List of published columns in chronological order

Toilet visits are therapeutically significant. Some clients go before the session delaying the start. Others go during the session, which can feel avoidant, or they go afterwards which extends it. What clients do when they get there varies considerably, as does what I discover after they’ve been. Like everything that happens in and around the therapeutic hour, trips to the toilet provide much to be pondered. 

Fifteen-year-old Tafa didn’t want to attend therapy. Each session he visited the bathroom and left a wet seat and a puddle of urine on the floor. Tafa appeared to be pissing all over the idea of therapy and after three weeks he refused to return.

Ten-year-old Darcy visited the toilet midway through each session and left slimy shit that she never flushed. I was anxious about whether or not she washed her hands or if she was spreading her shit around. Darcy was uncontained, literally and symbolically, which I had to bear until she was ready to acknowledge it.  

Eight-year-old Aasif’s toilet breaks were the opposite. He went most sessions but never left a trace. In therapy he presented as compliant but unable/unwilling to engage except at a superficial level.  Aasif couldn’t bear for me to witness the messy part of himself. Eventually he felt safe enough to remain in the therapy room and engage in messy play, providing me with the opportunity to contain his mess, and giving him the experience of feeling held.  

 Nine-year-old Bonny-Mae tried to avoid the toilet altogether. I prompted her as she jiggled about holding her crotch. She asked me to wait near the bathroom while she provided a commentary on what was happening inside – ‘I’m pulling my pants down’… ‘I’m doing a wee’… ‘I’m wiping my bottom’… I was invited to witness something messy and uncomfortable that Bonny-Mae worked hard to avoid.  

Thirteen-year-old Marcus provided a commentary too but one that was more difficult to fathom. His toilet visits were preceded by a ritual of removing his glasses and rolling up his sleeves, as if preparing for manual labour or a battle. I was invited to wait outside and witness his grunts and groans, unable to decipher what might be going on behind the closed door. 

I’m ok with swearing. As a writer and talking therapist I’m fascinated by language and curious to explore the meaning behind anywords my clients use. 

A supervisee told me she contracts for swearing in first sessions with young people, telling them ‘it’s fine, but I have a problem with the c-word’. I challenged her existing belief – that this was ordinary boundary setting – and wondered about two separate issues; understanding and censoring. I knew what she meant by ‘the c-word’ because I asked if she meant ‘c**t’. I wondered if all her clients, ranging in age from very little to 21 and from a variety of socioeconomic and cultural backgrounds, would have the same level of comprehension. She admitted that a few had asked ‘what’s the c-word?’ leaving her feeling tongue-tied. I wonder how many others didn’t know what she meant and either went away and asked someone else or were left not-knowing. So my first point is this; never assume that a word (or non-word) means the same to you as it does to your client, and vice-versa. 

I checked something out with ten-year-old Charlie, who described someone he’d fallen out with as ‘a f***ing paedo’, using the term as a generic insult. I acknowledged the rage he felt towards his peer, but wondered about his understanding of ‘paedo’. When Charlie reeled off a list of profanities he perceived as similar (including an a-word, a b-word and a c-word) I decided to clarify and provided a brief definition of paedophile.  Charlie told me his peer was a dickhead and we spent the remainder of the session exploring his feelings of betrayal. Because he hadn’t felt censored, Charlie had gained a better understanding; both of his rage and of language. 

I don’t have a problem with anything my clients say and I remind them of that often. I mirror their language, which means that sometimes I swear in sessions.  If a client says they are pissed off, I wonder what they are pissed off about. If they tell me their life is shit, I might agree there are things that sound shit to me too. Using the clients’ words, expletives and all, tells them they have been heard and validates their feelings.  It demonstrates my capacity to meet them where they’re at, alongside the f***ed-up, pissed-off, shittiness of life rather than negate it or attempt to clean it up. Which is exactly what my clients need from me, and deserve.  

Every therapeutic relationship should begin with a dialogue about when it might end. This might sound punishing. Many young people come to therapy carrying the burden of broken, damaged or insecure attachments. We want to offer a different experience of a relationship that models care and compassion, and that meets their needs. But it's important to manage their and their families' expectations, and acknowledge the limitations of therapy - one of which is that it is finite.

Some endings are based on time-limited or financial constraints that can feel arbitrary. The young person might not feel ‘better’, the parent/ carer/ agency might not perceive them as ‘fixed’ and the counsellor might feel less than ‘good enough’. In time-limited work, the ending is always in sight, but in long-term therapy, too, it’s important to distinguish a period that I think of as ‘weaning’. Clients and counsellors become attached, which facilitates therapeutic work, but they also need time for separation. Ideally, endings are jointly negotiated, based on a combination of clinical judgment and client wellbeing. They should be thought about as a process rather than a distinct event; a process that starts at the beginning. The aim of therapy is to be ready and able to end, and so helping our clients to manage endings and loss is one of our most important therapeutic occupations.

I’m in favour of rituals, and encourage clients to acknowledge their last session as something special. Some spend weeks planning, giving us ample opportunities to wonder about how we might feel, as well as what we might do. I have facilitated requests to make pictures, dance and eat cake! Some clients don’t attend their last session. But because the ending has been a process, rather than a one-session event, we will have already worked through some of the feelings that ‘ending’ has provoked. On these occasions, I write to my client to say goodbye and, if appropriate, acknowledge that doing so in person would perhaps feel too painful for them.

I’m aware of the temptation to leave the door open for future therapy, but advise caution. In order to experience a good-enough ending, we need to be clear that that’s what it is. I might say (honestly) that I will keep my client in mind, but I don’t say I will miss them, because that feels like blurring the professional boundary. Ending therapy is a celebration of the work we have done together, and I am mindful, as I move towards each therapeutic ending, that, in the words of TS Elliot from Little Gidding, ‘to make an end is to make a beginning’ and that for the client ‘the end is where we start from’.¹

1 Elliot TS. Little Gidding. London: Faber and Faber; 1942.

Lauren has a diagnosis of depression, is non-compliant with medication and self-soothes through cutting. She absconds and is often missing for days. She has indiscriminate sex, often under the influence of alcohol and/or drugs. She’s been coming to therapy for a few months and we’ve been thinking about how she can keep herself safe – she somehow manages to remain just about safe enough. I’m being attentive, I’m sharing my concerns and we’re building a good therapeutic relationship. She shows up and thinks, and I feel like I’m getting it right. 

I’m comfortable working with adolescents like Lauren, where the risk is obvious. What’s more challenging for me, is working with young people who present as less risky and more ambiguous; the ones who deny any self-injury or other risk-taking behaviour, who don’t appear mentally unwell and who present as compliant. 

Fliss is like that. She attends regularly and on time. She engages in futile chatter about her week and plays board games. She makes the thinking part of me feel idle and therapeutically redundant. It feels like we go through the motions, week after week. There’s no apparent risk, no obvious mental health concerns, no ethical dilemmas and nothing much to comment on or interpret. With clients like Fliss, there is nothing in the content of the sessions that tells me I’m getting it right. When I’m with them, I feel bored, and, on reflection, useless. 

And that’s the nub of it, right there. 

Clients like Fliss feel useless too. They are told, or tell themselves, that they are getting it wrong. They fill the space with chatter or activity or both. They are distracted or distracting because they can’t bear to think, and they can’t bear to be thought about either. Monotony is used as a defence because it’s perceived as less threatening than uncertainty. The deadliness I experience in the sessions could be perceived as a projection of the dead-ness these young people feel inside. 

Once I’m able to acknowledge my felt sense of the session and disentangle the content from the process, I can begin to make sense of what’s going on. I process the process, either in solitude or supervision, and reflect my reflections back to my client – ‘I’ve noticed it’s important for you to feel like you’re getting it right here. I wonder how it is for you when you feel like you get it wrong?’ 

And then our work can begin. 

You’ve heard of sugar daddies, right; rich, older men who pay for the company of attractive, younger women. Sugar Daddy websites were around long before more mainstream dating apps but both the quality and quantity of them is shifting. A recent (2016) report by BBC Newsbeat found that one site had over a quarter of a million university students registered as sugar babies, a rise of 40% in twelve months. The dating choice of consenting adults is their business. Therapy referrals have made sugar daddy-ing part of mine.

There is a sinister clue in the vernacular; barely pubescent sugar ‘babies’ are accepted onto websites by uploading provocative photographs and fake ages. They provide company to rich men for money and by company I mean sex. The younger, more attractive the girl and the more niche the sex, the higher the price tag. To be clear; if you’re thirteen and willing to be caged, gagged or participate in anal or sadomasochistic sex you can earn big bucks.

Legalities and safeguarding aside, I see my role as helping these girls to think about their choices. Many insist they don’t want to stop sugar daddy-ing. They reason that it’s the men who are being exploited and they who are in control. They see their age as their weapon; if a man gets too rough they threaten him with the charge of sex with a minor. It’s a dangerous game.

 They switch off, engaging physically but not emotionally. The effects of this inevitably filter out making ‘normal’ relationships impossible. An eighteen year old I worked with told me she’d never been kissed although she’d had sex with scores of men since she began sugar daddy-ing aged fourteen. She’s been beaten, whipped and asphyxiated for other people’s sexual gratification. She earned enough money to pay her way through university but, in her own words, it fucked [her] up. 

We need to be willing to ponder sex with our young clients, including depraved, immoral and illegal sex, in a way that helps them to ponder it too. Their best defence has been to not think. If we pretend this isn’t happening to our clients, we collude. If we share disclosures and report abuse without exploring it with the girls themselves, we risk losing them. If we cut off psychologically we mirror their cut-off-ness and they remain stuck. The way to change the unthinkable is to think about it. Now.  

A number of my clients are described as attention seeking by (mostly) well-meaning observers. Behaviours include being silly, clingy or feigning illness, as well as various acts of self-harm, including suicidal actions. Attention seeking is perceived as a derogatory term – which belittles the behaviour and suggests that both it and the individual shouldn’t be taken too seriously. Yet the arrival of the attention-seeking client in my clinic suggests that, after all, they are being taken – ever so slightly – seriously.

I often ponder aloud why the young person feels they need to do something that silly or that risky for attention. I’m encouraging a dialogue about what their actions might mean, because they need to be acknowledged and understood in a way that feels good enough. There isn’t a ready-made formula, so we need to work it out together. I try to model communication that acknowledges the action without judging the individual, and I express my curiosity from a position of ‘not-knowing’. The not-knowing bit is powerful because young people are often in that position themselves. It can be reassuring to have someone join them there rather than preach from a position of superiority.

And I don’t know why this person has taken an overdose, or that person makes rude comments, or the other one cuts, but I do know this: they want someone to notice and they want, at some level, someone to

know how it feels. There might be clues in the act itself, but also in the context. I might wonder aloud about the sense of loss that may have preceded the overdose, and go on to explore the young person’s beliefs about life and death. I might notice that the challenging behaviour began around the time that Dad left, and that it might feel as if he isn’t bothered anymore because his visits are so inconsistent. And I might wonder at the challenges and uncertainties of adolescence with the young person who self-soothes by cutting.

