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.
3 thoughts on “A Red Herring”
I really like this post, Chris, fascinating. I can’t comment on it really but thought it made a lot of sense. One tiny thing, unrelated to the actual subject matter really, and I realise the irony of this considering the title of your post…but “we open the hood, look for the broken part and fix it.” Hood?! bonnet surely 🙂 and fix? more likely to replace a broken thing in a modern car? (I’m not sure if your analogy stretches to replacing sealed unit components, rather than fixing, though).
Lol I’m sure you’re right – I know very little about cars!
There is an interesting debate in the current Journal of College Psychotherapy regarding should counsellor teams be generic (eg work with every issue that presents itself in the therapy room), or specialist. Jack of all trades? Stepped care?
Great blog post, that has got me thinking!