6 x Therapy Today: The Magazine for Counselling and Psychotherapy Professionals (Volume 22)

Product Information

US family therapist, academic and writer Dr Pauline Boss is taking a different approach. Originator of the concept of ‘ambiguous loss’, after years of writing, teaching and training practitioners, she has written her latest book, The Myth of Closure, 9 for the general public (reviewed in this issue). ‘Ambiguous loss’ may be physical or psychological. Physical ambiguous loss refers to deaths where there is no verification of the death itself – no body, no death certificate, for example. It can also apply to other losses, such as a job, money, and even the ability to mourn together, as happened in the time of COVID. ‘Psychological losses are amorphous and much harder to identify and quantify,’ Boss says. ‘For example, they could be loss of trust in the world as a safe place, loss in trust that your friends are safe enough to be physically near you, loss of feeling secure about going to buy groceries, of being able to go about your daily routine, go out of your house and feel safe. It is a really long list. If we ask you to provide us with any written client or other third-party consent, this should be done via one of the secure methods above. We will delete the consent from our system once we have seen them.

Collaborative meaning making is, of course, an intersubjective process: one of mutual recognition where we can shift between being in relationship as well as observing relationships around us. In the dementia relationship, as with any traumatic experiences, the capacity to observe breaks down. Therefore, as therapists and carers, the intersubjective question we may find ourselves asking is, ‘How can I remember for the person living with dementia?’ I am also delighted to bring you a heartfelt account of finding meaning after loss, written by David Kessler, the US grief specialist who worked with Elisabeth Kübler-Ross on her famous books about grief. He describes how no amount of knowledge prepared him for the impact of the sudden death of his 21-year-old son. But through his experience of surviving more pain than he ever thought imaginable, he offers valuable insights both for practitioners and for anyone personally dealing with loss. For me and, I am guessing, for thousands of other practitioners, reading Yalom’s books provided a beacon of hope during the early years of training, promising that, at some point, all this hard work would pay off in the creation of human connections like no other. It seems that, at the age of (almost) 90, Yalom is still creating those connections. Don’t miss our extraordinary ‘Big interview’ this issue. There is a generation of gay men still alive today who were criminalised and imprisoned. Being gay is still illegal in 70 countries and subject to the death penalty in around 11, and thousands of gay people still come to London from across the world for sanctuary. Even in the UK, it’s only in the past 20 years that legal inequalities have begun to significantly improve. And while we can eliminate laws, the shame and trauma inflicted on people over generations are not so easy to erase. Although young people today are growing up in a very different world to that experienced by previous generations, it is still hard to be different.This short multi-layered film speaks, sings and dances the lived experience of dementia. If, as witnesses, we become baffled in trying to solve the puzzle of the, at times, peculiar and other-worldly narrative (and imagery) of I Can’t Find Myself, it is because we are not looking, feeling or listening hard enough. Because dementia is peculiar, other-worldly and alienating. Most importantly, the film highlights that dementia is unavoidably an embodied, relational and affective experience. But some therapists worry that helping a client explore all aspects of their feelings about their gender or sexuality could be misconstrued as ‘conversion therapy’. This fear is explored by Paul Mollitt in our ‘Big issue’ article on therapists’ attitudes to working with trans clients. Menzies RE, Neimeyer RA, Menzies RG. Death anxiety, loss, and grief in the time of COVID-19. Behaviour Change 2020; 37(3): 111–115. However, she is not an advocate of passively sitting and waiting for the client to take the lead. ‘For the lay person, therapy can be an uncomfortable experience, particularly for people who are working class, because of the mystique around it. So it’s good to establish with them what would be a good outcome from therapy for them. But what we end up working on very often isn’t the issue that brings them through the door. Often it’s very much more flavourful – attachment issues, how they were loved or unloved, self-fulfilling prophecies, humiliation – how all of these feed into their personal lives. I articulate to clients that in unknowingness I have seen magnificence unfold that neither I nor the client could have predicted. I see what naturally emerges, which takes me into a space of spontaneity, listening as their lives are unfolded to me and reacting to what they bring.’ Jacobson agrees that the therapy platforms wouldn’t exist if therapy was easier to access. ‘I have been asked by friends in the past to recommend a therapist and, if it was not appropriate for them to come to a therapist at my clinic, I would do my own search in their geographical region, or for the specific issue that they or their child was needing help with. And what I have found is that it is very hard to sift through the practitioners and to get insight into their reputation. Another challenge was that often neither fees nor availability were displayed. It doesn’t surprise me that people can be easily discouraged in persisting in finding a therapist.’

We cannot escape embodied entanglements in life or in psychotherapy. Changes in physicality or gesture influence affective state, and the implications for this are profound. As people move together they learn different ways of relating; they develop shared networks of meaning making and communication that are important to intersubjective relating, neurologically and psychodynamically. 6 Both dance movement psychotherapy and neuroscientific research highlight how our ability to feel with others is intimately connected with our capacity to move with others, and for our bodies in turn to move in response to such feelings. 7,8 Moving with others, as Julia says, touches.We can support those living with dementia to learn to move themselves into life after loss. As Marina reminds us, perhaps as witnesses ‘we are not looking, feeling or listening hard enough’. Embodied interventions suggest that movement, emotions, cognitions and the body are not separate – they are entangled. A kinaesthetic awareness when engaging with a person living with dementia can allow for a relational intimacy – however fleeting (to borrow Marina’s words) such moments of connection, companionship, seeing and bearing (the pain) together may be. Biologist Ann Fausto-Sterling 13 points out that our bodily self-perception is formed on the basis of past information, which by definition is always out of date with our current physical body. So, embodied attention during the psychotherapeutic relationship with people who live with dementia offers a crucial possibility to activate the mirror neuron system in the brain, thus linking bodily awareness, empathy and intersubjective processes. 14 We can invite the person with dementia to re-member through the body. In my role as both clinician and educator I have observed over the years how the materiality of movement exchange between self and other can allow for an experience of finding self in other. For the dementia family this can mean re-connecting and building new kinds of relational intimacies with a loved one; for professional carers it can mean re-learning about a relational intimacy. Summoned

