Gay Affirmative Therapy

Since 2012 a statement of ethical practice regarding sexuality has been incorporated into the BACP Ethical Framework. Clients from diverse sexual orientations are to be included without any kind of discrimination. The BACP does not consider homosexuality as a kind of mental disorder and opposes conversion therapy. 

 

 

 

Davis and Neal wrote a book titled Pink Therapy in 1996, in which chapter 2 details some information about gay affirmative therapy. It contains guidelines about how counsellors can create a positive therapeutic relationship with gay, lesbian, bisexual etc. clients. Trust is central to this, clients will be able to accept help if trust is developed. Respecting the client’s integrity is equally important. Being aware of our own beliefs, values, fears and prejudices around sexuality is also crucial.

Supervision and personal therapy provides a good opportunity to explore these during our training. In some cases referral might be necessary if we can’t provide therapy for a client due to some of our beliefs (e.g. homosexuality is sinful, or against God’s wishes ) referral may be necessary.

There are 12 guidelines about working with gay clients. These guidelines can enhance empathy while working with clients from a diverse background. These include among others: enabling client to bring into awareness the subjective reality of being oppressed due to being gay, facilitating expressing their anger and other repressed feelings, enabling them to desensitize their shame and guilt around homosexual feelings, thoughts and behaviour; and facilitating them to identify their value and beliefs system.

This way they will become more truly themselves and integrations of gay feelings and thoughts will occur.

The BACP Good Practice across the Counselling Professions 001 details a lot of facts about different types of gender identities including cisgender and non-binary, sexuality and relationship types as well.

There was an artcicle published in Therapy Today : “Why Pronouns Matter?”, stating not everyone can be put into a male/female category but sexuality is considered more like a continuum. We might have some clients in the future who may wish to be treated in a similar fashion. Some contributors to the magazine who identify as non-binary started to use their names as XY. (they, them) Being aware of these developments we can provide a respectful environment to clients.

Bibliography:

Good Practice across the Counselling Professions 001Gender, Sexual, and Relationship Diversity (GSRD)Dr Meg-John Barker

https://www.bacp.co.uk/media/5877/bacp-gender-sexual-relationship-diversity-gpacp001-april19.pdf

Why pronouns matter: Have therapists really embraced gender diversity?

https://www.bacp.co.uk/bacp-journals/therapy-today/2021/march-2021/

Diversity 1

Intercultural therapy is a form of talking therapy when cultural differences, such as race,beliefs, culture, ethnicity, religion, gender identification, disability, language, values and many other socio-economic factors can be addressed in a sensitive way.

People from minority groups can be affected by external factors such as racism, gender issues, poverty, unemployment, being a refugee etc. These can lead to a higher rate of mental health issues in minority groups but the same group of people may be under-represented in the counselling profession.

Intercultural therapy can provide an inclusive, safe environment where these issues can be discussed. An interculturally trained therapist can facilitate a therapeutic relationship in which the client’s and the therapist’s similarities and differences can be explored, acknowledged and openly discussed.

First, a strong therapeutic alliance is formed in which the client’s cultural perspectives and beliefs are understood. A trusting, respectful relationship is essential. The client will be acknowledged not only as a unique individual but also as part of a group and the client will also be invited to share his culture’s collective narrative to enable the counsellor to see the wider perspective.

 

 

As Jafar Kareem, the founder of the Nafsiyat Intercultural Therapy Centre in London, said: “taking into account the whole being of the client– not only the individual concepts and constructs as presented to the therapists – but also the client’s communal life experience in the world, both past and present. The very fact of being from another culture employs both conscious and unconscious assumptions – both in the client and in the therapist."

A similar concept was explored about the 3 interlocking circles, which was presented in 1982 by Cox, Speight, Myers and Highlen. According to this concept when working with a person in the therapeutic process three factors should be considered including the individual uniqueness, human universality and cultural specificity: “every person is like all persons, like some persons and like no other person”. To see the person as a whole all these factors need to be taken into consideration.

There are fundamental differences between European, African and Asian cultures. These can give counsellors some insight when working with clients from different cultural backgrounds.

Clients may suffer from effects of trauma, depression, poor self-image etc. The aim of intercultural therapy may be to establish a healthy ethnic and cultural identity, with increased self-acceptance and self-esteem. CPD is also crucial for counsellors, they might need to do some reading or training on the history or culture of specific countries or nationalities to understand the wider perspective. In this globalised world, where mass migration is part of our reality staying open-minded and curious about other people’s culture is crucial for mental health professionals.