Just as the distressed baby will cry louder until its needs are met, the troubled child or adolescent will escalate their efforts to be noticed. And just as the non-verbal baby relies on an attentive (m)other to understand their needs, so, too, the child or adolescent who nds it hard to verbalise their distress might require help in working it out. It’s time to stop dismissing attention-seeking behaviour and start recognising it as a vital communication from a young person who wants to be heard.

I recall the moment a former client popped up on my television. I recognised the voice, before the face, as one I’d attended to for over 100 hours. Once the realisation about who it was struck me, I switched the television off. Obviously the now 18 year old had consented to public viewing, but it felt awkward to have them in my personal rather than therapeutic space, albeit via the TV. Naturally I was curious about what happened to them afterwards, but in that split second decision to switch off, I ensured that our therapeutic ending remained intact.

That experience prepared me for the now relatively common phenomena, in my work with young people especially, of the friend request. I explain to existing clients that our relationship remains within the therapeutic space to protect our individual privacy as well as that of our friends and families. I know counsellors who search their client’s social media profiles out of curiosity. For me, technological snooping crosses a boundary and feels intrusive. If I want to know more about a client I ask, I don’t spy. If they are inquisitive about me I encourage them to do the same. Even though I don’t share personal details, I think this models honesty and respect and it holds the therapeutic boundary.   

Requests from former clients, and sometimes parents, are trickier to refuse. I will have wondered how they have developed and whether our therapeutic work has been kept in mind. So when their name pops up informing me that they have remembered I’m delighted to hear from them and tantalisingly close to satisfying my own curiosity. 

So when their name pops up informing me that they have remembered I’m delighted to hear from them and tantalisingly close to satisfying my own curiosity. But I decline their invitations and respond instead by private message saying I’m pleased to hear from them and hope they are doing well. Some respond, some don’t, which provides clues about their motivations; increasing their ‘friend’ count, or a genuine desire to make contact. I know counsellors who accept ex-clients as friends, reasoning that once the professional contract is terminated, it’s a legitimate way of keeping in touch. I disagree. Clients have fantasies about me and my ‘real’ life as do I about them. I believe those fantasies should be maintained rather than contaminated by access to each other’s social media profiles.    

How we respond to clients afterwards should be as ethically informed as how we respond to them during. So before you accept a friend request from a client, former client, or parent, consider whose interests you are serving. If it’s your own; decline.

I had a referral from a mother struggling to manage her child’s oppositional behaviour. She wondered if he had ADHD and wanted to know if I could offer anger management; to him not her, although she sounded very angry on the phone. Archie was three and was a delight, curiously poking his nose and fingers into my things and asking endless questions during our consultation. I congratulated his mother on her bright and inquisitive child and modelled firm containment; ‘There are things in this room that are private and I’d like you not to touch them. Why don’t you have a look over here instead…’ Archie responded age-appropriately, by testing the boundary but staying within it once he realised it was firm. His mother expressed relief that there was nothing ‘wrong’ with her son and admitted her anxiety about being a good-enough mum.

I had a request for bereavement counselling for nine-year-old Oliver who was clingy, not wanting to leave his mother’s side. When I learned that his grandmother died just a week ago, I wondered aloud if Oliver was afraid that something might happen to his mum; that she might die too, and that’s why he wanted to keep her close. He nodded that he was. I pondered aloud that mum was probably distracted by her own grief and preoccupied with funeral arrangements so that Oliver might feel lonely. They didn’t need bereavement counselling; they needed to be reassured that it was ok to be sad together.    

A referral from school for seventeen-year-old Essie outlined concerns about depression, self-harm and suicidal thoughts. Essie told me she was struggling with UCAS and coursework. She hadn’t self-harmed and didn’t want to die. On the contrary, she had a clear life plan and wanted to be a success! She wasn’t depressed but she was understandably anxious and had told her teacher she ‘wanted it all to end’. ‘It’, I discovered, encompassed exams and choices which had become overwhelming. After verbalising her thoughts with me, Essie said she felt lighter. I’d listened and normalised her feelings and fears. 

I met each of these young people for a consultation but I offered none of them individual therapy. They weren’t mentally ill and they didn’t need psychological support. These referrals are examples of a worrying trend to pathologise ordinary emotion. Toddlers have tantrums, children feel insecure, adolescents fuss and fret And that’s ok. We should encourage them to feel and display emotion. It’s a healthy thing to do J

Some boys develop into big, strong men. Others become beautiful women. Most are somewhere in between. Gender, like sexuality, is not a binary concept. Working with transgender clients I often ask questions such as ‘how do you identify?’ or ‘will you tell me if I get it wrong?’ This directness rarely causes offence. On the contrary, an honest acknowledgment of comfortable not-knowing provides relief from the more familiar experiences of assumption and prejudice.

A quick straw poll suggests those above an arbitrary figure denoting middle age are against their public display, while those in the younger bracket are indifferent. Historically, tattoos were a male-dominated pursuit associated with soldiers, sailors, hoodlums and chavs. Today it seems no self-sanctioning celebrity is without one, so too 40% of 18 – 29 year olds and 21% of all UK adults irrespective of gender, class or aspiration. *Hushed whisper* - counsellors have them too. The figure for under-18s is unknown, largely because the Tattooing Of Minors Act (1969) deems it an offence. However, 

a good proportion of my adolescent clients have tattoos and, legalities aside, I’m interested in the whats, whys and whereabouts of their ink.

While purely decorative swishes and swirls may be de rigueur in certain circles, adolescents appear inclined towards something more blatant. I’ve observed graphic representations of parents who have died or siblings who have been separated. Tattoos that symbolize loss are particularly popular (and pertinent) amongst Looked After Children. They communicate that they weren’t always alone; once upon a time they were part of a family and their disconnected family remains part of them still.

It’s become common for young couples to have each other’s names indelibly etched to signify their commitment. The relationship may be faltering before the ink is dry but they don’t want to hear that, or the warning that they’re likely to regret it. They wouldn’t be in the relationship with the matching tattoos were they not certain it would last; they’re not stupid. On the contrary, these tattoos demonstrate love and devotion to someone who loves and is devoted to them in return, perhaps for the first time in their life.

They wouldn’t be in the relationship with the matching tattoos were they not certain it would last; they’re not stupid. On the contrary, these tattoos demonstrate love and devotion to someone who loves and is devoted to them in return, perhaps for the first time in their life.

Alongside the increase in tattooing has been a rise in demand for removal. I’ve seen some dreadful tattoos, the perpetrators of which were never identified for legal reasons. Misspelt names, unrecognizable images and meaningless symbols abound. Relationships fail. Tastes change. Skin sags. The young grow up. If only a leaf had been taken from Totally Tattoo Barbie’s book (yes it’s a thing) and a temporary version of their love-interest’s name had been opted for instead.

Adolescents are conspicuous consumers of fast everything. Relationships develop from swipe-right to fourth-base in days. Phones, tablets and other gadgetry are ‘old’ within months. In a life where nothing lasts for long, it’s curious that so many young people are opting for something with the potential to last forever. 

There’s a certain 22-year-old who’s become a frequent presence in my therapy room. Prepubescent girls bring his face on lunchboxes and book bags. Adolescents bring his music via smartphones and tablets. Parents discuss their children’s obsession, and confess that they quite like him too. Type ‘Justin Bieber’ into Google, as I did, and you get 153-million results. Bieber-fever has reached pandemic proportions and I’m wondering why.

 Justin Bieber is the only child of unmarried parents who separated during his early years. His proud single-mother uploaded videos of her son’s amateur performances to YouTube. A marketing executive stumbled across them, liked what he saw and signed 13-year old Bieber to a record label. It sounds like a fairy tale, although the family might call it divine intervention. They are practicing Christians, and Justin doesn’t hide his strong moral, and sometimes controversial, beliefs about suicide, abortion and rape.

The rags-to-riches story has universal appeal. Hopeless, stuck, struggling young people tell themselves – if him, maybe me too. Many identify with the humble beginnings, absent father and poverty, but also with Bieber’s lyrics, which I’ve spent many therapeutic hours scrutinising.

The break-up of a controlling relationship is explored through ‘… you told me that you hated my friends the only problem was with you and not them… you told me my opinion was wrong…’ And many adolescents identify with the effusive apology: ‘…you know I made those mistakes maybe once or twice. By once or twice I mean maybe a couple of hundred times’. While experiences in a multitude of relationships are epitomized in ‘First you're up, then you're down and then between. I really want to know... What do you mean?’ Scratch the surface and these lyrics help put words to feelings and experiences that young people would otherwise struggle to express. 

My clients have been telling me fairy stories. Six-year-old Jonas told me about the wild beasts that come into his bedroom at night. They have sharp fangs that bite him and big paws that grab at his tiny body. He attempts to scream but can’t make a sound. He struggles to move but feels pressed down. The beasts have faces he recognises. Jonas’ mother has presented him to adult men and women for sexual gratification; beasts in human form that violently molested him.

Milo is ten and relishes telling me about his adventures. He says his mother is in a coma and could die. When Milo arrives at sessions looking exhausted he tells me that he and his stepfather have been clubbing, drinking beer and talking to pretty ladies. They fight with rival gangs, and always win. Milo’s mother is not unwell, but in his narrative Milo is communicating his sense of her as absent and ineffectual. His stepfather is prone to violent rages. In Milo’s fantasy he is grown-up and they are on the same side. 

Twelve-year-old Sammy-Jo is certain she’s a mermaid and is trying to convince me of this too. She tells me that her mermaid tail appears when she gets wet below the waist because her mother gave her a potion of crushed pearls and seawater when she was a baby. 

Sammy-Jo has severe learning difficulties and was sexually abused by her mother as an infant. She is struggling to manage menstruation and is often ‘wet below the waist’ due to poor hygiene.  Mermaids have ambiguous genitalia and they are unable to stand on their own two feet. Sammy-Jo’s identification symbolises her incomprehensible sense of her adolescent self. 

Children who have been sexually or physically abused in particular have confused internal worlds. They cannot comprehend what was done to them and other people find it unbelievable too. So they invent stories, either as a means of escape, like Milo, or in an effort to make sense of their experiences, like Jonas and Sammy-Jo. But all their stories are autobiographical and so I tread gently, staying with the symbolism and responding to the feelings – ‘Those beasts sound terrifying…’ ‘It seems like you enjoy feeling strong with your stepdad …’ ‘I wonder what it feels like to be a mermaid…’-. I don’t challenge the children to ‘stop telling me fairy stories and tell me the truth’ because I recognise that they already are. 

