Reflective Practice and Professional Development in Psychotherapy 9354793096, 9789354793097

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REFLECTIVE PRACTICE and PROFESSIONAL DEVELOPMENT in

PSYCHOTHERAPY POORNIMA BHOLA CHETNA DUGGAL RATHNA ISAAC

SAGE was founded in 1965 by Sara Miller McCune to support the dissemination of usable knowledge by publishing innovative and high-quality research and teaching content. Today, we publish over 900 journals, including those of more than 400 learned societies, more than 800 new books per year, and a growing range of library products including archives, data, case studies, reports, and video. SAGE remains majority-owned by our founder, and after Sara’s lifetime will become owned by a charitable trust that secures our continued independence. Los Angeles | London | New Delhi | Singapore | Washington DC | Melbourne

Advance Praise

This book could not have come at a better time. In the current ethos of a search for instant solutions, there is the peril that therapists are becoming ‘technique-oriented’. Therapy involves a dynamic interplay of emotions, thoughts and behaviours of clients and therapists; however, the focus is often on clients’ reactions alone. This book is an attempt to redress the balance by urging practitioners to pause in contemplation of themselves and their work. Therapists at varying levels of competence and experience will gain new insights or find something that resonates with their experiences. Lucidly written, the chapters gently flow and persuade readers to embark on their own ‘reflective’ journeys. — Ahalya Raguram, Professor and Former Head, Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, India Reflective Practice and Professional Development in Psychotherapy offers psychotherapists and counsellors of all conceptual approaches—practical aid in the journey to ‘know themselves’. With warmth and wisdom, the authors of this lucid, accessible, comprehensive, clinically rich and deeply scholarly book provide useful guidance and supportive companionship for therapists at all career stages. A rare international perspective and cultural breadth make this book a unique contribution. Sure to be often consulted, it deserves a conveniently reachable place on every therapist’s bookshelf. — David E. Orlinsky, Professor, Department of Comparative Human Development, University of Chicago, USA

This is the most thoughtful and erudite book yet written on reflective practice for psychotherapists and is an absolute gem. That it has emerged from India, where the Buddha gave his teachings on self-reflection to the world, may be no accident. Somehow the authors have created a highly practical and accessible book, full of engaging therapist vignettes, while providing the reader with a sumptuous list of references. The wide coverage ranges from personal motivation and values to the relational self and alliance, and from supervision and self-care to how we can best engage with diversity and structural inequalities. This book definitely deserves a wide international audience. — James Bennett-Levy, Professor of Mental Health and Psychological Wellbeing, University of Sydney, Australia What makes this book a ‘must-read’ is the introduction of ideas of diversity, intersectionality, marginalization and oppression, and the focus on the role of supervision in providing the scaffolding required for reflective practice. It will serve as a text for trainee counsellors as well as a ‘go to’ book for experienced psychotherapists seeking to deepen their practice skills. — Dr Surinder Jaswal, Professor and Deputy Director, Tata Institute of Social Sciences, Mumbai This book draws on a wealth of literature, personal experience and thoughtful consideration to explore aspects of psychotherapy training and practice. It is a gem of a book that explores equally the strengths, the challenges and the paradoxes of therapy. Most mental health practitioners, not just therapists, would benefit from it, and it should be recommended reading for all of them. — Dr Alok Sarin, Consultant Psychiatrist, Sitaram Bhartia Institute of Science and Research, New Delhi

Thank you for choosing a SAGE product! If you have any comment, observation or feedback, I would like to personally hear from you. Please write to me at [email protected] Vivek Mehra, Managing Director and CEO, SAGE India.

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Copyright © Poornima Bhola, Chetna Duggal and Rathna Isaac, 2022 All rights reserved. No part of this book may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval system, without permission in writing from the publisher. First published in 2022 by SAGE Publications India Pvt Ltd B1/I-1 Mohan Cooperative Industrial Area Mathura Road, New Delhi 110 044, India www.sagepub.in SAGE Publications Inc 2455 Teller Road Thousand Oaks, California 91320, USA SAGE Publications Ltd 1 Oliver’s Yard, 55 City Road London EC1Y 1SP, United Kingdom SAGE Publications Asia-Pacific Pte Ltd 18 Cross Street #10-10/11/12 China Square Central Singapore 048423 Published by Vivek Mehra for SAGE Publications India Pvt Ltd and typeset in 10.5/13 pt Adobe Caslon Pro by AG Infographics, Delhi. Library of Congress Control Number: 2021952898

ISBN: 978-93-5479-287-8 (HB) SAGE Team: Amrita Dutta, Satvinder Kaur and Rajinder Kaur

Contents

Preface Acknowledgements

vii xi

1 Reflective Practice for Professional Development

1

2 Tracing Your Motivations to Become a Therapist

21

3 The Personal and the Relational Self of the Therapist

39

4 Adopting a Theoretical Lens

64

5 Connecting with Clients and Building a Therapeutic Alliance 86 6 Understanding Personal and Professional Values

122

7 Engaging with Diversity in the Therapy Room

143

8 Learning from Clients

179

9 Supervision and Reflective Practice

200

10 Being in Personal Therapy

225

11 Investing in Self-care and Growth

245

12 The Reflective Path: Integrating Reflection into Training, Practice and Research

274

References About the Authors Index

288 345 346

Preface

This book has been conceptualized as a companion for psychotherapists and counsellors. It presents a gentle invitation to pause and ponder on who we are, what happens within the therapy room and how our work transforms us. Practitioners are presented with reflection as a tool to further self-exploration and aid professional development through a critical re-examination of the personal and professional self in the therapeutic process. Through this book, we, the authors, aspire to make reflective practice more accessible, paving the way for a richer, fuller, deeper and more meaningful engagement with our clients and our therapeutic work. This book was written for anyone who ever said, ‘I would like to be more reflective in my work, but I don’t know how!’ We focus on applications within the therapy room, bringing relevant concepts, models and perspectives together for the benefit of both clients and therapists. Global and local research are introduced to contextualize reflective practice within our socio-cultural-political matrix and the times that we live in. Through the book, our attempt is not to answer questions but to raise them, so that we can open possibilities for practitioners to reflect and explore. Keeping this in mind, constructed vignettes and self-reflective exercises are interspersed through the book. We have introduced several practitioner narratives, experiential accounts and interviews that create windows into how reflective practice looks. The words therapists and counsellors have been used interchangeably through the book, as we envisage the book as relevant for all trained practitioners who provide psychotherapy, counselling and psychosocial care to individuals, families and communities. The book is relevant for therapists at all levels of development, from trainees to experienced therapists. The material addresses these diverse needs and is framed from an adult learning perspective, assuming

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self-directedness, active learner participation and self-paced learning. Each chapter ends with a section on training and development which outlines critical issues and recommendations on the integration of reflective practice into training and supervision contexts. Trainers and supervisors can use the resources with trainees and supervisees, either individually or in groups. While the book is conceptualized as a psychotherapist’s journey and is best when read from start to finish, each chapter can also be read separately. The book might offer different things at different times, and you could revisit sections that seem most relevant and useful. In the first chapter ‘Reflective Practice for Professional Development’, we introduce the idea of reflective practice and locate the role of reflection in psychotherapy practice. Models, methods and pathways to identify and create opportunities for reflective work are discussed. The second chapter ‘Tracing Your Motivations to Become a Therapist’ opens conversations on possible personal motivations for entering the profession and continuing in it. Drawing from existing research and therapist narratives, the reader is encouraged to develop their own story of how they entered the profession. The idea of the therapist as a wounded healer is examined from different perspectives, and the ongoing influence of motivations on therapeutic work is illustrated. In the third chapter ‘The Personal and the Relational Self of the Therapist’, we aim to facilitate self-exploration and the use of self as an instrument in therapy work. The reader is introduced to conceptual models of the personal and relational self, accompanied by exercises to deepen awareness about personal qualities and experiences, attachment styles and family of origin influences. In the fourth chapter ‘Adopting a Theoretical Lens’, we examine varied personal and contextual influences on the choice of theoretical orientations and note the different ways these alignments develop. The range of possible relationships with theory and the process of developing one’s personal theory of change are explored. In the fifth chapter ‘Connecting with Clients and Building a Therapeutic Alliance’, the reader is helped to reflect on various facets of the relational matrix between a therapist and a client, including

Preface  ix

attuning with clients, repairing ruptures in the alliance, attending to countertransference issues, balancing power and healthy termination. In the sixth chapter ‘Understanding Personal and Professional Values’, there is a focus on the interactions between the values inherent in therapy, personal and professional values of therapists and clients’ value systems. Reflective exercises help therapists to explore their own values as well as value-related experiences in therapy. The process of understanding and working through value conflicts is highlighted. Next, the seventh chapter ‘Engaging with Diversity in the Therapy Room’ introduces ideas of diversity, intersectionality, marginalization and oppression, with a special focus on the intersections of class, caste, gender and sexuality, and religion. The reader is guided to unpack their own notions of privilege and power and link reflective practice to culturally sensitive and affirmative psychotherapeutic practice. In the eighth chapter ‘Learning from Clients’, we highlight ways of opening ourselves to client preferences, eliciting the client’s theory of change and utilizing client feedback on therapy. The impetus from client voices and the user/survivor movement to re-examine therapy practise is accentuated. There is a deeper reflection on enduring and even transformative life lessons that therapists can learn from clients to enrich their personal and professional growth. A special emphasis on the role of supervision in providing the scaffolding required for reflective practice is the focus of the ninth chapter on ‘Supervision and Reflective Practice’. This chapter is aimed at both supervisor and supervisee and helps the reader identify their needs and expectations from supervision while detailing a reflective supervision framework for supervisors. We envisage supervision as a crucial reflective space and a significant contributor to professional growth and provide tools and perspectives to nurture these processes. The tenth chapter ‘Being in Personal Therapy’ helps the reader understand their needs and expectations from the personal therapy process and find ways to connect their insights and experiences with their work as therapists. Arguments around mandatory and voluntary seeking of therapy, the how and why of seeking therapy and the impact on us as professionals are examined through personal narratives and

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research. Reflections on the unique challenges of providing personal therapy complete this circle of enquiry. While being a therapist is a wonderful and enriching experience, there is a growing recognition of fallouts such as compassion fatigue, vicarious traumatization and burnout. The eleventh chapter ‘Investing in Self-care and Growth’ throws a spotlight on the stresses that arise from work with clients, our personal lives and the organization and setting we work in. The reader is equipped to map their self-care needs and construct a self-care plan which is responsive to their needs and emotional experiences. Therapists’ positive attitudes to self-care and compassion, resilience and meaning-making are emphasized as sources of strength. We make the case that therapists’ well-being and mental health should be cared for at both individual and systemic levels. Finally, in the twelfth and final chapter ‘The Reflective Path: Integrating Reflection into Training, Practice and Research’, we critically examine the research evidence and applications of reflective work and integrate it into their training and practice landscapes. The reader is encouraged to continue this journey through avenues such as networking and developing research-practice links. Reflective practice can be a powerful tool to enhance self-awareness and is ‘a means to see things differently and see different things’ (Ganly, 2018, p. 714). On completion of the book, we hope that the reader will use reflection to critically examine, personalize and own ideas that can nurture their personal and professional growth.

Acknowledgements

This book is our way to give back to the profession the gifts of reflection we have received from clients and teachers, supervisors and supervisees, and trainers and trainees. We thank the two institutes that we have been part of: the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, and the Tata Institute of Social Sciences, Mumbai, for nurturing us and our ideas. We are thankful to Dr Jyotsna Agarwal, Ms Brinda Jacob-Janvrin, Ms Malika Verma, Dr Susan Howard, Ms Jyothsna Chandur, Dr Soumitra Pathare, Dr Dharani Devi, Ms Mehak Sikand, Dr Prabha S. Chandra, Dr Ketki Ranade/KP, Ms Suman Bolar, Dr Hargun Ahluwalia, Dr Maitri Chand, Ms Nupur Dhingra Paiva, Ms Hiba Siddiqui, Ms Anuja Gupta, Mr Ashwini Ailawadi, Dr Pallavi Banerjee, Ms Asiya Niyaz, Ms Deepti Guruprasad and Mr Muzammil Karim for bringing reflective practice and its potential alive through their contribution of personal narratives. We hope that their openness in sharing their reflections will inspire many. Writing this book has involved a reflective process, of brainstorming and joint writing sessions. Our thanks to Kirtana Kumar, Konarak Reddy and Zui Kumar-Reddy, who opened their hearts and home at the Infinite Souls Farm and Artists Retreat for us to bring the book together. Most importantly, we want to acknowledge the love and deep understanding from our families that anchored us through this journey. Writing this book has not been a straightforward task; we meandered along till we found our voice. This voice belongs to the three of us and emerged from our experiences as practitioners, trainers and supervisors. We have used this opportunity to express our love for our work and stand up for what is important for us. This is also

xii  Reflective Practice and Professional Development in Psychotherapy

our deliberate attempt to open conversations that are much needed within the professional community, ask questions that might have been avoided and bring to the forefront voices that are often unheard. Most importantly, through this book, we invite those of us who are ready: to play, explore, be curious, get lost and be found.

Chapter 1

Reflective Practice for Professional Development

Human beings have always wondered about the world around them. Why are we here? Where does the sun go at night? Why did the apple fall from the tree? The stories and theories that we have developed in response to questions like these make up much of our knowledge and understanding of our world. They have become the truths that we trust, and that defines our perceptions, opinions and actions. This contemplation of the world around us—a serious and committed seeking to make sense of our observations, and to find less obvious patterns and meanings—can be termed reflection. While reflection is often deliberate and careful, it can also be unstructured, a sort of musing around rather than delving deep. Daydreaming, wondering, doubting, guessing, intuiting, criticizing (Dallos & Stedmon, 2009a), thinking and contemplating are all aspects of reflection, but the central process is one of learning. We all use reflection in our everyday life, though some of us might be more aware and conscious in our use of it. Reflection

2  Reflective Practice and Professional Development in Psychotherapy

helps us build knowledge and awareness of what is, as well as helps create what could be. Self-reflection is what happens when we turn this open, curious, questioning gaze onto our thoughts, emotions, bodily sensations, memories and experiences. This process of self-reflection is a dynamic and continuous process, and we may catch ourselves asking larger questions about the purpose of our life or dwelling on everyday experiences. This can lead to a more meaningful and mindful life overall or improve a particular area of functioning like relationships or conflict resolution. Our proclivity for reflection has also helped shape our social and psychological world. This helps us create a shared social world as we learn about the implicit beliefs and emotions in the minds of others, empathize with them and predict their actions (Frith & Frith, 1999, 2007). Allen (2008, p. 311) describes how we are mentalizing when we puzzle ‘Why did I do that?’ or wonder ‘Did I hurt her feelings when I said that?’ In this process, we see ourselves from the outside and others from the inside (Allen, 2008). This process allows for an embracing of uncertainty, holding of multiple perspectives and widening of awareness about self and others. Reflexivity involves a deep understanding of how we ourselves influence and create our knowledge realities. Markham (2017, para 6) describes reflexivity as ‘trying to look at yourself looking in the mirror’. This involves us owning our involvement and actively becoming aware of how our personal values and beliefs impact how we view the world (Bager-Charleson, 2010a). It is a process that challenges us to examine our assumptions, ideas and emotions and how they influence ‘what’ we reflect on and ‘how’ we reflect. Who we are influences what we see (and do not see) and how we see it. In her book On Looking, Horowitz (2013) takes us on a series of walks with 11 ‘experts’: an artist, a geologist, a sound designer, a naturalist, a typographer, a physician, a sound designer, an urban sociologist, a blind woman, a toddler and a dog. The same neighbourhood is viewed through different lenses, and in this process, ‘the familiar becomes unfamiliar, and the old the new’ (Horowitz, 2013, p. 13). The author shows us how these multiple walks can help us zoom into the varied details and layers of

