Categories
About Counselling

Why I charge the full fee for DNA’d sessions.

Different therapists will each have a different rationale for their counselling session fees, and what they do when a client does not appear for an arranged session,

With respect to a client not appearing for a session with me (giving no warning): I charge the full fee for that session (and charge a half-fee for sessions cancelled with notice).  This arrangement is put in writing at the beginning of the clinical work so that the client is informed.

Now, you may think that the absent client aught not to pay for a session that they do not/could not attend.   After all, the client was not actually there for that session.

But… I was still there for the session… the whole of it… and I stayed there with the absent client

Read on for a more full rationale that informs my approach for missed/DNA sessions…

Paying the full fee for sessions not attended.

In a client’s absence, I will still be working during the session:-

  • I will sit in the room with the client’s empty chair.

     Sometimes a cigar is just a cigar.

…apparently Sigmund Freud said this… but other sources say he didn’t 😉

What this phrase means that sometimes therapists who work with the unconscious may interpret evidence… when actually the interpretation is a bit of a miss and a literal understanding may be more appropriate.

Freud’s attributed quotation, above, is referring to how the cigar may be interpreted to represent (say) a penis. Sometimes this interpretation may be accurate (the man who always takes out a very large cigar from the box may be compensating for the small penis… or whatever the “penis” represents for him: lack power, potency, etc.) and sometimes the interpretation may not be accurate (the man simply likes large cigars).

So, baring this in mind…

 

  • I will contemplate my responses to the client’s absence (otherwise called “counter-transference”).

As human beings, we often effect other human beings.

Something we might say something like “he made me so angry” – and what we mean by putting it this way is that one person effected anger in the other.

It works a little bit like a dance (an actual one… two… three… physical dance): if you pull me towards you then I’ll feel that pull; your action resulted in my reaction.

It’s similar with emotions.

If I sit there and contemplate my emotions around the client’s absence (my “reaction”), this might help me understand what might be the client’s part in the dance (the client’s “action”).

Do I feel angry at this absence? Abandoned?

Am I feeling relieved? Was this following a difficult session?

Am I puzzled? Was I expecting this?

This pondering about my emotions can help me begin to appreciate maybe what the client’s “pull” on me may be asking of me… begging me… to understand. Something that, maybe, the client’s conscious mind cannot tell me.

 

  • I will ponder about what the absence might be (called unconscious communication).

Sometimes a DNA (“Did Not Attend”) might be about communicating something that could not be said in words.

Thinking this over can assist me in understanding a little about what might be happening for the client unconsciously (e.g. something that the client cannot put to me verbally, or if the client might be acting something out that wishes to be understood by someone).

Maybe the client became angry with something I said in the last session, but the client can’t tell me.

Maybe the client and I are going at a pace that’s too much for the client, but the client hasn’t been able to say “I want to slow down”.

 

  • I will look over my case notes.

It can be useful to read my notes from the day we started up to today’s session. Maybe there’s something I’ve not seen or have not been looking at since it appeared on the first day.

Perhaps the day of the absence is significant: could be an anniversary that’s important to the client, for example.

Maybe there’s a pattern forming with the client’s absence that the client and I have not paid attention to before.

  • From time to time, I’ll check my email & telephone messages…

… to see if the client has left a message for me about their absence or late arrival. Sometimes a cigar…

 

What I won’t do during a client’s session time…

  • I won’t telephone the client / chase them up.

Unlike some other therapists, I won’t telephone the client asking them where they are.

Behind my rationale for this is

(1) It’s likely that both of us already know that they’re not here.

(2) It’s true that the client might have forgotten about the session – but telephoning them during the session time isn’t going to change that.

(3) I believe telephoning during a session time can risk being quite persecutory or shaming.  It also breaks a boundary (that during this time we work in the room together). Telephoning goes contrary to my approach to unconscious communication (if a part of the client is needed to tell me something important by an absence, my approach is to understand/respond to the communication, not react to it).

 

  • I won’t email you/write a letter to the client.

 … for similar reasons to the item above.  I may draft some thoughts for inclusion in an email or a letter as part of trying to understand an absence, but I will leave the writing/sending to after the session.