As is so often the case, alcohol progresses to harder substances. Drugs are a common part of the gay male scene and it is in this area that the problem most visibly manifests. In the past 20 years, the use of drugs such as cocaine, ecstasy and marijuana has evolved into far more dangerous substances, such as GHB, mephedrone and crystal meth, often in a sexual setting, which has contributed to an unseen public health crisis. The British crime survey 2013/14 showed that 33% of gay men had used illicit drugs in the previous six months, three times the rate of straight men and the highest rate of any group. 4 Over the past 10 years or so, there have been many high-profile cases of successful gay men either overdosing or taking their own lives or killing people while under the influence of drugs. These are extreme cases but not as uncommon as they should be. Taking outcome measures can help validate a client’s sense of distress – that they really do need help, which for some is important if they are to engage with therapy. Continuing to do so then provides a measure of progress, or an alert that progress has stopped. But McInnes’ own main reason for doing it originally was curiosity, he says. ‘I wanted to know how I compared with the overall effect rate. What’s my effect size? I’d be disappointed if therapists had no curiosity to know what difference they are making.’ Our cover theme, the ‘Big issue’ report ‘Riding the waves’, assesses the impact of the predicted post-COVID mental health tsunami and confirms what many of us know from our own practice – that it’s the most vulnerable in our society who have been most impacted. In this article, we ask what needs to happen now to minimise the effects. Given the scale of probable need – unsurprising, given the massively increased exposure to bereavement stressors – how do services meet it, and in a timely way? John Wilson is Director of the Bereavement Service at York St John University Counselling and Mental Health Clinic (CMHC), and an honorary research fellow of the university. He set up a Facebook group for people bereaved by COVID in the very early weeks of the pandemic. It was, he and colleagues decided, the best way to reach people who would be needing help now and, moreover, because it was online and so global, would be a resource that would be available 24 hours a day every day; given time-zone differences, someone somewhere would be there for people to talk to at any time of day or night. Chatbots are providing ‘therapy’ to thousands of people around the world. Sally Brown learns what artificial intelligence can offer counselling.

Department of Health. 2010 to 2015 Government policy: dementia. London: www.gov.uk/government/publications/2010-to-2015-government-policy-dementia And if there’s an uncomfortable silence? ‘I’ll explore that with them. I’m interested in why. But I carry some cards with me, and I’ll sometimes bring them out and we’ll just play a game if a young person is feeling particularly anxious or uncomfortable. It’s all part of building the relationship.’ The key mechanism in people’s recovery is the exchange of stories. People can’t make sense of the death – because they weren’t there, they had to rely on reports from healthcare staff, they’ve been denied the eulogies and conversations after the funeral – it’s delayed grief and, as the research has found, people aren’t recovering. But we have been monitoring participants in our Zoom groups that we’ve also been running, using an Assimilation of Grief Experiences Scale that we developed to measure how well participants are beginning to accommodate their loss into their lives, and it’s clear that, even when the rest of their lives are still difficult, and they may be struggling with their anxiety and depression as shown on the PHQ and GAD scales, their relationship with the deceased and making sense of the death steadily improve. We are seeing changes and adaptation in the people in our groups.’ Allegranti B, Wyatt J. Witnessing loss: a feminist material-discursive account. Qualitative Inquiry 2014; 20(4): 533–543. The recent turn towards re-defining ‘affect’ describes it as a process of embodied meaning making. 3 A crucial aspect of embodied meaning making involves how we quite literally ‘make sense’. Kinesthesia can be defined as ‘the sense of movement’ and is informed by all the senses, as well as internal sensations of muscle tension and body position. Also, we know, through research in the fields of cultural studies and neuroscience, that all the senses interrelate. 4 Here Julia Burton-Jones, a professional dementia educator and carer who works for the social enterprise Dementia Pathfinders, reflects on her kinaesthetic response when watching the film and how the moving body can be seen as a vehicle for kinaesthetically-mediated empathic responses.

Brooker D. Person-centered dementia care: making services better. London: Jessica Kingsley Publishers; 2007. But they also take pains to stress that treatment method is important: ‘It remains a matter of judgment and methodology on how much each contributes, but there is virtual unanimity that both the relationship and the method (in so far as we can separate them) “work”. Looking at either treatment interventions or therapy relationships alone is incomplete. We encourage practitioners and researchers to look at multiple determinants of outcome, [and] particularly client contributions.’ We are living in a time of grief – we are grieving not just the millions of deaths from COVID-19, but the loss of much that we previously thought we could take for granted. Despite all our medical breakthroughs and technologies, we have discovered we are not in control, and that a tiny virus can evade all our protective barriers and overwhelm us. We are grieving the loss of our assumptive worlds 1 – that is, the beliefs and values that grounded and secured us, that gave us confidence that we could keep ourselves and those we love safe.Meantime, the July issue offers rich reading, not least Phil Hills’ and Rachel Lawley’s description of how they, as newly qualified counsellors, set up and are now taking a specialist counselling service into schools to offer support to the teachers. It’s a story of head, heart and sheer business-mindedness that, as they say, has meant they can work to the values and principles that brought them into the profession.