Reflective Practice for Professional Development  3

experience. The physician speculates about people’s medical conditions from their appearance and gait, the typographer illuminates the city’s history through fonts and lettering on signs and buildings, the geologist notices the fossils of sea creatures trapped in building walls and the dog leads us to explore through smell. The process of reflection allows us to ask questions about what happened, how we felt and what we did when that happened. Reflexivity helps us ask what led us to focus on a particular aspect and miss another. It is important to acknowledge that our beliefs and ideas create the lens through which we reflect. What is even more important is to take cognizance of the fact that these beliefs and ideas are in turn shaped by the cultural context we belong to. The sociocultural-economic-political milieu we are part of determines the larger discourse and influences the ideas we internalize. Critical reflexivity is the process of becoming aware of our own assumptions and beliefs that influence how we reflect, linking these beliefs to our sociocultural context, and critiquing the assumptions that they are based on (Morley, 2015). We have conceptualized reflective practice to include reflection, moving to reflexivity and critical reflexivity. So what is the relevance and importance of reflection and reflexivity for professionals? With the formalization of education systems and easy access to information through books and other sources, knowledge comes readymade and packaged to us. Expert knowledge on a range of disciplines such as medicine, engineering and law is transmitted by formalized systems and is easily accessible through multiple platforms. While this saves time and personal effort, it can also lead to a blind acceptance of external systems and book learning, leaving little scope for reflection (Dewey, 1933; Schön, 1983). In his classic book The Reflective Practitioner, Schön (1983) opined that a complete and unquestioning reliance on what is taught was one of the main reasons for the erosion of professional standards, increasing professional failures. His solution was what he called reflective practice—a process of thinking about what we are doing, before, during and after the act, and understanding why we make the choices we do, evaluating their applicability and their connections to what others are doing and what

4  Reflective Practice and Professional Development in Psychotherapy

our books tell us. It is only through constant reflection that one can continue to improve and evolve professional work quality and respond appropriately to newer challenges. So how is reflection relevant to the profession of psychotherapy? Many of the concepts underpinning reflection, such as looking into oneself, searching for deeper meanings and underlying structures, or understanding motivations, have been key to the development of the discipline of psychology. Psychology and psychotherapy have always emphasized the necessity of reflection and introspection for growth and understanding of both the field and the self. The purpose of therapy itself is to help clients reflect on their lives in new ways. All schools of therapy encourage self-reflection and self-awareness as the path to progress in therapy. So, in many ways, as psychotherapists, we are already comfortable with the idea of learning through reflection. We use reflection to make sense of our clients’ difficulties and ask, ‘Why this client, with this problem, at this time?’ This leads us to develop an individualized approach that recognizes the uniqueness of each client. Culture, location, gender and socio-economic status, all these factors (and more) influence the trajectory of therapy, and readymade, one-size-fits-all solutions are limited in their efficacy. While we need formal systems of research and theory development to base our profession on, dependence on these alone cannot help us work with our clients. In our work as therapists, we often encounter situations that call for a creative and flexible response, and it is here that reflective practice becomes particularly relevant. These ‘zones of indeterminate practice’, events or moments characterized by uniqueness, unexpectedness and inherent value conflicts call for a critical engagement with our beliefs, feelings, values and motives (Schön, 1983). Johns and Burnie (2013) discuss the continuum between ‘doing reflection’, which addresses the more behavioural aspects (tools, how to, reflection in and on action), and ‘being reflective’, which involves asking questions about ‘who I am’ rather than ‘what I do’. Such explorations may be particularly relevant for helping professions, which demand the use of the therapist self as an instrument. Reflective practice integrates the reflective and scientific facets of the discipline and integrates the rigours of science with the artistry of reflection

Reflective Practice for Professional Development  5

(Stedmon et al., 2003). The therapist who gains the most is the one who can use both positions to critically throw a spotlight on each other. This position has been validated with the inclusion of reflective practice as a core competency by mainstream professional organizations (British Psychological Society, 2017; Fouad et al., 2009; New Zealand Psychologists Board, 2018; Psychology Board of Australia, 2015). The declarative–procedural–reflective (DPR) model (Bennett-Levy, 2006; Chaddock et al., 2014) provides a framework for understanding how psychotherapists learn and apply therapy skills, and describes the intersections between three paths to learning (Figure 1.1). The declarative system consists of information about therapy and psychological theories—the kind of material we find in a good textbook or learn through lectures. The procedural system involves the practical application of declarative knowledge about conceptual, technical and interpersonal relational aspects of therapy. These are the skills we use in the therapy room and involve both clinical decision-making and subsequent actions. They are usually learnt through role-plays, demonstrations and practice. Finally, the reflective system involves observing, interpreting and evaluating output from our declarative and procedural systems. As we re-experience and reflect on our thoughts, feelings and behaviours in the session, and their outcomes, we may develop new insights or learning about both theory and procedural skills. The role of a reflective system is a comparative one: to hold and analyse past, current or future experience; compare and contrast it with stored information; identify a plan of action; and either maintain or change encoded information in the light of the analysis. The DPR model emphasizes the central role of the reflective system as the engine of life-long learning (Bennett-Levy et al., 2009). It is this system that enables us to make fine distinctions, sense when to sit in silence or when to seek connection and when to slow down or when to move faster, and develop our sensitivity as therapists. As our therapist identity develops, the use of therapeutic skills is inevitably influenced by the person of the therapist (e.g., personal experiences, attitudes and interpersonal skills) and in return the therapist self also impacts the personal self (Chaddock et al., 2014). Reflection helps knowledge flow

Reflective System

Mental Representation

Cognitive Operations

Therapist Attitude

Conceptual Knowledge

Interpersonal Knowledge

Technical Knowledge

Technical Skills

Source: Chaddock et al. (2014, p. 3, reproduced with permission).

Figure 1.1  The Declarative–Procedural–Reflective Model of Therapist Skill Development

Declarative Knowledge

Conceptual Skills

When–Then Rules, Plans, Procedures and Skills

Therapist Communications

Interpersonal Relational Skills

‘Therapist Self’ Therapist-specific skills

Procedural Skills

(used for general reflection or for specific self-reflection)

Focused Attention

The person of the therapist e.g. self-awareness, attitudes, interpersonal skills, personal knowledge and experience

‘Personal Self’

Interpersonal Perceptual Skills

Client Communications

Reflective Practice for Professional Development  7

between these two sources of information and experience, ultimately building a bridge between our personal and professional selves. It is not our years of experience alone that leads to growth but how much we reflect on, learn from and incorporate this experience into our practice (Skovholt et al., 1997).

Reflective Practice: Asking the Right Questions The best way to learn is to ask questions, and we discuss some key questions around reflective practice. Understanding what areas of practice to focus on, increasing awareness of useful reflective methods and models, as well as considering where and when reflection occurs, can open new pathways to learning and professional growth. Who Should Reflect? In reflective practice, all of us are learners from trainee therapists to their teachers. Even the most advanced practitioners continually learn and grow through the powerful process of reflection. Looking back on his decades of work as a therapist, Yalom reflects on diverse experiences in his life, his own therapy and his work with clients (Yalom, 2017). He delves into his childhood memories to share how he learnt the key lesson of empathy. He interrogates his life; shares his experiences with clients, family and professional colleagues; and explores the intersections between his personal and professional selves. While all of us need to reflect, what we reflect on and how, when and where we reflect, varies across individuals, contexts and stages of professional growth. What Do We Reflect On? In the invisible gorilla test, people were asked to focus on a video in which six people, half in white shirts and half in black shirts, passed basketballs around. They were asked to count the number of passes made by the people in white shirts. At some point, a person in a gorilla suit walked in and out of the scene, thumping its chest. Although

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it seems hard to imagine anyone missing this, Chabris and Simons (2010) demonstrated that about half of the watchers did not see the gorilla. These unexpected findings show us how selective attention operates; if we are not looking out for something, it is easier to miss it. As therapists, we may experience challenges in attending to the array of feelings, memories and sensations that are evoked during, after or before a therapy session. What do you look out for in a session and what do you think you might be paying less attention to? Entering the reflective space with a broad question or focus is always useful, as it ensures that reflective practice remains purposeful. The psychotherapist has rich areas of exploration for reflection, both inside and outside the self and at their intersections. This includes reflections on practice, employing general reflective skills where the focus is on examining therapeutic material such as the therapeutic stance, formulation, goals and approaches, as well as the reconstruction and exploration of therapy events, processes and progress. Self-reflective skills, on the other hand, use reflection for a deeper exploration of therapists’ personal and professional selves, developmental experiences, relational styles, motivations, feelings, thoughts, attitudes and preferences (Bennett-Levy & Thwaites, 2007). We can set aside some time to think about these aspects of ourselves, our strengths and limitations and how they manifest in our practice (Bhola et al., 2012). Reflecting on who we are and the work we do are closely interlinked, and it is only when these two areas are bridged and integrated in our awareness that the greatest learning takes place (Aponte et al., 2009; Bennett-Levy, 2019). Although both skills are essential, Bennett-Levy and Thwaites (2007) discuss how some therapists may be competent at one form of reflection (e.g., general reflection) but uncomfortable or avoidant of the other (e.g., self-reflection). Another important sphere of reflection is the socio-economic-political context in which both the therapist and client are situated, as this is a context that impacts both. Reflecting on our social positions and contextual realities and how they influence the values, biases, assumptions and attitudes we hold, and might bring into the therapy situation, is also critical. This might be something that is easily missed, unless deliberately integrated in personal and interpersonal reflective spaces.

Reflective Practice for Professional Development  9

Reflections on the Therapy Process There are a range of thoughts, memories, metaphors, visual images, feelings and sensations that are evoked during the therapy process and may operate as signals for us to direct our reflections. Typically, therapists tend to reflect when they encounter unfamiliar situations, when they feel stuck or when they recognize skill or knowledge gaps (Bolton & Delderfield, 2018). The critical incident framework (Lister & Crisp, 2007) can be useful in identifying which events to reconstruct and explore and how to analyse and synthesize that learning. Often, it is only moments of crisis and uncertainty that are identified as critical incidents, for instance, when a client does not show expected change or terminates therapy unexpectedly. However, this framework relates to anything that may be significant, including moments of success, what was forgotten or something that seemed innocuous. An aha moment with a client also calls for reflection (Dallos & Stedmon, 2009a) when a client makes a disclosure, when a reluctant client agrees to come for another session or when a client shares how things are finally beginning to make sense to them. Focusing on what is going well (rather than just on what is going badly) can help us build and crystallize skills and create our own database of good practice. Equally, one needs to reflect on the yawns of occasional boredom or even unexplained drowsiness during sessions. Finally, one can also reflect on what is routine and seems expected, such as the twinge of loss when a longterm client terminates sessions. While events that bring out strong or unusual emotions may more easily stimulate reflection, thinking back on other events may have to be deliberately built into our practice. Reflections on the Therapist Self Whatever model of psychotherapy we use, we are people, with histories, experiences, strengths and vulnerabilities. These emerge in any social interaction, and therapy is no exception. The inward focus on the self of the therapist reflects the recognition that the therapist factor can influence change processes and outcomes, both positively and negatively, beyond the tools and techniques used (Orlinsky et al., 2004). Social and neurocognitive research illustrates how the ability

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to examine and understand ourselves is connected to the ability to think about others’ thoughts and emotions (DiMaggio et al., 2008), suggesting that a critical reflection on one’s own life narratives can lead to a more nuanced understanding of the thoughts and emotions of others, making us more empathetic therapists. The journey of self-discovery is not without challenges; our travels through this inner landscape may uncover hidden selves that are difficult to accept and integrate. What happens in the therapy room may also resonate with or trigger emotions and memories of our private and personal experiences. We can have a parallel inner conversation about these experiences, sometimes using them to understand what might be happening between therapist and client (Rober, 2017). The Satir model (Lum, 2002; Satir, 2000), person-of-the-therapist (POTT) model (Aponte et al., 2009) and self-practice/self-reflection (SP/SR) model (Bennett-Levy, 2019; Bennett-Levy & Haarhoff, 2019; Thwaites et al., 2014) emphasize how therapists must know themselves and actively use this knowledge to work more effectively with clients along with engaging in their own personal journeys of growth and change. These frameworks require a deep commitment to self-scrutiny as therapists uncover and explore their emotional and interpersonal styles, psychological and family histories, motivations, values and personal challenges. Clearly, as therapists, we must walk the talk as we work towards self-awareness and reflection with our clients. Reflections on Context The interwoven tapestry of socio-cultural-economic-political influences on the therapist, client and therapeutic process are assumed to be outside the therapy room. The reality is that they enter the therapy space even when unvoiced or unaddressed as explicit agendas. Our clients come from diverse backgrounds; we may begin the day by seeing a migrant worker from a minority religion and end in a session with a divorced parent of an adolescent. Therapists need to recognize and reflect on these intersections within the client and indeed on their own ability to connect with these contextual influences. Sometimes, the therapist and client have little in common in their social locations, and yet they are supposed to work within the intimate

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context of a therapeutic relationship (Aponte & Nelson, 2018). If we are disconnected from the experiences of a client who has experienced caste discrimination, who belongs to a matriarchal community or who identifies as bisexual, how then do we engage meaningfully with our client’s experiences, fears, wishes and realities? An integral part of this journey is the recognition of the bidirectional nature of contextual influences. As we locate ourselves and look inwards at our own culturally based templates, we can identify our own assumptions, biases and stereotypes. Together, these efforts can help us build empathic connections with our clients and find a shared language to work together. Paradoxically, the more we become attuned to differences, the more we may be liberated to work with persons from diverse contexts (Eleftheriadou, 2018). This reflexive stance might lead us to question the dominant sociocultural framework in which psychotherapy itself is embedded. Are the theories, techniques, ethical paradigms and underlying assumptions relevant across cultures? Do they need to be translated? Or do we need newer paradigms and discourses? Reflective dialogues on the applicability of Eurocentric psychotherapy frameworks across cultures (Jacob & Kuruvilla, 2012; Watkins & Shulman, 2008) can help examine their content, assumptions and methodologies more closely. Psychotherapy itself is a social construction, and a critical perspective is essential to locate and interrogate our therapeutic work. At its highest level, reflective practice goes beyond the therapy room, to understanding and challenging the political and social structures that create clients, therapists and the therapy space (Fook & Gardener, 2007). How Do We Reflect? Models of Reflection Models of reflection offer templates for practitioners to go deeper into the process of reflection. One of the simplest models of reflection was proposed by Borton in 1970 and later extended by both Rolfe, Freshwater and Jasper (2001) and Driscoll (2007). It is based on three questions: What, So what and Now what? The beauty of this model lies in the fact that while it provides simple guidelines for reflection, it

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offers the promise of depth. It begins with What, which is the descriptive phase, and involves asking questions like ‘What happened?’ ‘What did I do?’ ‘What did the other do?’ ‘What was I trying to achieve?’ or ‘What was good or bad about the experiences?’ This is usually a good start point to understand an experience or event. Once we understand the What, it is followed by the reflective phase, So what? This is the phase of analysis and comparison. Here, we ask questions like ‘So what is the importance of this?’ ‘What more do I need to know about this?’ or ‘What have I learnt about this?’ After a thorough analysis, it is followed by the emancipator phase, Now what? This is the phase to consider what steps need to be taken to improve practice, learn and change from this experience. Here you can ask ‘Now what could I do?’ ‘Now what do I need to do?’ or ‘Now what might be the consequences of this action?’ (Borton, 1970). Kolb and Fry (1975) in their experiential learning model describe a four-step model, which involves identifying a concrete experience of doing or experiencing something, followed by reflective observation which involves reflecting on and reviewing the experience. This helps us build an abstract conceptualization of what we can conclude or learn from the experience, finally leading to active experimentation where we can plan and apply the new learning. Based on our concrete experience of trying out the new learning, the reflective cycle can start again. Another popular model for reflection was proposed by Gibbs (1988) and described as a cycle involving six stages. The first stage involves the description of the event, including the context, setting, time and purpose along with one’s own response and the response of others. Once the event is described, the focus is to identify feelings and thoughts, which is followed by the next stage of evaluation of the event, including considering what went well and what went badly. The analysis stage is the meaning-making stage where sense is made of the data gleaned, which is followed by the conclusion stage, to consider what one could have done differently. This finally leads to the action plan which involves making a concrete plan of action about what could be done in the future if the event is encountered again. This model is a cyclical model and provides clear sequential steps to

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review any significant experience a practitioner may encounter in their work with clients. When we experience a disorienting dilemma, or a critical incident in the therapy process, we can use a reflective practice model to guide us deeper into that experience (Collins & Pieterse, 2007). Our internal dialogue helps us examine and contrast our immediate thoughts and feelings during that event, with our current reflections. As we make meaning of the experience by considering alternate perspectives, we use that to guide our next course of action. It is the development of a new perspective, a new understanding or learning that lies at the end of a reflective exercise, which spurs further action. This process goes beyond guiding the next therapy session with this client, or when we encounter a similar event again. It extends to learning, changing and developing our practice as therapists and can even affect our belief systems. What is important to note is that subjecting our experiences and reflections to persistent self-questioning adds another layer of understanding, a meta-cognitive view on what we experience and why. Through reflective practice, one can review current knowledge, develop a new understanding and create a commitment to act based on this new knowledge (Mezirow, 1991). One of the better known and researched reflective practice models is the SP/SR model developed by Bennett-Levy and colleagues (BennettLevy, 2019; Bennett-Levy & Haarhoff, 2019; Thwaites et al., 2014). In this model, trainee therapists are taken through a workbook where they use methods from cognitive behaviour therapy (CBT) to better understand themselves (self-practice). They are then encouraged to reflect on this experience with supportive groups of peers and supervisors (self-reflection). Through this, trainees have reported that they ‘realize’ a concept, rather than just ‘knowing’ it. Similarly, there are models that have been tailored for use in supervision. For instance, Ladany et al. (2005) proposed an events-based process model of supervision, with three phases—the marker, task environment and resolution—that are embedded within the supervisor–supervisee relationship context. This model explores how specific critical events can be identified by the supervisor and supervisee for reflection and review to facilitate their resolution, leading to some new learning for the supervisee.

