Category Archives: Clinical Practice

supervision

What do you look for in a clinical supervisor?

What do you look for in a clinical supervisor and how do you know if you are getting your needs met? When looking for a clinical supervisor I would recommend thinking about the following:

  • What qualification and experience does the supervisor have?
  • Will the supervisor encourage and support you to engage and grapple with defensible ethical decision-making?
  • Is there need for a supervisor with specialist knowledge, for example, working with gender, sexual or relationship diverse clients/supervisees, racial/cultural differences, or children and young people?
  • Is the supervisor willing to do their own learning (in their own time) about areas of difference or marginalisation which impact you and/or your clients? Do you anticipate having to educate the supervisor before you can discuss what you need to?
  • Do you envisage a helpful mix of containment, exploration, knowledge for you?
  • What is the style of the supervisor? Do they work more in a collaborative, informative, passive or integrative way? Does the supervisor prefer working with trainees, qualified or experienced therapists? How does that fit with your requirements?
  • How do you respond to questioning, empathy, authority? Are you able to discuss how you experience supervision? What might make you feel defensive? Do you feel able to bring all parts of you into supervision?

How do you assess if you are getting enough of your needs met?

If the arrangement doesn’t feel helpful, what would it need to look like to make it more helpful? What would it need to look like to know it’s time to change supervisors?

In each supervision experience I ask myself if I feel I’m getting my needs met in my supervision irrespective of how long we’ve been meeting; essentially what do I look for in a clinical supervisor. This translates into how I work with my supervisees also.

We have regular moments where I ask the supervisee if they feel able to ask for more or less of something. Many supervisees find it difficult to ask for certain needs to be met so it can be an area of personal growth to learn how to ask and negotiate in what is hopefully a safe environment.

I invite supervisees to say what feels helpful and unhelpful and have open discussion about what we can change in order to get their developing needs met. I encourage supervisees to reflect on where any anxiety or ambivalence might be coming from so we can collaboratively assess our working relationship.

Many therapists, once qualified, have more than one supervisor and reap the benefits of this. Where needed I will recommend the supervisee engages with specialist additional supervision for working with gender, sexual or relationship diverse clients/supervisees, racial/cultural differences, or children and young people.

Professional boundaries

Boundaries are really important to me both professionally and personally.

In my work as a psychotherapist and clinical supervisor I come across so many instances where professional boundaries have sadly been broken, often to the detriment of the client.

It’s been difficult during lockdown; the way we work as a profession had to change overnight. Thankfully (for me) I was used to providing services via video and phone so that part didn’t stretch me so much personally. What did challenge me was that for several consecutive months I worked from my very compact home office, a place where I also do lots of other things. The once clear work/home lines felt well and truly blurred. It took a couple of occasions of noticing I had checked my work phone as I was heading to bed – something I don’t generally do – to compassionately challenge myself. I’m pleased I did. It made me think about other small changes that could have evolved into something more unhelpful if left unattended. I’m now back in my therapeutic space, albeit mostly online still, but that clear demarcation between work and other is back where it needs to be.

Maintaining boundaries is often crucial. We need to maintain professional boundaries to keep our clients (and ourselves) safe. It’s why we don’t become friends, socialise or engage in social media with our clients, irrespective of how drawn to them we are, how much we care about them, and how much we might feel pulled into rescuing them. It’s why we also maintain confidentiality. We don’t post anything about clients online; we don’t discuss clients with friends and family. A huge portion of complaints to BACP involve boundary/contract violations and it’s got me thinking again about why we might potentially get pulled out of shape.

Naturally, for most therapists, there’s an element of ‘wanting to help people’.  Left unchecked though this desire to help – often rooted in early complicated histories – can lead us into hot water. Many a time a supervisee has announced a change with their client and I’ll gently ask, ‘what brought that change about?’. ‘Because the client asked for it!’ is so often the reply. If the supervisee is willing, we explore this in more detail with some deeper questioning about how they might respond if this question were put to them in a law court or through the BACP complaints procedure. Then we start to see something different emerging…that they have responded from an emotional place rather than a professional, ethically-driven one. So, in terms of professional boundaries, it’s not enough to simply say yes because a client asked or to become friends with a client because we feel sorry for them or because we genuinely like them. How is that remaining professional? Each decision we make professionally needs to be backed up with a sound ethical decision-making process. The client asking for something simply isn’t enough.  

Equally, with friends and family, it’s not as easy as saying ‘they asked me to so I will’. We need to know 1) if we have the resources available to carry out the request, 2) has the other person actually asked or are we perceiving a request through emotional content, e.g, ‘I don’t have the bus fare!’  = ‘please lend/give me the money’ and 3) are we actively consenting to using those resources on this person, at this time and for this particular thing?

