This is the text of a recent email to our therapists on these themes. We are aware of the very different way in which these issues are addressed within the NHS/similar medicalized contexts in health and social care – and the extent to which the medicalized approach increasingly seems to have been reflexively adopted by swathes of mainstream therapists, as if it represents the only possible or ‘ethical’ approach to ‘best practice’. This phenomenon (and its apparently unreflective/assumptive nature) seems to us incompatible with serious respect for client autonomy or a person-centred way of working. Our observation is that it seems to be driven more by therapist fear of perceived ‘risk’ and responsibility, than by what truly serves the people we work with.
It is important to us, given the currency these ideas have, to have the relevant conversation with our own therapists, and to raise these questions in the wider therapeutic world through this blog. Comments welcome:-
“Where is PGCS on contracting, and on suicidal thoughts?
This document invites you to reflection/discussion, with each other and with us. Feedback welcome. It covers two ways we see – and so do – things differently from some other agencies/therapists. They are subjects on which people in the therapeutic world express strong opinions. In the medicalized model of human distress – e.g. the NHS/Social Care ‘mental health’ framework – this can involve a perception of only one ‘right’ or ‘ethical’ approach. Given this culture, it feels important:-
- to be clear about what we do and don’t want to offer at this service;
- to support you working in a counter-cultural way; and
- to engage with you on whatever this brings up for you.
From a person-centred perspective, we work with the client’s agenda and frame of reference. We think that does not sit well with the therapist introducing a written contract. This is even more so early in the relationship, when we are co-creating a relationship and trust. Congruence and a careful following of the client’s frame of reference are so important in this. We think there is a big incongruence, if a therapist seems to support the client’s internal locus within the work – yet also brings in the external locus/directivity of a written contract. In our experience, clients seldom or never raise the subject of a formal contract.
So we do not initiate written contracts with clients at PGCS.
Of course, person-centred working includes contracting. Some elements (e.g. payment; frequency and duration of sessions) are covered early on. Most other elements are covered in an organic way over time, as they arise naturally in the work. We notice clients raise issues they care about – e.g. confidentiality: ‘Might you ever talk to anyone else about what I say here?’.
Issues may come up during relationship. What, for example, if your client becomes angry with you and decides they want to ‘complain’. From a person-centred perspective, a meaningful response can arise only in the circumstances at the time, co-created by therapist and client so far as possible, with our support as a service. We cannot cover eventualities up front, because it always depends on circumstances. We define ethics as a careful working through specifics, within relationship, whilst remaining present and offering the core conditions (to self/other). This is our up front commitment.
We know some of our therapists may be navigating external contracting requirements. We are all qualified to Diploma level. Some of us are taking part in further courses of study, committing to work within the training provider’s parameters. Please raise this with us as early as you can, when we first meet and/or in supervision. Our intention is to explore with you how we might meet your needs in a way that respects the client’s internal locus/autonomy, and is compatible with our service ethos.
Clients expressing suicidal thoughts
In many therapeutic contexts, a client expressing suicidal thoughts can lead to an immediate/near immediate call to the client’s G.P., whether or not this is what the client wants.
Our clients are self-referring adults. As person-centred therapists, we trust their abilities to self-determine, actualise, heal and grow, in the presence of the core conditions. We believe this is what most/best serves human well-being. The challenge to us as therapists is to remain present; to remain respectful of the client’s internal locus/autonomy; and to be alongside offering the core conditions, when this gets complicated and frightening for client and/or therapist. We will support you at these times, and in this work. We think the culturally favoured switch – if suicide comes up – to external locus, ‘mental health’ language and actions taking away the client’s autonomy:-
- steps away from an honouring of the demands and complexities of loving human relationship;
- disrespects the client’s personhood;
- damages client/therapist trust;
- increases risk, and
- is fundamentally incompatible with a person-centred way of working.
So we do not do this at PGCS. This feels like a fundamental part of our ethos. So far no-one has taken their own life whilst working with one of our therapists, in our 20 year history.
We are increasingly telling clients/prospective clients up front we will maintain confidentiality if they disclose suicidal thoughts or intent. We know this is a big issue for some clients – especially following disempowering/coercive experiences in the ‘mental health’ system. So it is vital to us to talk this through with our therapists, so we can keep our promises to the people who come to us.
What do you do, if your client is talking about suicide?
- Stay with your client, as with any subject. Offer a safe space to explore their experience;
- Explore with yourself/them if they actually intend suicide. What is unspoken/under the surface? e.g. desperation to escape pain; not knowing how to be with difficult feeling; an expression of how bleak life feels; an angry lashing out/in? Follow the threads. Trust your intuition;
- Given your client is bringing their thought – rather than acting on it – they have an ambivalence, perhaps a lot of ambivalence. Explore making alliance with this part of your client’s experiencing, and co-creating ways for them to stay alive and safe/safer;
- Explore with them whether they want to involve anyone else and, if so, who and how?
- Support them in identifying and putting in place whatever resources might feel useful to them – following and supporting their process, rather than directing;
- Don’t be afraid to let them to see the emotional impact, if that is what’s there – there is a lovely Brian Thorne account of a client consistently bringing overwhelming bleakness, despair, and a desire to die. Brian acknowledged this was their reality and they might indeed make that choice. He then said he cared very much about it and very strongly did not want that to happen. The client began to cry, and cried hard for most of the session. After that, the work shifted;
- Talk to your supervisor, as much as you need. Or anyone in the supervision team. And your colleagues in group/down the corridor. We have a wealth of experience, and are here to support you. Carrying challenging client work is a communally held responsibility, not a solitary one.
Again, this way of working can create tensions for therapists also working in other contexts or undertaking training courses. If this affects you, talk to us. We will do all we can to find a way through that is respectful of your client’s needs, your needs and our service ethos.
2 March 2016″
Palace Gate Counselling Service, Exeter
Counselling in Exeter since 1994