Bibliography:

Intercultural therapy

https://www.counselling-directory.org.uk/intercultural-therapy.html

Why we need to talk about race
Therapy Today, October 2018 Volume 29 Issue 8

https://www.bacp.co.uk/bacp-journals/therapy-today/2018/october-2018/why-we-need-to-talk-about-race/

Between black and white
Therapy Today, April 2019 Volume 30 Issue 3

https://www.bacp.co.uk/bacp-journals/therapy-today/2019/april-2019/between-black-and-white/

‘I thought I was a lost cause’: How therapy is failing people of colour

https://www.theguardian.com/lifeandstyle/2020/feb/10/therapy-failing-bme-patients-mental-health-counselling

What is intercultural therapy?

https://www.nafsiyat.org.uk/index.php/what-is-intercultural-therapy/

Becoming a Culturally Competent Counselor

https://counseling.education.wm.edu/blog/multicultural-counseling-competencies

Culturally Sensitive Therapy

https://www.psychologytoday.com/gb/therapy-types/culturally-sensitive-therapy

Does Race Affect Working Alliance?

https://www.goodtherapy.org/blog/does-race-affect-working-alliance-0111122/

Aisha Dupont Joshua, BAC Counselling Journal, Towards Healing the Split between Black and White People in Counselling, 1998

Klein

Melanie Klein was an influential 20th century psychoanalyst who worked mainly with children and analysed them using play therapy. She developed her own theory within the object relation theory, which belongs to the psychodynamic theory. 

 

 

 

Later, she led the Kleinian side of the British Psychoanalytical Society apart from the Anna Freudian and the Independent side. She had major losses at a young age, she lost her sister, brother, father then her mother and she probably had postnatal depression too after rushing into a marriage and having three children. She entered analysis first with Ferenczi in Budapest, Hungary in 1914, then with Abraham in Berlin in 1924. He died shortly after that. Finally, she relocated to London in 1927 after her divorce. Apart from all the personal trauma and losses, it was an extremely stormy period of European history and being a Jewish woman it must have been hard for her to get by, settle down, find her place and fit in. Maybe she never did. Sadly, she was also estranged from her daughter, probably as a result of analysing her as a child. She could have found solace in the world of academia but her professional life was also troubled by the split between the different object relationists.

Her theory was not only an evolution of Freudian theory but also a departure from it. She agreed with the personality structure of the Id, Ego and Superego but she focused on the mother-infant bond. Her contribution was the concept of primitive phantasies in early infancy. Infants experience these in relation to the mother. These can be frightening images and sensations long before the infant can use language. She used symbolic language to illustrate complex ideas. The mental activity she describes happens at an unconscious level. Object refers to a significant person in the subject’s life. Object parts include anatomical divisions of others, such as the face, the breast etc.

Klein thought that the infant is caught up struggling between the forces of life and death. In other words, they try to deal with the feelings of goodness and badness after internalising the good breast and the bad breast. She agreed with the oral, anal and genital stages but she thought the transition between the stages is less finite.

In addition, she described the paranoid-schizoid and the depressive positions. The former one occurs during the first 4 months of the infant’s life. After the security of the womb the baby feels distressed, and the first object she encounters is the breast. Aggression is directed towards the breast but it’s also a source of comfort. Positive and negative feelings are experienced in relation to the breast. The breast is identified as a separate object from the mother. To make it more manageable, splitting occurs, good and bad experiences are kept apart.

Later, the resolution of these impulses affects how the child feels about herself and others. Frustration can be balanced by the mother’s affection though. As a result of trauma or neglect negative experiences can also be introjected, which may cause relationship problems in later life. The mother-infant relationship is seen as a template for subsequent relationships.

The depressive position occurs between the age of four months and 1 year. The infant starts to perceive the mother as a separate object, the good and bad parts are embodied in her together. This integration is important but also creates guilt and anxiety because previously aggressive feelings were experienced in relation to her. This imagined damage needs reparation. The resolution of this crisis is also important. Fixation at this position can cause depression in later life.

Problems related to both positions include low self-esteem, difficulties in forming relationships or inability to make commitments or trust others.

Klein’s important theoretical contribution was the realisation that all experience arises from the interplay between internal and external reality. We project onto others and also introject the external reality into the inner world of ourselves. The interplay or recycling between the two is constant. Our perception is subjective. Psychologically healthy people can see beyond what they project.