The therapy room is no place for politics; except everything seeps in here! One boy, Peter, told me about his recent trip to France and the migrants he witnessed at the port. The nine-year-old told me he was worried they would touch him and he hopes they are prevented from coming here because they carry diseases. I wondered about the messages he’s picked up from the media and from politicians visiting our corner of the South East. Peter perceives migrants as ‘foreign bodies’, literally antigens that could infect our green and pleasant land. I had a role in helping Peter to make sense of his experience, one that had felt threatening and nonsensical because of its unfamiliarity, and in helping him to explore difference.

Eight-year-old Alison Piper lives in a caravan with her large traveller family. People at school call her Pikey Pauper because they think that her family can’t afford to live in a house. Alison is one of the neatest, well-presented little girls I’ve met and she doesn’t understand why her peers think she’s dirty. I try to help her to make sense of the nonsense. 

The children have noticed that Alison is different to them and that makes her a ‘foreign body’ in the school. Lots of people are frightened of the unfamiliar. Sometimes when we’re frightened we get angry and cruel to make the other person feel more frightened than we do.

 Alison begins to warm to the children at school. She’s not afraid of them anymore, but is keen to demonstrate that, as well as difference, there is sameness too.

Difference is confusing. Social etiquette makes us feel we must accept rather than question so that we are silenced by political correctness. I welcome curiosity and I model it too. I tell my transgender client I don’t understand. I encourage my Jehovah’s Witness client to tell me about his beliefs. I ask the nine-year-old what he fears about people from other countries. 

Difference should be questioned; it’s how we learn, and so should our beliefs. Where did they originate?  Are they true beliefs or ones we’ve simply conformed to? Does experience support or refute them? Do we believe them still? An unquestioned belief can be like a foreign body, festering away and causing harm. Reflecting honestly on our beliefs, and modelling curiosity to our clients about difference, develops our understanding. Difference feels less alien, less frightening and a whole less ‘foreign’.

I’ve been watching another one of those television series about children who are out of their parent’s control. You know, the ones that aim to determine whether the child is mad or bad. The experts decided it’s 50/50 – well they would wouldn’t they; this is mainstream telly and they have to perch politely on the fence. Diagnoses doled out included the usual gamut of ADHD, ADD and ASD as well as the more controversial Oppositional Defiance Disorder (ODD) and Pathological Demand Avoidance (PDA). Parents have been relieved when their child receives a diagnosis because it lets them, the parents, off the hook. This is the cynic’s opinion. 

The positive aspect of receiving a diagnosis is that it opens a door to treatment and support. We see countless families, both on television and in practice, that have struggled on for years finally getting better. It’s not the label that makes the difference but access to the right educational and/or therapeutic provision, denied to those who deserve it because of a lack of understanding about their needs. 

A diagnostic label is a shortcut to explaining behaviour and a ticket in to services. But it acts like a stereotype in that it only partially explains the idiosyncratic reality of each child. Let’s consider ASD.  

The authors of DSM-V have made Asperger’s Syndrome obsolete and instead included it in the spectrum of autistic disorders. I would argue that all normal and disordered behaviour lies somewhere along a continuum, which individuals oscillate up and down depending on situation, context and mood. On any given day, any one of us could be labelled with some disorder or other; depression, anxiety, ADD, PDA, but it doesn’t mean that we should. What would be the point of that?

It seems that the point for many families is that without a label there is no support. For some it means that things have to reach crisis point before their child meets the necessary criteria of the necessary agency that is equipped to make a diagnosis. Others feel the need to exaggerate their difficulties so that they do. The third option, it seems, is to apply to a television programme, which provides a fast track route. While the fourth, rarely mentioned, option is to pay for a private diagnosis. Everything has its price.

I saw an advertisement for a drinks company recently that read ‘Labels are for bottles’. They are also for children, and without one many are screwed*. 

(*published article reads 'overlooked' in place of  'screwed).     

First dates

Ten years ago I arranged to meet a woman I didn’t know in an unfamiliar part of town. A mutual friend set us up and thought we’d get along. I remember the trepidation as I decided what to wear for our first meeting and the nervous anticipation as I rang her doorbell.  During the hour we spent together I gradually relaxed. The conversation flowed and she seemed interested in getting to know me. She encouraged me to open up in a way that nobody before her had. She was older than me, witty, attractive and dressed in a similar style to my own. We were a good match and our relationship thrived for five years. Did we fall in love? Perhaps a little.

Choosing a therapist can be like choosing a lover and a first session is much like a first date. The introduction might be arranged by a well-meaning friend or the date self-selected from the Internet using whatever criteria seems important at the time. It’s a risk. It’s anxiety provoking. And it can be ever so slightly exciting. 

I remember Stanley, an outwardly confident eighteen-year-old full of swagger. He announced his arrival at our first session by hammering so loudly on the door I thought he might punch a hole through it. Once inside, he relaxed onto the couch not waiting to be invited and started chatting almost immediately. Stanley talked about his college course, family, aggression, scrapes with the authorities and the hour flashed by. Stanley shook my hand enthusiastically and swaggered off. I’d found him intriguing and looked forward to us working together. The following week I waited for Stanley and as the minutes ticked by the realization struck me that he wasn’t coming. I tried unsuccessfully to contact him, leaving messages saying I was thinking about him and wondering if he was coming back. He didn’t reply. On reflection, that first session with Stanley had been the therapeutic equivalent of a one-night stand.  He’d charmed me with his stories and faux intimacy but it had all been bluster and our relationship had no future. He wasn’t ready to commit. 

Samantha was in her mid-teens and, like Stanley, engaged enthusiastically in our first session. She had many questions; about what therapy is for, how long I’d been a therapist and what I enjoy about my job. Her questions didn’t feel intimidating they felt fair enough, and I was delighted she had the confidence to be so openly curious. The following session Samantha arrived a few minutes late and with much less gusto. She responded monosyllabically to my wonderings about her week and after about seven minutes she fell asleep, a state she occupied for the remainder of the session. During our first meeting Samantha hadn’t told me anything about herself at all. Instead she’d employed a sophisticated form of defense disguised as engagement. Her catatonic state was less subtle and her communication loud and clear. Samantha was testing out levels of intimacy and control that would feel comfortable enough and I needed to respect these if we were going to have a meaningful therapeutic relationship; which we did, for about a year. 

First sessions, like first dates, contain a wealth of information about how the relationship is likely to pan out, contained in our feeling response to the other person in the room. It’s mostly a gut instinct that experienced therapists (and serial daters) learn to trust. 

I have an attractive female client, let’s call her Polly. She’s eighteen, slim, immaculately made-up and fashionably dressed. Every week she compliments me on my appearance; ‘You look nice today’. ‘I like your hair’. ‘Are those new shoes?’ She’s socially polite and we’ve talked about her desire to be compliant and likable. She’s exceptionally observant and we’ve explored the ways her vigilance links to her experience of trauma. But Polly has noticed something about me too, the reflexive grimace that crosses my face when she comments on my appearance. It’s almost imperceptible, but not to Polly who says huffily that I can’t take a compliment.

Why dads matter

Published in BACP Therapy Today,  June 2015 © BACP

We live in a patriarchal society. Yet it remains a sad irony that many young people will not be sending a father’s day card this month because they have no dad they know about to send one too. They might have a father figure in the form of a step-parent or family friend, while a male teacher or counsellor can provide an adequate male role model too. But there is a fundamental difference between a father figure and a dad proper that goes beyond the biological.

I ran a Thinking and Feeling group for 8/9 year olds. Jack was angry because his mum had a new boyfriend and he was angry because he didn’t have a dad. Lenny told the group he was sad because he didn’t see his real dad anymore. Skye said, matter-of-factly, ‘oh I know what that’s like; my dad isn’t my real dad either’. I encouraged the group to consider what a real dad is. Millie knows her dad is her real dad because he’s in photos she has of herself as a baby. Lenka has been DNA tested to prove whether her dad is her real dad and whether her mum is her real mum. The children’s naivety, in an absence of accurate explanation, had left them feeling confused. So we struggled on, trying to make sense of their nonsensical, father-less worlds. 

One of the things about dads is that they anchor us and give us a sense of belonging. Even for younger children who are unacquainted with the biology of paternity, there is a recognizable, yet nameless feeling associated with having a dad that is ‘real’ that makes us feel real too. 

Nell, a woman in her forties, reflected with me on a father-less childhood and a lifetime of not-knowing. She was three when her parents separated and Nell’s father was described by her mother as a wannabee, a dreamer and a weak man who remained living with his mother into adulthood rather than living in the real world. The real world involved being Nell’s dad and he’d opted out. Nell remembered her mother’s words so precisely because they were all that she had of her father. She’d never seen a photograph of him and her memories were depleted. Nell grew up believing she wasn’t good-enough, a certainty instilled in her by her mother’s story. As a consequence, she worked hard and excelled in academia and in her career. But despite her successes, she had never felt like she fitted in and had an enduring sense of not being good-enough. She struggled to get along with female bosses – replicating early maternal rivalry, and felt let down by male ones, mirroring the father who disappointed her. She opted eventually to work freelance, taking care of herself as she had learned to do from a young age. Unsurprisingly, Nell had a history of failed relationships. She chose good-enough men, who she left when they fell in love with her, so as to deny them the opportunity of repeating her father’s abandonment. Nell told me ‘I just don’t know who I am’. 

I think about the adults the children in my Thinking and Feeling group will become; perhaps adults like Nell with a fragmented sense of self, endlessly striving for perfection in an imperfect world. Fathers offer an alternative perspective to mothers, as well as support and equilibrium. Children without a dad have a sense of something missing and are likely to internalize that sense so that they feel inadequate too. They blame themselves (or are blamed) for their father’s absence and go on searching for what isn’t there, never really knowing what it is they are hoping to find. Knowing about our real dad helps us to recognize and consolidate our real self. We are a part of them and they are a part of us; biologically, emotionally and psychologically. That’s why dads matter. 

Published in BACP Therapy Today,  May 2015 © BACP

I recently facilitated a workshop for trainee counsellors and suffered the familiar pangs of anxiety about whether I’d be interesting/knowledgeable/entertaining enough? Although my superego was more disparaging than my audience, I know that they judged me.

At the start of the day we negotiated our group boundaries and the first suggestion was that we strive to be ‘non- judgmental’. I challenged the group to contemplate the term we bandy about so freely, and I challenge you to do the same. What are we asking of each other and of ourselves, and is it even possible? I think the answer is no. It’s in our nature to judge; evolutionary theory supports this, our survival depends on it and anyone who suggests otherwise is misguided. You’re judging me now. You may even go to the bother of sharing your judgments. The positive and polite will go to Therapy Today; the others directly to me; that’s usually what happens. Critical therapists feel shamed into anonymity. 