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While being extremely helpful in guiding the reflection process, these models should not be considered as fixed input–output systems for reflection. On the contrary, a blind following of the steps of any model, ticking off the boxes as it were, can make reflective practice less reflective. The idea is to use a system that works for us and fits our profession/needs. It is a good idea to freely and frequently consult oneself, peers and mentors and the research literature to look for effective ways of reflecting. Using a systematic approach to reflective practice has been found to be extremely useful in both training and supervision. However, too rigid a frame with an excessive focus on faults may be counterproductive and inhibit our creativity and genuineness. Rather, using reflective models to support our sense of curiosity, and create comfort with uncertainty as well as a space to play with perspectives and possibilities, engenders a deeper engagement with our therapeutic work. Methods and Tools Reflection and critical thinking can be integrated into all our professional activities. The reflective lens can be applied to the way we write session notes, think and speak about our clients, what we take to supervision and even how we consume literature. Searching for larger patterns, looking for underlying meanings, and connecting with deeper experiences are all aspects of how we reflect every day. Carl Jung kept a personal journal of his feelings, fantasies, dreams and visions during the most difficult period of his life, after his break with Sigmund Freud. This calligraphed journal has evocative images that accompany imaginative writing, documenting his process of self-exploration and self-discovery, and has been published as The Red Book. Writing a journal has often been considered a powerful and rewarding way to connect with oneself and one’s experiences and can aid personal and professional development by providing a space for clarifying thoughts, identifying feelings and developing more congruence in therapy sessions (Boud, 2001; Daniels & Feltham, 2004). Reflective journaling channels the imaginative process and could include many creative forms of writing such as stream of consciousness

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writing, dialoguing, unsent letters, writing from different people’s perspectives and writing about a memory (Johns & Burnie, 2013). Similarly, projective exercises like responding to images/photographs or movie clips can help the therapist peep into their own unconscious. Graphical exercises like using timelines, mind maps or algorithms can help organize and make sense of large amounts of information, making them digestible and available for analysis, consideration and reflection. Art expressions are another reflective pathway, where therapists use visual journaling through painting, doodling, sculpting and other creative exercises to facilitate self-transformation, self-care and learning. Experiential exercises, such as dramas and role-plays, encourage self-awareness by facilitating a connection with our emotions and reactions (Fryer & Boot, 2017). This here-and-now awareness can build a more dynamic sense of relating with the self and the other that does not rely solely on verbal expression. This can create more openness to what happens between a client and a therapist in the therapeutic space. When to Reflect Reflection can happen spontaneously or deliberately, but it is always useful to set aside time for reflection, whether daily or weekly. Schön (1983) addressed the question of when to reflect, by distinguishing between reflection in action and reflection on action. Reflection in action refers to the process of reflecting on what one is doing while doing it (Lavender, 2003). Bolton and Delderfield (2018, p. 66) define it as ‘the hovering hawk in the mind’, and for the psychotherapist, this implies holding a reflective position during the therapy session. It involves becoming aware of one’s own body and emotional reactions and interpreting them to understand what is happening and using them to guide immediate action (Lavender, 2003). Reflection on action, on the other hand, happens after the action is over (or before it starts). It includes analysing one’s reactions to a situation, in this case the therapy session, and exploring reasons around and consequences of the same. Here, the focus is more on developing awareness and conceptualizing about the client and the self and connecting this with theory and research. Immediately after the session, when we are still

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flush with thoughts and feelings, and defences and other experiences have not taken over, is a good time to ask ourselves ‘What am I feeling?’ ‘What am I thinking?’ or ‘What happened to make me think or feel this way?’ We tend to be more open to ourselves when stirred up, so this is the best time to access our experience. Where others might seek to soothe themselves, the reflective therapist seeks to learn. Information from during and after session, both spontaneous or intuitive and planned or deliberate, is ideally integrated in planning interventions. Taking from the concept of deliberate practice, setting goals to improve on specific targets in a planned and repetitive manner, periodically reviewing progress and sustaining efforts over an extended period can enhance the effectiveness of reflection (Ericsson & Lehmann, 1996; Rousmaniere, 2017). What seems to differentiate more from less effective therapists is the amount of time spent outside of regular practice, in various activities that improved performance (Chow et al., 2015). Specifically, engaging in reflective activities, like reviewing difficult cases alone or reflecting on past and future sessions, is linked with better client reported outcomes. Giving time to return to an experience repeatedly, in a process of cyclical reflection, can enable the therapist to access new nuances and new learning (Turpin & Fitzgerald, 2006). Reflection in Different Phases of Professional Development Reflective practice is now an integral part of many training programmes. This comes from the understanding that it creates an opportunity for experiential learning, and a deeper understanding of concepts and techniques which is not available through more conventional training methods. While reflection is useful through all the phases, what, where, how and how much we reflect are also impacted by where in our careers we are. Before we start formal training, we often use our intelligence, instinct and conventional wisdom to solve psychological problems, rather than theoretical knowledge or reflection. Ideas of what helps and how to help may be more nascent and amorphous. Early in the training phase, we start learning about various psychological and

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psychotherapeutic perspectives on the self. We may be excited but also overwhelmed by huge amounts of new information. We are also likely to have our first encounters with actual clients. This can lead to anxieties about the ‘self ’ and ‘competence as a therapist’ and our focus may be more on learning than on reflection. At this stage, mastering step-by-step approaches in the context of supportive supervisory or teaching relationships may be most helpful. As we near the end of training, we may be working with clients on a regular basis, often under supervision. This is a good time to start reflecting on models and theories, their applications and limitations. This can happen through classroom discussions and assignments, as well as through early experiences of being a therapist. While we may be more comfortable in the therapy room, we are often acutely aware of all we do not know as yet and may remain heavily dependent on supervisors. Reflection often happens in the supervisory context and may be stimulated by stuck points in therapy, feelings of doubt and client responses that are challenging. At this stage, our need for certainty and clarity might go counter to the essential uncertainty inherent in the reflective process. Supervisors who can balance support and confirmation with challenge and exploration make reflection a stimulating rather than an overwhelming experience. As we advance and become more comfortable with the basic tenets of therapy, we may feel an increased readiness to build awareness of ‘self’. At this phase, reflection often focuses on boundaries between self and other, so we learn to stay separate from the client while offering empathy. Reflection on psychological theories coupled with a deeper understanding of the self enables the psychotherapy student to develop a unique ‘stance’ or style and choose their theoretical orientation(s). We may also wish to reflect on the central role of the therapeutic relationship and what we can do to enhance it. This includes getting more comfortable expressing the self in the therapy room and asking deeper questions about the therapy process and human psychology. Faced with the challenges of work in the real world, we may wish to confirm the validity of ideas learnt in training and sometimes feel disillusioned with them. This is often followed by an intense exploration

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of the self and the professional environment with the aim of resolving personal and professional conflicts and developing our identity as therapists (Rønnestad & Skovholt, 2003). As novice professionals, we may be intrinsically motivated and wish to experience and explore our autonomy. Many times, we may seek to learn and reflect on our own for a while (through literature, workshops, etc.) before seeking formal supervision again. Once we have evolved a more nuanced understanding of theory, we may focus our reflections on interactions with clients, life experiences, other professions, arts or spirituality, rather than just textbook material. Of course, having these experiences is not enough, it is reflecting on them that converts them into a rich understanding of human nature, self and the process of change in therapy. This enables us to develop congruence between our personality and the theoretical model or orientation we use and be more authentic in the sessions. As we come to understand the rules and processes of therapy better, we learn how to modify and adapt them, even questioning the notion of ‘rules’. We do grow in both competence and confidence, blending our personal and professional selves, but there can be unexpected challenges at any stage of our career. Even as experienced practitioners, we may find ourselves doubting our abilities or reacting intensely to negative effect from our clients, and these moments signal the need for a reflective retreat (Vaskoch & Strupp, 2000). As we advance in our careers and play the roles of teacher, mentor and supervisor more often, reflection may occur in the context of our supervisees’ therapeutic work in addition to our own. In this final phase of our working lives, continued reflection can help us avoid stagnation, find meaning and excitement in our work and build wisdom that can be shared. Through the journey, the effective reflective practitioner connects their personal selves with their professional selves, their understanding of their own reactions and how they fuel therapy behaviours with a deeper and more nuanced understanding of theory and research. Think about the phase of professional development you are at now: perhaps a confident student, an anxious professional or transitioning

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from one phase of development to another. As you identify the primary challenges that you might be experiencing as a therapist, remember that these can come from more than one phase. Consider what you would like to reflect on, and what you hope to gain from a more reflective practice. While reflection is one of the pathways of professional growth, too much unsupervised reflection too early can be overwhelming for therapists. Fauth and Williams (2005) warn that particularly for novice therapists, attempts to manage the ‘self’ during sessions can interfere with the therapy process. Bennett-Levy (2006) echoes this idea, noting that beginner trainees do better at reflecting on action rather than reflecting in action. As trainees and novice practitioners, we may be more focused on how to respond to the verbal content of sessions— what we hear and speak. Gradually, we may be more able to note and respond to non-verbal content in sessions as they happen. However, we may need the distance and safety that supervision provides, to not just reflect on the client’s verbal and non-verbal communication but also integrate what the session evoked in us. More experienced professionals are likely to show personal reflexivity or a practice of acknowledging how their ‘own agendas, experiences, motivations and political stance contribute to what goes on in work with clients’ (Chinn, 2007, p. 13). We gradually learn better how to reflect on our own and how to allow all our experiences to inform professional work. Where Do We Reflect? While reflection can occur anywhere, it can help to carve out a reflective corner, a space and time that is set apart from busy schedules and commitments. Eventually, just going to this quiet, undisturbed, comfortable and safe space may cue your reflective state. While the image of a solitary thinker is accessible and intuitively appealing, learning about ourselves is not always a solo endeavour, as expressed in these words, ‘It takes two to know one’ (Culbert, 1970). Being open to learning from peers and supervisors and from our clients can all throw light on aspects of ourselves that we do not otherwise have access to. Trainers, supervisors and mentors who partner in this journey and

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lead by example are essential in this process. We can learn not only through the way others mirror our psychological realities but also through reflecting on our impact on those around us (Lavender, 2003). Personal development programmes and personal therapy offer opportunities for deeper reflection (Elliot & Partyka, 2005; Råbu et al., 2021; Wigg et al., 2011). Some of our other professional activities, attending conferences or workshops or engaging in psychotherapy research, can also stimulate reflections. We learn outside the therapy room and draw from our repertoire of life experiences and relationships, and from our reflections on art and literature. Setting aside time to actively reflect on and connect these experiences to therapy work is recommended. If we reflect on and engage with our work and selves assiduously, we can develop what Casement (1985) calls the internal supervisor—an ‘observing ego’ which can help us notice patterns in self and client. Background information from awareness of self, life experience, culture, theory or experience with the client, all help the therapist make clinical decisions in the foreground of the therapy session. We learn to consult our reflective self while also remaining immersed in the interaction with the client. Our personal and professional selves come together to create a more unified experience, and we carry our supervisors and reflective spaces within us wherever we go.

Conclusion We hope that interacting with the ideas in this book helps you continue to grow as a practitioner. As our levels of reflection deepen, we are also better able to support our clients in their reflective journeys. However, it should be noted that reflection alone cannot solve all therapeutic dilemmas and needs to be balanced with practice and theory. To be effective, the reflective space needs to be playful and creative. It requires both commitment and the belief that it is worth the effort. There is a personal challenge in being open and vulnerable and examining the limitations within ourselves and in the theories that we deify and love. An experimental approach that focuses on the joy of discovery can make the reflective leap a joyous one.

Chapter 2

Tracing Your Motivations to Become a Therapist

Why do you want to hear other peoples’ stories and commit to helping them with their concerns? Why did you choose to engage with the distress that people experience and help people heal and grow? Do you see being a therapist as a job, a ‘curious calling’ (Sussman, 2007), a healing profession or a serendipitous turn? We belong to a profession that seeks to understand the motivation for everything. We have theories that explain why artists paint pictures or why astronauts go into space. However, how often do we step back and reflect on what motivates us as psychotherapists to do the work we do? Understanding our motivations can be relevant at any stage of our career as psychotherapists, whether novice or expert, whether one has dreamt of this career their whole lives or found it as part of a mid-life career change. Layered and complex motives are perhaps more the norm than the exception. While some reasons may be obvious when we join the profession, others may become evident much later in our careers or during our own personal therapy (Norcross & Farber, 2005). Also, our motives may not always be in our conscious awareness, and even if they are, we may not have actively articulated them.

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Not many therapists would describe their choice of profession as ‘just a job’, and this is a career that is hard to sustain unless we really believe in it. Why we choose to be therapists is therefore an important question—one that has implications for the kind of therapist we end up being, and the kind of work that can bring us true joy and meaning. Being a psychotherapist is a fulfilling and rewarding profession, often described as a passion, and many of us feel grateful and privileged at being able to play the role of a healer (Karter, 2002; Mander, 2004). While the work presents many opportunities for self-discovery and growth, we are also more open to and present in the pain and suffering of others. Loneliness and isolation are very much part of the territory, and compassion fatigue and burnout are very real possibilities (Figley, 2002). Further, it is not necessarily a high paying profession in some parts of the world. So why are we still drawn to working with people experiencing distress and psychological pain? Through this chapter, we explore possible motivations for entering and remaining with the profession of psychotherapy and counselling, use exercises and delve into therapist narratives to locate our motivations and discuss ways in which our motivations can colour therapeutic interactions.