This type of object relation therapy may be beneficial for clients who experience relationship problems, feel stuck or are unable to make sense of their lives. Also, it may help clients who suffer from illness or had some loss. It can be used in family or couple therapy, too. During therapy clients can understand their problems at a deeper level. Underlying causes that stem from the past might be identified. However, it requires commitment from the client and the capacity for self-reflection and awareness. As a result, clients will become more aware of their emotional world and their capacity to relate to others will improve.

Bibliography:

M. Hough, Counselling Skills and Theory, 4^th edition, Hodder Education, 2014

L. Gomez, An Introduction to object relations, 1997

https://www.goodtherapy.org/famous-psychologists/melanie-klein.html

Winnicott

Donald Winnicott was an influential psychoanalyst within the psychodynamic tradition. His concepts shaped how therapists work today.

 

 

 

Originally, as a paediatrician he had the opportunity to observe the infant-mother relationship at close range. During his childhood his Mum had mental health problems and he described himself as a disturbed adolescent, these experiences might have been his inspiration to become an analyst. He developed the concept of the good enough mother, according to which, during early infancy the mother should be completely devoted to the infant’s needs to protect the baby with an illusion of omnipotence. After a while a small amount of frustration is allowed though, but in an ideal situation the mother is still good enough, attuned, empathetic, consistent and caring.

First, the mother is perceived by the infant as part of himself. As the child grows and the mother is away for longer and longer periods of time, he experiences this separatedness and has a sense of the external world, too. This process is important and the timing has crucial importance. Both of these phases are equally important and the transitional experience should be gradual, it is considered as a balancing act from the mother’s part. In the former one, in the fantasy phase, (or subjectivity) the infant’s needs are immediately fulfilled, in the second one, in the reality phase, (or objectivity) his needs are not fully met and frustration occurs.

He also coined the term “holding” which is based on the mother’s nurturing and caring behaviour that results in the child’s feeling safe and secure and thriving emotionally. Similarly to the mother-infant dynamics, in therapy the counsellor can provide holding, a safe, supportive environment in the therapeutic relationship. The client feels safe enough to explore both his internal world and his external reality and to examine painful feelings.

If the client could not experience this during childhood the therapist can provide a sort of reparative relationship. The therapist’s holding, containment and non-defensiveness can create a new type of relationship, in which the client can replay relationships with significant other’s without the therapist being defensive. The counsellor is reliable, objective, available, consistent and by these qualities, she can meet the client’s neglected ego needs and the client’s true self can emerge as a result of this new relationship.

Winnicott also developed the concept of transitional objects, these can include blankets, dolls or even the child’s thumb. These can help children to feel safe and secure in the mother’s absence and can play a role in transitioning towards independence. It’s almost like an illusion between fantasy and reality.

W. believed that the true self starts to develop in infancy through the relationship between the infant and the mother. The mother responds to the infant’s needs in a reassuring way. As a result, the infant develops an authentic self. The infant has confidence in expressing his needs and does not control or avoid them. He does not have to invest energy into defences. In later life it is a sense of being real in one’s mind and body, which allows people to be emotionally close to others and also capable to be creative. W. thought play was an important path to gain awareness so he encouraged creative activities and sports, too.

However, if the mother is not responsive or emotionally attuned enough, the infant may start to develop a false sense in infancy, as a defence against an unsafe environment. The infant may experience emotional or physical distress or discomfort. This lack of illusion of omnipotence results in the infant’s finding a way to get a positive response somehow from the mother who may be unhappy or depressed by displaying a false self, a kind of masking of behaviour that complies with others' expectations. Or in other words, it’s a defence when one constantly seeks to anticipate others' demands and comply with them. This is an unconscious process and it also protects the true self.

W. also believed that the false self was a mannerly, orderly, external self that enabled a person to fit into society, a polite mannered attitude in public. Clients with a false self may feel empty inside and their behaviour is motivated by a desire to please others. Through the therapeutic relationship they can learn to spontaneously express their own feelings and ideas.

Bibliography:

https://www.psychologytoday.com/gb/blog/suffer-the-children/201605/what-is-good-enough-mother

https://www.goodtherapy.org/famous-psychologists/donald-winnicott.html

https://en.wikipedia.org/wiki/Donald_Winnicott

Attachment 3. Loss and Grief

There are several theories related to the stages and tasks of grief that can help mental health practitioners understand the clients’ experience and support them. There are even some charities providing individual support or support groups for the bereaved, for example Cruse.