So, in short, whilst you might not be present for your session, your session is still happening in your absence, and I’m still working for you.

Boundaries help us identify conversations to be had.

Setting boundaries help us – the client and I – to identify when a boundary has been stepped over.  Without boundaries being there, we cannot know when a boundary has been transgressed.

Transgressions are an invitation to conversation.

Whilst I may say that “if you miss a session without giving notice, I will charge for that session”, I’m also saying that this is open to a conversation too.

There will be exceptions to boundaries – and we can talk about those as they happen.

Boundaries aren’t meant to punish (although some of our childhood experiences will tell a different story); in counselling they’re there for safety, for containment and to help the counselling work.

Clearly, I may never receive the session fee for a client who has abandoned the work. If the client has left our counselling relationship they will have their own views and perspective about their absence, and we can’t talk about it of course (the client won’t be coming to see me any longer). So even through the client got a full session in their absence, I will be at a financial deficit and may well have to absorb that loss (rather than repeated chase up for it). It’s my position that containing this “loss” is an appropriate approach.

Reading Bion and Winnicott are helpful authors for a more detailed resource for my approach who are interested in learning more.

Categories
About Counselling

Why Counselling is like Decorating a Room (An Analogy)

A question often asked of me is: “What is it like to be in counselling?”

A difficulty in answering such a question is that counselling (even couple or group counselling) can be quite an individual’s experience.

But I would suggest there are also some common experiences.

Let me “paint” an analogy for you 😉

When did you last decorate a room?

When did you last decorate a room in your home?

If you were not in the position of having an empty room to work with (e.g. moving into a new home, or had the capacity to move everything out of an existing room) then you had to move things around as you worked.

You might have had to cover some furniture with dust sheets.

You might have had to move some furniture out of the area in which you were working; often moving it in the way of other things or making it get in the way of the usual walk-way through the room. Things are now becoming awkward.

There was the preparation work: filling in cracks and smoothing over filler. Sanding. Noticing more flaws than you had before you started this work.

Then there was the decorating itself:  Perhaps you’re using wallpaper or using a roller to smooth emulsion over the walls. Each one can be quite messy as you try to get it right.

Then there was the errors during progress: wallpaper -paste accidentally spills onto the floor. Or the emulsion reveals damp-effected paint (causing “bubbling”).

Re-decorating a room can be chaotic!

Two steps forward, three steps back.

You might have regretted ever having started the project. Perhaps you felt like you wanted to give up.

Maybe at other times you might have seen progress, but then lost sight of it.

Sometimes you might have gained inspiration during the project: those lights would look far better at the other end of the room; the shelves you had planned would look better if they were divided in half and segmented across the corner wall (and so on).

Am I capturing the spirit of re-decorating a room for you?

Recovering from the finished work.

When finishing the decorating, and the paintwork is drying, and the wallpaper is staying up, we can start to put the room back together.

There may be pleasure in experiencing what you had achieved, after all the effort.

There may be some disappointment, that the finished product was nearly – but not totally – what you had wanted.

We might say the “injuries” experienced during the work began to heal after the work was completed.

The furniture was moved back into position.

Some of the new ideas we put in place began to work.

Finally, the room became something we could enjoy again.

Soon enough, we forget the old room and the new room integrated back into our lives.

There are no “professional” clients in counselling.

Sure, professional decorators won’t have many (if any) of the experiences I’ve described above.  But we amateur decorators often do… and as an analogy for counselling, there at not very many professional clients who go into counselling: we’re all amateur when we first go to see a counsellor.

An Analogy for Counselling.

As an analogy to counselling: the room we have spent time on altering is analogous to the person we want to improve upon during counselling.  The version of ourselves who exits counselling may not be one hundred percent the version we had hoped for when we went into counselling, but the parts of us that we wanted to look at, the life-experiences that we were having trouble managing, the flaws, cracks and faults discovered during counselling are repaired enough for us to begin to put aside the version of ourselves before counselling.

 

I often say that it takes courage to enter counselling.

