I recently learnt that the BACP (British Association for Counselling and Psychotherapy) discourage counsellors from working with people experiencing psychosis unless they are working in a specialist setting, and have specific supervision and experience of working with this ‘client group’. This is described by them as ‘working within our competence’.

This intrigues me.

I’m not a counsellor or BACP member myself, so I’m kind of ‘on the outside looking in’.

As a mental health nurse, I’ve never really experienced exclusivity. I’ve always been expected to work with everyone who comes my way, and as a result, what’s struck me is the human commonality amongst everyone, regardless of diagnosis and clinical presentation. People really are simply people.

Apologies to any counsellors and/or BACP members reading this if I’m missing crucial considerations here, by the way. Please feel free to share your perspective if so.

How can a counsellor (or anyone, for that matter) truly know if someone is experiencing psychosis?

History (including diagnostic history) is the past, it is no certain indicator of the future, any more than eventual outcomes being dependent on current obstacles (they’re not – anything is possible whilst obstacles are being negotiated).

Every word someone uses to describe their situation has unique meaning to them. We cannot have an accurate understanding of the meaning behind their words without actually being them.

When someone tells us they are ‘psychotic’, or if someone else tells us they think that person is ‘psychotic’, or if we start to explain our internal response to the things they’re saying or doing in terms of an interpretation that they are/might be ‘psychotic’, we’re being distracted by, as Steve De Shazer sometimes put it, a red herring.

Here’s an example of how this might show up in conversation:

“The doctor has prescribed these anti-psychotics. They help a bit, but I don’t like the side effects and the idea of relying on them, you know? I prefer to be free from all that, independent, so I don’t always take them”

A lot of people living in a culture infused with the language and taught perspectives of western medical practice, consumerism and risk aversion, would be likely to respond to hearing something like this with reservations about the wisdom of the choice to not take the medication, and might also wonder about the meaning of ‘free from all that, independent’ in this context – possibly even construing it as a preference to be psychotic.

Now if we substitute ‘anti-psychotic’ with a word we’re culturally more likely to believe refers to a surmountable obstacle, and something we’d be more inclined to trust someone’s subjective judgement about, we might end up with something like:

“The doctor has prescribed these painkillers. They help a bit, but I don’t like the side effects and the idea of relying on them, you know? I prefer to be free from all that, independent, so I don’t always take them”

In both cases, the same desire is being expressed – to be ‘free from all that, independent’, the potential obstacles being psychosis, pain and/or a prescription. One needn’t detract from the possibility of the other (in fact, in the examples above, there is a clear possibility that the person could be describing managing to experience the closest they can get to the realisation of their desire at this point, although I personally would still prefer to keep an open mind and not draw any conclusions). The natural flow of the conversation could therefore be considered to continue with asking the person about what being ‘free from all that, independent’ means to them (not so much so that we might share their understanding, but simply so that they can further develop their own clarity around what they hope for), what difference it would make in their life, how it would impact on the other people in their life, what else they might do to help them become more ‘free from all that, independent’, how they would know they’re succeeding in being ‘free from all that, independent’ in a way that was right for them and other people, and so on. ‘Psychosis’ and ‘pain’ actually needn’t come up in the conversation again from this point forward in order for it to be a useful conversation with someone about how they might continue towards the future life they would like to live.

These are simply words. They could mean anything. People recover from anything. Everyone is capable of change (in fact we can’t not change), and a key catalyst in change happening is talking with other people who believe change is possible. This has been evidenced many times by research.

If a car breaks down, we open the hood, look for the broken part and fix it. But we don’t really currently have the technology to do that with the human brain. Besides which the human brain is very different to a car engine. It literally constantly rewires itself, and part of this process (as has been uncovered through advances in neuroscience research) involves us thinking about what we’d like to experience.

Therefore, a really useful thing for us all to talk about with anyone looking to recover from anything (including ‘psychosis’) is what their recovery will look like to them and the people around them. The self re-wiring nature of their brain will take care of the rest. This can take place alongside use of medicine if felt necessary too. Whatever anyone finds works for them is all good.