The theme of judgment recurs repeatedly in therapeutic practice. Parents feel judged on their capacity as parents, work/life balance and social status. Children sense judgment on their popularity and appearance. Adolescents perceive judgment on everything. To rehash a familiar flippant phrase, just because you’re feeling judged, it doesn’t mean people aren’t judging you. The fact is, they probably are. 

I perceive clinical judgment-making to be an important therapeutic responsibility. I’m carefully attuned to the depressed mother so that I can make judgments about her capacity to care for her children. When she accuses me of judging her as an unfit parent, I tell her truthfully that I’m wondering if she can be a good-enough mother at a time when her struggles are so overwhelming. Much of my work is with adolescents, many of whom feel judged about their lifestyle choices and coping mechanisms. I do my best to comprehend their internal struggles. They tell me that consuming drugs or alcohol or cutting their skin helps to keep them alive. I don’t judge their choices, but I do make judgments about their capacity to keep themselves safe and I say so. Working with children who have been neglected or abused, I’m often asked to share my clinical judgments in meetings and court cases where decisions are made about children’s welfare. I share my judgments honestly and always with the families involved before anyone else. Do these families feel judged? Of course they do, but I assure them that my role is to help to make sense of their situation and communicate their needs so that they may access the support they deserve.

Every therapeutic encounter invites multiple hypotheses about a client’s state of mind, safety, and physical needs. Therapists are trained to be analytical and what is analysis if not a type of judgment?  Not discriminatory or disparaging judgment, but considered, exploratory judgment couched in theory and clinical experience.  

It’s time to rethink judgment and overturn its bad rep‘. To be judged is to be noticed. As a writer, I sit tapping at a keyboard, not knowing if my constructions will ever be enjoyed. When judgment arrives in the form of a letter or comment I know that someone else has had a reaction to something that I did. I’m judged therefore I am! So let’s harbour this notion to support the judged-and-helpless-feeling client. Let us not fool them or ourselves into believing that we are non-judgmental. Instead let us share our judgments honestly, transparently and without shame. I judge you because I have noticed you and had a feeling response to you. I judge you because I care.

Behind the shades of grey

Published in BACP Therapy Today, April 2015 © BACP

I read book one of that trilogy when it was first published and shared my thoughts in a column in the December 2012 issue of BACP Children & Young People. At the time the general consensus was that the books were a ‘good thing’ because they revived sexual experimentation and this was seen as liberating for women in particular. I didn’t read anything that questioned the protagonists’ relationship, which I had perceived as dysfunctional and abusive.

Since the film’s release there have been varying reviews, including psychosexual psychotherapist Julie Sale’s critique in this journal last month, and so I’m taking the opportunity to revisit, and perhaps refine, the reflections I made previously. 

Fifty Shades of Grey went on general release on Valentine’s Day and is being flaunted as a romantic love story with beautiful actors having lots of erotic sex. Everyone remotely attached to the film has been interviewed and photographed looking sassy and gorgeous. Author ELJ has transformed her image from frumpy, middle-aged mum – ‘Look, I’m just like you!’ – to vampish sex kitten – ‘Hey, you can be just like me!’ All this has made me feel rather queasy. But my overwhelming emotion has been indignation at the widespread ignorance about themes touted in Fifty Shades – the books and the film.

The lead actor, Jamie Dornan, got his break in the television drama The Fall, where he played an athletic, sexy, charismatic professional, a counsellor actually, with a disturbing second life. So far, so Fifty Shades. His character was a predator who hunted beautiful young women before tying them up for his own sexual gratification. Again, very Fifty Shades. The Fall challenged the viewer’s perceptions and caused us to ask, ‘How can I be attracted to this man who I know to be depraved?’ But when the character murdered the women he stalked, our desire turned to repulsion. I find Dornan’s casting as Grey quite chilling. 

For those who still don’t know, Christian Grey is a handsome, charismatic billionaire who is partial to BDSM-style sex. He is a dominator, in and out of bed, who seduces virgin Ana with luxurious dates and expensive gifts. Smitten, Ana takes up the role of sexual submissive and relinquishes control of her life. Christian decides what she wears, who she sees and where she goes. We learn that Christian’s sadistic desire is the result of childhood abuse – an ominous plot line. 

I recognise the narrative from my work with victims of domestic abuse who tell me their partners want to have them to themselves. They are told to dress attractively to please him and are rarely allowed to see their friends. He earns and controls the money. Some women tell me it’s romantic and chivalrous. I recognise too the justifications: ‘It’s not his fault, he had a terrible upbringing’ and ‘He does it because he loves me’ – a displaced responsibility that saddens me.

Arguing that a relationship like Ana and Christian’s is consensual is akin to saying that women who remain in abusive relationships and are beaten or those who dress provocatively and are raped are ‘asking for it’. They are not; the culpability always lies with the perpetrator. Fifty Shades peddles a belief that women fantasise about being dominated by men. Some do, but there is a distinction between fantasy and reality, and it has become blurred. Fifty Shades has reached an adolescent audience, and so has the notion that women want to be physically and psychologically controlled by men. Jokes about domination, sexual abuse and rape have become mainstream. This film legitimises abuse. The sex is just a smokescreen. Take it away and you’re left with manipulation, misuse of power, violence and exploitation.

Not old-fashioned romance but old-fashioned abuse.

Whisteblowing: it’s time to speak up for the sake of our clients

Published in BACP Therapy Today, March 2015 © BACP

When the weather is inclement and the evenings short I find myself more aware than usual of what’s in the news. As I write this we are approaching the awards season (I will have been overtaken by events by the time you read this, I know) and there’s an air of anticipation surrounding the nominations for the Oscars, Grammys, Globes, Baftas and Brits, all weeks before the actual awards ceremonies take place, when there’ll be another consignment of frenzy. The entertainment industry likes to honour its heroes. Among the show biz glitz, healthcare industries have been a regular focus of our news too. But they’re not being awarded, rewarded or regaled: quite the opposite in fact.  

Images of failing services are beamed into our homes, with accompanying narratives about scandal, abuse and exploitation. The names we recognise belong to those who have failed the most vulnerable members of our society. We hear nothing about the successes. Hospitals and GP surgeries deemed inadequate by the Care Quality Commission (CQC) have been named and publicly shamed, while those graded good or above remain anonymous. Waiting times are up, patients are treated in corridors, staff are overworked and underpaid, blah, blah, blah. The names of the worst ‘offenders’ are touted. 

This is the antithesis of what happens in the entertainment industry, where achievement is publicly applauded and ineptitude ignored. I spoke recently to a senior practitioner in occupational health for a large NHS trust. He told me the department is inundated with referrals for mental health clinicians who are on the verge of collapse. They have become a kind of ‘squeezed middle’: pressured by management to treat more patients in less time while quantifying every move on electronic databases that aren’t fit for purpose; pressured too by patients who demand and deserve to be treated according to their needs. I heard that stress, anxiety and depression have seeped into the system so that mental health clinicians are now just as likely as their patients to receive such diagnoses.

I also heard about the upsurge in referrals relating to bullying. We hypothesised that the NHS has become a (top) dog eat (under) dog world, with the bullies marking their territory at the top of the tree by nonchalantly pissing on those below them. It seems that individuals with an unconscious desire for power and control are the very people most likely to rise to the top in organisations set up to support the needs of the vulnerable, exploited and abused, so that the system itself becomes abusive. Professionals on the ground feel neglected by supervisors and abandoned by managers who are preoccupied with the business of accounts rather than accounting for the quality of their team’s work. In organisations where numbers matter more than people, clinical safety feels dreadfully precarious. 

The majority of clinicians who work in the healthcare sector do so because we are passionate about implementing positive change for those entrusted to our care. Could this be the reason that professionals in these industries have so far put up and shut up? But perhaps the wind is changing. We’ve heard in the news that NHS organisations are to be required to appoint guardians to protect whistleblowers from the fallout of speaking up about bullying and clinical safety issues. So I wonder how long it will be before someone, somewhere blows the whistle loud enough for a media kingpin to hear. Lips are pursed, but many remain too depressed to blow. 

The games people play

Did you hear the one about the MP caught playing Candy Crush during a Commons committee meeting? He said he’d try not to do it again. For those that don’t know, Candy Crush is an apparently addictive game accessible via mobile app. Players match rows of brightly coloured sweets accompanied by tinkley music. It resembles something designed for a three year old but the typical player is aged 25 – 45. The best selling games of 2014 were FIFA 15 (Xbox 360 rated age 3+), Grand Theft Auto V (PS4 rated 18+) and Minecraft (Xbox 360 rated 7+). Time was that families would sit together and play a board game. Old fashioned perhaps; but Monopoly, in its various guises, remains the best selling game of all time.

As ever, cultural trends, fantasies and fears are reflected in my practice. Among my therapeutic resources I have a selection of twenty or so board games. Some have survived from my own childhood while others were sourced from charity shops. When I first set up in private practice I had a few games ‘just in case’ and soon discovered their popularity among clients of all ages. I also realised their therapeutic worth and so my collection grew. 

I recently completed a period of therapy with a girl of 11, an only child who presented as precocious and pseudo-adult. Evie’s parents had strong moral and religious values and placed high emphasis on educational success. Evie was unquestioningly bright but I had a sense of a lost childhood. During our first session, she noticed the games inside a glass-fronted cabinet and told me proudly that she was a ‘Scrabble champion’. Surprisingly then, she opted to play Snakes and Ladders for the duration of her six week therapy. This game is more about luck than skill and can be incredibly tedious. As Evie wriggled about excitedly (like a snake) I commented on her enjoyment of playing, and about the going-ups and going-downs of the game. Evie learned that my observations about the game also signified recognition of her own internal ups and downs.  

Ethan, a boy of 13 struggled to read or write. He’d been terribly neglected and I suspected he’d been abused. He couldn’t make eye-contact or express himself verbally and didn’t like to draw. Ethan selected Junior Monopoly, a game based on the original and designed around a fair with fairground ride assets and ticket booth properties. We played it every session for the duration of Ethan’s therapy. The game has low stakes. You earn £2 pocket money for passing GO and pay to ride the attractions. We spent eight weeks playing together in/on fair ground while reflecting unconsciously on the unfairness of Ethan’s external world.         

Tom was a sullen 18 year old on the brink of exclusion from college and caught up in gang culture, drug use and theft. He noticed my ancient Solitaire and wanted to know what it was. We dipped in and out of playing the game designed to be played alone, together, taking turns under Tom’s instruction to jump over marbles with other marbles, working collaboratively to accomplish a mutual goal.   

The sessions with Evie, Ethan and Tom were often monotonous and I wondered about the value, in monetary as well as therapeutic terms, of what we were doing. But each of them displayed progress in their capacity for reflection and expressed emotion, inside the therapy room and externally. Parents reported calmness where there had been chaos, calamity was replaced with creativity, isolation with connectedness. In short, the therapeutic process had been effective. The games we played together provided consistency, stability and containment and there just isn’t an app for that. 

