People who come to see me for the first time often tell me: “I’ve never done this, what happens now?”. The workings of psychotherapy appear indeed to be shrouded in mystery, which is why I’d like to list a few useful bearings for people who are considering psychotherapy or counselling and haven’t carried out extensive research. I have taken those from a longer article from this blog, which you can find by following this link.
The goal of the initial consultation is to find out if therapist and patient can work together, and if so, how. To do this, I pay attention to what a person tells me, and how they say it to me. At the end of the consultation, I am able to tell the person if psychotherapy could be of benefit to them, and will discuss frequency, term and boundaries.
The “what?”
There are a few direct, specific questions that I like to ask to find out more about the person’s history and current circumstances.
For example, I may ask someone suffering from symptoms of anxiety to describe how they experience them, and what impact they have on their life and their daily functioning. I’ll also be curious about the history of these symptoms: are they a new experience, are they reoccurring? Also, do they seem to be triggered by external factors (such as, for example, an deadline approaching for a performance, being in the same room as a specific person, or being in crowded places) or do they seem to be occurring spontaneously?
I also consider all facts about a person’s earlier life to be a very important source of insight for both patient and therapist, for two reasons: first, it tells me what external factors may have influenced their development during childhood; second, it tells me how the person understands themselves. When I know more about what a person’s life has been like, and how they have this in mind, I have useful, factual information that allow me to decide whether or not it is appropriate to offer to help them through psychotherapy.
The “how?”
Not all of us will have paused and thought about ourselves as a person with a past, present and future. To many people that I have worked with, this even initially looked like “a luxury”. Life indeed seems to afford few opportunities to stop and truly reflect on oneself. And we are often given the message by our parents, friends, colleagues, partners and bosses to “get on with it” and not indulge in “navel-gazing”…
This is why it is not rare that people aren’t really able to tell me much about themselves, even when I ask them specific and precise questions. This is why I pay as much attention to what people tell me to he way they tell me it. And if I find that, in an initial consultation, a person find it difficult to tell me about themselves using words, I will help them to concentrate on this very difficulty, so that they may begin to see themselves more clearly and progress towards a better comprehension and verbalisation of their experience.
I have written an account of such a consultation in a longer version of this article, which you can read here.
What happens at the end of the session?
Before the fifty minutes of the consultation are up, I will tell the person if I can offer to see them for psychotherapy. If they tell me that they would like to start therapy, we then discuss the frequency of the sessions, and whether they want to set a term to their treatment from the outset. Some people also want to set specific goals, which we can discuss, and some will prefer to have free rein to get into whichever area of their life they feel is important in every individual session.
In my experience, my patients benefit most from therapy when they are able to come at least once a week, and the large majority of people choose not to set a term for their engagement in therapy right at the beginning. Some choose to do this later on.
Once I have communicated my policy that I require seven days’ notice for any change of session, the patient and I decide whether or not we will see each other again, and if yes, we make an appointment for the following time. Many people choose to start treatment right away and will set their appointment time and frequency there and then.
I offer psychotherapy and counselling consultations on Skype. Some of the people who see me regularly sometimes use Skype to ensure that, wherever they may be in the world, they can keep to regular appointments. Skype offers a greater depth of communication than the phone, because it is possible to convey a greater array of non-verbal cues (which for over 95% of all of our communications).
As per the words of some of my patients, “it works”. This means that they think and feel that they still receive what they need from a consultation that is conducted via this method of communication. However, is it possible, as a rule, to engage meaningfully with the process of psychotherapy on Skype (or even on the phone), whether the sessions are all or partly held via this medium?
Is therapy on Skype “real therapy”?
While developing this medium for my practice, I have carried out research into how it affects the therapist, the patient, and the therapeutic relationship. I wrote a short paper and gave a lecture on this topic at the Multilingual Psychotherapy Centre. You may read a short summary here.