A Range of Reasons: Exploring Therapist Motivations It has been speculated that ‘psychotherapists are motivated by contact, discovery, fame, fortune, growth, healing, power and/or vicarious experience’ (Marston, 1984, p. 456). With so many diverse potential motivations, how well is it possible for therapists to know themselves? How many of us may consider it important to put time and effort into this process? Staying aware of the purpose, meaning and motivation of why we want to be therapists can add another layer to our work with clients and what we do in therapy. Further, it may also determine our satisfaction with our work and keep us meaningfully connected to what we do. Questions about our motivations may arise at different times: during an intense moment in the therapy session with our client,

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during a supervisory discussion, when we experience a professional crisis or when we experience burnout. As we begin our journey of self-exploration, it helps to start at the beginning, with asking ourselves what motivations led us to choose this identity and profession. We may find that there are a range of reasons for getting into the field, rather than any one specific motivation. Some reasons why therapists enter the profession include getting admission into a psychology course, being inspired by a relative or mentor in the profession, stumbling upon a job opportunity, just serendipity or even destiny (Bager-Charleson, 2010b; Farber et al., 2005). Therapists also mention feeling an endless curiosity on why people act and feel the way they do as being a critical factor in choosing to work with people (Farber et al., 2005). Research findings across the globe, and across different times, indicate that intellectual curiosity, fascination with the inner world of a person, an early interest in reading and an inclination towards the humanities may also be initial drivers for psychotherapists to enter the discipline (Duggal & Sriram, 2016; Henry et al., 1971). We may also join the profession as we experience a fit between what the profession requires and how we are as people. Inherent qualities of being thoughtful, patient, understanding and good listeners and having a deep interest in others’ life stories have been shared as motivators for therapists to enter the field of psychotherapy (Duggal & Sriram, 2016). As we tap into our competencies—our empathic abilities, communication, language and relatedness skills—our work can leave us feeling competent and fulfilled. We might also be drawn into the profession, looking for an opportunity to be authentic and experience our real selves (Hester, 2014). While these may be more accessible reasons and initial thoughts, there may also be deeper considerations which could underlie our choices. It is not surprising that many therapists claim to never really have thought about what motivated them to take up the profession. It might therefore be a transformational moment when someone asks us: ‘Why did you train to become a therapist? Why did you really train to become a therapist?’ (Adams, 2014, p. 10).

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Altruism: Help Others, Help Yourself? In her book Strangers Drowning: Grappling with Impossible Idealism, Drastic Choices, and the Overpowering Urge to Help, Larissa MacFarquhar (2015) explored the concept of extreme altruism. While it is true that we are all interconnected and feel empathy for others, there are only some who would donate a kidney to a stranger, adopt 20 children or, like Baba Amte, eschew privilege to live with and work for the welfare of persons with leprosy. Reading these essays provokes reflections about people who place giving and goodness at the centre of their lives. This also makes us wonder about the choices that we might make. When asked to reflect on reasons for choosing this profession, the most cited reason is altruism. Therapists often share how they were drawn into the profession because of their desire to help another human being by alleviating their suffering, promoting their growth and in some way making a difference to their life (Duggal & Sriram, 2016; Farber et al., 2005; Stevanovic & Rupert, 2004). In the process of giving and seeing our clients change, we may also experience the helper’s high, with increases in self-esteem, well-being and feelings of generativity (Heppner, 2014). An inclination to value altruism may develop through early experiences within our families. Reflecting on why she became a psychotherapist, McCullough (2005, p. 997) spoke of several family members who were models of generosity and compassion and of deeply held family values about helping those in need. Taking the role of the helper, the values of caring, kindness and family closeness emerge frequently in therapists’ recollections of their childhoods (Kaslow, 2005; McCullough, 2005; Orlinsky, 2005). As members of a helping profession, we are committed to engage with the suffering of others. As therapists though, we probably know too much about human nature to be able to accept altruism as the sole motive for our choice of profession. Norcross and Farber (2005) suggest that altruism is an incomplete motive, and it is important to go deeper into it and understand why else we might want to help others. Can our need to be helpful sometimes overpower our client’s needs or in part reflect our need to help ourselves as well? If we see ourselves as solvers, protectors or rescuers, this may leave less space for clients

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to use their own strengths and resources (Rober & Seltzer, 2010). As we reflect on how altruism may play out in our work, we may become aware of its shadow side and more fully understand the complexity of our motivations (Barnett, 2007). The complex reasons for choosing to define ourselves as therapists may reveal themselves as we question ourselves at different stages of our professional trajectories. Perhaps just as we ask our clients what has brought them to therapy, we need to ask ourselves what has brought us to the profession (Sussman, 2007).

The Storied Lives of Therapists Understanding our motivations to become a therapist involves both the processes of looking back and looking within, to explore ‘who I was, who I am (and why) and who I might become’ (Shamir & Eilam, 2005, p. 402). As we read the deeply reflective autobiographical accounts of therapists (Barnett, 2007; Bager-Charleson, 2010b; Duggal & Sriram, 2016; Farber et al., 2005), it seems that we are indeed our stories. The therapists’ gaze imbues our life experiences with meaning and as we see, we are also seen. Therapists have connected their career choice with both positive, enriching experiences and more difficult ones, often stemming from childhood. Not all our stories are pleasant, and as we explore them, we may feel like Bloomfield (2014, p. 48), who said, ‘I have not always liked what I discovered.’ Many narratives depict a complex mingling of chance and choice in the process of becoming a psychotherapist (Heppner, 2014). Take the time to explore your own life stories and experiences and connect the dots on what might have shaped your own decision to be a therapist. Each phase of your life can be thought of as one of the chapters that make up your story. Drawing from a narrative approach (McAdams, 2001), you could identify markers such as high points (e.g., winning a college scholarship), low points (e.g., a childhood illness), turning points (e.g., migrating to another country), both positive and negative childhood memories (e.g., summers with doting grandparents, the time father left home) and vivid adult memories (e.g., birth of a child). The identification of wisdom events, ones in which you acted in a wise way or provided wise counsel to others,

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might illuminate your journey to a helping profession. You might also search for religious, spiritual or mystical experiences, where you felt a sense of transcendence or oneness. Our immersive reflections about what happened, where and when, who was involved, and our thoughts and feelings, can link our important motivators in a meaningful and personally relevant way. Some therapists have spoken of their families as a central influence on who they are and what they value. The sense of being loved and cared for, environments which fostered independence and selfexpression, and interactions with positive and encouraging role models were all powerful themes in some therapists’ narratives (Heppner, 2014; Orlinsky, 2005). There can also be struggles, unmet needs and trauma in the childhood and adult lives of many therapists. Feelings of invalidation and loneliness arising from difficult family contexts involving parental marital conflict or parental mental illness and personal experiences with illness or disability have been noted as critical (Barnett, 2007; Duggal & Sriram, 2016). Experiences of early loss and separations from loved ones have been echoed by many therapists; Fransella (2014, p. 112) wrote about the early loss of her mother after which her ‘life was lived secretly and internally’. Quite early on, some therapists may take on the role of putting the ‘familial Humpty Dumpty back together again’ (Brown, 2005a, p. 952) and professionalize their early experiences by becoming psychotherapists in their adult lives (Adams, 2014). Therapists’ narratives contain many evocative descriptions of themselves as the giver, the parentified child or the white knight (Brown, 2005a; DiCaccavo, 2002; Glickhauf-Hughes & Melman, 1995; Street, 2014). Speaking of the impact of her mother’s depressive illness, Brown (2005a) shared how she became acutely sensitive to interpersonal and emotional nuance as a young child, constantly alert to the emotions and needs of her family members. These experiences, coupled with her feelings of being an outsider at school, led her to become a psychotherapist—a relational space where she felt at home with herself. The archetype of the wounded healer (Jung, 1963) connects closely with the idea that our vulnerabilities may lead us to this profession (Hamman, 2001). Marsha Linehan is known for developing dialectical

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behaviour therapy, a pioneering treatment for individuals with concerns of self-harm and personality vulnerabilities. In an interview in 2011, she decided to reveal her personal struggles with mental health during her adolescent years, after a patient asked, ‘Are you one of us?’ Linehan’s journey from being wounded to becoming a healer embodies the motif of resilience and transformation embedded in the wounded healer archetype. ‘I honestly didn’t realize at the time that I was dealing with myself,’ she said. ‘But I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got’ (Carey, 2011). Referring to wounds, the poet Rumi (1997a, p. 142) says, ‘That is where the light enters you.’ These words exemplify the positioning of the wounded healer trope in the therapeutic process. Wounds are seen as conferring an advantage to therapists who can use them to build an empathic bridge with their clients. For instance, a therapist hurt by parental neglect in childhood could be sensitive to subtle or disguised signs of similar wounds in her client, something a therapist with a secure childhood might miss. The therapist may demonstrate skills and commitment in reaching out to her client and in turn could learn new perspectives and solutions, that she can then apply to herself. Take a moment to think about your perspective on woundedness. Do you think that all therapists are wounded, perhaps to varying degrees? How might therapist wounds be detrimental or helpful to the therapy process? Much of our understanding about therapists’ personal challenges comes from studies of their life narratives and their reflections. One perspective is that all therapists are wounded and drawn to this profession due to their compelling but often unarticulated needs. While many therapists, both trainees and practitioners, can make a connection between their career choice and their motivations to explore and resolve their personal problems, this is not everyone’s story (Bhola et al., 2017; Hoyt, 2005; McCullough, 2005; Orlinsky & Rønnestad, 2005). In fact, Hoyt (2005) argues that seeing therapists solely through the wounded healer lens may overly pathologize our motivations and commitment to being psychotherapists. Looking at this on a continuum, therapists might have experienced varied degrees of emotional

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stress, trauma and wounds. We have little information from empirical research to confirm if therapists have had more painful or difficult childhood experiences than others (Elliott & Guy, 1993). Perhaps as therapists we tend to approach our life experiences differently, holding on to them and trying to delve into their meaning (Farber et al., 2005). Literature often focuses on the impact of early childhood experiences on the choice to be a therapist, but a few therapists have spoken about experiences and crises in their adult lives as an impetus to joining the profession (Bager-Charleson, 2010b). Some of us may pick therapy as a ‘second career’, perhaps because of our experiences or perhaps because we feel that being a therapist aligns better with our values, personality or life goals. We are more likely to be aware of and deliberate about our motives under such circumstances, and this could impact our approach to therapy. In fact, our current interests, experiences or contexts can intersect with past experiences, coalescing to create a larger narrative about why we do what we do. As we go through life, critical experiences, both affirming and discounting, may shape our choice of work, the approach we adhere to and the communities we work with. Life events, such as immigration that leave people feeling marginalized, like a stranger, outsider or an outcast, may lead some therapists to choose certain theoretical orientations or work with certain client groups (e.g., working with women survivors or adolescents). The purpose of these reflections is not just to focus on our wounds but also the spaces that they occupy in our minds and relationships, how they are soothed within ourself and in our interactions and, importantly, make meaning of how they might be guiding our lives and our work. It may also be important to think of how our journey of healing and resilience may also impact our choice of taking on the healer role. Having seen a therapist in childhood or even later in adulthood has been mentioned as an inspiration by some therapists. This influence has been discussed in many ways—as an eyeopener to the transformational power of therapy, as a response to a negative experience in therapy or arising from the desire to give others the therapeutic help they had not received (Bager-Charleson, 2010b; Hill et al., 2013; Mahoney & Eiseman, 2014).

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There are, of course, many more dimensions to our experience, people we meet, books we read, places we travel to, cinema we watch and events we participate in that shape our sensitivities and inclinations. As we reflect more deeply, we can increase our awareness of the complex web of motivations that guides us to enter the profession and sustain in it, and shapes how we approach our work.

How Motivations Enter the Therapy Room What is clear is that entering and staying in this profession are driven by many conscious and unconscious motivations. These motivations are often brought into play at decision-making junctures in a therapist’s professional journey. As an undercurrent through the psychotherapy process, they can also have an impact in terms of both moment-tomoment therapist–client interactions and overall psychotherapeutic outcomes. For instance, an altruistically motivated therapist who takes pride in being able to help their clients may find it easier to temporarily tune out their own life and needs and be there for the client. A wounded healer who has found a path out of their own troubles might find it easier to be patient or hopeful in the face of their client’s struggles. A therapist who retains their curiosity and fascination for the vagaries of human nature may find it easier to sustain interest and stimulation from what can be a very taxing profession. Therapists are ideally aware of their motives, able to separate them from client’s motives and privilege the client’s motives over their own. Straight off the bat, we need to appreciate that what we most want for ourselves from our work—whether a deep understanding of motivations for behaviour or an intimate connection with another—may not be what our clients need from us (Richardson et al., 2009). Here is a vignette about a therapist and client that throws light on the varied ways in which the therapist’s motivations can enter the therapy room: Annie was an experienced therapist, known for being gentle and empathic. She had experienced conflict with her mother, who wanted her to get married rather than become a professional. Annie had stuck to her path, and later married a man of her choice. She now had a beautiful home, a teenage daughter, a happy marriage and had

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made peace with her mother. Her only concern was about her daughter who seemed disinterested in a career, instead shifting from one shortterm course to another. Noor was a young woman seeking therapeutic support to manage her low mood. Her parents were divorced and continued to be inconsistent in their parenting—sometimes offering love and possessions and at other times being critical. They were particularly concerned about her use of cannabis and her relationship with a controlling boyfriend. Both her mother and boyfriend disapproved of her ambition to build a career through her artistic talent. Annie and Noor hit it off instantly, and there were significant changes in Noor’s ability to contain her emotions and negotiate her relationships. Annie felt very deeply for her client and really wanted to support her desire to be financially independent as an artist. She was conscious of an occasional stab of outrage and anger at Noor’s parents, particularly her mother, who did not seem to appreciate how courageous and ‘true’ her daughter was. Annie is a therapist who finds joy in being able to help others find happiness, as she has managed to find it for herself. Annie does not give up on her clients, and this is a huge part of her success as a therapist. However, these altruistic feelings could also play out in complicated ways. What might happen to Annie’s feelings towards Noor if she stops ‘improving’? What if Noor gives up on her art or does not want to break up with her abusive boyfriend? A therapist whose sense of self depends a little too much on their ability to help may experience distress and discomfort with clients who do not change or heal as their therapist desires them to. This distress can manifest in annoyance, withdrawal from or rejection of the client. This in turn can impact the therapeutic relationship and therefore client progress—a vicious cycle that can trap both the well-meaning therapist and the frustrated client. Some of us may try to help too much by offering extra sessions, free sessions, home visits and personal resources, so that we can be there for our client every time they need it, even at a personal cost. As we become more experienced, we may stay clear of such dangerous waters, but may still find ourselves emotionally giving more, spending more time thinking about this one client and searching even harder for ways and means to help them.

