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As a counsellor in both private practice, and in the voluntary sector (a rape and sexual abuse support centre), I spend a lot of time thinking about what helps clients and service users take full advantage of the help on offer.
Sometimes clients are inclined to offer their input on this subject, when they feel confident to do so, and occasionally, if I feel it’s appropriate, I will ask for their thoughts. There is a theme, like the baseline of a melody that runs through their offerings. They manage to lose the fear of being judged. They get the feeling that they will be ‘safe’.
The act of selecting a counsellor for a client to work with in private practice has thrown up some interesting feedback over the years. I am a member of a professional body, but not an accredited member. I have some unusual professional qualifications, not necessarily highly academic ones, but never once have I been asked by clients about my qualifications, or whether I am accredited.
By and large, they couldn’t care less – they are looking for the person underneath the pile of certificates, and not at the confusing jumble of letters after the counsellor’s name. Will they feel comfortable with this person or will they want to run for the hills? One client reported that they looked for the therapist who looked ‘the least scary’ in their profile picture. Another, that the total lack of jargon in my profile and bio had been the deal breaker. Wanting to feel safe is such a basic need, so why is it often so elusive in mental health circles?
I feel the problem partly lies in the way we, as counsellors, are trained. One of the commandments taught to my cohort of students way back when (and probably the vast majority of trainee counsellors since) was ‘Thou shalt not touch’, and so for many years I didn’t, believing it to be ‘wrong’, but feeling uncomfortable at times all the same when I could have, but didn’t. It took a long time to start to question the order, and to trust myself as a therapist with experience and integrity to know when it was appropriate to offer or receive a hug or handshake.
Yes of course clients have to be protected from unscrupulous therapists and other mental health professionals who take advantage of the power differential to meet their own needs, but aren’t we really throwing the baby out with the bath water if we forbid it altogether? Are we just being forbidden to trust and be our true selves in this situation?
Far from making clients feel unsafe, a warm response to a request for a hug or an outstretched hand, has often deepened the trust between a client and myself, and taken the work we are doing to another level in a way that detachment could never have achieved.
People come to us as therapists to be heard and understood – they do not come to be stuck between the pages of the DSM and be processed, judged and diagnosed. Most do not want to be told how to feel, or medicated to the point where they can feel nothing at all, good or bad. The human need for safety is at the very foundation of Maslow’s well-known Hierarchy of Needs, only one step up from the first level basics of air, food, water, warmth and sleep.
Clearly this is one of the things we should be aiming to put in place for those to whom the world feels like a dangerous place. How can we expect them to look toward higher levels of need or attainment when they are full of fear and feeling powerless? The world often is a dangerous place, and holding space for someone in distress in the midst of it is the greatest gift we can offer to those who come to us for help.
But from the reports of many service users and staff on Twitter and other social media, psychiatric services can often be frightening and distressing places. The basic need for freedom from fear is something that mental health services seem to have lost sight of, but surely this has to be in place before real change can happen.
I don’t want to be overly critical of mental health services because there are pockets of excellent practice and people within the system who work tirelessly to improve it. But I believe it needs a massive rethink about how to meet the needs of the most distressed and traumatised people. Are our psychiatric facilities places of peace and safety? Or are they even more frightening and chaotic than the outside world? If so, what can be done to bring about much needed change?
One major problem is the hierarchical structure within NHS mental health services, indeed within the NHS as a whole. Consultant psychiatrists, or indeed any other consultants, often seem to be deferred to like gods, and have been known to form a diagnosis having spent a bare minimum of time with a patient. A nurse or healthcare assistant may often have a much clearer view of what is going on for a patient in their care, but their opinions count for nothing if they dare not speak up.
Often they will have spent much more time with the patient than the consultant has. I feel very strongly about these structural issues and also about the lobbying power and influence of Big Pharma, but they run beyond the scope of this piece. They are huge problems to be tackled, but the service has lost sight of something very important here. These are real people, individuals – each with their own unique backstory which needs to be heard and understood, it is not enough to just process, diagnose and medicate.
The focus needs to be shifted back onto the patients, and those who work closely with them, and away from the ego of the ‘expert’, who actually knows nothing until they start listening. This is the most fundamental change required as I see it. The aviation industry has benefited from a completely different culture in recent decades.
Now the lowliest flight attendant or member of ground staff can question decisions made by those in authority, without fear of reprisal, and it has revolutionised safety throughout the industry, reducing the number of accidents and incidents and greatly increasing passenger safety. Why can’t the NHS practise something similar?
So besides this, what are the solutions? I don’t think they necessarily have to be expensive, indeed many could become at least partially self-financing after the initial investment. I have in mind residential projects where members of a community are supported, offered opportunities to be usefully employed within the project, and given access to empathic listening from both staff and peers to find a way back to a ‘normal’ life, given duties and responsibilities as and when they are able, and encouraged to become part of a functioning community.
Places where, most of all, they can feel safe. I have in mind as a model, a project like San Patrignano in Italy which receives no state funding at all. The commercial activities of the community plus donations provide everything needed to run the facility. San Patrignano is vast and houses approximately 1,300 residents at any one time, but smaller scale enterprises could be rolled out here, at least to try something different in a system that is fundamentally broken.
Restoration projects that become visitor attractions, mills, country houses, farms, farm shops, cafes and places to stay. The possibilities are endless, with some vision and a little investment. The system as it stands is not fit for purpose; we are in a hole, and it is time to stop digging.
In the meantime, starting from now, I would encourage fellow therapists and professionals to bring our humanity to our work, along with our expertise, knowledge and experience. It is our humanity and basic human kindness that our clients are really looking for, and it is this, I believe, that really kickstarts the healing process. The rest, I hope, will follow.
Jill Davies is a counsellor in a rape and sexual abuse support centre, and also in private practice in the UK. Her main area of interest is in complex trauma and dissociative disorders.
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