I have noticed that, when using Skype, some of the traditional boundaries of psychotherapy are blurred. First, it is no longer just the patient visiting the therapist: the two parties physically see into each other’s spaces (rooms, offices) and are therefore invited into each other’s worlds. Second, both parties can see a “selfie” thumbnail superimposed upon the image of the other, like a moving stamp onto a moving postcard. And third, patient and therapist seem to become talking heads to each other, which begs the question of Skype being a watered-down version of its face-to-face counterpart.
These challenges are real, but my my experience of Skype is that it does not create new problems for therapy – it only highlights essential aspects of the human encounter, which become lines of inquiry in the therapy, and therefore means of helping the patient become conscious of themselves.
Indeed, therapists are always figuratively invited into the patient’s inner world – Skype makes it concrete. Similarly, we always see a reflection of ourselves in the other (this is supported by neurological research into the phenomenon of mirror neurons), and again, Skype makes it concrete. Finally, communicating via Skype helpfully brings into conscious focus the challenge that true relationship represents.
In short, I have found that, for all the challenges that it presents, Skype is a meaningful medium for psychotherapy, especially when it is combined with face-to-face sessions.
Article review – Peter Fonagy on psychotherapy in the NHS
I am reading Martin Pollecoff”s interview of Peter Fonagy in the Psychotherapist, the magazine of the United Kingdom Council for Psychotherapy, of which I am a member, and find myself resonating with Pollecoff’s concern that “in IAPT (increasing access to psychological Therapies) you have people who have been through a year’s training with no therapy of their own. I am concern about the political shift between the therapist and the client. It’s a model in which the expert, who is OK, is treating the poor client.There is something wrong there for me”.In my view, Peter Fonagy is absolutely right to point out that the medical model has failed in the provision of adequate mental health services to a broad public, and that the IAPT initiative is a way to Address this failure. But I don’t feel that in this interview he answers the interviewers’s questions with total clarity. Fonagy says that the psychoanalytical model is the best way to understand how the mind works and how a person can heal. He also describes three essential elements in psychotherapy (the working alliance, mentalisation and compassion). In my experience of practising psychotherapy in London, all three elements are totally contingent upon the relationship between the patient and therapist, and I feel it can only be beneficial to the patient if the practitioner has experienced these elements in a relationship with a confirmed practitioner for a significant amount of time.
Fonagy says “you have to be robust”, and in my view this comes as a result of the practitioner having tested out the solidity and healing potential of a working alliance, not as a result of a short one year training. Generally, it is my experience that the patients who come to see me at my London practices will only ever go as far as I have been myself. If there is something that I cannot negotiate within myself, then it follows that I cannot help my patient negotiate this corner for themselves. Fonagy has gone through intensive analysis himself, and I am surprised to see that he remains quite vague when discussing the essential aspect of practitioner therapy with Pollecoff.
Integrative psychotherapy and coaching – how do the two mix?
As published in the Autumn edition of the Newsletter for the Association of Integrative Coach-Therapist Professionals (AICTP) Coaching interventions in psychotherapy: challenges to the transferential relationship
As I was looking for inspiration to write this short piece about how we can draw upon our coaching skills as psychotherapists, I noticed a thought-provoking comment on the AICTP discussion thread “How do you manage movement between disciplines when using an integrative coach-therapy approach?” A participant described how he had decided to challenge his client, who was “reluctant to make external decisions and changes” so that she would get out of the comfort zone of her inner exploration, and suggested moving from counselling to coaching.
It is quite a common assumption (which I have seen expressed even by the most senior practitioners of counselling and psychotherapy in London) that coaching is future-oriented and psychotherapy about the past, and that coaching is about the outer world, and psychotherapy about one’s inner world. If we choose to accept the assumptions as the truth, then it follows quite naturally that there is a line in psychotherapy that the therapist and his or her client need to cross together when the focus of the work shifts away from the inner life and the processing of unmet childhood needs, and towards achieving life goals within a partnership of equals. The participant’s comment on the AICTP thread describes a situation when it is the therapist who takes the initiative of introducing the coaching perspective in order to shift the focus of the work.