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Unaddressed psychological difficulties can be detrimental to therapeutic work and may be our Achilles heel in working with particular clients who touch those wounds (St. Arnaud, 2017; Weingarten, 2010; Zerubavel & Wright, 2012). A therapist’s strong need to help might lead to advice-giving and persuasion, which may cross therapeutic boundaries. A compulsive need to rescue our clients can inhibit their autonomy, competence and ultimately their psychological growth (Misch, 2000). We may feel a strong need for clients to get better, insisting on improvement and feeling disappointed at slow rates of recovery. One way for us to tune into whether our need to help is becoming restrictive is to observe if we feel upset or disturbed when a client does not take our advice or feel stuck or resentful when the client is not doing what seems obvious to us. We may feel a need to always be the one with the right answers, to be idealized as the ‘sorted’ individual and practitioner. Our need to help our clients should not come in the way of the clients’ need and ability to help themselves. In therapy, we need to sit with not knowing, quieten our own anxieties and give clients the time and space they need to discover their own answers (Partington, 2009). Sometimes, therapists who have had a healthy and happy childhood, and feel that they have discovered important truths in their own life journey, may be a little too eager to impart this knowledge to clients. Cecchin et al. (1994) call this being a missionary therapist and warn that therapists should not assume that solutions that worked for them will also surely work for their clients. Our in-session behaviour could be motivated by our personal needs, desires and conflicts which may lead to over-identification or under-identification with client experience. Occasionally, we may find ourselves trying to relive certain experiences through our client in the hope of achieving a different outcome. Such an experience can make it harder for us as therapists to objectively identify our client’s needs, thus coming in the way of the therapeutic alliance, goals and processes in therapy (Wheeler, 2007). The way we have dealt with our own wounds can impact therapy process. As therapists, we may limit explorations of our clients’ feelings and responses to align with our own or even push for the same resolution in our clients’ stories. In a deeply personal account, Adams (2014) shared how her client’s struggles with

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a night shift resonated with her own previous experience. She recalled having to quit a difficult job and choosing a career shift to training as a psychotherapist. During sessions, she found herself repeatedly encouraging her client to reflect on the purpose and meaning behind his work. Finally, her client shared that he was invested in his work and only wanted a change in timings—it seemed that it was the therapist who wanted him to leave his job. Our fears of not being good enough, not being respected or failing can leave us feeling very vulnerable in sessions. We may address these fears by trying to be more structured in our work, exerting control over interactions and outcomes and aiming for perfection in ourselves and clients. When our fears are too strong, the need for control can become narcissistic and limit client autonomy and growth (Barnett, 2007). For instance, being liked, valued and accepted by her clients could act as a balm for Annie which soothed her from her mother’s initial rejection. But this can also leave her overly sensitive to perceived rejection by the client. Anything less than the perfect response from Noor, even a slight disconnection or dissatisfaction, might make Annie evaluate herself and her therapeutic skill negatively. Reflecting on our needs, drives, wishes and fears and working through them may keep them from interfering with the process of psychotherapy (Richardson et al., 2009). For instance, Annie’s struggle with her own daughter might be pushing her to at least achieve success with Noor, by persuading her to take up a more stable profession. If Annie is aware of this, she can keep her motives from interfering with her client’s choices and goals. In fact, therapists need not just put away their motives but can use them to bring a deeper and more nuanced understanding to the session. While the knowledge of the wounded–healer duality may support deeper sharing, growth and change in clients, there are many complexities related to therapists’ disclosure of personal struggles and wounds to clients. Clients may not always appreciate our disclosures, and we must reflect on the degree and timing of disclosures as well as consider whose needs are being met in the process. Therapy is in essence a very intimate enterprise, and as therapists, our needs for intimacy can also get expressed in sessions. Emotional

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neediness or dependency can be significant personal contributors among therapists who fail to maintain adequate boundaries in therapy. These needs can become problematic in two ways: First, we may be uncomfortable with our intimacy needs and have difficult or complex relationships in our ‘real’ lives. This can lead us to seek the safe and controlled intimacy of the therapeutic encounter. Here, the intimacy is one-way, with the client doing all the sharing, and the therapist remaining safe and removed (Barnett, 2007; Farber et al., 2005; Waldroop & Hurst, 1982). Noor can never threaten Annie as her own daughter can. Annie can pour all her tenderness into Noor while remaining in control of the encounter. She can terminate or taper sessions, prescribe topics for discussion and subtly stay away from material that is threatening to herself. Time spent with clients can start to feel more rewarding than time in personal relationships, keeping us vested in our client’s appreciation. Thus, Annie may miss opportunities to challenge Noor and might be scared to confront her on her drug use. If Annie hesitates to bring her own reactions and emotions into the session, she could be less authentic in the session. She may want to hide her vulnerabilities and confusions from Noor, and so retreat into an expert position when Noor might need her warmth. Second, some therapists may have less control over their intimacy needs, and this can result in ethical transgressions. Abuse and exploitation of clients is unfortunately not unknown in the profession. While sexual boundary violations are relatively rare, therapists might express this need by showing undue curiosity about client’s intimate experiences, fostering sexual feelings or making inappropriate self-disclosures. This of course can potentially lead the therapist and client down a slippery slope of boundary violations (Gutheil & Gabbard, 1993). Addressing one’s motivations in sessions can be built into regular practice. If Annie had reflected on her work with Noor, she might have asked herself why she was having such strong reactions. She might want to explore where her empathy ends and her control of the session begins. She could become more aware of her own needs and take steps to meet them outside the session, by improving her relationship with her daughter, for instance. She may decide to start supervision to help keep her needs for altruism, narcissism or intimacy in check. If she recognizes that while she has come far, she still has

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areas of insecurity or times when she shuts down, she may decide to seek personal therapy. Annie has many strengths as a therapist, not the least of which is her relatively successful negotiation of her life hurdles and the confidence this has brought her, as well as her empathy, curiosity and desire to help. But we all have buttons, and we all have blind spots. A willingness to become aware of and reflect on them, and act on our learnings, is what might be critical to our growth as therapists. Everybody brings something of themselves and their life experience into therapy. These may be positive experiences of being supported and cherished or negative and traumatic experiences. It is how we understand, acknowledge and deal with them and actively use them that counts. What Sustains Us Reflecting on our motivations and connecting with what is driving us to stay in the profession are life-long pursuits. It is well recognized that motivational factors change for therapists through their career, and while many of the factors that initially influence therapists such as interest, curiosity, or the desire to help and serve others continue to be important, newer motivations emerge over the years. Over the years, therapists may feel privileged to be able to have fulfilling relational experiences with clients and feel inspired by the effectiveness of the psychotherapeutic process. This may continue to drive them to be even better in their work and know themselves better. Understanding the meaning that our work gives us, and sharing it in our training and supervision spaces, may help us stay connected to our purpose and therapist identity. As we reflect on what we are doing and why it is meaningful for us, new drivers may emerge which may help us further deepen our work in a particular area or pursue some aspects of it. For instance, we may notice that we find it more meaningful to work with a specific client group or type of presentation. We may also come to value allied roles, like research to stimulate our intellect or teaching to meet our desire for generativity. Sometimes these roles may sustain us even when being a therapist feels more

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challenging. Connecting to our motivations, when things might be tough or we may be feeling depleted, can energize us and even prevent burnout. Finally, it is useful to note that all our motivations cannot (and should not) be met only in our work. Feeling fulfilled in our personal lives and more complete as human beings also works to sustain our motivation to remain therapists. We invite you to close your eyes, take a deep breath and think of your role as a therapist. Reflect on what guides you, sustains you and keeps you anchored as you reach out to people and support them in their journeys of healing and growing. See what comes up for you; allow the image (or images) to form in the eyes of your mind. As you stay with this process of visualization, think of people, places and objects. You may make a note or draw what emerged in the visualization, so you can stay connected with the symbols of your sustenance. As therapists, we can reflect on whether we have stayed close to the motivations that brought us to the profession. Have they remained the same, evolved or have we lost touch with what makes our work meaningful? Checking in on whether we feel we are building on our motivations can help us consider whether we need to change anything about our professional lives. We can ask ourselves what else might we need from our careers. Is there a part of ourselves that wishes for more expression? Looking at our typical workdays to see what resonates with us and what might feel at odds with our motivations can be a window into underlying concerns. When we feel like the therapist role defines not just what we do but also who we are, it is likely that our motivations are congruent with our career choices and can continue to nourish us.

Perspectives on Training and Development Selection Processes and Policies in Psychotherapy Training Programmes The selection process for psychotherapy training programmes is varied. While some training centres do not include or prioritize the personal motivations of applicants, others are apprehensive when applicants

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identify no specific challenges or present a positive picture of overcoming all adversity. Such programmes may be more open to applicants who share narratives of early vulnerabilities, with experiences of having overcome these challenges (Ivey & Partington, 2014). Another perspective has been that of gatekeeping at the admission stage, by screening applicants who may be too vulnerable to support clients. This position, however, could be extremely discriminatory and unfair and may adversely impact openness within the professional community. A more inclusive approach suggests that trainees who come with difficult life experiences may be ‘unready rather than unsuitable’ (Lafrance et al., 2004, p. 326). Perhaps what is most important is that potential trainees demonstrate a willingness to reflect on the links between their life experiences, their choice of professions and the potential impact on practice (Ivey & Partington, 2014; Lafrance et al., 2004). Training institutes may proactively need to create spaces in the programmes for facilitating this process. What is also important to recognize is that motivations and needs might not always be easy and clear to identify, and some of these connections often come to light only when the shift occurs from academic to clinical work (Regehr et al., 2001). Working with clients experiencing trauma, abuse, injustice or neglect can be particularly triggering and might uncover our vulnerabilities. Once trainees enter professional programmes, a reflexive approach may help them connect their life experiences and motivations with ways of relating with others (Carlson & Erickson, 2001). Personal and Professional Responses to Therapist Vulnerabilities and Motivations While we are always available to hear our clients’ stories, there may be less openness to reflecting on and resolving our own disappointments, fears, anxieties and pain even as we realize how this is connected to our work and well-being. All too often, there is a belief (which may also be held by therapists themselves) that those in the helping professions must be invincible and complete. In certain cultures and contexts, the image of the therapist as a ‘guru’ or a benevolent dispenser of wisdom predominates (Neki, 1973), and this can encourage therapists to

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represent themselves as well-adjusted or even ‘perfect’. If we take on this identity too strongly, it could limit the space for self-exploration, examination of our frailties and recognition of our complex and even hidden motives to become therapists. Moreover, while the more altruistic motivations for joining and being the profession might be recognized and celebrated, other aspects of personal needs and wounds may be dismissed or shamed. The higher levels of shame proneness in certain cultures (and the pressures to keep family secrets) could additionally constrain some therapists from acknowledging and sharing their vulnerabilities and difficult childhood experiences (Sommers, 2012). Difficulties with disclosure also reflect the inconsistent response of the professional community to therapist wounds. While compassion and empathy form the bedrock of this profession, wounded therapists seem to expect negative reactions from their colleagues and supervisors and may conceal their struggles (Cvetovac & Adame, 2017). A sensitive, non-judgemental and non-pathologizing approach within training and supervision spaces and within the professional community at large is key, where motives of wanting to help, care and connect are given primacy instead of focusing on ‘real’ motivations or dysfunctional family issues that must first be discovered, explored and resolved. Cushway (1996) reminds us that tolerance begins at home and urges the acceptance of vulnerabilities among trainee therapists. Training contexts need to develop systems to support trainees and provide a safe space for these issues to emerge in supervision. Resolution and working through our wounds can prevent impairment in our therapeutic role. The focus perhaps needs to be on building resilience, a critical attribute of an effective therapist. The potential for healing, change and growth extends as much to us as it does to our clients, and ‘no one needs to be a victim of their biography’ (Fransella, 2014, p. 127). Advocacy for a Strengths Perspective Carlson and Erickson (2001, p. 210) advocate for professional communities that honour the ethic of care, privilege personal knowledge and foster the personal agency of therapists. They outline an approach

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that can help new therapists connect with their desire to care for others, values that this represents and lessons learnt from their own experiences of being cared for. Through questions such as ‘Could you share with us your sincere desires and hopes for becoming a therapist?’ ‘What personal experiences in your life nurtured these desires?’ ‘What do you think these desires say about you as a person?’ and ‘Do you think these desires represent certain qualities or values that you hold?’ this strengths perspective helps build a meaningful connection between the personal and the professional.

Conclusion Many therapists describe a deep sense of connection and resonance with their work and professional identity, even as sense of inevitability. Our motivations to enter and stay in the field are often complex and multi-layered, and not all of them are accessible and integrated in our awareness. Like the protagonist Masuji Ono in Ishiguro’s book An Artist of the Floating World (Ishiguro, 1986), we must cross the ‘bridge of hesitation’ and re-examine ourselves and our life stories. This understanding can help us see how our motivations inform, support, enrich or impede our therapeutic work. We may return to this exploration at different times in our professional journey; the reasons that pushed or pulled us to become a therapist and the motivations to remain a therapist may not be one and the same thing. As we get familiar with and grow in our careers and lives, it is natural that our motives also evolve. As the field of psychotherapy itself evolves and changes, the dominant motivations to enter the profession might also shift.

Chapter 3

The Personal and the Relational Self of the Therapist

The relationship between the client and the therapist is the cornerstone of therapeutic change. However, it is the person of the therapist that meets the client in the therapeutic encounter to build the alliance that makes change possible. The self or personhood of the therapist enters therapy regardless of the theoretical orientation or approach that is followed. As Satir (2013, pp. 20–21) pointed out, ‘Techniques and approaches are tools. They come out differently in different hands.’ The concepts of the ‘self of the therapist’, ‘person of the therapist’ or ‘self as instrument’ encompass a reflexive awareness of thoughts, values, experiences, roles and social identities that have developed within the context of our relationships, experiences, training and sociopolitical environment. It also includes how therapists relate to clients, get emotionally triggered and use themselves therapeutically through self-disclosure, humour or presence in the therapy room (Sude & Baima, 2021). The self of the therapist has often been conceptualized in terms of the personal and professional selves. While the personal self is the part of the therapist that exists in all situations both inside and

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outside the therapy room, the professional self is the part that plays the therapist role based on training and skills (Rønnestad & Skovholt, 2003). Aspects of our professional and personal selves percolate into each other. For instance, we may incorporate the communication skills we learn as therapists into our personal repertoire of skills. Similarly, we may apply our personality traits like agreeableness or extraversion to help us form relationships with our clients. Thus, the personal self impacts the therapeutic work and the professional self impacts personal life, both moving together, like ‘two sides of the same railroad track so where one goes, the other goes as well’ (Woodward et al., 2015, p. 782). You could try this creative exercise to explore your personal and professional selves. Choose any material or medium that resonates with you. Words, images, metaphors, songs, phrases, clay, collage and paints can be used to depict how you see your personal self and therapist self. As you see what gets created, reflect on how you experience your personal and therapist selves and think about their evolution through your professional journey. Diverse ways of seeing our personal and therapist selves have emerged during reflective practice workshops that we have conducted with trainees and practitioners. Some participants drew lines to separate the two distinct selves, while others represented them as integrated or overlapping like a Venn diagram. Another represented her personal self as a coiled rope, gradually untwisting as her professional self is strengthened. For others, the two identities were intertwined in complex ways with personalized meanings, for instance, depicted as matryoshka dolls nested one inside the other, or as parts of the personal and professional selves—both hidden and revealed in origami folds. This balance between the ‘self-schema’ (the non-therapist self which has developed through personal life experiences) and ‘selfas-therapist schema’ (which develops during training and includes therapeutic knowledge and skills) also changes with time and experience (Bennett-Levy, 2006). While the self-schema might be active before a person starts training, the self-as-therapist schema may become dominant during the process of professional training. As we gain professional experience and confidence, the self-schema may

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find more expression, and we may feel more confident to use more of our life experiences and personal qualities. This congruence of the professional and the personal is considered a hallmark of the therapists’ development. However, there may be different parts of ourselves that we might bring forward in our personal and professional worlds. For instance, we may be calmer, more patient or more accepting inside the therapy room than we are outside, where we may allow ourselves to act and express more spontaneously. While our personal style of relating and attaching has an impact on how we are in the therapy room (Orlinsky et al., 2019), the way we are in sessions is also influenced by the dictates of therapy. The post-modern perspective further proposes that the bifurcation of the self as personal and professional is an arbitrary and false one. There are, in fact, multiple selves that exist and the self is co-constructed in the relationship we share with each of our clients (Knight, 2012). Different aspects of ourselves are activated in different relationships, with one person bringing out our caring and another our sense of humour. It is through reflection that we can best discover ourselves and fathom the interplay of our personal and professional selves. Being self-aware also allows us to use our selves more effectively in therapy. The use of self involves the deliberate and intentional extending of aspects of the self to influence the client and change process (Dewane, 2006; Reupert, 2008). We bring our emotions, personality, belief system and relational dynamics as tools for change—it is, therefore, who we are with our clients. The modernist perspective positions therapist self-awareness as important, so that any personal issues are resolved and do not contaminate or interfere with the process of therapy. Lines are firmly drawn, and the therapist is seen as a neutral and invulnerable expert (Cheon & Murphy, 2007). In contrast, Carl Rogers advocated the ‘use of self’, with therapist transparency and authenticity with clients as the facilitators of change (Baldwin, 2013). Going further, the post-modern perspective encourages therapists to disclose their social location as well as associated values and beliefs, in order to stimulate a discourse about these aspects of the client’s self (D’Arrigo-Patrick et al., 2016). It is not just self-awareness but also

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self-acceptance that is important. Therapists with a more positive and caring view of themselves have better client outcomes, especially if they are also more reflective and critical about their work (NissenLie et al., 2017). In this chapter, we examine the relationship between the personal and professional selves of the therapist and explore two key questions that therapists can answer through reflective practice: How do I become more aware of myself? And how do I understand how I use my self in therapy?