Counsellors can do that. They’re generally highly skilled in doing that. Research has identified the common factors in effective counselling. They were recently very eloquently discussed by Professor John Murphy, in the Simply Focus Podcast (episode 56): http://www.sfontour.com/project/sfp-56-dont-assume-ask-a-unique-conversation-about-common-factors-respect-and-keeping-clients-at-the-center-with-prof-john-murphy/ ; the ‘alliance’, expectancy, hope, acceptance of the client’s viewpoints and a willingness to work on what the client thinks is important. All of these can be part of the clients experience regardless of the approach used by the counsellor, and regardless of whatever problem the client brings (including ‘psychosis’)

In the February 2019 issue of ‘Therapy Today’, the BACP’s journal, there was a fascinating article discussing the influence of a culture of psychiatric diagnosing on the work of counsellors. It is available to read online here: https://www.bacp.co.uk/bacp-journals/therapy-today/2019/february-2019/who-needs-a-diagnosis/

If individual practitioners feel unable to work with particular clients for any reason, then I think it’s right that they signpost them to someone else. However, I would also like to invite the counselling profession as a whole to move on from doing this purely on the basis of an excluding interpretation of the clients perceived mental state, instead simply encourage each other to work with anyone they believe is capable of change, and recognise that belief as their competence.

Within the realms of hypothetical possibility, no matter how unlikely, and within your sphere of influence, taking into account any constraints you have to contend with, what would you most like to achieve?

Suppose that you somehow achieve it at some point. What difference would it make to you and others? What difference would it make to the way you view yourself – the person you would consider yourself to be? And the person others would consider you to be?

Now suppose that somehow, at some point, you become that person. That person you’d most like to be. No matter what happens in your life from this point forwards.

If you could somehow send a message to yourself back through time from then to now, what would that message say?

What would you notice that’s different about you in any particular situation, from that point on?

What’s different about how you might handle such a situation then, compared to now?

What would a small difference be in the way that you handle such a situation between now and then, if it were to be a little closer towards how you would then?

What would you like to keep about how you handle such a situation now?

What about in other situations?

In as many other situations as you can imagine? Typical, everyday situations.

What else, out of everything you’ve been doing so far, might be useful to keep doing?

What might other people notice about you that could be a sign that you’re on your way to becoming this person?

How might you know they’ve noticed that?

What difference would it make for you to notice this happening?

What signs have you noticed that you might already be on your way to becoming this person, even if only sometimes?

If you like, list 10 more signs, then another 20, then another 50.

Out of all the answers you’ve come up with to these questions, what stands out to you as something that will be useful for you going forwards from this point?

See you then.

This post touches on the same themes I addressed in my previous post ‘A Matter of Life or Death‘. I hope it reflects how my thinking has developed.

Asking a client “what’s been better?” is a typical way for a solution focused practitioner to begin a follow up meeting.

I received a powerful reminder of why this is recently.

A client had seen me and several of my colleagues over consecutive or near consecutive days during an apparent suicidal crisis. In between contacts with the client, we were all saying things to each other like “they’re in a really bad way” and “they’re really struggling”.

When it came to my turn to see them again, I had a brief moment of doubting whether “what’s been better?” would be an appropriate opening question, given how much we all knew they were in a really bad way and struggling.

…Then it occurred to me that we didn’t know that at all!

Nobody knows how someone else has been since they last met, even if other people have told them what their impression was when they saw that person during the interim. This is because the only information to go on is an interpretation of a third party’s description of their perception in a moment that came and went, which represents a tiny proportion of the other persons experience.

By asking “what’s been better?” we’re at least entertaining the possibility that a corner might have been turned, even if only fleetingly, perhaps unwitnessed by others at the time. In actual fact, it’s more than a possibility, it’s a certainty, because we know that experience is inconsistent. It just doesn’t always seem that way at first glance.

In reference to state of mind, nobody can possibly know how someone else is right now if that person is not in front of them. Even then, they can’t actually know, because perception is always subjective. The closest anyone can get to knowing is through their own interpretation of verbal and non-verbal language, filtered by their own assumptions, experiences and expectations. Attempting to know is therefore inherently futile, so not likely to be particularly useful.