Quite possible a similar courage needed when we amateur decorators have to tolerate our potential for destroying our old room completely, but enough confidence on hand to know that we’re creating a new one that we’ll be satisfied with.

 

Categories
About Counselling Articles

Absorbing People’s Emotions

This article from The Mind Unleashed talks about how to prevent yourself from absorbing other people’s emotions: http://themindunleashed.org/2014/06/stop-absorbing-peoples-emotions.html

Those of us therapists who include notions of counter-transference & projective identification/introjection in our therapy work actually make use of clients’ emotional affects upon us…

psychodynamic therapists use these phenomena to effect change in the client. We digest what unconscious emotional signals we “receive” from client (or what of our own emotional makeup may be triggered by the client’s story), try to understand it, then offer it (discretely) back to the client if the client is able tolerate it (and postpone further offers if the client rejects it).

This way of working comes from theoretical works published by Melanie Klein, Wilfred Bion, Donald Winnicott and others.

But – with the more skilled therapists – as a client you’d not be aware of this process going on, other than maybe noticing just how much your therapist seems to “get” you.

Categories
About Counselling

An Allegory for Couples Considering Counselling

Something I hear quite often in couple counselling is:

“We want our relationship to be how it used to be”.

This statement is actually about loss: the couple’s relationship is in a place that’s far away from the (supposedly happier) experience that the couple used to enjoy, and they are comparing now with how things used be.

The thing is: couple counselling provides no way for a couple to go back in time… and the hurt and conflicts that have brought the couple to me for counselling cannot be erased or forgotten.

The following allegory is a lovely way of suggesting a couple’s beginning in couple counselling:-

1002196_10151639990871840_1307377321_n[1]

“Grab a plate and throw it on the ground.”

– Okay, done.

“Did it break?”

– Yes.

“Now say sorry to it.”

– Sorry.

“Did it go back to the way it was before?”

– No.

Do you understand?

… because couples who complete their work in counselling, and who have decided to stay together, have often commented that their relationship is in a different place to how it was before counselling – and how different the place is from the place that they’d originally wanted to return.

Rather like what the Japanese call kintsukuroi (“golden repair”).

 

To learn more about couple counselling – click hereclick here.

Categories
About Counselling Blog

Why are some Counsellors Charging Surprisingly Low Fees?

Unlike NHS counselling (which may be limited to just a few sessions, can only be accessed by visiting your GP, and may not be available until after a long waiting list) private therapy such as counselling isn’t limited to a set number of sessions (so it doesn’t cease mid-therapy), you don’t have to be referred by your GP (your GP doesn’t even have to know you’re visiting a counsellor if you want to keep matters private) and is usually available on-demand (no long waiting lists).

Private counselling also costs you a fee (actually, NHS counselling costs you a fee too but you pay for the fee through your National Insurance tax).

For some on a restricted income, it may seem as if private counselling may be a struggle to afford – but many (responsible) private-practice counsellors, such as Dean Richardson, will cater for this situation; some offer low fees across the board and some (like Dean) will offer to negotiate with you to find a rate that you can responsibly afford.

Because it’s ethical to assist the public in making an informed decision about which counsellor to choose, this article discusses some of the perfectly legitimate reasons for counsellors who charge much lower fees than other counsellors in your area.

Counsellors offering Low Rates.

Some counsellors offer cheap session fees because:-

  • The counsellor may not yet be qualified or is inexperienced. Sometimes we call a pre-qualified counsellor a “counsellor-in-training”.  The counsellor is working towards receiving their first qualification and is meeting regularly (eg weekly) with a supervisor whilst they are attending their training in counselling*.
  • The counsellor may have a qualification in another form of counselling, and they may be re-training in a new (to them) form of therapy … which is the counselling that you’re thinking about buying from them*.
  • The counsellor may require 450 practice-hours to apply for professional accreditation. Professional bodies (like the British Association for Counselling & Psychotherapy) have an application procedure that proves a counsellor’s competency (see http://www.bacp.co.uk/accreditation/).  Counsellors working towards having sufficient hours within the set period (i.e. >=3 years <=6 years) may be offering lower fees to attract clients.
  • The counsellor may be working through a charity (which is funding the sessions with your counsellor).
  • The counsellor has no qualifications (and is not investing in any training nor ongoing competency).  The person isn’t a member of a professional body and is not attending regular monthly supervision. IN REALITY, there is no UK law preventing people from saying that they are a counsellor (“Counsellor” is not a protected title) , but it’s highly unethical practice. It would be wise to ask your counsellor about his qualifications during your first meeting (and judge for yourself how you feel about his response).