Discovering the Self While working with our clients, we embark on a parallel journey of self-discovery. We all have certain aspects of our ‘personhood’ that are an asset for us and make us a good fit for the profession. We also have some quirks and idiosyncrasies that make us who we are, and these are expressed in the therapeutic encounter—in terms of the language we use, our demeanour or sense of humour, characteristic ways of greeting people, our ways of responding to ambiguous or crisis situations and solving problems. At times, we might miss how certain ‘ways of being’ (e.g., anxiety in the face of interpersonal challenge) enter our work, these insights only emerging later through reflexive processes. The self is not static but keeps evolving, and each time we look inside us, we may find something new. Just as we need to ‘catch up’ with our friends, regular self-reflection enables us to ‘catch up’ with ourselves and stay in touch with our strengths and the ways in which we are evolving. Each client brings alive the inner world of the therapist in different ways. Sometimes what might happen in a session might trigger a past memory, bring to surface an emotion and at other times highlight a bias or reflect a preference. A client discussing their closeness with their parent may bring up feelings of warmth about our own parents, or a client sharing an incident of a conflict with their partner might trigger memories of painful conflicts with our partners. One way to understand this is in terms of our inner self and outer self—the parts which are accessible to us and can be seen by others and the parts that

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are hidden from others and not always in our awareness. Satir (2013) proposed the personal iceberg metaphor to gain awareness of our inner world and become more authentic in the therapeutic relationship. Beginning with the behaviours which are at the tip of the iceberg, the model explores what lies below the waterline or what may not be immediately accessible to us—these could be feelings, feelings about feelings, perceptions such as our values and beliefs, expectations from self and others, yearnings (e.g., for love, acceptance, connection and freedom) and the core self—the sense of ‘who I am’ (Banmen, 2002). These layers of the self can be accessed through our senses, and monitored during sessions by tuning into our bodies, or through reflections on why we may be feeling or responding in a particular way (Cheon & Murphy, 2007). As we become aware of what is occurring at each layer, we can work towards building congruence within ourselves, thereby attuning better with our clients and increasing our sense of competence as therapists (Lum, 2002). The spiritual self is often considered the deepest level of self or the core of our being. Indian philosophical traditions offer a unique metaphysical perspective that can guide us in the discovery of our inner selves and offer an added layer of meaning and experience that can be used to help our clients. A Therapist Speaks: Meditations on the Self We invited Dr Jyotsna Agarwal, a clinical psychologist and faculty member at the National Institute of Mental Health and Neurosciences (NIMHANS), India, to share her reflections on the self as understood in Indian spiritual thought. ‘In the Indian psycho-spiritual tradition, the self is differentiated between outer (ahamkara) and inner (antaratman/purusha). The outer self is constructed by our experiences, memories and actions and tied to our bodies. The inner self is considered as transcendental, a spark of divine infinity and a source of sublime knowledge. While the outer self may be helpful initially in individuating from others, going beyond it to discover one’s inner self is the aim of these traditions. Connecting with one’s inner self is transformative, but it is a hero’s journey— effortful and full of adventure—so only a few commit to it. Those who go till the end may find their outer self dissolving like a ‘salt doll’

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when it meets the ocean water (metaphor by mystic Sri Ramakrishna Paramhansa) and experience the “oceanic feeling”. One way to get closer to one’s inner self is to attenuate the outer self, which is made up of our thoughts, feelings and actions. Four psychological components of the outer self have been acknowledged and studied, that is, agency (kartatva), identification or our relationship with objects or people (abhimana), separation from others (dwait bhava) and individuality (vaishisthya). Becoming more aware of these four components and their dynamic interplay, and then growing beyond them, can come naturally as people mature, but doing it intentionally is the essence of the yogic path. For example, we may grow to accept that we cannot control our lives. However, we can also deliberately develop flexibility and a healthy separation from the outcomes of our action. Doing things for their inherent meaningfulness and offering one’s efforts to something larger than oneself (karma yoga) may help us progress on this path. A sense of separation from others and a strong focus on our own unique individuality are two other components of the outer self. While some individuation is healthy, rigid boundaries between self and others may strengthen the outer self, making these boundaries look like walls with shards of broken glasses. The natural way may be to see these boundaries as seashores, where the separation between the earth and water consists of a beautiful back-and-forth dance. We may have our uniqueness and differences, but we also have many commonalities with others in our joys and sufferings. So balancing our uniqueness with a sense of the collective would bring us closer to the truth and our inner self. These components have their play both within us and in our therapy room. Our personal growth can bring more healing in our therapy work, as we become open and flexible with our clients, in their uniqueness and differences. We may find it easier to develop genuine warmth and positive regard for clients, especially the ones who challenge us. As we let go of our attachments or fixed agendas, we create a therapeutic space that fosters deeper growth. In growing closer to our inner self, we can convincingly show to our clients how far they can go themselves.’

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Self-of-the-therapist Work ‘Self-of-the-therapist’ work helps us recognize our characteristic ways of thinking and relating, and how they might potentially impact our therapeutic work. It helps us explore and understand our personal histories, our psychological, relational and spiritual challenges and struggles and how they developed, and use them more consciously and meaningfully in our work. All our personal experiences are relevant, and even those we may think of as barriers or constraints can be a strength or resource that we draw on (Timm & Blow, 1999). It is important that we are not ashamed of our personal struggles and challenges but accept how they might help us connect deeply with the vulnerabilities our clients experience (Aponte et al., 2009). Acknowledging our own histories makes it possible for us to be both compassionate towards ourselves and commit to our well-being and growth. Self-awareness involves the overall awareness of our thoughts, feelings, beliefs/values and how they might be linked to our personal contexts and family of origin experiences (Pieterse et al., 2013). The POTT perspective (Aponte, 2016) introduces the concept of a ‘signature theme’ (e.g., need for control, fear of rejection, lack of selfworth and fear of being vulnerable) that often reflects our ongoing struggles with ourselves. A series of reflective questions can bring us closer to understanding our signature theme; asking ourselves about our sources and areas of anxiety, fear or frustrations; recognizing our typical responses in stressful situations and any difficult patterns in our relationships; and contemplating what aspects of ourselves we conceal from others (Aponte & Kissil, 2014). No matter where we are on the road to the acceptance or resolution of our signature theme, it shapes our journeys and influences how we think, feel and relate. For instance, some of us may no longer feel as overwhelmed by our fear of rejection now as we did when we were children. However, the way we overcame that fear of rejection, social skills we learnt or self-affirming habits we have developed are likely to remain a significant part of who we are. Awareness of these themes may be beneficial for us as therapists, as they could help us recognize similar themes in clients and separate our own issues from theirs and use

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them as an asset or strength. When we are less aware, we may feel triggered in sessions, without fully comprehending why and perhaps misinterpreting our emotional signals. A positive psychology framework may help us tune into the unique combination of character strengths that make us who we are (Peterson & Seligman, 2004). Discovering our character strengths, perhaps through completing the Values in Action (VIA) Survey of Character Strengths,1 can bring an intentional focus to their use in our therapeutic work. We can identify which of these 24 character strengths (e.g., kindness, forgiveness, perseverance, teamwork, self-regulation and spirituality) we manifest most strongly in our personal lives and therapeutic work. There are times we might express some strengths in our interactions with our clients (e.g., kindness) but neglect to apply this to ourselves in the same measure. We might even be overusing some of our strengths, for instance, perseverance at tasks that could sometimes manifest as inflexibility. Actively reflecting on our key assets and resources can guide us to cultivate and use them meaningfully in our therapeutic work. Pause and reflect on which of your key strengths you use intentionally in your therapeutic work. Perhaps there are strengths that you use only in one domain (either work or personal life) that you would like to extend to both domains. Momentary awareness of our reactions, feelings and thoughts may also help us attune to parts of our self. During role-plays, we can pause at significant moments and deep dive into our experiential world, to find answers on what was going on for us and how it was impacting the therapy process, for instance, the discomfort in our bodies or tightness in the stomach that we felt when we were stuck in a session. When we become aware of this, it can lead us to what might be underlying this experience; maybe we were feeling frustrated with the client or/ and ourselves or were not being able to think of anything useful to say. We may interpret this feeling as indicating that we are not being 1

www.viacharacter.org

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‘good therapists’ or that our clients are not being ‘good clients’. In the presence of supervisors or peers, we can empathically enter this experience and connect with our need to feel and appear competent. This may lead us to a new understanding of ourselves and perhaps even our clients. In critical moments, asking questions that focus on the self of the therapist might be helpful: For a moment, try to let go of your role as a therapist and what you are trying to accomplish, and instead just think about yourself. What do you notice happening in this session? What do you want to happen or believe needs to happen? (Sude & Baima, 2021, p. 6)

In triad work proposed by Satir, participants play three different roles in turn: that of the client, therapist and observer. When playing the client’s role, we get an opportunity to present and explore our personal issues; in the therapist’s role, we may develop insights into our personal process through observations shared by the observer; and in the observer’s role, we may cultivate our sensitivity to the therapy process (Lum, 2002). Rober (1999) introduced the concept of an inner conversation, the dialogue between the self of the therapist and the role of the therapist. For instance, if a client describes preferring to listen to his music with his headphones on when his wife is at home, the self of the therapist may observe and respond to this. As we picture our client with his headphones on, we may wonder if he fears disturbing his partner or if he wants to keep her out. The experience could also evoke images from our personal lives, perhaps of feeling shut out by a loved one or even wanting to shut them out. Although such connections to our own inner worlds can bring difficult emotions or images, attending to them gives us access to experiences that are yet unspoken. While the role of the therapist brings in the theoretical knowledge and hypothesis, it is the self of the therapist that observes the goings-on, evoking a range of images, feelings, intuitions and so on. Through this inner conversation, the self of the therapist and the role of the therapist negotiate what and when something could be brought into the outer conversation with the client. When we become aware of and present the content

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of these inner conversations in the therapy space, it can change the therapeutic relationship, enabling us to reach a deeper level of awareness of the client’s experience. Giving importance to these personal experiences and checking if they can be meaningful for therapy are crucial steps in the use of self and can be helpful in moving through therapeutic impasses. Another lens to view self-of-the-therapist work is that of our social identity—the advantages, privileges and power we have access to and the oppression, internalized stigma and discrimination we might have lived through. Even when we are culturally aware (having knowledge of diversity or power issues), we may not be culturally sensitive (being affectively attuned to the other in a way that makes them feel seen and valued). Most of us are aware of our social location but not on how it can operate on the client. Where we and our clients are located (for instance, in terms of gender) influences what will be spoken and what will be withheld, what will be seen or not seen and who feels more comfortable to contradict or challenge the other. Adapting cultural awareness as a therapeutic strategy, without also growing into a more culturally sensitive individual, is only half the job done, and this kind of growth is a significant aspect of self of the therapist work (Sude & Baima, 2021). Looking into ourselves for times when we felt excluded or disempowered can bring us closer to understanding similar experiences in clients. Active disclosure of our values, politics and social locations may help make the therapist–client relationship more equal and help clients choose if and how they would like to work with us (Watts-Jones, 2010).

The Relational Self The idea of the looking glass self emphasizes how our sense of self is tied to our interpretation of how significant others see us (Cooley, 1967). Our ‘self’ develops relationally, and it is only in the presence of others that we come into being. Developing an awareness of the thoughts, emotions and behaviours others automatically elicit in us, as well as how we in turn impact them, is crucial for the relational enterprise of therapy.

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All in the Family Our patterns of interaction, how fused or differentiated we are, the roles we play and expect others to play, and our understanding of these interactions are often internalized from our experience with our families (Kerr & Bowen, 1988). Revisiting these childhood interaction patterns may help develop awareness and acceptance of our individual and relational selves. To deepen this reflection, you could draw a three-generational relational genogram for your own family. Using the relevant symbols to depict close, distant, conflictual, cut-off or fused relationships can help you recognize key interaction patterns in your family. Who did you feel close to or distant from in your family during your growing years? How did your family express and resolve differences of opinion? How was anger expressed? How was care expressed? Through this process of examination, you might also notice multigenerational patterns that reflect in your current interactions and relationships. The experience of working on our genograms can be emotionally demanding, bringing up unexpected memories or information, and is best done in a safe space. Locating the exercise to a specific point in time might also be critical, as relationships and interaction patterns may evolve over time. Further, connecting to specific experiences or memories and noting our age and life cycle stage may provide context to our reflections (McGoldrick & Gerson, 1985). Revisiting our family patterns through the family genogram may help us take a fresh look at the roles we played and how these patterns could sometimes continue in our adult lives. This may help us consider new ways of relating to our family members as well as others in our lives (Rovers, 2004). It can also extend our growth as practitioners when we notice similar patterns of self-protection, over functioning, under functioning or triangulating playing out with clients (Getz & Protinsky, 1994; Lim, 2008). We can follow up the exercise with focused reflections on frequently seen patterns as well as unexpected findings. For instance, we might consider how ideas about marriage stemming from our families of origin are playing out in our current relationship (e.g., gender roles, ways of communicating or problem-solving). Looking back at our family

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of origin experiences can help us understand how we relate with our clients, our beliefs about relationships (e.g., boundaries and emotional dependence), changes we look for and what we feel must stay the same (Pieterse et al., 2013). Therapist’s Relational Scripts As therapists, we recognize the importance of providing a secure base for our clients and being sensitive to their attachment styles and schemas. An awareness of our own relational self is equally crucial, particularly as our patterns of relating can have a significant impact on the therapeutic process. We might wonder if having a secure attachment style is a prerequisite for being a good therapist. Research suggests that therapists who were more securely attached or had more affiliative introjects were indeed perceived as warmer and kinder towards their clients and were able to build a better therapeutic relationship and manifest better outcomes (Heinonen & Nissen-Lie, 2020; Steel et al., 2018; Talia et al., 2020). The impact of our attachment style may be more significant with clients experiencing more distress. For instance, therapists who are more self-loving and securely attached may be particularly well suited to treat clients with personality disorders and co-morbid conditions (Bruck et al., 2006), while therapists with insecure attachment styles could struggle to connect with more symptomatic clients (Bucci et al., 2015). Our attachments styles do impact the therapeutic process in general. Therapists with a dismissing attachment style may be less empathetic or deep in their interventions, while therapists with a preoccupied style may fail to see that the client can cope on their own and feel frustrated if the client does not connect with them (Talia et al., 2020). However, therapists come with many layers to their being a ‘repertoire of relational selves’ (Andersen & Chen, 2002, p. 619)—we are not ‘all secure’ or ‘all insecure’, and this combination may serve us well. In one study, therapists who reported experiencing both secure autonomy and fusion and triangulation with their parents showed the best client outcomes through the course of therapy (Lawson & Brossart, 2003). Perhaps therapists who can retain an autonomous sense of self in the

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face of emotionally charged interactions with their parents can bring these skills to benefit their clients. It seems that it is not the ‘self’ that matters for our effectiveness as therapists, as much as the use we put that self to. Further, combinations of traits may balance each other out; our reflective abilities can compensate for our insecure attachment vulnerabilities, and our secure attachment can buffer lower reflective functioning (Cologon et al., 2017). When we recognize our relational vulnerabilities and their impacts on our connection with clients, reaching out for supervision and personal therapy can foster change and growth (Taubner et al., 2013). The therapist’s attachment style is not conclusively an asset or a hindrance. With (at least) two people in the therapy room together, the interactions between therapist and client attachment styles can have their unique contributions to outcome. There are some indications that anxiously attached clients do better with avoidantly attached therapists and vice versa (Steel et al., 2018). It could be that emotional or preoccupied clients benefit from more detached interventions, while dismissing clients benefit from interventions that increase emotional expression and engagement (Levy et al., 2012). A therapist style that is different from the client’s style may well offer the client the opportunity to try out new ways of being. Our clients can cue the activation of one of our relational selves through their resemblance to a significant other in our lives (Andersen & Chen, 2002; Chen et al., 2011). If this was a person we liked, we may wish to connect or feel closer to the client. We are likely to remain open and welcoming and miss cues that the client may not be feeling the same way. Conversely, when the client cues a significant other with whom we had a difficult relationship, we may move away, expecting rejection. This may happen automatically and be impacted by both our personal experiences and cultural context (Chen et al., 2011). For instance, a tendency to soothe others in the face of their anger may manifest in the following ways: With male clients, we may automatically sooth anger or distress, without even knowing why we are doing it; with female clients, we may feel more comfortable letting them feel distressed; or, with all clients, if we fear they might be angry with us, we may withdraw emotionally, even as our words stay soothing.