Also, there’s no accurate way of knowing what the future holds. The only thing we can know with any real certainty is that everything changes. That’s the definition of the passage of time as we perceive it.

By asking about the moments in which our clients experienced/might experience preferred changes, and what was/might be different about them in those moments, especially about the part they played/might play in constructing and sustaining the change that took/might take place during those moments, we’re amplifying their skills, resources, solutions and their reorientation towards the life they hope to live.

An alternative, less solution focused question could be “how are you?” or “how have you been?”, and this type of enquiry may conform more with cultural norms. We can ask this and still listen to the reply with a solution focused ear, catching references to better moments. The reason why we opt for the less conventional “what’s been better?” is that it’s more direct. It’s also literally safer to assume that relatively better moments have occurred and choose to ask about those moments. Those are significant moments in the client’s life, most aligned with the direction of travel towards the life they hope to live. Opting to focus straight in on the safest moments by asking directly about them is the more efficient use of time, given that our intention is to maintain and cultivate safety. “How have you stayed safe?” would be an alternative solution focused question. However, it’s possible that things have improved for the client to such an extent that staying safe is now a given, and they’ve moved on to even better progress. We wouldn’t want to inadvertently disregard such progress, so a more general enquiry is preferred (we could always ask that as a next question, should their reply indicate that safety is still their primary concern)

…So, armed with this perspective and a decision to trust the process, I asked the client “what’s been better?”

And their reply?

… (after some thought) “Quite a lot actually!”

We went on to discuss how they had achieved this progress and what their next step would be.

They could have said “nothing” or even “nothing, it’s worse”, in which case we could have talked about how they stopped it from being even worse, how they held on to enough hope to keep going sufficiently for us to be talking with each other again today, and what would be the signs to look out for going forward that indicate that things are getting better again.

In any case, the point is I can’t possibly predict an account of the past any more than I can predict the future, and the present is equally subject to perspective, so in order to have a useful conversation with someone who has talked about struggling to stay alive, the most appropriate questions for me to ask them are those about the moments in which their struggle results in them staying alive and heading towards a better life. Not so that I might attempt to know anything, but simply so that their answers might provide useful insights for them about how and why they’re doing that.

“What’s been better?” is a very good start to a conversation like that.

The following poem is the result of a collaboration between me and my Dad, Tony Ward.

His poetry book,  ‘Unravelling Sussex’ is available from the publisher here and from other booksellers. He recently won best poem by a primary carer in a National Memory Day competition, sponsored by The Alzheimer’s Society, for his poem ‘What Will Survive of Us’, which can be found here

——–

I’m putting myself back together

I used to think,
“I’d better not show my mania”.
Then I got tired of worrying about what people might think,
and decided to just be myself.

Now people keep saying to me
“I love your enthusiasm!”

I used to think,
“I’d better keep a lid on my psychosis”.
Then I remembered the value of having an open mind.

Now people keep saying to me “you’re so creative!”

I used to think,
“I need to get rid of my anxiety”.
Then I found out what it takes to do the things I never thought I would.

Now people keep saying to me
“you put so much energy into that!”

I used to think,
“I can’t afford to lose time to my depression”.
Then I noticed my emotions gradually returning.

Now people keep saying to me
“you have such patience!”

I used to think,
“this is an addiction. I need help to avoid losing everything”.
Then I discovered I can take it or leave it whenever I choose.

Now people keep saying to me
“You always have the solution!”

I say to them,
“Just listen, just listen to yourself,
there is no problem you cannot solve,
no condition you cannot overcome”.

Now people are saying to me
“If only she had heard
those crucial words!”

But, haunted by praises, unseen,
she left too soon.

And now, I must myself believe,
that had she heard, that had I seen,
I would not be weeping now beside her grave,
putting myself back together.

One day I was feeling grumpy as I left the house, then I noticed birdsong and felt ok again. Now I make a point of listening out for it everywhere I go and as a result the world is full of birdsong.