I have also frequently observed in my practice that it can be the client who requests that the therapist intervene as a coach. This can be the case when clients feel particularly stuck in their therapy, or are particularly anxious for their lives to change in a way that they can control. I noticed that people who suffer from addictions and who experience repeated relapses will from time to time ask for a directive, solution-focused approach.
What is then supposed to change when we make coaching interventions in psychotherapy or move the relationship on and away from therapy, towards coaching? If coaching is about the future-external and therapy the past-internal, are the corresponding ways of working respectively dictated by concrete goals, and by the inner process unfolding in the person? And if so, what is the effectiveness and appropriateness of doing so, and what are the pitfalls?
What are the appropriateness and possible pitfalls of switching between therapy and coaching?
One of my patients[1], a woman in her late thirties who has been in twice-weekly therapy with me for the past three years, has been constantly frustrated by her inability to build lasting relationships. She was also unsure whether she should seek a same-sex or heterosexual relationship, and her inability to decide has caused her great frustration. During the early stages of her therapy she was able to discover, accept and act on a sexual appetite, which she had perceived as non-existent since her early teens. As a result of this, she had several same-sex encounters, sometimes resulting into brief and casual sexual relationships. She also formed an ambivalent attachment to a man of her age, who already had children from a previous marriage.
But she continued to berate her inability to “get started in earnest” and remained deeply dissatisfied at the “sterile” nature of her encounters and longs for a steady partner, with whom he would be able to settle down and have a family.
A few months ago I took the initiative of introducing goal-oriented work in one of her sessions with me. Rather than reflecting back her helplessness, her frustration and her anxiety, I decided to help her articulate and clarify her hitherto vague thinking about what needed to be done concretely to start looking for suitable partners and making herself available to be found.
As I expected, the first part of the conversation resembled a game of “why-don’t-you-yes-but” game (Berne, 1971), but instead of reaching the conclusion of mutual defeat described by Berne (the therapist runs out of suggestions and the client demonstrates that there is nothing that she can do to change), she trailed off and eventually said to me: “it feels quite weird, you coaching me like this. I know why you’re doing it but I don’t think my problem is about that”. I ventured “it feels weird to be coached when you don’t actually know what you want”. She agreed completely with my statement. This allowed us to explore how ambivalent she was towards her sexuality, arriving at the conclusion that in her mind, having a sexually satisfying relationship and a relationship in which she could thrive and find meaning in seemed mutually exclusive.
This proved to be a watershed moment, as she fully realised that her ambivalent position towards creating relationships exactly mirrored her mother’s own ambivalence towards her family, manifested by a series of affairs that were never spoken of in the family. My client had known that this mirroring existed in the way she conducted herself in her life. But until it only ‘landed’ when it was made real and tangible as a manifestation in her therapy. She was able to relate emotionally and intellectually to an past-internal item on the basis of a failure to progress on a future-external one.
What is at the heart of Coaching?
My decision to change my stance and become more inquisitive, active and even risking suggestions by asking such questions as “…and have you thought of doing x?” momentarily changed the dynamic of the relationship. As I fostered her taking ownership of the problem, she became aware that her problem was not so much in her inability to take appropriate action, but to know for sure what it was that she needed to do in the first place.
In my view, the heart of coaching lies more in the process where two parties reach a clear contract about the boundaries, means, general purpose and outcomes of the coaching session, than in the set of actions that the coach agrees to hold the coachee accountable for. With the above example I hope to have shown that by making interventions that challenge the client by bringing up her outer world and goal-directed activity in a space that is in principle dedicated to the exploration of her inner world, we can draw from essential aspects of the contracting process in coaching in order to create awareness.
However, before seriously considering experimenting with a coaching intervention I had to identify and reflect on all the aspects on my own countertransference of helplessness and frustration, lest my intervention be an acting out.
This is what has I am in the process of exploring with another patient, a young man who has come to me because he currently lacks the vision and confidence to plan and execute a change of careers. He was referred to me by his GP, after suffering a series of panic attacks.