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Clients who bring out a negative aspect of the relational self may be experienced as threats to the self, eliciting self-protective mechanisms within us, whereas with clients who bring out more positive aspects, we may be more concerned about protecting the relationship, perhaps by being too conciliatory or being unwilling to challenge them (Andersen & Chen, 2002). When we experience a struggle with our clients, we may first need to reflect inwards to understand why this is happening. Our relational schemas tell us what to expect from others and can have strong impacts on our responses to our clients (Tufekcioglu & Muran, 2015). For instance, if a therapist expects that a client will not trust them very easily, they may withhold from the client, waiting to see a sign of trust. Seeing that the therapist is withholding, the client may be slower to extend their trust, in turn reinforcing our lack of trust. These aspects of our relational selves can play out in our interactions with clients as we seek closeness or distance and enact our own interpersonal patterns. Of course, clients may also operate under the same conditions expecting distance, hostility or care from therapists. When we respond as they expect, for instance, distancing from a withdrawn client, we confirm their belief about others being undependable and emotionally unavailable to them, and this may leave them feeling unworthy of care. Similarly, therapists may also draw clients into their own schemas. For instance, a therapist who expects hostility is likely to act in a hostile manner, thereby eliciting hostility in clients. These interaction patterns may become rigid and fixed, with both the therapist and client getting stuck in their roles, for instance, the client remaining eternally helpless and the therapist eternally trying to help (Wiseman & Atzil-Slonim, 2018). Our internal fears and blocks are likely to convey themselves to the client without our awareness and, therefore, limit our capacity for intense emotional work (Wylie & Turner, 2011). For instance, a therapist who fears dependence may unwittingly communicate that relying on others is not as healthy as being independent. With a client who has received a similar message from their parents, this may feel like a repeat of their original relational trauma (Lewis et al., 2000).

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An awareness of our own schemas and a sensitivity to our client’s schemas may help us respond more therapeutically. Tufekcioglu and Muran (2015) recommend two possible responses: The therapist can decentre the experience by revealing how they feel in the client’s presence, thereby helping the client see their own contribution to the interaction. For instance, the client may understand that their withdrawal has an impact on the therapist’s inner experiences (it may make the therapist wonder if the client really needs them) and outer behaviours (it causes the therapist to be more distant). The therapist can also disconfirm the client’s schema by not responding as the client expects them to, for example, not responding with hostility when the client is hostile. As we self-reflect and expand our awareness of our relational selves, new ways of being open for us and our clients. It is in the context of the therapeutic relationship that we may get to know our clients, and they may get to know themselves.

The Revealing and Concealing Self As therapists, we are guided to be genuine and authentic in our encounters with clients and, at the same time, to maintain a professional demeanour and only show parts of us that will be therapeutic for the client. How are we to be both real and therapeutic at the same time? If our personal self is very timid and non-assertive, should we mask this to seem more confident and competent? If we feel moved to tears hearing a client’s story, or if our funny bone is tickled at an inappropriate time, how much of this do we reveal to our clients? As therapists, we need to reflect deeply to understand how we can reconcile these contradictory but important professional imperatives. Perhaps what is required is a committed search for what can be both real within ourselves and helpful to our clients and how we actively ‘use’ ourselves in therapy. ‘As therapists, we are always revealing ourselves to the patient whether we know it or not; the question is when and to what extent we reveal ourselves’ (Tufekcioglu & Muran, 2015, p. 469). Some aspects of ourselves will be revealed to clients whether we choose it or not, while at other times we may choose to deliberately disclose a reaction or a personal detail.

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Think about the therapy room you usually practise in. What does it look like? Does it have a desk or a low table? Are the chairs formal or comfortable? Do you have any certificates, family photos or art on your wall? What is the colour scheme and the amount of light and air available? How much of your setting is deliberate and planned with your clients in mind? What do you think your client might surmise about you from your setting? As you visualize your space and what it says about you, do you want to change anything about your therapy room? Based on our theoretical orientations as well as our personalities, we may choose to allow more or less of our personal selves into the therapy room. Over time, we may also learn to incorporate our personal style into our professional style, leading to an amalgamation that feels both natural and therapeutically effective. Allowing our human side into the room is essential if we are to form a genuine human connection with our clients. Sometimes when a client asks us a question or their story resonates with our own experiences, we respond spontaneously without much prior thought. At these times, clients have perhaps reached our personal selves and drawn us out into the session. Such unplanned disclosures could be subsequently discussed with clients and may often bring life into the therapy session and further therapeutic work (Kramer, 2013; Shulman, 2008). We do not need to only show what is healthy about us, and we do not need to ‘get it right’ each time. In fact, our comfort with our imperfections and our acknowledgement of what is messy in both life and therapy can be appreciated by the clients who are themselves trying to come to terms with what is messy in their own lives. There are also occasions where therapists cannot help but reveal themselves—life events like pregnancy, illness or bereavement have a way of intruding into the client’s awareness. Our choice here is whether we speak about it openly and how much we choose to say. The intentional use of self, on the other hand, involves choosing to disclose either our immediate responses and experiences or stories from our lives and history as a way of addressing therapeutic goals (Henretty et al., 2014; Hill et al., 2018). While immediacy involves discussing the client–therapist relationship, through the medium of

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therapist revelations about their here-and-now responses to clients, therapist self-disclosure refers to therapists actively sharing information about their life outside of therapy, which can include experiences, insights or strategies (Hill et al., 2018; Knight, 2012). Therapists might share immediate responses, with the intention of encouraging clients to state their unstated feelings (e.g., ‘That would make me really sad. I’m wondering if you feel the same way.’) and attempting to negotiate (e.g., ‘It seems that we have reached an impasse. I know I am feeling frustrated by it. I would like to know what you are feeling.’), enhance (e.g., ‘I feel particularly worried for you today. What can I do to help?’) or repair (e.g., ‘I am so sorry that what I said hurt you.’) the relationship (Hill, 2014). Therapist self-disclosure about shared mental health concerns may occur with the intention of infusing hope and motivating clients to change (Wasil et al., 2019). It can also be a means of equalizing power, building solidarity and reducing client shame, as well as providing context by sharing relevant information about background, demography and culture (Mahalik et al., 2000). Of course, sharing information on training and qualifications is an ethical obligation (Knox & Hill, 2016). Acknowledging cultural differences and revealing a lack of knowledge or showing a willingness to learn about the client’s culture can help bridge gaps in cross-cultural work (Mahalik et al., 2000). Its most significant purpose perhaps is with reference to helping the client feel understood and connected with the therapist (Hill et al., 2018; PintoCoelho et al., 2018). Telling a client when we have been through a similar experience builds emotional connection in a way that telling them that their experience is ‘normal’ does not necessarily do. Further, when the therapist is open about their experiences, it encourages the client to also be more open and more willing to participate in therapy, furthering the therapy process (Henretty & Levitt, 2010). Traditional perspectives view self-disclosure as wrong and selfindulgent, emphasizing that oversharing or unsolicited sharing can be experienced as intrusive by clients (Hanson, 2005; Knox & Hill, 2016). The other caution is that clients who may be particularly vulnerable and have boundary issues may find it harder to distinguish their experiences from therapist experiences. So the question of how and

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why and when we self-disclose is of utmost importance. In general, it is recommended that therapists respond to any direct question that is put to them by clients, as side-stepping this is often experienced as disrespectful (Knight, 2012; Kramer, 2013). In the Indian cultural context, where asking personal questions is considered a part of social conversations, clients may be hurt or stymied by a therapist who does not respond to questions about whether they are married or what their ‘native place’ is. Careful attention to where the client is, as well as reflection on the intention behind therapist disclosures, is warranted. We may also need to pay more attention when the material we wish to disclose could be challenging for the client to hear, as these disclosures are more likely to have a negative impact. In early stages of therapy, or when the client is still feeling overwhelmed, it may be better not to disclose our own experiences (Kramer, 2013). When the intention behind self-disclosure is our need to share our stories, this does not benefit the client. In fact, the typical antecedent behind unsuccessful therapist self-disclosure is a countertransference reaction of the therapist (Pinto-Coelho et al., 2018). Once rapport is better established, therapist self-disclosure can be more useful, helping clients to work through impasses or leaving them more willing to hear negative feedback. We may need to carefully weigh the potential costs and benefits of our self-disclosures and evaluate whether the transparency, respect and trust the disclosure conveys outweigh any burden the client might feel. Think of a time when you shared information with a client and it left you feeling uncomfortable or uncertain. What prompted you to share something personal about yourself? What about the disclosure made you feel uncomfortable? Looking back, do you think that you could have said or done anything else in that moment? There are no straight answers however, and self-disclosure may go wrong even if we follow all the rules. Our internal or bodily reactions, feelings of stiffness or uneasiness can indicate that we have opened a door which should have remained closed. To disclose or not to disclose is not a single decision but a series of decisions, based on the therapist, client and moment in therapy. When we do choose to disclose, we may

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still need to be tentative and brief, perhaps starting with non-verbal indications (e.g., nodding) or a simple statement identifying a shared experience. Rather than thrust our disclosure on the client, this leaves the door open for them to ask about our experience if they are interested. Once we have disclosed our story, we need to turn the focus back to the client, to see how it might be meaningful for them (D’Aniello & Nguyen, 2017). We may each have a personalized perspective on what it means to be authentic in sessions. This can be influenced by textbook ideas about how we ought to be, as well as our cultural norms, personal comfort and values. As we tune into what feels real and reflect on how we can be ourselves while remaining professional with our clients, we may discover a truer blend of the personal and professional.

Creative Pathways to Self-discovery The self is both intangible and unknowable in its entirety. Sometimes we need to ‘feel’ our way towards the self, rather than ‘think’ our way towards it. Creative approaches, both verbal and non-verbal, offer meaningful pathways of bringing it all together—discovering self, connecting this with therapy and using the self more effectively and reflectively. Reflective Journaling When we journal, we make stories about what is happening to us, and through these stories, we make sense of who we are. In the pages of our journals lie possibilities and preferences, not just our pasts but also our potential futures. Hubbs and Brand (2005, p. 60) refer to a journal as a ‘paper mirror’, indicating its value as a reflective method. By its very nature, it forces us to slow down, mull over ideas, organize our thoughts and express them in a somewhat focused manner (Hubbs & Brand, 2005; Wright & Bolton, 2012). It allows us space to express our own feelings, examine prejudices or set patterns of thought, and transform as we integrate new perspectives in ourselves. Because our journal is a confidential and private space, we can feel freer to express our complete selves. Journals are usually written in the first person, so

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the connection with our inner being is inescapable. Unlike other writing we may need to do as trainees or therapists, our journal does not have to showcase our knowledge or achieve an immediate goal. These conditions may be ideal for a free-flowing reflection that can take us to new places and revisit old experiences (Wright & Bolton, 2012). Some of us may like to have a ritual around our writing, with set targets for frequency or time spent. Fixing a time, a day or a medium of writing can make it a regular and potentially more useful part of our life. Attaching it to other activities (e.g., soon after yoga and before each supervision session) can also anchor the practice. For those who do not like routine, keeping a journal handy to make notes on the go is also useful (Wright & Bolton, 2012). To begin with, we can keep aside an hour’s time, settle into our space, clear our mind, look around and imbibe our surroundings. We can ask ourselves what experience we wish to write about. We may let different thoughts swirl around until something calls on our attention—a block in therapy, a great session, a challenging moment or a typical interaction seen through new eyes. We can organize our subsequent ideas in the following format:





Entering into the experience: A detailed description of the session content and process is a good place to start. Write down what you might be thinking and feeling about it in retrospect. Express yourself as you feel comfortable without being limited by language. If you are multilingual, choose the language you think in, the one closest to your heart. Reflecting on the experience: Step back and think about what has come up for you and what it means for you. How are your thoughts and feelings about your experience linked to your values, identity and contexts? Are they influenced by theory or what your supervisor might say? Think about how what you would hope to do if you had the experience again. Applying it back to ourselves: Try to crystallize what you might have learnt about yourself as a person or as a therapist. This process helps us think about who we are and who we would like to be by turning the reflective gaze on our experiences in therapy. When we engage in a reflective journaling exercise, it can sometimes bring

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up painful feelings. However, reflection may be deepest when we engage with repeated patterns or strong emotions from the past, and we therefore need to be prepared with our safe space and emotional support before embarking on this exercise. Expressive and Experiential Routes to the Self Art, drama, storytelling, music, movement and other experiential methods offer unique reflective routes to self-exploration, healing and growth for psychotherapist development and should be used more actively. These methods harness the power of imagination, and for therapists who are so often anchored to words, this immersion in visual, tactile, symbolic and embodied modes can add a unique dimension to the process of self-discovery. A Therapist Speaks: To Move and Be Moved We asked Ms Brinda Jacob-Janvrin, a dancer, a movement-based expressive arts therapist, an Authentic Movement practitioner and trainer, and a Natural Dreamwork practitioner, to share her experiences of working with the body. ‘One of my favourite body-based practices is Authentic Movement. In this simple but profound movement discipline, the mover moves with her eyes closed in front of a witness. The mover is not “performing” for the witness, but waiting to see what the body suggests, thus experiencing the sense of “being moved” as opposed to “moving”. During this process, she also tracks her movement, refining her own inner witness. This is accentuated by the presence of the external witness, who not only tracks the mover but also her own responses to the mover. Compassionate witnessing creates a safe and sacred space within which we can encounter both our wounding and our potential— that part of ourselves that is greater than our wounding, the Self with a capital S as defined by Jung. In my movement exploration at a retreat, I found myself trying to separate from a large mound of earth, which felt like my father who

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had passed away in 2000. As I struggled to separate myself, I saw (in my mind’s eye) images of important men in my life (my husband, past boyfriends) escape from between us. This act of separation was heartbreaking, and I was crying for over 20 minutes. The compassionate witnessing provided by my two teachers allowed me to continue and witness myself experiencing the most devastating pain and grief. I was finally mourning my father, something I hadn’t done in 17 years. In doing so, I began peeling away the projections of my father from these various men. The experience also revealed to me my own inner strength that allowed me to stay with this pain. In learning to hold this pain, I learnt to love in deeper ways. As a trainer, I always begin with a short movement visualization to bring trainees into the space with a heightened sense of presence. They learn to listen to their body signals in the here and now—a tightening of a muscle, the quickening of the heartbeat, sweat on the palms, etc. Interestingly, one part may feel quite different from another—with the lower body feeling heavy and the upper body light, or the right side of the body feeling stiff, while the left part is fluid. When we consciously move our body, we are moving layers of suppressed memory and releasing unexpressed emotion and energy. The body holds incredible wisdom and is always moving towards healing and balance. Our body is our most intimate home and being at home in our body is one of the greatest indicators of positive mental health.’

Perspectives on Training and Development Training Frameworks for Use of Self in Therapy Learnings gleaned from the use-of-self training frameworks such as the POTT model (Aponte, 2016; Aponte et al., 2009) and the SP/ SR model (Bennett-Levy, 2019; Bennett-Levy & Haarhoff, 2019; Thwaites et al., 2014) can guide the planning and implementation of self-of-the-therapist initiatives. Such training is time-, knowledgeand resource-intensive and requires commitment from institutions, trainers and participants. If trainees struggle for time in a packed academic and clinical schedule, both engagement and attrition are likely to be problematic. Programmes that are integrated into the curriculum are likely to be more sustainable.