 

 

 

According to Worden’s theory, which he developed in the 1980s, there are four stages that people go through when a loved one dies or a significant loss occurs and there are 4 tasks of the bereavement process. The whole process can be of various lengths depending on the individual’s personal experience, which is very unique to everyone.

The first stage is shock and the task is to accept the reality of loss, that the person is dead and will not return. One needs to accomplish this stage first to continue the mourning process. One may be in denial at this stage, some people may keep the possessions of the deceased for a long time. Denying the meaning of loss can also happen by removing all the reminders of the deceased. Rituals such as a funeral can help this process.

The second stage is the growing awareness stage, at this stage the task is working through and experiencing the pain of grief. People may experience a range of different emotions such as anger, regret, guilt or relief. They may also have various feelings, thoughts, physical sensations and behaviours with various intensity. Experiencing these and working them through can help instead of suppressing or avoiding them. The stronger the emotional attachment was, the more painful these emotions are. Avoidance can involve using alcohol or drugs or idealising the deceased by remembering only the positive things. Some people avoid grief by moving away from the place where they lived together. Denial and avoiding conscious grieving usually leads to some sort of a breakdown and may result in depression. A supportive social system can help the person work it through and if the society does not stigmatise grief that can also be helpful.

Stage 3 is the transition stage, the task is to adjust to an environment in which the deceased is missing. Apart from the emotional and psychological adjustments during this stage one may need to adapt to a new role, learn new skills, return to their career, raise a child alone etc. The bereaved person might feel helpless, inadequate, incapable first, so the sense of self needs adjusting too. A more positive sense of self is created over time and they manage to regain control over their life.

Stage 4 is called incorporation and the task is to find an enduring connection with the deceased while moving on with life. The counsellor can help clients to find an appropriate place for the deceased in their emotional life. This will enable them to live on effectively and reformulate their life. They will be able to think of the deceased without pain, regain an interest in life, feel more hopeful and experience gratification again. 

 

 

 

The grief process can be 1-2 years but in some cases it can be longer or shorter.

 

Bibliograpy:

https://www.cruse.org.uk/get-help/coping-grief

https://www.goodtherapy.org/learn-about-therapy/issues/grief

https://www.verywellhealth.com/the-four-phases-and-tasks-of-grief-1132550

Wordem W.J., Grief Counselling and Psychotherapy Chapter 1

Attachment 2. (Adult Attachment)

Mary Main wanted to develop a tool to assess adult attachment too, so she and her colleagues developed the Adult Attachment Interview with 20 questions about the quality of childhood attachment with the primary caregivers and significant others and how these experiences and relationships affected the personality of the adult being questioned.

In addition, there are some questions about other significant life events, such as loss and trauma. In addition, there are some questions about how childhood experiences impacted on parenting style in later life. The adult’s general state of mind regarding attachment can be examined by using this tool. In the 1980s Main and her colleagues observed interviewees and based on these they created three categories of adult attachment styles. Apart from the content of the responses, the manner and the relevance of the responses had also significance during the assessment. They also found a strong correlation between the mother’s internal working model of attachment and how the infant was attached in infancy, and also in later life, by conducting longitudinal studies. This suggests that relational patterns may be passed on through generations and may have long lasting effects on how we form, maintain and end relationships.

Securely attached adults have a positive self image and a positive image of others, they have a sense of worthiness and expect others to be accepting and responsive to their emotional needs. They can form trusting relationships and they value relationships and expect their needs to be met. (as a result of consistent, responsive, sensitive parenting) They are ready to discuss the AAI questions in a collaborative way and seem to be objective when talking about past experiences with significant others. (no distortion) Their narrative is coherent and concise.

Adults who have a dismissive/avoidant attachment style hold a positive self-image and negative image of others. They avoid emotional intimacy and being vulnerable. They learnt not to demand too much from the caregiver and expect their needs won’t be met. (as a result of disengaged parenting) They downplay the importance of being attached and view others as untrustworthy, they don’t value relationships. They value their independence more and are self-reliant. They are brief and general when answering the AAI questions. They also have difficulty viewing others without distortion.

Adults with a preoccupied (anxious) attachment style have negative self-image and positive image of others. They feel unworthy, they seek validation and approval from others. They learned that to get their caregiver’s attention and to get their needs met, they had to be demanding. (inconsistent parenting) They seek higher levels of contact and intimacy in relationships and are fearful of losing relationships. They tend to be preoccupied with past attachment relationships and experiences. They may ramble when answering the AAI questions and have difficulty viewing others without distortions.