This young man is expressly asking me to coach him, but wants a coach who has the “sensitivity of a psychotherapist”. He explained in the initial consultation that his parents would react very strongly if they knew that he is seeing a therapist, and that they have very strong prejudices against psychotherapy. This is why he chose to speak to a coach. He told me that he knew that it was likely he needed to work on himself, but that his priority would be to create concrete actions. It seems that he is asking me to focus on concrete actions and remain “sensitive” to the way that he feels in himself. All the material that he brought to the session was linked to his family and his relationship with his partner.
At the end of the consultation I recommended that he consider psychotherapy above coaching, and bring to the therapeutic space any concrete problem that he wished to explore, and that he could set a short-term review deadline to make an informed decision about what he felt would suit him best. I told him that by agreeing to coach him I would enter into a contract that perpetuated his childhood experience, where his inner life would be in full view but not the focus of my attention. I also felt – but did not tell him – that he was setting up a transferential situation where I would get and experience close to his childhood’s, which was to feel a frustration at not being able to engage with him as he genuinely needed.
The healing process in therapy and coaching
With both clinical examples I hope to have shown that it is possible, to some effect, to change one’s stance towards a client to either help raise awareness. However, in my experience, this change of stance should be clearly “called” (by the client or the therapist) and it should function within, and not instead of, the transferential relationship. With this in mind, it would seem that the assumption that seemed to underpin the comment on the thread is incorrect because it posits that therapy and coaching work only in succession, not in unison.
The essentially ambivalent position of the therapist (as a separate person and a recipient of various projections and transferences) is, I feel, brought in sharper contrast when the therapist is also a coach. I would like to suggest that in person of the coach-therapist, the client is seeking the clear line that may exist between the past and the present, the outer and the inner. If we do not give due consideration to the transferential factors that arise out of this situation, we run the risk of facilitating an inner split when we act as if that line were really there. As integrative coach-therapists, we need to ensure that we facilitate integration in the person, not splitting. It is my view that the client always knows what is good for them, but that the vagueness of the cues they give us (their requests for different modes of intervention, and our countertransferential feelings) is commensurate to the vagueness of this self knowledge. It us up to us to tolerate this vagueness and help the client connect meaningfully with their own healing process.
In this article, David Zigmond, who is a GP, Psychiatrist and psychotherapist, gives us four fundamental questions to ponder when we see patients for psychotherapy. Zigmond is concerned that the medical model, prevalent in the NHS, does not equip us with the mindset that is necessary for an authentic encounter.
He proposes four fundamental questions for therapists, which “escape subsumption to prepackaged, designatory psychologies”, and are, in his experience, “primal to any likely successful engagement”.
1. What is it like to be this person, to have lived their life?
2. What is the meaning and experience, for them, of this kind of distress?
3. What is the meaning and experience, for them, of me, now?
4. What do I need to understand of their needs that theyvpossibly cannot yet express, or even think about?
Zigmond describes these questions as “naive”, in that they assume very little. Indeed, by asking ourselves these questions as practitioners we are necessarily led to discard accepted theories and conventional perceptions so that we can form an understanding of the person’s presenting needs based on our experience of them, of ourselves as we are in relationship with them, with empathy, curiosity and openness.
The term “naive” is quite important here and I find myself drawn to it. As a psychotherapist and counsellor in London I have, like my colleagues, undergone years of therapy, supervison and training, and I know still that my learning has only begun. Psychotherapist D.W. Winnicott prefaced his book “playing and reality” with the following words: “to my patients, who have paid to teach me”.
It is tempting for many to adopt a top-down approach to psychotherapy for depression, relationship problems or problems such as anxiety. By this, I mean that the practitioner concerns themselves with acquiring an understanding of the symptoms that each condition presents and developing an approach whereby they can track progress in treatment according to criteria of functioning that may have nothing to do with the person, but that are instead taken from a group-level view.
While the latter approach is necessary in driving some areas of research and monitoring outcomes in institutional settings, the former needs adopting in every encounter. By doing this, the practitioner has the better chance of not only fulfilling their role in an institution, but also to meet the person who is suffering as an equal and give them a chance to be understood more fully and more immediately.