One evening I was walking home from work. It was dark, misty and muffled. Earily silent. No matter how much I strained, I couldn’t hear any birdsong. I saw a beautiful tabby cat perched on a neighbour’s fence and wondered why I couldn’t hear any birds. Were they hiding? Do birds do that? I would generally expect to hear at least one warning cry from a sentry, alerting other birds in the vicinty of a dangerous presence. Maybe something to do with the mist, I guessed.

It was fine though. Intriguing rather than bothersome, because I knew that even if I couldn’t hear the birds in that moment, they were out there somewhere and sooner or later I’d hear them again. I reckoned I’d appreciate them even more next time I heard them, and felt some excitement in anticipation of that moment. Excitement that fuelled my enthusiasm to warmly embrace my family when I stepped back into my home.

Next morning I woke early with the dawn and a glorious firework display of chirps, calls, responses and arpegios delighted my ears all the way into the core of my soul. I couldn’t wait to start what might possibly turn out to be the best day of my life. I decided to savour that moment, and look forward to savouring other similarly joyous moments as I journey on through time.

Birdsong is my thing.

Other sensory perceptions and experiences might be your thing.

There’s another word for birdsong and any of those things.

It’s hope.

1: So what would you like to get out of coming here today?

2: I don’t know. I just want to talk about some difficulties I’m having I think

1: No problem. We have about 20 minutes, up to an hour if we need more time. You can talk about whatever you like

2: Ok thanks. Well I’m basically just on edge all the time and it’s exhausting. I can’t sleep, I can’t work, I’m isolating myself. In fact I wonder if I might have depression, I don’t know if you might have an opinion on that?

1: On edge all the time? I could imagine that would be exhausting. When you say all the time, you mean like every second of every day?

2: Yep, pretty much

1: Woah, yeah that’s pretty bad news, I can see why you’ve come here. How did you manage to get through whilst you were waiting for the appointment?

2: I don’t know man, it’s been difficult… I have some friends I can talk to, that helps sometimes, but they don’t always say the best things. They’re only trying to help, I know that, but I can see they’re just worried by what I’m saying sometimes, or they just give unhelpful advice, and that doesn’t help

1: Ok, I see… but it helps sometimes?

2: Yeah sometimes, but not all the time. That’s why I’m here

1: Makes sense… So instead of being on edge all the time, what would you prefer?

2: What would I prefer? Not to be on edge I guess

1: And instead?

2: Well, you know, just not on edge… I don’t know

(silence)

1: On edge all the time… phew…

2: Well yeah… Ok, maybe not all the time. I’m chilled occasionally. Very occasionally. I want to be like that more of the time, obviously

1: Obviously, yeah. That’d be better. So we’re going for chilled more of the time here?

2: Yeah that’d be a good start

1: Ok, what else?

2: hmmm, I don’t know

(silence)

2: …Just normal I guess. Doing what normal people do, you know? Being normal. Doing normal things. Like I used to.

1: Ok. Chilled more of the time, and just… normal.

2: Exactly

1: Ok, let’s start with this… How would you know you’re chilled more of the time, instead of on edge all the time?

2: …I’d be doing normal things again. I’d be back to my normal self.

1: Right. So what might be a typical situation in which you might notice yourself being this way again? Being normal, chilled. Just being back to your normal self

2: Well that’s the problem. I’m not, I’m just on edge, I can’t do anything.

1: Absolutely. So let’s just suppose for a moment that you’ve somehow managed to achieve this, and you’re back to your normal self. Chilled more of the time. Chilled most of the time even, perhaps. A typical situation in which you might notice yourself doing something differently to how you have recently…

2: Oh ok, I see. Hmmm…. No idea

1: Have a moment to think about it. It’s a stretch to think about I’m sure

2: Yes it is. Hmmm…

(silence)

2: Ok, well, I’m meeting with a friend after this. He always suggests going for a drink later, but I usually say no.

1: So what would you be doing instead? As your back to normal, chilled self?

