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Therapy Today, October 2021

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Managing client expectations

There are many reasons why clients drop out, and Frances Bernstein (‘Understanding why clients drop out’, Therapy Today, September 2021) identifies one as being ‘dissatisfied’ and ‘not helped by their therapy’. This hints at some key points – client expectations, therapist marketing and the limitations of what therapy can provide.

Media representations of people seeking therapy have proliferated in recent years, and many are far from accurate portrayals of what happens in ‘real’ therapy. As a result, people turn to therapists for help with a wider range of issues than ever before and often with very high expectations of how therapy will help them. Yet much of the distress that clients bring to us is existential in nature, the natural and inevitable result of living in a far from perfect world. Such suffering is not amenable to quick-fix interventions; indeed the notion of ‘cure’ is often simply not relevant.

Clients may (unconsciously) hope and believe that their therapist holds a magic key to an escape from the pain of the human condition. What is projected onto us – healer, wisdom, ‘perfect life’ – inevitably leads to disappointment as the reality of the limitations of therapy is revealed. Handling that disappointment is, surely, one of the key tasks of therapy – the understanding that we therapists do not lead problem-free or neurosis-free lives, yet can arrive at a position of self-acceptance and compassion, seems to be one of the key offerings that we bring to our work.

But we can be complicit in fostering unrealistic expectations of what therapy can provide. As I look at therapist websites, I’m struck by how often phrases such as ‘take the first step to positive change’, and ‘I can help you with xxx’ appear. Websites also increasingly include client testimonials, inevitably glowing with praise for the therapist’s work. In a competitive field, the temptation to overpromise and oversell is hard to resist, but absolutely fundamental to ethical practice.

It behoves us to be modest and realistic in the way we promote our services, and to be unafraid of saying to someone, ‘I am not the person to help you at this stage’ or even, at times, ‘You may not need therapy – perhaps another kind of support would be more appropriate‘. One of the most powerful criticisms of therapy is that it individualises suffering that is best understood at a societal/political level – this, again, calls for modesty and realism in our appraisal of what therapy can offer, and what we as individuals are equipped to provide. Therapy is not a panacea and, unless we acknowledge our limitations and gently but firmly deal with unrealistic client expectations, drop-out is an inevitable result.

Dr David Mair MBACP (Snr Accred)

Adolescent drop-outs

I was interested in reflecting on Frances Bernstein’s article (‘Understanding why clients drop out’, Therapy Today, September 2021) in the context of my work with children and adolescents.

I follow a clear assessment process, after which, if the formulation is to enter therapy, I find it helpful to think with both the child and their parents about those challenging times where negative transference may be experienced in the course of therapy. This corresponds to Frances’s idea of ‘anticipating difficult areas of therapy where drop-out might occur’. It is crucial to engage parents in thinking about those areas, how their child may react and ways in which they can help the young person navigate them. Child therapy is more likely to be successful when their environment is conducive to and supportive of the process.

The added dimension here is the parental experience of sending their child to therapy. It can at times trigger or reinforce internal feelings of failure or rejection. When a child explores a particularly difficult area in their therapy, they may want to avoid the next session, or voice their dislike of the therapist.

Failing to acknowledge parental experience from the outset increases the risk of parents unconsciously colluding with their child acting out negative transference. A parent who feels rejected by the young person building a therapeutic alliance may be driven to project their feelings onto the therapist by supporting the child’s request to end the work. Meeting with parents on their own during the assessment process allows us to create a thinking space where they feel heard and their fears, assumptions or worries can be named and acknowledged. Drop-out rates are, in my experience, much lower when parents feel actively involved and held in mind by the therapist as they work with their child.

Florence Nadaud, children, adolescents and families psychodynamic psychotherapist in private practice

Patriarchal culture?

In response to two articles in the July/August issue of Therapy Today, ‘It changed my life’ by James O’Brien and ‘Sometimes it’s hard to be a man’ by Catherine Jackson, I noticed a wave of rising rage. The words that come with that sensation are, ‘You expect understanding and compassion for the oppression and expectations you have endured over the centuries?’ My rage says, ‘Do you know I (like most women) have spent my early life terrorised by men? I have spent decades shamed and humiliated by men. I have been casually insulted daily by the patriarchal culture in which I live.’