When I submitted my previous column, Reflecting on... Operation Yewtree, there was a suggestion that it lacked some of my usual pizzazz. I conceded the point, but felt that what I’d said needed saying and said it anyway. On reading the December journal I was struck by a recurrent theme of what can’t be talked about. For example in Cath Knibbs excellent ‘Cybertrauma’ as well as Nick Luxmoore’s brilliant pieces ‘How do I look’ and ‘Talking About Sex’. 

I recently attended a counselling workshop with the same title as Nick’s column (no connection) and was struck by how uncomfortable counsellors were with acknowledging the sexual life of their adolescent clients. I was shocked to discover that many of them weren’t talking about sex at all as it’s a pretty regular topic in my own therapy room. Ditto my client’s activities in cyberspace. 

Several participants recognised my name as the one they’d read in this journal. They remembered me talking about shitty families, constipated systems, violent computer games and BDSM. It was reassuring to hear that people are actually reading this stuff and that their thinking has been stimulated by what isn’t usually said; either in print or in the therapy room.

And that’s the key thing here; my clients, colleagues and readers recognise me as someone with whom that which can’t be talked about can. Anything goes. 

But just as there’s a time for pizzazz, there’s also a time for mundanity. Not every clinical encounter will contain a ‘eureka’ moment. Not every session will feel stimulating, for us or our clients. Some sessions will be dry, dull and monotonous. Time will be spent checking-out the meaning of what our clients bring and making sure we’re speaking the same language. We’ll refer back to previous sessions and issues around boundaries, confidentiality and safeguarding time and time again. We’ll discuss things our clients have heard about in the media and how it might relate to them. 

It’s been impossible to ignore Operation Yewtree, which has made several appearances in this journal as well as therapy and supervision sessions since its conception. There’ll be times when we don’t know what’s going on, times when nothing seems to be going on and that’s ok; it’s all part of the therapeutic process. Mundanity is reassuring and safe. It provides the secure base from which our clients can talk to us about anything at all; with or without pizzazz. 

So this is Christmas

Published in BACP Therapy Today, December 2014 © BACP

It’s Chriiistmaaas. Actually, it’s early November but I’ve already heard Noddy Holder’s screeching pronouncement half a dozen times and by the time this goes to print he’ll be laughing all the way to the bank for the 41^st consecutive year. Many readers will have decked their halls, stairs and sitting rooms to a festive soundtrack, while others will have opted out depending on the meaning of Christmas where you are. I won’t assume I know what that is, how could I.

When people talk about the true meaning of Christmas we assume they’re referring to Christianity in varying degrees. The nativity is re-enacted in schools across the land where girls as young as three compete for the chance to play Mary. What they understand about the virgin birth and the doll in the feeding trough is contestable but their sing-songing to you and your king (sic) about morning being night (sic) suggests significant confusion. In reality, the true meaning of Christmas is far from cheerful for many families as evidenced by the Office for National Statistics*. There are 20% more deaths in December than any other month, commonly caused by road traffic accidents, fires, falls and poisoning. Women are 12% more likely to be murdered in December while for men the probability increases by 5%. Figures for matricide and infanticide rise by 25% in the two week period between Christmas Eve and Twelfth Night, while there are 33% more incidents of domestic abuse on 25^th December alone than on any other day of the year. We know that alcohol is a significant risk factor and consumption is almost double in December (+41%) than in any other month.  These figures make for grim reading but they also illustrate what I already know from my therapeutic practice; everybody’s not having fun.

One young man found his way to therapy in early December suffering from a severe bout of depression. He lost his mother when he was 15. She was killed on Christmas day by her partner who was found guilty of murder. My client’s family encouraged him to focus on his studies and he’d achieved significant academic success. But he described an emptiness that these accomplishments failed to fill as well as a series of unsatisfying relationships with older women at university. My client was tormented by all-things-Christmas and the extended festive period at home was experienced by him as a living hell. I hoped that my metaphorical ‘holding’ would convey something of my understanding of his desire to be mothered.       

An adolescent attended a short period of psychotherapy. She said nothing and barely moved. Often she allowed her head to drop forwards as if detached from her body. She slept deeply for most of the session most weeks. Being in her presence felt bleak and disturbing and I experienced the silent sessions as a deadly part of my week. I knew from the referral that the girl’s father had hung himself on New Year’s Day. My client gave me a sense of what it must have felt like to discover her father’s lifeless corpse and to bear a physical memory of that experience in her own body.   

I work therapeutically with young people in residential care and for most of them Christmas is a cruel reminder of everything they have lost. It’s a time for family; but they are alienated. A time for presents; but they receive a generic token. A time for extravagance; but they reside in underfunded institutions. A time for parties; but they receive few invites.  The tendency for these children to act-out at Christmas proliferates dramatically. Reprimands, restraints and runaways escalate as the young people demonstrate their desire to be contained, nurtured and loved ‘the same as everyone else’ – a meagre wish I hear often. 

So I urge you to be mindful of the true meaning of Christmas for each of your clients as you say goodbye for the holidays. Before the festive greetings fall unbidden from your lips take a moment to consider what the next two weeks might be like for them. Yes it’s Christmas, but I’m certain everybody’s not having fun.

*Statistics obtained from Office for National Statistics http://www.ons.gov.uk

Jimmy Savile. Rolf Harris. Gary Glitter. Household names of an 80s childhood. Men who found notoriety on the role-call of Operation Yewtree. Publicity surrounding police investigations has led to terms such as grooming, paedophilia and child pornography entering popular vernacular, often inaccurately. It has also led to widespread mistrust and mislabelling and it’s time to set the record straight. 

Personal disclosures

I’ve been interviewed three times this week. Enquiries were made, in varying degrees of interrogation, about my professional and personal experiences, my age, marital and parental status as well as whether or not I smoke or like Iggy Azalea. The impromptu interviews came about during therapy sessions and my adolescent interviewers were not easily gratified. Individual counsellors and psychotherapists have their own rules about personal disclosure which are informed by their modality and individual inclination. Very few, especially of those working with young people, occupy the traditionally psychoanalytic blank slate, and mercifully few share everything. So how do we inhabit a space that feels comfortable on the personal disclosure continuum? 

Working from my therapy room at home, clients often enquire about the rest of the house. These are simple enough questions which I answer willingly to illustrate the therapeutic boundaries. Some clients want to know why we can’t sit in the garden (obscured by an opaque window) on a sunny day, and I have to work harder to explain about physical and therapeutic containment. I hear about previous counsellors, real or fantasised, who invited clients to accompany them on dog walks, smoked with them and offered a lift home. I’m judged harshly against my unboundaried predecessors and accused of not caring, if I did I’d let the session run over when my client arrives late. I try to explain that the opposite is true; I care very much about my client and also about honesty, reliability and integrity.   

When I’m asked about my own life (or not) during a therapy session it always tells me something about my client. One young man was particularly interrogational. He’d grown up in the care system with a belief that decisions were made for and about him rather than with his consent. He’d witnessed domestic abuse as a child and been raped during adolescence. He’d suffered a lifetime of intrusion so obviously his questioning felt intrusive as he projected these experiences onto me. He told me it wasn’t fair that I wanted to know all about him while he knew nothing about me. I commented that his therapy was supposed to be about him but he wasn’t satisfied. In fact he was really un-fucking satisfied and I knew he wouldn’t come back after session one if I didn’t change tack. So I attempted to negotiate. I said it made good sense for him to work out if he thought I could help him and in order to do that he needed to know about me. He visibly relaxed but held onto a healthy dose of scepticism, wanting to know why I was a psychotherapist dealing with other people’s shit. Could I deal with his shit was the implied anxiety but it was too soon for smart interpretation.

I’ve realised that what I’m willing to share is what’s on my CV, information that’s readily available via Google to anyone who can spell my name. Nowadays we call this public domain information and I’m comfortable with it being known. But to simply provide facts-and-figures type stuff to clients without facilitating exploration is to miss a trick. The questions are always more revealing than the answers.  I was asked during my training, fourteen years ago in case you’re asking, how I could be a child psychotherapist when I didn’t have my own children. In response I wondered aloud if a male gynaecologist would be judged on his lack of a vagina. He wouldn’t. It’s insulting and ignorant. Reproductive assemblages do not influence medical aptitude anymore than parental status influences therapeutic ability. The most important thing is a capacity to empathise, both with my client’s experiences and with their curiosity about mine. So I’m always willing to explore why it matters if my parents are alive, whether or not they abused me, or if I’ve ever taken MDMA. I don’t share anything that my clients couldn’t find out for themselves and that becomes more bearable as they learn to understand that I mean what I say; the sessions really are all about them.   

Thinking about dying

Published in BACP Therapy Today, October 2014 © BACP

I live in a small town close to a slightly larger town in a semi-rural part of the UK. Yet despite my whereabouts, I can’t travel far without passing an impromptu shrine apparently marking the site of a recent fatality, forcing personal loss into the public domain. I write this piece in the wake of the actor Robin Williams’ suicide with images bombarding our screens of floral tributes outside his Californian home, on the Hollywood Walk of Fame and at various film locations around the US. Meanwhile, social media is awash with homages to the ‘acting genius’ mostly from people who never met him.  There is no escaping Public Displays of Grief (capital letters merited) the most striking example of which followed the death of Princess Diana in 1997. Images of waist deep stacks of bouquets remain indelible in the minds of all who witnessed them. This seemed to set a precedent and signify a new cultural norm; but to what end?
Grief is a deeply personal emotional state, so the desire to demonstrate it publicly seems paradoxical. Perhaps the laying of floral tributes externalises, and therefore splits-off, those feelings of personal grief that are too painful to contain.  Maybe the shared mourning of a celebrity creates a socially acceptable outlet for the expression of individual loss, discouraged in our typically buttoned-up society. 
We have heard much about Robin Williams’ struggle with depression which is in contrast with the more familiar face of the ‘comic legend’. Millions of people identify with this and with the urge to self-harm or to attempt suicide.  When someone takes their own life, opinion rages and those who do so are branded as brave and tormented or insensitive and selfish.  And all this in the context of another debate currently being contested in the public sphere; that of assisted dying. The associated moral, ethical and legal considerations are too vast for the constraints of this column, but they do highlight issues which cannot be avoided; issues about how we manage death, personally, publicly and in practice.   
Benjamin Franklin wrote in 1789: ‘In this world nothing can be said to be certain, except death and taxes.’ Death is certain of course, but the where and when and how is rarely known about in advance. How could we live with certainties about our own demise despite knowing, cognitively, that we and our loved ones are mortal? Some of our patients have fewer unknowns; those who live with terminal illness, their own or their families’, and those who are contemplating assisted dying or suicide. This raises a further paradox in that although these issues are in the public domain, personal suffering too frequently remains hidden – few spoke about Robin Williams’ depression prior to it being cited as the cause of his death. 
I have worked therapeutically with many patients for whom death is an ‘alive’ reality. Their ages and circumstances vary enormously but all are beset by physical and/or psychological pain, often accompanied by a heavy dose of shame. Talking helps. Having a space to verbalise fears, fantasies, what-ifs and if-onlys helps. Not being judged, persuaded, discouraged or emotionally blackmailed helps. Humour helps. Of course I have an urge to keep my patients alive physically, but the crux of my work is to facilitate psychological aliveness. I have witnessed transformation in the most fragile individuals as they gradually become more robust. I have rejoiced as, after numerous overdoses, a patient begins to make alternative, safer choices to manage their despair. I have reflected on life after death with children whose parents have completed suicide and who thought there was no alternative for them. I have explored treatment choices and decisions to terminate treatment with those who are terminally ill. I have helped manage the psychological ache of termination. One very ill young man summed up our work with a metaphor: ‘There’s a tonne of bricks hanging over me. You haven’t taken them away, but you’ve climbed under here with me and are helping me hold the weight. I’m ready now. I’m ready to go.’