* In the training category, counsellors are usually required to obtain a number of practice hours before a qualification is awarded (eg 100 hours within two years). Offering cheap counselling rates may be one way an unqualified / in-training counsellor can get sufficient clients.

Working towards qualification or accreditation is an ethical way for a counsellor to improve their practice – and a low fee does not necessarily reflect on the quality or competency of the counsellor’s skills.

It can be helpful for you to ask the counsellor: “What is your qualification to practice counselling” or “Are you still in training?” and judge the answer for yourself.

 

Other counsellors may offer cheap rates because:

  • The counsellor may be just starting out in private practice, and has no (or very few) clients – they are trying to build up their practice and/or may be in competition with other more established / more experienced therapists in the area.
  • The counsellor is inexperienced in business, marketing or promoting their therapy service, believing that the only way to attract clients is by offering a low fee (counselling training doesn’t provide businesses training).
  • The counsellor may struggle with their own self-worth: often counselling training courses encourage counsellors to be humble and to focus on their humility. This can give the impression that counsellors are very kind, or even weak, but the training approach is to help counsellors show empathy and avoid being “too powerful” in their approach, particularly to sensitive situations (eg rape, abuse, addiction).  This can sometimes have an adverse effect on how ow the counsellor views their own “value” or “self-worth”; and this may be reflected in their struggle to charge anything but a very low fee for their services.
  • The counsellor may have been sanctioned by their professional body (eg the British Association for Counselling & Psychotherapy) and may require a number of supervised practice hours before they can re-apply for their accreditation status again.

It can be helpful for you to ask the counsellor: “Why are your fees so low” and judge for yourself how you feel about their response.

Compare Dean Richardson’s Approach to Lower Fees.

Dean Richardson Registered Member MNCS(Accredited Registrant) originally trained in a counselling charity which was offering a BACP Accredited diploma in counselling.

The charity did not turn people away from individual counselling due to not being able to afford it (though couple counselling, when introduced, had a minimum rate).  Clients were invited to offer their own a rate-per-session.

A significant number of people struggle to value themselves, though, and this can be reflected in the rate they offer for counselling (e.g. thoughts might include: “I don’t think of myself very much, so I don’t see why I would pay a much money for counselling”).

Dean learned a valuable lesson in discussing money with clients – to discuss a fee that the client can responsibly afford.

He continues this approach today in his private counselling practice. Whilst he has standard fees for each of his counselling services, he also have a number of places where he will discuss what a client can responsibly afford to pay for weekly counselling – to those whose income prevents them from accessing private counselling.

Click to to read more about How to Discuss a Lower Fee for Counselling with Dean Richardson.

When Finances change During Counselling.

Sometimes a client’s finances change during counselling.  Some clients choose to end their counselling without working towards the end. Others find ways to discuss with Dean how to renegotiate payments.

Discussing the fee might include:-

  • Reducing the weekly payment and keeping a tally of what is owed. The owed money are paid off weekly after counselling has finished until the amount is paid in full.
  • Renegotiating the fee to a level that the client can responsibly afford (and discussing this again when the financial situation improves).
  • Rarely, it may be appropriate to change the frequency of sessions (eg from weekly to fortnightly) but this isn’t like “taking the week off” and this change in approach will need to be carefully discussed.

 

 

 

Categories
About Counselling

Right brain: Now – Left brain: Past/Future

Helping Clients understand how our Brains control our Minds.

The video below  is a TEDTalk presentation from Jill Bolte Taylor.