2: I’d say yes, why not! Sure, let’s go for a drink!… I suppose I could always just have one and go back to my room after an hour or so if I didn’t feel up to staying any longer than that

1: Yeah absolutely, that sounds like a step in the right direction. Can you see yourself doing something like that any time soon?

2: Yeah, of course. I might even do that today, or at the weekend otherwise. I’m invited out all the time, so…

(conversation continues in this vein, with discussion about other situations and further detail about differences the client and others might notice)

1: Nice. Good start. Would you say you’re heading towards being chilled more of the time, back to normal?

2: Yeah… yeah I’d say I am. Thanks

1: Cool. Well, we’re about out of time. Do you feel you need any further professional input? or are you ok to leave it there, see how things go and get back in touch again if you feel you need to?

2: Actually, yeah I think I’ll be ok. Thanks.

1: No problem. You know where we are. You’re welcome any time.

2: Thanks man, see you around.

1: It was a pleasure. You take care. See ya

 

Last week I attended the Solution Focus – London festive gathering.

Amongst the games we played was one in which we passed around sheets of paper, writing three words then passing it on, until the piece of paper arrived back in the hands of the first writer.

The resulting passages of writing delighted us all. We agreed these were all examples of legitimate poetry; providing an insight into the human condition, expressing perspective and emotion, and transporting the imagination.

We agreed there were interesting comparisons to be drawn from this experience with the process which takes place in solution focused conversations.

Both involve the co-creation of moments in time through the use of language, which affects all participants’ perception of reality.

We noticed that the shared nature of the creative process led to a sense of shared responsibility towards the outcome, a shared and therefore eased pressure, and a shared sense of satisfaction with the end product.

We were also struck by how much quicker we had written this many poems as a group, compared to what it would’ve been like if we had tried to write them individually.

We agreed it beautifully demonstrated the power of collaboration.

The resulting poems are presented below.

If you are a solution focused practitioner living in or near London, and you think you might be interested in joining our meetings (mainly, we reflect on our experience of working in a solution focused way and find ourselves inspiring each other), you are very welcome to join us via our meetup group here: https://www.meetup.com/Solution-Focus-London/

We currently meet monthly on a weekday evening, mutually agreed in advance each time, at the BRIEF offices in central London.

 

Supposing you were everyone you know.

What would you find pleasure in?

Pretty much everything, and yet I love being me.

Here, there, everywhere.

 

Every other direction seemed doomed, to be clear.

And I knew which was best.

Knew so well, I just reflected, knew so well.

 

Now is the moment of truth.

Here I stand.

Amongst the lies.

Head and shoulders, feet apart.

I rally the facts and weep no more.

 

The glaciers melt on the north face of Mount Everest.

Global warming is not cool.

When will people hear the crack and get wise?

 

The evening falls.

Alone am I

In the dark.

In the park.

It starts to rain and sleet.

Beyond the dark

All is well

 

It is good to take stock

when life prompts me to reflect on life’s joys

and how I embrace them most

I am glad!

 

 

When we look at clouds in the sky and watch them change we can see recognisable shapes form (a horse, a map of Britain, a face).

Our brains do exactly the same thing when we listen to people talk and watch their body language.

Ideas about what defines them can seem very clear and evidenced, but it’s only what we are comparing to the familiar.

It’s simply a cloud, constantly shifting and changing as it moves through it’s journey across the sky.

They’re simply a human being, constantly shifting and changing as they move through their journey in existence.

If clouds could talk and one were to call out “how am I going to make it across the rest of the sky?”, we probably wouldn’t answer “well you look like a rabbit, so try hopping!”.

We’d be more likely to say something like “by doing whatever you did to get as far as you have, I guess!”.

We’d probably also be fairly confident that they will make it, because we know that moving and changing is just what clouds do.

The different shapes clouds take on as they go through their journey depend on what shapes other clouds around them take on, as well as being influenced by environmental factors.

If two clouds converge they flatten as they collide. If a plane flies through a cloud, turbulance caused by its wingtips creates swirls.

Then they carry on.

Similarly, humans are shaped in the moment by the actions of others around them and by environmental factors.