The 70^th anniversary of the D-Day landings, the beginning of the end of World War II, was commemorated on 6^th June. While 4^th August marks the centenary of the outbreak of WWI. Summer 2014 has a distinctly commemorative feel. Until a few years ago, my knowledge about WWI consisted of sketchy memories of war poetry I’d studied reluctantly at school. So it was with some ambivalence that I took the opportunity to visit the Somme area of France. During my stay I became immersed in history, desperate to improve my meagre understanding of the atrocities of WWI. I visited countless cemeteries and gazed with awe at immaculate row upon immaculate row of war graves. What I found most striking about the Somme was its vastness and its immense beauty. It is truly breathtaking how vile and bloody battlefields have been transformed into the serenely exquisite memorials that stand in their place today. The experience of bearing witness to this was the epitome of poignancy.

And of course there are poppies. 

Papaver rhoeas (field poppy) has an innate capacity for survival. Every flower head contains over 1000 seeds, each with the potential to become a new plant. Those seeds, once dispersed, lie dormant in fields and craters until they are disturbed and exposed to light. Perhaps this is why the poppy has long, literary associations with sleep, oblivion and homoeroticism. One hundred years ago the Western Front was reduced to mud and trenches. But when fighting ceased, hidden seeds germinated creating miraculous swathes of red poppies. Their colour mimicked the bloodshed and the Royal British Legion adopted the poppy as its ubiquitous emblem.

There is much symbolism in the imagery of war that feels pertinent to my therapeutic work. Often when I meet families they tell me about the battles at home, the fighting, futility and hopelessness. They express despair and despondency. They describe separation and splitting without hope of reconciliation. I hear about verbal attacks and abuse as well as physical assault, rape and violence. Some clients describe the internal war raging within them, and the tireless fight against psychological demons that are an omnipresent enemy. It is human instinct to turn away, not to listen or want to learn about other people’s bitter experiences, just as some people turn away from images of conflict. But therapists in practice have a different instinct which encompasses a desire to hear our client’s stories and visualise their awful realities. We are curious and empathic. We can hear the unspeakable and we do ponder the unthinkable. And we are rewarded with the opportunity to facilitate change, to awaken the latent hope that we know must be hidden somewhere beneath the hopeless devastation that our clients share with us. 

The poppy would make a fitting emblem for therapy, or rather for clients in therapy. Not because of its connotations of bloodshed and oblivion but for its extraordinary robustness and its potential to endure suffering, regenerate and survive even the most ferocious experiences. Within each of our clients there are minute seeds of hope and potential. There is also an innate instinct to survive, emotionally and psychologically as well as physically. When our clients come to us, the seeds of hope are often dormant and buried deep within. Our role is to unearth them (sometimes by shaking things up a little!) We shed light by illuminating our client’s realities; their strengths and difficulties, what can change and what is unchangeable. We fertilise their potential with care and attention. We bear witness as the seeds flourish and our clients emerge psychologically and emotionally more robust, ready to survive and shape the future. 

So as we commemorate the two World Wars this summer, let us also be reminded, in the symbolism of the poppy, of our client’s battles and of the journeys we accompany them on through devastation, depression and dormancy to something alive and hopeful. This summer, and always, let us remember them all. 

Published in BACP Therapy Today, June 2014 © BACP

My reputation for blaming gaming for the rise in ASD and ADHD is based on a distortion of my article ‘Where Lunatics Prosper’ (¹). I maintain that children living in an environment furnished with chaos and violence are likely to present as chaotic and violent or emotionally shut-off and socially isolated and I remain troubled by the popularity of 18+ games in under 18s. However, the rumpus surrounding my previous article focused on a misunderstanding of my thoughts. I explored off-screen chaos and violence too but it was my reference to the computer generated stuff that got people’s goat.  Those in the gaming camp felt illegitimately attacked, while the anti-gaming posse jumped on the overcrowded bandwagon pedalling the notion that the internet is the root of all evil. And that seems to be a theme; technology fuels the terrifying headlines while external reality remains worryingly unthought-about.  

Take Facebook, now in its 10^th anniversary year. Conversations I’ve had with adults about it usually go one of two ways. Either (a) they prohibit access to under-13-year-olds because it’s illegal. Or (b) they prohibit access to over-13-year-olds because it’s unsafe. Both perspectives demonise technology and shut down thinking. There is a third position; the perilously uninformed one of turning a blind eye. Those who ban Facebook ignorantly assume that prohibition will alleviate the much-hyped problems associated with it. It won’t; children will just keep shtum.

I don’t understand why the 13+ age restriction is clung to so vehemently by adults who veto Facebook yet turn a blind eye to children as young as 5 playing 18+ games. Have you seen those games? They contain violence and sex, sometimes violent sex, all in graphic technicolour. They have a chat function too so while your child’s avatar is killing and having sex s/he can link up with ‘friends’ who are killing and having sex too. Their online friends might be of similar age or they might be over 18s playing perfectly legitimately. Is that comforting? The paradox is that the main reasons cited for prohibiting young people from accessing Facebook are fears about cyber-bullying and sexual grooming. Warning: these risks exist outside Facebook. And anyway, the 13+ age restriction has nothing to do with safeguarding and everything to do with US advertising laws in relation to minors. Surely everyone knows that?

Consumer reports estimate that of Facebook’s 900 million+ users, 8 million are under-13 and 6 million are under-10(²). These figures are likely to be underestimated because many under-13s are too scared (or too savvy) to own up. I don’t think it will be long before Facebook lowers their age restriction and there is talk of linking children’s profiles to those of their parents. That’s an interesting proposal; making children’s online safety the responsibility of their parents and carers. I wonder if it will catch on.   

One boy I talked to was being bullied via Facebook. He finally told his dad who threatened to report him to the Police because he was only 11! Will this boy stop using Facebook? – Probably not. Will he confide in his father if he gets into a sticky situation online again? – Ditto. Meanwhile, a 12-year-old told me she’d used her mother’s login details to access Facebook and ‘see what people were up to’. She found sexually explicit messages between her mother and a family friend as well as photos of them semi-naked. It’s impossible to un-know something like that or to un-see those images. She knew she’d be in trouble if she admitted using Facebook but she did admit it to me during a therapy session and we were able to think it through together.

Lots of young people ‘bring’ Facebook to therapy, sometimes literally. In these examples, as in countless others, Facebook isn’t really the concern; it’s simply the vehicle of expression for real-life issues such as bullying, betrayal, secrecy and sexuality. Is this an appropriate use of therapy? Totally. Why? Because the client has asked for help to explore something that’s troubling them in a non-judgemental, safe, thoughtful and contained way and that’s exactly what I seek to do. 

1.    Where Lunatics Prosper, bacp Children & Young People, September 2011

2.    Consumer report figure quoted in BBC News Technology, 4 June 2012

The human need for connection

Therapy fulfils a human need for connectedness. It does other things too but the relationship is fundamental and evidence supports this. By connectedness I mean actual, in-the-moment connectedness. It feels nice to be with someone who wants to be with you. When we are, we often face each other, attuned to each other’s facial expressions and micro-communications. We listen and we hear what is said and what is implied. We recall previous shared conversations and experiences. We laugh, we cry. We experience things together, at the same time and we hope we will do it again. 

Well sometimes it’s like that. Sometimes I meet people and within moments their eyes glaze over as if they’re not really present, not connected with me at all. I perceive a twitching in their hyperactive fingers that aren’t used to staying still for so many seconds. Temptation gets the better of them and within minutes they are checking their phone to see if anyone has texted or tweeted or updated their status. ‘What about my status? ‘What about what I’m doing?  Right here, right now!’ I want to yell as I metaphorically wave my arms in their vacant faces. I don’t want to jump up and down to gain their attention; why should I? But I have a need to be attended to, to reassure myself that I am cared about. That’s what Henry and all our other clients need too. They need to feel attended to and connected and cared about.

I witness a miserable lack of connectedness happening to all kinds of people in all kinds of places. Doctors review patients by staring at computer screens, avoiding eye contact with the person in the room. Highly skilled and highly paid professionals idle away meetings tapping on phones secreted under their notebooks. Counselling sessions are interrupted by the all-too-familiar ‘ping’ that serves to inform client [or in some cases counsellor!] that someone, somewhere else, has just uploaded a picture of their dinner. People like Henry experience this too. It’s the antithesis of maternal preoccupation, the epitome of un-connectedness and it’s depressing.  

Therapy offers the possibility of a real, live person who is totally preoccupied with just you. Little wonder that some clients, adolescents in particular, find this baffling, especially if their earliest experience of being mothered was less than good-enough. It is the norm for most of my young clients to have hundreds of online ‘connections’ but the idea of being connected with someone whose primary concern is them for almost an hour can feel alien. But it can also feel exquisite. That sense of feeling connected, once they are attuned to it, can indeed be magical.

In my first column for CCYP two years ago I quoted from T.S. Eliot’s Little Gidding – ‘the end is where we start from’. In this first column for Therapy Today I am again borrowing from literature. The opening of Ruth Ozeki’s novel A Tale for the Time Being contains the following: ‘A time being is someone who lives in time, and that means you, and me, and every one of us who is, or was, or ever will be’.  As therapists we are attuned to the here-and-now of our client sessions; the relationship in time between the two beings in the room and in the transference as well as the ‘ghosts’ of many other beings from our client’s internal and external worlds. But we must be mindful, particularly in first sessions, that our clients may not have experienced being attended to, as infants or adults, in the way that we attend to them. They may need time to adjust to this kind of connectedness. And when they do, it will feel magical. 