Jill’s talk is about her learning from a stroke she had some ten years ago.  But the parts of her presentation that I’m discussing here are the ways in which the two hemisphere’s of the brain operate: right looks after the “now” whilst left looks after the “past” to prepare for the “future”.

 


Jill Bolte Taylor’s: “Stroke of Insight”

 

Hemispheres and what they’re responsible for.

We generally know that the Right Brain is artistic, whilst the Left brain is Logical. What’s generally less known – according to Jill Bolte Taylor (time: 00:03:00) – is that the Right Brain operates like a parallel processor, whilst the Left Brain works like a sequential processor. In other words, assuming speeds to be the same, the Right Brain operates like a Sony PS3 (many things can be processed all at the same time), whereas the Left Brain operates like the first IBM PC computers whereby one task is processed to completion before the next can begin.

For the purposes of psychotherapy, we also learn from Jill’s presentation (time: 00:03:25) that the Right Brain “is all about this present moment”; it is responsible for the “now” parts of our life.  Conversely, the Left brain “is all about the past, and all about the future”; it is responsible for remembering the past, categorising it, comparing it with what’s happening in the now and making predictions about what’s going to happen next.

I find this knowledge helpful to have in mind when new patients come to work with me in counselling; those who tell me that their pasts have no influence on their present lives.  

Patients who (need to) deny past influences.

We recognise, of course, that people who say this kind of thing have a very important need to believe it – and it’s not the therapist’s role to disavow a patient of those defences.  

It can be helpful for a client to learn that that unfortunate or distressing repeated behaviour is simply their brain trying to figure out a best course of action, based upon traumatic & historic information that is no longer applicable to the present day.

Psychotherapists following a psychodynamic/psychoanalytical model of therapy are already aware of the mis-functioning of our mind with respect to how how pasts can effect our present lives:-

  • The patient who experiences something the therapist says as inordinately wounding (“transference”).  Assuming what the therapist has said might generally be thought of as not intended to wound, we might wonder what in the patient’s past has been transferred onto the therapist as if the therapist is behaving exactly like someone the patient’s left brain has previously categorised as “that’s a wounding statement”.  We call this transference.  Nevertheless, it’s an unconscious process for the patient and the patient’s experience of us is very real … it’s just not real in the sense of the therapist’s intention.  A robust therapist can work with strong transference in order to help the patient learn that there’s a difference between what the patient experienced (one form of reality) and what was intended from the therapist (another reality) … and, together, the patient & therapist can find ways discuss what was happening in those moments.  A psychodynamic approach can be helpful here.

 

  • The patient who avoids places or situations (“deflection”) – sometimes we’re consciously aware why a place or a situation is bad for us.  Behaviours like these can become automatic – even spontaneous.  We actually don’t need our brains to say “Hello, you might be in danger, what do you want to do?” because we want them to respond on our behalf.  But when that automatic response is no longer needed, brains can be very slow in learning this.  We have to teach them that it’s OK.  A cognitive behavioural approach can be helpful here.

 

  • The patient who repeats behaviours in (subsequently failing) relationships: Couples brains respond to each other’s brains in a whizzing pattern of action & reaction.  We kinda like this when the relationship is going well (“we finish off each other’s …”, “…sentences!”).  But when behaviour becomes distressing and conflicts emerge in the relationship, our brains may be trying to protect us, but may be destroying the most valuable relationship in our lives.  Couple counselling can help a couple learn what’s going on in their relationship behaviour.  With knowledge comes choices … and with choices comes the ability to perturb the behaviour and take new directions.  A systemic approach to couple counselling can be helpful here.

Knowledge of Neurology to help Nervous Patients.

So, it’s interesting that sometimes that we can forget that our physical brain is in charge of our abstract minds.  That there are physics going on in our heads that our minds don’t know about, but that react to the physics anyway.

We’re not going mad, we’re just at the mercy of the auto-pilot running in our hemispheres.

It can helpful for people afraid of counselling (as if something magical or intrusive might be done to the insides of their heads) to understand something of the science behind the art … and Jill Bolte Taylor’s presentation can be helpful in this regard.

 

Ted Talks: Jill Bolte Taylor’s “Stroke of Insight”