Cedric Bouet-Willaumez, London psychotherapist, received an email from a person who visited his website (www.london-counselling-psychotherapy.org.uk) and who wrote to him: “My parents sent me a place to be talked out of [my feeling self-conscious] once a week for quite a time when I was very young. It did not good at all”.
Very often there is an expectation of people seeking counselling in London orpsychotherapy in London that the practitioner will ‘do something’ to them to make them feel better. It will be either that the counsellor or therapist will make an unhelpful behaviour stop, or that they will create a new behaviour that can help them feel better in themselves or resolve a situation that appeared stuck. People often feel that if they can be convinced to change the way that they think, their suffering will stop.
Cedric knows from experience that this is not the case. A psychotherapist does give the client an opportunity to change their behaviour and approach life situations differently. What the psychotherapist should not do, in Cedric’s view, is to ‘talk the client out of their beliefs’. Even if the intent is felt to be positive by the practitioner, the effect of this practice is to undermine the client’s worldview and to create a relationship where the therapist is yet another person ‘who knows better’.
So, how does counselling work if the psychotherapist does not seek to replace the client’s views with his or her own?
The therapist will seek to understand the client’s deepest motivations that contribute to creating their worldview and behaviours. The therapist will help the client become aware of these, and will show the client how he or she is affected by them. The therapist’s particular skill, in Cedric’s experience, is to do something for his client that is actually very close to what a good parent should do to a growing child: that is, to be present, interested and allowing the child to grow in a direction that is meaningful to them, and not necessarily to the therapist.
Cedric Bouet-Willaumez, Harley Street psychotherapist, workshop leader at the annual conference of the College of Sexual and Relationship Therapy
London psychotherapist Cedric Bouet-Willaumez was invited by the College of Sexual and Relationship Therapists (COSRT) to run workshops for its annual conference on 19 and 20 May 2012. The conference had as a central theme the importance of considering race, culture and language in sexual and relationship therapy. Cedric ran four workshops to a good reception by the conference delegates
(PressReleased) May 31st, 2012 – psychotherapy and counselling can greatly help people suffering from problems in their relationship and in their sexuality. In the case of couples psychotherapy and couples counselling, the couple jointly attend appointments. The role of the therapist is, quite simply, to provide a place for the couple to try and meet, so that they can see what it is that they are doing together.
In the case of relationship therapy or relationship counselling, one person attends the consultations and brings their issues for working through with the help of the psychotherapist.
Cedric knows from his extensive experience of working with couples and individuals who suffer from relationship and sexuality problems that it is the breakdown in communication that is the most telltale sign that something urgently needs to be solved between the partners with the help of an impartial third party.
Communication breakdown happens when two partners are unable to convey to one another what they think and feel. This may manifest as silence, violent communication, and/or repeated misunderstandings. The space offered by the therapist aims to facilitate communication and to help the two partners see each other with more understanding and clarity, and to make informed decisions about where to take their couple.
This work is made more complex when the couple has a multicultural and/or multilingual aspect to it. When this is the case, communication can be made even harder, and the Divide between the partners can seem to be beyond bridging. Cedric has researched the topic of multilingualism and given lectures and run workshops to help people with two things :
to understand how their multilingualism can affect the way that they see and understand themselves (or not!)
In the case of non-multilinguals, to “walk a mile in the shoes of the multilingual individual” and to get a feel of how it is to be them.
Cedric practises in two languages and has years of experience helping people communicate better and make sound decisions about their couple, their marriage or their sexuality, whatever that decision may be.
Cedric Bouet-Willaumez is a qualified psychotherapist and has three clinics in Maida Vale, Central London and Harley Street. Should you wish to seek help or make an appointment, the clinic hours are from 9:00 Am to 8:00 PM.
For more information on psychotherapy, counselling, vacancies and fees please contact +44 (0) 7876 035 119 or send an email to cedric@cbwpsychotherapy.com. You can also visit the website www.cbwpsychotherapy.com for further details
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