1. Winnicott, D. (1956) Primary Maternal Preoccupation, London, Hogarth

Reflecting on...  Ann 
(unpublished) 

The Ken Loach film I, Daniel Blake portrays the stark reality of poverty and need for its two central characters. Daniel can’t meet the requirements for Job Seekers Allowance because his cardiac consultant deems him unfit for work. But he is ineligible for disability support because a health assessor judges him too well to claim. Single mother Katie is rehoused in an unfamiliar part of the country. As a consequence, she takes the wrong bus, misses her signing-on slot and receives a financial sanction. She can’t afford to heat her damp, dark flat and is reliant on food-banks to feed herself and her two young children.

Daniel and Katie have stayed with me, but I’ve also been reflecting on Ann.

Ann works at the benefit office amongst a staff team depicted as hard-hearted jobsworths. They do what they are paid to do without deviation or emotional involvement, but Ann is different. She demonstrates empathy and understanding, offers support and kindness and is disciplined for it by a faceless manager who warns her to play by the rules and not get involved. I recognise Ann and identify with her predicament.       

The benefit office segments feel familiar. They depict what happens in any number of organisations where ‘service users’ find themselves caught between a rock and a hard place, this benefit or that, one service or another. Clients slip through nets, their mental-health deteriorates, sometimes they die. 

The way to hang onto those precious jobs is to tick the box, not get involved and not ask questions, especially about the inadequacies of the system.

Resources are diminishing in correlation with rising demands and tightened referral criteria. Professionals debate the origin of the problem – It’s environmental! No it’s health! No it’s education! – in order to gate-keep and protect their own workload. There is no time or inclination to think or work together. Stretched community counsellors hammer at the door of tier three services where stricter gatekeepers reside. Clients are admitted if there is a crisis, if not, the wait will be long. Once inside, there is pressure to get them out, until they are re-referred. Most services seem to operate a revolving door.

Serious incidents are increasing. Staff burnout and turnover is high. The way to protect yourself is to be an automaton, turn up, tick the box, discharge the client. Repeat. Thankfully, there are some of us who are still willing to get emotionally involved, to accept complex clients onto our case loads and bend the rules to protect their well-being, often risking our own in the process. We are the Anns of the services. Our clients deserve us to be more Ann.  

A colleague was struggling with an adolescent client he’d been seeing for several months. The client attended every session and mostly sat in silence while he, the therapist, sat silently too. He was considering ending the therapy, which had already been reduced to fortnightly, due to his client’s difficulty in engaging. Every session left my colleague feeling drained and often with a headache. He felt frustrated and didn’t know what to do. When I wondered what he thought he was doing he replied ‘I’m doing nothing!’ We explored ‘doing nothing’ in the context of the client’s story.  

The client was a child in care who had moved placements and been excluded from school since starting therapy, repeating an all-too-familiar pattern. Her social worker had resigned and not yet been replaced. She had sporadic contact with her parents who were separated and each had new partners and new children; her own half siblings who seemingly took priority over her in their parent’s lives and minds. Father’s partner was pregnant again. I felt an immense sadness in relation to the multiple experiences of rejection and abandonment this girl had experienced. I thought her sense of being un-wantable must be overwhelming and her projections so powerful that her therapist was considering abandoning her too. We considered how the therapeutic relationship seemed to mirror others, where contact had been reduced or terminated and now the therapist wanted to get rid of his unsatisfying client in order to make space for a new, potentially more rewarding ‘baby’.    

We considered how the therapeutic relationship seemed to mirror others, where contact had been reduced or terminated and now the therapist wanted to get rid of his unsatisfying client in order to make space for a new, potentially more rewarding ‘baby’.     

But, rather than ‘doing nothing’, he had contained his client’s projections week after week. He’d felt useless, hopeless and deskilled, just as she did, but he’d endured those feelings alongside her. At other times he’d sensed the parental transference and felt punishing, hating and rejecting. So far, much of the communication between therapist and client had been unconscious and nonverbal, but there had definitely been communication. Why else would she keep coming back? My feeling was that she sensed something nurturing in the therapeutic relationship; it wasn’t harsh or judgemental, but it was real. There were no rights or wrongs, she could just ‘be’ and perhaps, most powerfully of all, experience another person just being with her too. 

How valuable that space must have become for a girl who lacked any consistent, dependable, safe space, and what a wonderful thing to provide for her. Doing nothing? Not at all!  

Six-year-old Jessica talked about her hamster. ‘He looks funny and doesn’t want to play anymore.’ Jessica’s hamster had died but ‘because she’s too young to understand’ her parents substituted the much-loved pet with a replacement hamster and said nothing. Two adolescent brothers have diagnoses of schizophrenia. Their ten-year-old brother Miles has a worrying presentation which requires assessment. An offer of family therapy has been accepted but the boy’s parents don’t want Miles to attend ‘because he’s too young to understand about mental illness’. Eight-year-old Leon’s grandfather died. They’d had a close relationship before Leon went into care and became estranged from his family. Professionals decided that Leon was ‘too young to attend the funeral’.  Twelve-year-old Elsie believed she was becoming a monster. Evidence for this was hair on her ‘privates’ and blood in her knickers. Elsie’s father withheld consent for her to attend sex education classes throughout junior school ‘because she’s too young to know about that sort of thing’. 

Anecdotes like these make me incredulous at adults who deny children knowledge about their experienced realities. Not-knowing is an unbearable position so inevitably, ‘unknowns’ are filled with worry or fantasy; ‘my hamster is sick’; ‘my grandfather didn’t love me’; ‘I’m going mad like my brothers’; ‘I’m a monster; I’m bad’. Consequently, these negative beliefs manifest as ‘acting-out’ angry behaviours or ‘acting-in’ withdrawal and despair. Adults seek to medicalise children when all they are trying to do is make sense of their experiences. This is buck-passing and abusive.

Adults seek to medicalise children when all they are trying to do is make sense of their experiences. This is buck-passing and abusive.

Questions come to my mind about what is unknowable or unthinkable about and by whom. It isn’t usually the child, equipped with innate curiosity. I have engaged in many ‘facts of life’ conversations in children’s therapy sessions. Initially, I wondered if this was beyond my remit but I would argue not. Therapy is a safe space where children bring their worries, fears and fantasies to be thought about and made sense of. 

So I have explored ideas about death with a six-year-old, explained the characteristics of mental illness to a ten-year-old, described what might happen at a funeral to an eight-year-old, and discussed pubescent development with a twelve-year-old. And I have done so confidently and candidly. Children are never too young [whatever their age] to be treated with respect and protected from ignorance. They can manage information about life, sex, illness and death if an example of being able to manage is modelled for them. They are always old enough for that.  

Working with Looked After Children (LAC) has offered a valuable opportunity to explore the unconscious meanings contained within the language of the care system. An emerging acronym for children in care is ‘ChiC’. For me, this redefinition has uneasy undertones of cute, fluffy fledglings needing a home. Is this how we’re supposed to think of children in public care? Is it supposed to make them more care-able-about? More foster-able, perhaps? 

Children are described as ‘taken’ into care which has connotations of an impulsive, unannounced act. Regrettably, this matches the experience of many LAC/ChiC who are not prepared for what is about to happen to them. Colloquial language describes sick people as ‘taken’ into hospital. Are children in care sick in some way they don’t yet know about? Will they get better? Will they die? For many children, the emotional pain of not-knowing feels like a physical illness; while the loss and uncertainty is as dismal as death.

Many children imagine they must have done something dreadful if they are taken into care and language can perpetuate this belief. Children are ‘removed’ from home, while other things that are removed include tumours, cysts and warts; bad things that cause harm and which, once removed, leave us feeling relieved. 

‘My parents are better off without me’ is an all-too-common refrain, which can be interpreted as ‘now the bad me is gone, the good parent will be better/happier’. 

As is often the case, the children I work with describe their experiences more eloquently than I can; using language with a lack of self-consciousness that absolutely defines their experience. One child likened himself to a five-pound-note, explaining to me that, like money, he had been passed around between numerous owners and was usually kept in a dark place. As well as describing his experience of multiple carers, I think this metaphor also expresses his sense of self as an owned/passive object with little value. Like many children in care, he didn’t perceive himself as care-able-about and he couldn’t comprehend what was being done to him or why. 

Children encouraged to explore their experiences in their own language communicate in a profound way that gives us a real sense of what it feels like to be them. We must listen and we must ensure that their language is assimilated into the way we communicate about children who are looked after in the public care system.

I am often asked what I do when I ‘do’ psychotherapy. Depending on who’s asking; a student, parent, potential client or service provider, my response varies. I don’t have any stock answers, in my experience, they don’t really wash. And anyway, non-psychotherapeutic people have watched ‘The Sopranos’ and ‘In Treatment’ and think they know what therapy is about. So what is therapy about?  

In theoretical terms, psychotherapy is about helping patients to think about, reflect upon and come to terms with what’s going on, or has gone on, in their lives. So far, so comprehensible. It gets complicated when I add that much of these ‘goings on’ are beyond conscious awareness. At this point the questioner does one of three things: 1. Glazes over, none-the-wiser, 2. Assumes I’m talking about Freud and all that [I quote] ‘wanting-to-shag-your-mother stuff’, or 3. Remains interested enough to want to know more; then repeats ‘but what do you actually do?’

If I’m feeling playful, which I often am, I might wonder what it is they think I do. Answering a question with a question is the stuff of therapy, right? This may sound glib, but there’s truth in it too, because wondering back, when a patient asks a question encourages joint exploration and demonstrates that I, the therapist, don’t have all the answers (and even if I did, I wouldn’t deliver them readily). 

Patients frequently use metaphor to describe what therapists do. I hear about the ‘wounds’ that brought them into therapy, which has been described as ‘picking at’ or ‘uncovering’ something difficult. It sounds painful, and of course psychotherapy often is, as the defense mechanisms/plasters/scabs are gradually removed to reveal the unconscious trauma/wound beneath the surface. Only then can healing begin, and this can take a long time. As one patient who wasn’t ready to end treatment told me, ‘if I leave now, it will just scab over again but the badness will fester away inside me’. 

So when people ask me what I do when I do psychotherapy, they are usually asking what I can do for them/their child, and that depends on what they are ready, willing and able to do for themselves. If the time is right for them to start treatment, I will respect the defences that have served them well-enough for long-enough and be alongside them as they start to slowly remove the plaster and reveal the wounds beneath. We will examine those wounds together and try to make sense of them, and finally, with patience and compassion, we will embark on the healing process together. Because that is what I do. 

An increasing component of my work with adolescents involves assessing the risk of suicide. Our first meeting often comes at a time of crisis; when a young person has verbalised or acted upon suicidal ideation, perhaps by taking an overdose or cutting themselves very deeply with intent. This communication is often met with anger or confusion from parents and peers, which can lead to alienation. Sometimes an adolescent’s suicidality is over-dramatized, while at other times suicidal actions are dismissed as ‘attention-seeking’. In some respects that’s right; suicidal acts do attract attention, but the implied assumption that they need not be taken seriously is dangerous. 