I understand that the push to control and oppress comes from fear. I also understand that until that fear is taken seriously and held, it will continue to run amok. However, there is a step missing here – the ownership of dominance. Until dominance is owned, the buried shame of it will continue to feed pomposity and lack of true empathy for others. Until men stand up and say, ‘We do dominate’ and ‘We do unconsciously believe we are superior because we are afraid of our vulnerability’, change is nominal. Misogynism is the last bastion of tolerated bigotry.

Feminism means ‘the belief that women should be allowed the same rights, power and opportunities as men’, according to the Cambridge English Dictionary. I cannot find a concomitant word for men’s equality. A friend’s sardonic answer was ‘patriarchy’ – but that is not about equality. The dictionary definition of patriarchy is the ‘social organisation marked by the supremacy of the father in the clan: control by men of a disproportionately large share of power’.

We have lived in a patriarchal society for centuries. We don’t know what it would be like to live in an equal society. Do we not have a word for the equality of men because it hasn’t been needed in a patriarchal society? Yet, having read these recent articles, I see that oppression of men exists within this system. Their vulnerability is denied. Their strength therefore remains brittle.

The rageful part of me wants to scream ‘Just get over yourselves! You have had enormous power and privilege and this plea to be understood is an excuse not to take responsibility for the hurt patriarchy inflicts.’ There is another voice, one that says those men brave enough to voice vulnerability and to challenge the patriarchal model are the pioneers of a new world.

What would be the word for the equality of men? ‘Hominism’?

Noelle Adler, counsellor, supervisor and trainer

Who needs fixing?

I’m writing to express my disappointment and incredulity at the cover of the July/August issue, ‘Fixing the male mind?’ I applaud the principle of addressing every client group and, as a male counsellor in my 40s, with male clients, this is a welcome attempt. However I take issue with several aspects of both the cover and the article.

The word ‘fixing’ should have any counsellor or trainee recoiling with disbelief. The idea that a client’s or potential client’s mind needs ‘fixing’ runs contrary to any overarching person-centred approach – the foundation of most therapy. Would ‘Fixing the female mind?’ or ‘Fixing the non-binary mind?’ be considered acceptable? The ‘male mind’ (groan) is as diverse and varied as any other. To imply that men, or any group, can be lumped together is reductive and counterproductive.

Regarding the image on the cover, the concept of a man in the role of mechanic working away beneath a brain is rather clever, but this kind of stereotyping is unhelpful. I would ask the female writer and editor to consider how they might respond to a cover featuring an image of a woman in a clichéd ‘female role’.

As for the article itself, ‘whether you subscribe to the biological, environmental or cultural explanations (for men being reluctant to seek therapy)…’, I have heard the much-disputed ‘biological differences’ often used to explain why statistically women earn less and occupy fewer positions of power. These arguments are flawed, and to state that there are biological differences between men and women that result in different therapeutic needs leaves me incredulous.

I’m happy to see an attempt to discuss the reluctance of some groups to engage in therapy, but this overgeneralised, borderline sexist cover and reductionist article is not the one.

Jon Wright MBACP

Next in this issue

Vaccination politics

I reacted very strongly to September’s dilemma ‘Can we ask clients about their vaccination status?’ (‘Dilemmas’, Therapy Today, September 2021), and the conclusion that doing so might lead to a discrimination claim. I appreciated the thorough analysis of the guidance offered by the BACP Ethical Framework, but I was surprised that the point about potential loss of income was not covered. What if a counsellor in private practice caught COVID-19 and ended up unable to work for two to three weeks (or more), significantly impacting their livelihood?

Of course, respect for human rights and personal choice should be considered, but I feel that this issue is different from other types of discrimination because the client’s vaccination status can have a direct and tangible impact on the counsellor (and their close contacts). I feel that it would be a fairer approach to give equal consideration to the client’s and the counsellor’s needs. While there is an element of this in the article, it concludes that it may be ‘safer’ not to ask, putting undue pressure on counsellors to minimise their basic need for safety (health and financial). I feel that being upfront, open and transparent about reasons for asking, as well as offering an option to go online if not fully vaccinated, is reasonable. Current advice is for everyone, including pregnant women, to have the vaccination.

Marie Rigley, counselling student