If we view someone as unchanged from last time we saw them, they tend to conform, or at least appear to us to conform to that perception. If they get too cold they head towards a warmer place, if they find a door is locked they search for the key or open another door. If they get tired they stop what they’re doing and rest.

Then they carry on.

In the same way that clouds have the greatest propensity to take on any form, and move smoothly across the sky when they find themselves in open space with the least interference, humans naturally adapt and change most efficiently when afforded the space and freedom to do so.

This means that by keeping an open mind about what anyone we meet might feel, think or do next, putting aside any ideas about what would be most likely according to our ascribed definitions, we step out of their way and get to witness them take on their natural form.

They might then look like anything to us (even reminiscent of a rabbit perhaps!) but regardless, you can be fairly confident they’ll make it (or at least head in their preferred direction), because all this moving and changing is just what humans do.

By asking “what are your best hopes?” we’re throwing a lifeline to a person caught in dangerous waters.

With each hope filled question we lovingly ask, we pull the lifeline taut.

Our belief in them gives us strength to keep it taut as we await their answer.

With each answer they pull themselves closer to safety.

Wednesday October 10th is World Mental Health Day.

The theme for this year is ‘Young People and Mental Health In A Changing World’.

What we regard as poor mental health in an individual is often their expression of the emotional impact of struggling to thrive in the face of difficult circumstances.

Yesterday I attended a regional UKASFP meeting in Bristol.

It took place in a wonderfully inspiring community centre in an area known for high crime rates. I often find the greatest good is being done in places like this. They sit on the front line in the battle between love and hate. Often underfunded and struggling but doing the best they can with what they have. This enables them to occasionally do one small thing that might make a difference, leading towards their hopes for the community to experience greater peace and harmony. On this occasion, they provided an affordable venue for us to meet.

One attendee who had visited the community centre before, remarked that it is showing the signs of being less well maintained, probably a consequence of diminishing financial investment. This clearly hasn’t deterred the staff we encountered, who couldn’t have been more welcoming and warm hearted.

We all agreed that this meeting had made a difference to us, which will ultimately benefit our clients, some of whom will be residents of the area in which we met.

Even if we can’t do anything directly about crime rates, underfunding and other difficulties faced by our clients, we can discuss with them what small things they might be able to do that might make a difference, doing the best they can with what they have.

My employer, The University of Surrey, recently took part in a project, alongside other local organisations, partnering with an underperforming school in a relatively deprived area. Through a focus on the hopes and aspirations of students at the school and their parents, and a recognition of existing resources enhanced by the partnership, the school received a ‘Good’ offsted rating. This is part of an ongoing programme called “Finding Our Futures”. You can read more about this here

In Surrey and across the UK, youth workers are also doing all they can to make a difference.

The Key Purpose of youth work, according to Youth Work National Occupational Standards (2012) is to…

‘Enable young people to develop holistically, working with them to facilitate their personal, social and educational development, to enable them to develop their voice, influence and place in society and to reach their full potential’

Even for youth workers faced with the prospect of funding cuts threatening the continued existence of their services, the possible lasting impact of what they can do in the meantime is not lost on them, so they’re doing all they can with what they have. I know this for a fact because I’m lucky enough to be married to one of them!

If we all maintain this approach, I’m confident that a consequence of our successes will be a noticeable improvement in what we regard as the mental health of young people (including future university students).

The efforts of UKASFP members, and other people working in the same facilitative way, ensure that the same applies for people of all ages everywhere. It’s entirely possible that through finding ways to thrive despite difficult circumstances, the residents of even the most deprived areas might find more ways to lift themselves and their communities towards a better future, by doing whatever they can to make a difference.

I think it’s also likely that by achieving success in this particular way, there is likely to be a lasting impact on the ‘mental resilience’ of all involved, because they will have the advantage of being able to draw on the experience of using a simple (even if sometimes difficult) process of identifying hopes and aspirations, then the resources that can be used to attain them.

By being clear about what we hope for and what we have, we can all make a difference in a changing world, which we pass on to our young people, to do the same.