My role, as well as assessing risk, is to take the suicidal adolescent seriously. Generally, they value the attention of someone who is interested in them and their story and this can lead to productive, long term therapy. Often it is their first experience of thinking with another about their vague and bewildering thoughts and feelings, which therapy can help make sense of.

 I like the definition of adolescence as a period of ‘sturm und drang’¹ (storm and stress). Instability and turmoil come with the territory, even for those with a stable, loving family to help them navigate the way. Charged by rampant hormones, the transition from childhood to adulthood brings forth contemplation about life, the universe and everything, but mostly, if we’re honest, musings about sex and death. This is both ordinary and terrifying. 

Freud identified an enduring conflict between Eros and Thanatos, the life and death instincts; the former, sexual and self-satisfying, the latter, antagonistic and hostile². Eros and Thanatos resemble adolescence personified when everything is perceived as a matter of life or death. Indeed, the trigger for suicidal ideation is often a relationship break-up, sexual confusion or poor self-image; experiences which challenge the adolescent’s sense of self, question their meaning of life, and intensify their sense of loss. With their childhood dying and their adult life gathering speed, Thanatos and Eros are in battle. 

So, when an adolescent presents with suicidal ideation they are contemplating their own life and mortality. Thinking alongside them about life and death can help to identify the internal alive and dead parts, leading to resolution of the life/death conflict. The adolescent who is taken seriously enough becomes less fragmented, their desire to be dead diminishes and they are freed-up to continue the journey into adulthood with alive, sexual potential. 

1.     Hall, G. Stanley. (1904) Adolescence: Its Psychology and Its Relations to Physiology, Anthropology, Sociology, Sex, Crime, Religion, and Education, Vol I and II, New York, Appleton

2.    Freud, (1930) Civilization and its Discontents, London: Hogarth Press and Institute of Psycho-Analysis. New York: Cape and Smith

In 2012, it became acceptable to talk about sex. ‘Mummy-porn’ transcended economic and educational status and everyone was talking about BDSM (bondage, domination, and sado-masochism). The new normality diminished people’s defenses and awkwardness. It facilitated communication and experimentation. It freed people up. The similarities to therapy are noteworthy. 

Inevitably, Fifty Shades of Grey¹ began to filter into adolescent’s therapy sessions. I found young readers’ responses uncomfortable. They weren’t fazed by depictions of BDSM because they’d been there, done that. Fair enough. While sexual experimentation is to be expected, whatever form it takes, of concern is the idealisation of the ‘Fifty Shades’ relationship and its effect on adolescent liaisons. 

Fifty Shades is essentially a romance between 22-year-old graduate Ana and 27-year-old businessman Christian. Adolescents can aspire to this without stretching the realms of possibility too far. It’s akin to the crush-on-a-teacher scenario; a naïve partner seduced by a sexually experienced authority figure. Christian is obscenely wealthy and turned on by controlling Ana, a physically and emotionally pliable virgin who is sexually up for anything. Their story depicts a common fantasy.

But many adolescents slip unwittingly into roles carved out by controlling partners, and into sexual relationships which are abusive. Social learning theory conditions them into believing that if they consent to whatever fantasy their partner suggests they will be rewarded with a grown-up, stimulating relationship. Christian is gorgeous, rich and powerful and uses his assets to stalk and control Ana who, despite her reservations, gives in easily. 

Christian is gorgeous, rich and powerful and uses his assets to stalk and control Ana who, despite her reservations, gives in easily.  clients give in easily too. I’ve heard from many who allow themselves to be controlled, sexually or otherwise. For them, the power imbalance and sense of danger is a turn-on. They have a dysfunctional and damaging model of relationships which tells them they must control or be controlled. 

When I discussed my anxieties with a colleague, they were horrified. Not by my clinical observations, but that girls as young as 13 were indulging in ‘clit-lit’ and BDSM. We can’t pretend this isn’t happening; ignorance is not bliss. Young people view porn and read erotica. This forms part of their sexual education. We have to be ready to explore and reflect with them about all kinds of sex and relationships. We must not abuse them further with judgement or ignorance but rather acknowledge their defences and manage their awkwardness (and our own) in order to free them up and facilitate communication, however uncomfortable this might be.

1.     E.L. James, Fifty Shade of Grey, 2011, Vintage Books

Compared to my usual case load of complex presentations, hoarding seems to be an uncomplicated condition, usually originating from loss and often characterised by disordered attachments. I am yet to receive an explicit referral of a child hoarder but signs of hoarding are implicit in my current case load, both physically and symbolically. 

Hoarding is described as ‘a pattern of behaviour characterized by the excessive acquisition of, and inability or unwillingness to, discard large quantities of objects that are seemingly useless or without value’¹. This definition (and others) pathologises hoarding as a disorder which, by implication, demands treatment.  Assessment should be relatively straightforward: with little encouragement, hoarders can usually identify a trigger for their hoarding, which is inevitably the loss of a loved ‘object’ (in the Kleinian sense) or of something representative of ego; for example job, status or youth. Hoarders replace their losses with physical objects and form strong attachments to them to defend against their grief. Relationships with things then replace relationships with people.

We are breeding a generation who want ‘stuff’ – lots of it – and who are becoming socially isolated, for (adult) fear of exploring the big bad world. Possessions pile up and relationships happen online. A young patient told me how she loves her messy bedroom, strewn with personal belongings. It makes her feel cosy and safe. In contrast, a room where everything is tidied away makes her feel lonely. She has no friends. She is in her ninth foster placement and is 10 years old. Perhaps she is demonstrating early signs of hoarding. 

From a psychodynamic perspective, hoarding is a fitting metaphor for the internal worlds of my clients. Many could be classified as ‘mental hoarders’, their minds littered with ‘large quantities of objects that are seemingly useless or without value’ but to which they remain firmly attached.  A deeply traumatised 15 year old client told me her mind feels like a ‘really messy room’. She isn’t ready to throw anything away yet, but she likes having my help to ‘tidy things up’. I feel privileged to be invited in and am treating her ‘hoard’ with care. 

I remember being advised, as a trainee, to have faith in the process of therapy. I trusted my mentor wholeheartedly but this thing she called ‘the process’ was an enigma. Gradually, I began to disentangle the content of therapy from the thinking-about therapy, although initially, most of my processing happened outside of the consulting room. With clinical experience, the doing and the thinking-about became reconciled, so that for me, the process has a unique identity which is linked to, yet also distinct from, the content. This is a difficult concept to explain, and one I have struggled to illustrate to patients who are finding it difficult to ‘have faith’ just as I did.

Non-believers come in all shapes and sizes. Examples from my clinical practice include the child who wants me to set the agenda; the concrete-thinking father who draws me into philosophical debate and is reliant on logical argument in lieu of emotion; the abused adolescent who perceives each interpretation as an intrusive attack; the mother who screams ‘there is no such thing as the unconscious!’ right in my face; and the boy who yells ‘why do you have to analyse everything I say?’

These clients are focussing on the concrete content of the session and finding it difficult to consider the process. Perhaps they don’t know how. Perhaps they would find it too unbearable. 

Non-believers can be colleague-shaped too; professionals from other disciplines who ask: ‘what do you actually do in therapy?’ A fundamental part of what I do is notice, name, digest, highlight and, perhaps most importantly, have faith in the process of the therapeutic relationship, as it alters and develops over time. 

As psychodynamic practitioners we understand the value of the therapeutic relationship in its own right as, what Winnicott called a ‘good-enough’ experience of maternal preoccupation. This is the process of therapy. In this we must continue to have faith.       

The business of therapy and counselling involves empathy, nurturing, care and love. As therapists we are often on the receiving end of loving projections from our clients and this makes us feel good about our work and about ourselves. I think this is particularly apparent when our clients are children. So we reciprocate by loving them back, in the maternal, nurturing sense, so that we and they are enveloped in a circle of love. Love matters; it enables children to thrive and to survive out there in the big bad world. Therapy provides the perfect (aka ‘good-enough’) model of a loving, thoughtful relationship, incorporating maternal preoccupation and infant gratitude. How wonderful to make a career out of loving and being loved! 

But just as day needs night, love needs hate. So where is the hate in child therapy? We love children therefore we can’t hate them. If we did we would be hated back and that wouldn’t be very gratifying for anyone. I think hate can get split-off and lodged in our peer relationships at work; unconsciously and in a disguised form of course. 

Hate gets played out in office banter, rivalry, dysfunctional meetings, ignored suggestions and cancellations. It is implicit in the invitation that goes out to all except one, and in the Christmas card that one colleague ‘forgot’ to send to another. 

These all-too-familiar experiences are subtle forms of attack and could provide clues about the [dis]location of hate. They are reminiscent of playground bullying which feels infantilising or empowering depending on our perspective. They re-enact the experiences of our clients so that our system replicates theirs and becomes just as chaotic and hateful. They cause us to feel unloved and taken-for-granted, resentful and suspicious. When we recognise that we are under attack we retaliate; we fight like with like, we hate back. Or, we retreat into absence from work. Or maybe we do something else. We might try to acknowledge the hate, name it, own it and take it to supervision where it can be given a fair hearing in a loving, thoughtful environment. Just the same as when 

our clients bring their own experiences of hate into the therapy room for us to 

know about on their behalf.

Reflecting on endings during beginnings, and vice versa, seems pertinent. Endings are something I struggle with in general and I find therapeutic endings difficult in particular. They don’t follow the same rules as ‘normal’ relationships which end when they go bad or when they no longer gratify whatever need they were supposed to. Good relationships don’t end. Therapeutic relationships are different.   

I recently ended with a patient I’d become very fond of, who had been coming to see me for four years. I’d spent about half that time wondering when we should end. Whenever I considered ending, something got in the way; either external issues – his, or internal dilemmas – mine; ‘how could I abandon him?!’ And then something changed. The adolescent boy in the therapy room regressed into the little boy I’d met years earlier. I became aware of re-emerging themes I hadn’t seen since his early sessions. It felt as if he was leading me back to the beginning. 

I was reminded of a poem which was read aloud towards the end of my training by a favourite tutor in her rich Irish brogue. The poem was T.S. Eliot’s ‘Little Gidding’ and the quote I was reminded of is this: ‘What we call the beginning is often the end. And to make an end is to make a beginning. The end is where we start from.’

My ending with the client, like the poem it brought to mind, was quite beautiful. It reminded me that therapy, like writing, is a creative process which is often beyond control and may never feel fully complete. Both follow themes and boundaries, such as time/word count, but they must also be allowed space, because nothing stifles the creative process more than rigidity. And so, I will continue to challenge supervisors and commissioners (and frustrate editors) as I wait for my endings to come.