It might sound a bit laboured but by doing this we spend less time tangled up ‘on the drama triangle’ and more time in an adult-to-adult space = much healthier = more resources available.

It’s often when our resources are more depleted personally that we get pulled out of shape professionally. Clearly the pandemic has made us all change some of our behaviour. Seven months on, maybe it’s time to check-in with ourselves to ensure we have enough resources to remain professionally boundaried and ethically driven in our decisions.

Resilience to engage in dialogue

In my work with the BACP Ethics team I wonder how many complaints or threat of complaints could be resolved by simply having open dialogue. In the hearing and telling of each perspective we get the opportunity for greater understanding of ourselves and others, though this does require a level of bravery for all involved. 

As therapists we need to have done enough work on our own emotional development so that we can truly tolerate hearing clients tell us that we have got something wrong. Reacting without retaliation, but with compassion and understanding is hopefully our goal. With an apology we can often bring in challenge where it’s needed so that we can help clients to see what part they may have played in the situation as well as check out our own responses.

Therapists often have a dual role (and it’s these dual roles so often at the heart of conflict) so it’s also really important to be able to voice our concerns, disappointment, frustration etc. with our therapist, supervisor or manager. Without that open dialogue, ruptures go unrepaired and the roots of the conflict (envy, anger, frustration, misunderstanding etc.) are left unchecked and can fester into something much bigger than was originally there. We understand that sometimes clients need to run away from dialogue to (un)consciously generate a repeat of previous unresolved conflict.

Our aim is hopefully one of providing the opportunity for a different sort of ending or response than has been experienced previously. We can only provide that space; the client then choses whether they can take the risk for a new experience. The same space is provided for supervisees and colleagues. In having more than one role we need to develop the resilience to engage in those difficult conversations. If we don’t have the resilience to engage in dialogue the relationship can break down and potentially result in unresolved conflict. 

In my own experience, across my roles of client, therapist, supervisor and manager, I have seen the benefits of open dialogue in bringing about change both for myself and others. 

Considering Online Therapy?

Tracey Thomas 25 June 2020

For many years a small number of clients and therapists have been working online while the majority of therapeutic relationships have been conducted face to face. A short while ago that flipped in the UK, with most clients and therapists switching to working together online to support the reduction of the spread of COVID-19.  This means that more therapists than ever before are available for online work. But what is right for you?

Some clients have always appreciated online therapy because it allows them to attend when they wouldn’t otherwise be able to. For example, people who work away from home. Others have accessed therapy online because they want a therapist with a particular skill set that can’t be found in their geographical area.

Some clients have regular face to face therapy and access therapy online or by phone occasionally when away from home.  Others would rather take a break from therapy when away from home as for them, the therapy room, the journey to and from the room and the experience of having a break are important parts of the therapeutic process.

Many professional organisations are saying that many people would benefit from mental health support as a result of the stress and anxiety that they are experiencing due to the response to COVID-19. At the same time, there are fewer face to face sessions available while many therapists continue to work only online to reduce the spread of the disease.

So what might be helpful to consider if you are weighing up on line therapy now versus waiting to have face to face therapy?

  • What is it that you need just now?

Were you generally happy with life “before” but the stress that many are currently feeling means that you could do with some help just now? Will waiting be unhelpful?

  • What is it that you want in the longer term?

Do you have a long term difficulty that you want to address that the current situation has highlighted in a way that has led you to realise that you want help now? Would one or two sessions at this time be helpful so that you can deal with what is most pressing? Could you then leave the therapeutic door open to come back to the longer term difficulties when you have more energy and can meet face to face? Will tackling the difficulty once everything else has calmed down be more helpful?

  • How do you feel about online interaction?

What has been your experience of online interactions before and during lock down? How comfortable do you feel interacting with people online? To what extent have you noticed yourself interacting differently one to one online than you would in person? How have your recent interactions left you feeling about meeting people online? To what extent might working with a therapist online, help you with your day to day online interactions or hinder you from building a relationship with your therapist?

  • How free will you be to speak?

Where will you have your online conversations with your therapist? How safe does that space feel to you? What concerns do you have about being overheard?  What will be the impact on you if you are not able to speak freely to your therapist? How might you overcome this? Where could you go safely with sufficient Wi-Fi signal or data coverage to have these conversations?

  • How will you transition back to your household role?

What will happen immediately after the end of a session? Where will you be? Who else will be there? What will you expect of yourself? What space can you give yourself if you need some time to collect your thoughts? How much freedom will you have to be sad / angry / self absorbed if that is what you need for a little while? To what extent can you park these thoughts and feelings until later in the day? Could you take a walk straight afterwards to give yourself some time to think?

In stereotypical therapist fashion, I am giving you lots of questions but not many answers. I hope that some of these questions might be helpful in developing your thinking and moving you towards making a useful decision.