 

 

Most people oscillate between different attachment styles and we can display different attachment styles in relation to parents and friends.

Being aware of our subjective experiencing and reflecting on these including our attachment styles can be very helpful in therapy. Reconceptualising past experiences and changing internal working models is possible, according to research about 30 % of people managed to change their attachment styles.

In therapy the counsellor can provide a secure base and a sort of reparative relationship can be created. Healthier relational patterns can be experienced by the client, with the help of the counsellor’s non-defensive communication style.

Bibliograpy:

Huang, S (2020, Nov 03). Attachment styles. Simply Psychology. https://www.simplypsychology.org/attachment-styles.html

https://www.goodtherapy.org/blog/patterns-of-attachment-in-adults/

https://www.verywellmind.com/attachment-styles-279534

Attachment 1.

Attachment is a lasting psychological connectedness between human beings, a deep emotional and affectional bond. Children naturally seek proximity to the primary caregiver and feel secure in the presence of them. According to Bowlby (1950s) this is based on behavioural and motivational factors, (not learnt behaviour) children are motivated to seek comfort and care when they are frightened, upset or threatened.

Bowlby believed it is an innate drive, which improves the chances of survival of the baby and it is universal across cultures. The caregiver’s sensitive emotional responsiveness (and physical touch too) to the child’s needs has crucial importance in forming an attachment. (not feeding, Harlow’s wire monkey/cloth monkey experiment) 

 

 

 

This helps the child develop a sense of security and comfort, it’s a secure base, from where the child can explore. Attachment develops from a very early age and influences subsequent relations. The first 5 years of the child is a crucial period to develop attachment. If the attachment is not formed during this period or disrupted it can have irreversible consequences in later life in forming intimate relationships and in parenting. Attachment styles also involve expectations that people develop about relationships with others, based on the relationship they had with the primary caregiver during infancy. Bowlby called this phenomenon the internal working model of relationships.

Mary Ainsworth conducted groundbreaking research called “the strange situation” following Bowlby’s footsteps in the 1970s and described 3 major attachment styles. They observed how 1-1.5 years old toddlers react when a stranger appears, their mum leaves and then returns. Based on the results she described 3 major attachment styles: secure, ambivalent (insecure) and avoidant (insecure). Later, in 1986, Main and Solomon identified a 4th style, disorganised attachment. They also confirmed that these attachment styles impact on behaviour in later life, on how people form and maintain relationships.

 

 

Securely attached toddlers have a capacity to connect well. They have trust and believe they are worthy of love. In the strange situation they explore freely and actively seek and maintain proximity with their mother. They are slightly distressed when the mother leaves, but they have confidence that she will return and when they reunite they display joy and settle soon then return to exploring soon. Their emotional regulation is good enough and they have the capacity to self-soothe. Their mother is responsive, emotionally available and consistent, as a result children believe that their needs will be met.

Children with avoidant (insecure) attachment style show no proximity seeking with their mother and no distress when separated. They explore the toys, interact with the stranger and show signs of avoidance when reunited with their mother. This can be interpreted that the parent probably ignored the child’s attempts to be intimate (emotionally distant, disengaged) and the child internalised the belief that they can’t depend on others. They don’t believe their needs will be met. (a defence mechanism against mother’s rejection)

Children with ambivalent (insecure) attachment style show little interest in exploration, they are preoccupied with where the mother is. When she returns the child doesn’t settle easily (anxious) and focuses on the mother and fusses or may be resistant. They don’t return to exploration. These children feel anxious and unconfident about their mother’s responsiveness. They feel concerned that their desire for intimacy will not be reciprocated. This can be the consequence of unreliable or inconsistent parenting. The mother may sometimes be sensitive, sometimes neglectful.

Children with disorganised (insecure) attachment style display a sequence of contradictory behaviours in the mother’s presence. When she returns they may freeze or be clingy, cry and lean away. This can be a consequence of frightened or frightening parenting; passive or intrusive parenting. These children are confused and later have no strategy on how their needs will be met.

Bibliography:

Wallin D. J., Attachment in Psychotherapy, Guilford Press; 1st edition, 2007

McLeod, S. A. (2017, February 05). Attachment theory. Simply Psychology. https://www.simplypsychology.org/attachment.html

Huang, S (2020, Nov 03). Attachment styles. Simply Psychology. https://www.simplypsychology.org/attachment-styles.html

https://www.verywellmind.com/what-is-attachment-theory-2795337

https://www.goodtherapy.org/blog/patterns-of-attachment/