundary of the body, but the boundary of the body never fully belongs to me.’ What is afforded to us, as therapists, as carers, I wonder, if we begin to understand in our intersubjective engagements that we do not inhabit ourselves by ourselves? Our sense of self emerges from our developmental relationships; we learn to understand not from conceptual knowledge but through intersubjective bodily interactions and feelings during an early intimate dance with our primary caregiver. A common experience for the person living with dementia is losing a sense of self – what, then, of their experience of loss, vulnerability, intimacy and dependence? Taking outcome measures can help validate a client’s sense of distress – that they really do need help, which for some is important if they are to engage with therapy. Continuing to do so then provides a measure of progress, or an alert that progress has stopped. But McInnes’ own main reason for doing it originally was curiosity, he says. ‘I wanted to know how I compared with the overall effect rate. What’s my effect size? I’d be disappointed if therapists had no curiosity to know what difference they are making.’ I Can’t Find Myself communicates all that is unspoken in the lived experience of dementia. It calls for our attention (and intention) in our relational and kinaesthetic engagement with people living with the illness. It is not about what we can do for people living with dementia; it is about how we can be with them.’Collaborative meaning making is, of course, an intersubjective process: one of mutual recognition where we can shift between being in relationship as well as observing relationships around us. In the dementia relationship, as with any traumatic experiences, the capacity to observe breaks down. Therefore, as therapists and carers, the intersubjective question we may find ourselves asking is, ‘How can I remember for the person living with dementia?’ Research into humanistic counselling has been given a major boost by the findings of two randomised controlled trials (RCTs) published earlier this year. The PRaCTICED trial, 1 which was funded by BACP and conducted at the University of Sheffield, established that person-centred experiential therapy (PCET) does achieve comparable results with CBT when delivered in an IAPT setting – as analysis of practice-based data had already indicated. The ETHOS RCT, 2 which was supported by funding from the Economic Social Research Council (ESRC) and led by a team at the University of Roehampton, found clear benefits for children receiving person-centred school-based counselling in terms of achieving their goals. Chatbots are providing ‘therapy’ to thousands of people around the world. Sally Brown learns what artificial intelligence can offer counselling. As a helping profession, and as human beings, our instinct is to want to do something, which makes Anthea Kilminster’s article on providing culturally sensitive, trauma-informed counselling for displaced people, written before the recent events, seem all the more pertinent. She shares how the Yorkshire-based service, Solace, has supported displaced people from around the world, including Syria and Iraq. The thousands of people fleeing Ukraine will join the estimated 70 million already displaced worldwide, greater than the total population of the UK. A number will make their way to the UK, and counsellors like Anthea will be there to help them adjust.
Elsewhere in this issue, we look at what is arguably every therapist’s worst nightmare – being on the receiving end of a client complaint. It is a tribute to most therapists’ commitment to working ethically that complaints leading to Professional Conduct hearings are still rare, but many more could be avoided if therapists knew how to properly respond when a client first raises their dissatisfaction with their therapy experience. In our ‘In practice’ piece this month, BACP’s Acting Registrar John O’Dowd talks us through the process and offers advice for both avoiding and dealing with client complaints. I would also like to thank Matthew Campling for sharing his personal experience of how he coped when a complaint came out of the blue from a former client. To sum up: ‘... a pluralistic perspective of good practice that is inclusive of all modalities is essential. The therapeutic relationship is key to effective therapy, and a focus on ingredients such as collaboration, empathy, and responding to client preferences is vital to ensuring ethical and effective therapeutic practice. The recognition that different clients need different things promotes a more pluralistic provision of therapy services.’ Another highlight of this issue for me is our ‘Experience’ piece, in which Max Marnau, a BACP senior accredited counsellor, shares the dilemma of whether to ‘come out’ to clients about her late diagnosis of autism. She also questions why therapy for autists still focuses on helping them conform to a neurotypical world.
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The knowledge gap seems to start with training. Therapist Josh Hogan says the ‘diversity’ module on his course was mainly focused on race and ethnicity. ‘We were asked to reflect on our differences and how this would affect us in the therapeutic relationship, but there was no specific guidance around working with LGBT clients,’ he says. Stroebe M, Schut H. Bereavement in times of COVID-19: a review and theoretical framework. OMEGA–Journal of Death and Dying 2021; 82(3): 500–522. If you've included information or discussion about any member or members of your family, please confirm that what you've included is made in good faith and is true and accurate to the best of your knowledge; that you’ve considered any potential impact on them and on other family members if they read the article; and that, having done so, you wish to go ahead with publishing.
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