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Any sustained focus on the use of self involves deep emotional investment in accessing and revealing parts of our inner selves, and this has several ethical ramifications. Close attention to confidentiality and safety is paramount, and boundaries between self-work and therapy need to be delineated. Personal stories and sharing are invited only when directly relevant to therapy work and therapist development in POTT (Aponte et al., 2009). While certain aspects could be personal reflective exercises, for example, personal histories and genogram, others such as signature themes could be brought to the group. Trainers also require preparation to connect with the language and philosophy of the training model and ways to process the emotional impact of this work, which will inevitably evoke aspects of their own selves as well. This is an area that needs to be addressed more strongly in both these training models. Working with experienced practitioners or those in supervisory roles would require tweaking of the content, process and aims of programmes developed for trainees or novice therapists, so each person is met just beyond their current level of development (Freeston et al., 2019; Thwaites et al., 2014). Of course, whether the target group is trainees or more experienced practitioners, there may be individual variations in the abilities to self-reflect. If training programmes do not have the space to implement intensive modules, we recommend that conversations and exercises aimed at self-awareness and use of self be integrated into academic teaching, classroom discussions and most importantly within supervision sessions. Trainers and supervisors could select methods that promote active self-reflection, for example, identification of self-schemas or signature themes, use of reflective blogs and therapy simulations. As therapists, we may seek personal therapy or follow our own paths of self-discovery in ways that feel personally meaningful. Use of Self-work within Supervision It can help to create a space for self-work within the supervision agenda, so supervisees feel that they can bring their dilemmas related to self-disclosures or have reflective discussions about their personal and professional selves. The use of process recording, where supervisees

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bring first-person narratives with notes about their emotions, reactions and observations, can be a powerful reflective tool (Urdang, 2010). As supervisors, we also need to assess our supervisee’s readiness, use gentle and indirect feedback when needed, and circumvent issues that are too sensitive while trying to build a collaborative space. The POTT model offers a structured, pan-theoretical supervision instrument which bridges relevant aspects of the supervisee’s personal life and the therapeutic process (Aponte & Carlsen, 2009). Supervisors could also operate from within a specific orientation and use techniques grounded within its theoretical framework to facilitate self-work for supervisees. Even supervisors who value the use of self in therapy and find it meaningful could be uncertain or unwilling to open conversations on these issues. Supervisors have shared a number of roadblocks that include a limited theoretical foundation and confidence in supervising use-of-self issues and tailoring or personalizing their approach, the emotional reactions of frustration in the supervisory process and concerns about supervisee fragility (Vance et al., 2021). Reaching out to our own supervision and consultation networks can support the expansion of our skills in addressing use-of-self issues. Emergent Focus on Therapist Mentalization Ability As therapists, our ability to understand our inner world and envision the cognitions and emotions of our clients can impact therapy outcomes and our own well-being (Brugnera et al., 2021; Cologon et al., 2017). We anticipate an increased focus on assessment and training of therapist mentalization ability and note an emergent focus on self-oriented aspects of mentalization, as this is seen as contributing to effective mentalization of clients’ actions and experiences. Equally, if the therapist is unable or unwilling to explore their own emotions and experiences through a not-knowing stance, this can preclude an understanding of what might be happening within the client’s mind (Barreto & Matos, 2018). There is some evidence that brief experiential training can increase mentalizing abilities among therapists (Ensink et al., 2013), but there is scope for further conceptual elaboration and empirical support.

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Conclusion The self encapsulates not just who we have been and who we are, but also our hopes, goals and aspirations—what Markus and Nurius (1986) refer to as the possible selves. As new ideas and perceptions come in and the old are discarded, the self continuously changes. As the story goes, Theseus, the founder hero of Athens, returned from Crete on a ship which was preserved to mark his glorious victory over the minotaur. Over time, the decaying planks were gradually replaced by newer and stronger parts. The Greek historian Plutarch presented two philosophical perspectives: one which held that the ship had ceased to be the original ship of Theseus, while the other declared that the restored ship fundamentally remained the same despite the changes. What are the parts that make up our ‘self’? Are we the same today that we were a few months ago? As things change, are there some intrinsic parts that stay the same? These questions about change and persistence can also be extended to understanding our self and identity, thereby making the reflexive process of self-awareness an ongoing endeavour.

Chapter 4

Adopting a Theoretical Lens

At the heart of psychotherapy lies the effort to alleviate emotional distress. Each theoretical model of psychotherapy proposes a route to facilitating emotional and behavioural change and was developed as ‘a product of time, place and creative personalities’ (Feltham, 2014, p. 10). Each theory also ‘has its own language, grammar, rhetoric and poetry’ (Clarkson, 2000, p. 312) and is embedded in a particular world view. While we more easily relate a theoretical lens with the techniques and strategies that it offers, each approach also carries philosophical assumptions about human nature that determine our understanding of well-being, pathology and change. Our theory provides an anchor as we navigate the mindscape of our clients, helps us make meaning of our clients’ stories and builds a therapeutic relationship. The theory we adopt tells us what to pay attention to, gives us ways to listen, a language to communicate with our clients, and becomes a guidebook or map on how to work together in the journey of change. Psychotherapy training, therefore, usually includes a considerable emphasis on introducing trainees to one or several different theoretical models. As we progress as therapists, many of us identify a therapeutic lens that we prefer to work with. This is by no means an easy task, and the choices are multitudinous. We not only have the four major approaches of psychodynamic,

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cognitive behavioural, humanistic–existential and systemic traditions to choose between but also need to navigate the many new developments happening both within and outside these frameworks. Research on the comparative efficacy of each model indicates the value of each tradition, suggesting that ‘Everybody has won and all must have prizes’ (Castonguay & Beutler, 2006; Luborsky et al., 1975; Rosenzweig, 1936). Many commonalities have been identified across orientations (Grencavage & Norcross, 1990), in addition to the techniques and processes that are more orientation-specific (Luborsky et al., 2002). For instance, therapeutic models differ in the way the therapeutic relationship is construed, in the degree of therapist directiveness, how much analysis and planning are prioritized and how important it is to go into an unknown territory. Currently, we see a shift towards a more pluralistic approach towards theoretical orientations, rather than a polarized or competitive one (Cooper & McLeod, 2012). Increasingly, theoretical models are considered to represent different doors through which to enter the therapeutic arena. Differences between models are becoming less important with the emergence of integrative psychotherapy and transtheoretical models (Fleuridas & Krafcik, 2019; Livesley, 2018). These changes parallel the larger cultural shift from modern (empirical science/positivist) to post-modern (social constructivism/constructivist) views (Corey, 2009). Newer perspectives such as feminist (Greenspan, 2017), critical psychology (Feltham, 2014) and social justice (Fleuridas & Krafcik, 2019) have firmly placed the individual back in their social context. With this plethora of information and perspectives to navigate, we need to remember that ‘Models are words on paper, and as such are not “effective” in and of themselves; rather, models help therapists be effective’ (Blow et al. 2007, p. 308). As therapists, we interact with our orientations to help clients. While some of us may be clear about our theoretical positions and carry an image of who a therapist is and what they do, others may still be on the journey of discovery. The ways in which we imagine a therapist can help us explore the theoretical orientations we feel closer to. There are several legitimate ways to look at the role of a therapist. Each of us may respond to different images, perhaps a guru, a healer, an architect, a scientist, an angel, an archaeologist, a mother,

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a puppeteer, a magician, an explorer, a detective, a gardener or a cotraveller. Pause to reflect on what you associate with each archetype; for instance, do you see yourself as the archaeologist excavating into the past and joining lost pieces, as a detective, even possibly in disguise, who uses clues and searches for evidence to solve problems, as akin to a gardener who clears weeds and cultivates growth, or as a mother who cares unconditionally? If you connect with many images, then you can reflect on how these different ways of being a therapist fit together for you. Do any of these possible ways of seeing a therapist make you uncomfortable? Do you see a therapist in any other way? In this chapter, we explore the various ways in which our theoretical orientation can manifest in the therapy room and understand how we can intentionally position ourselves vis-à-vis theory. We reflect on the several factors and experiences that influence our choice of orientation as well as the evolution of that choice, acknowledging the dynamic nature of our relationship with our orientation. Each therapist evolves a unique personal relationship with theoretical orientation and its practice, and we also explore this process.

The Opening Gambit: What Do We Listen For? Our theoretical lens can influence what we observe, attend to, listen for and ‘encourage’ our client to share during a therapy session. As you read through this constructed vignette, note what strikes you as a therapist: Ananya comes in looking very disturbed and emotional. She says that while her husband ‘really cares’ for her, sometimes this gets too much. Just as her mother used to do, he does everything for her, including carrying her bags and doing her bank work. When he does this, it feels like he does not respect her or think of her as competent. She fears trying things out on her own, feeling sure that she will make a mistake. With her husband, she is often withdrawn, irritable or silent. In response, her husband is more affectionate and constantly checks on her. Her mother does not like her husband at all, and Ananya feels pressured to change him or leave him. She is not sure if she has the strength to do either.

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If you were Ananya’s therapist what would you observe, listen and ask for? What are the focal problem areas that you have identified as needing more exploration and attention in therapy? Therapists from different orientations may direct their focus on different aspects of this first session. While there are definite overlaps between orientations, particularly in terms of attention to client experience and building the therapeutic relationship, each orientation also has some unique foci. Practitioners from the cognitive behavioural tradition might first focus on identifying Ananya’s negative automatic thoughts that are triggered in a situation. They may listen for antecedent events and the cognitions they lead to and track the consequences in terms of behaviour and emotional patterns (Beck, 2011). Psychodynamic therapists might want to understand her inner experiences, conflicts and defences and will attend closely to her emotions. They are likely to examine the therapeutic relationship and attempt to identify patterns across the past and present (Yakeley, 2014). Humanistic therapists would perhaps like to get a sense of the client in the here and now of the session, especially in terms of who they think they are and who they wish to be (Worral, 2014). A systemic therapist will often begin by exploring relationships and interaction patterns, the thoughts, feelings, and meanings that surround them, and the associated contexts (Gurman, 2015). A narrative practitioner may focus on listening for exceptions to the problem story and attempt to identify the dominant discourses that maintain her narrative (Payne, 2014). Each orientation focuses on a different unit of analysis and asks different questions based on that. For instance, all orientations ask the therapist to observe non-verbal behaviour, the emotion being conveyed, and specially to note verbal and non-verbal discrepancies. Therapists aligned with the psychodynamic orientation will use this data to build awareness of their own and client’s emotions as they are being experienced to identify processes like projective identification. Therapists from the cognitive behavioural tradition therapists may use the same data to identify underlying dysfunctional assumptions that the client is less aware of (Dallos & Stedmon, 2009b). Reflecting on how we listen to our clients and approach their narratives, and which experiences we focus on, might help us see how the theoretical model shapes our therapeutic work and how we in turn shape how the model is utilized.

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Positioning Ourselves Take a moment to consider this situation. Your new client comes and asks about the theoretical framework which informs your work. How would you respond? Is it invariant, does it differ with client needs or is it a combination that is difficult to articulate? Is there any one theoretical orientation that emerges as a dominant influence on your practice? As therapists, it is useful for us to reflect on where we stand vis-à-vis each major orientation and which perspectives and methods we value and use more often. At a larger level, an awareness of which orientation(s) our profession is moving towards, and where our contemporaries are situated, can broaden our horizons and sharpen our focus towards research and new developments. The analytic psychodynamic tradition is almost synonymous with the term ‘psychotherapy’ in the popular imagination. Nearly 60 per cent of therapists surveyed in an international study indicated that that this orientation was a salient influence on their therapeutic work (Orlinsky & Rønnestad, 2005), but there are significant variations across countries. While the psychodynamic orientation remains popular in some countries like Poland (Suszek et al., 2017), it is rarely endorsed in others, for instance in India (Bhola et al., 2017). CBT is favoured by growing numbers of psychotherapists around the globe, including countries such as India (Kumaria et al., 2018), Australia (Hicks et al., 2016), Canada (Jaimes et al., 2015) and China (Liu et al., 2013). Allegiances towards theoretical orientations can and do vary within and across contexts, countries and time frames, based on the choices and training of individual practitioners. We may locate ourselves within one of the major traditions, or we may feel like outliers, valuing perspectives that many of our contemporaries are less familiar with. It does seem more fruitful to understand how each theoretical orientation can influence our work and contribute to our professional identity, rather than ranking or choosing between them. Many alignments are possible and, in fact, it is quite rare for a therapist to be very exclusive in their preferences (Cook et al., 2010). This is reflective of the growing acknowledgement of the value of integrated or broad-spectrum therapies, particularly in clinical settings

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(Boswell et al., 2009; Rihacek & Roubal, 2017a; Suszek et al., 2017). Norcross and Alexander (2019) recognize four routes to integration: common factors (i.e., focusing on effective therapeutic practices which are common to all approaches), technical eclecticism (i.e., using effective ingredients or techniques from different approaches), theoretical integration (i.e., transcending diverse models by creating single but different conceptualization and approach) and assimilative integration (i.e., working primarily from within one model but integrating aspects of others when needed). Thus, there is no single ‘integrative model’ but many ways of integrating, with each therapist finding their own path and integrating theories to a greater or lesser degree (Boswell et al., 2009). Positioning ourselves in terms of our orientation then is a more complex process than merely finding a name to attach to. For this process to be meaningful, it needs to be intentional and purposeful while allowing for experimentation. Of course, as we grow, our allegiances may also change, sometimes along with the zeitgeist and sometimes against.

How Does Theoretical Orientation Manifest in Practice? Our theoretical orientation can manifest in the form of our questioning style, the specific techniques we use, our relational approach or the goals we are working towards. In a search for unique features that distinguished psychodynamic interpersonal therapy from cognitive behavioural interventions, Blagys and Hilsenroth (2000) identified an interest in the emotional world, interpersonal experiences and past experiences during psychodynamic interpersonal work. In these sessions, therapists engaged in an exploration of client’s wishes, dreams or fantasies and a search for patterns in behaviours, thoughts, emotions, experiences and relationships. In contrast, CBT was marked by a focus on intrapersonal/cognitive aspects, education about symptoms and treatment process and future experiences. Therapists tended to engage clients in activities within and between sessions and prioritized symptom management skills (Blagys & Hilsenroth, 2002). Reflecting on treatment-specific interventions and processes can guide our practice and help us monitor adherence during sessions. We can use audiotapes,

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transcripts or detailed session notes to identify therapeutic processes and techniques used in our work with clients. Through this, we can discover how we engage with and respond to our clients, track our level of activity in sessions and learn if our focus is more on the past, present or future. As we reflect on similarities and differences across clients and sessions, our conceptualization of what we actually do as therapists can get crystallized. Watching therapists in action can make theoretical orientations come alive for us. We recommend video resources, for example, those from the American Psychological Association which depict how master therapists from cognitive therapy, emotion-focused therapy and psychodynamic therapy orientations translate these different concepts into practice with the same client. Even when we adhere to a dominant theoretical orientation, we may in fact be using ideas from different orientations (Ablon et al., 2006). Reflecting on our sessions or using a measure such as the Multitheoretical List of Therapeutic Interventions (McCarthy & Barber, 2009; Solomonov et al., 2018) can help us identify and understand the patterns and intensity of use of varied interventions across eight psychotherapy orientations. If we find ourselves using techniques outside of the orientation/s we are aligned with, this is certainly not uncommon. Therapists often expand their repertoires by adopting diverse approaches, even when they reflect divergent philosophical assumptions about human behaviour and experience (Thoma & Cecero, 2009). These choices could be intentional and clearly articulated or could become evident only when we pause to reflect. Of course, therapists who are eclectic-integrative in their practice may be quite conscious of the different hats they put on. Often when we shift hats intentionally during sessions, this may come from the experience that ‘nothing works all the time’ (Hoyt, 2005, p. 988). As we deepen our understanding about different theoretical orientations and our own practice, we can reflect on the reasons we stay within the frame of our self-identified orientations and on when we borrow from other perspectives. Such shifts might be part of the plan to begin with or emerge in response to what we notice with a client on a moment-to-moment basis during a session. We may also reflect after the session, in supervision or by ourselves, and arrive at

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an understanding that the client may need a different approach. Such explorations can bring us closer to understanding the amalgamation of multiple change processes and the ways in which we can match our therapeutic techniques to the unique needs of each client. As reflexive practitioners, we also make choices based on our understanding of the cultural fit and acceptability of dominant counselling and psychotherapy theories. Assumptions that theoretical orientations derived from Eurocentric or Anglo-American perspectives are completely irrelevant in other cultural contexts like India may be simplistic. All theoretical orientations are drawn from human experience—thoughts, feelings, behaviours, memories and motivations—and some aspects of these are universal, shared by human beings across the world. While we do need to develop locally rooted epistemologies and approaches (Bayetti et al., 2017; Bhargava et al., 2017), the use of simplified categories such as West vs East or West vs the Rest can lead to an essentialized understanding of culture. The infusion of cultural and religious idioms and metaphors has been recommended to enhance the applicability and impact of theoretical approaches in the Indian context (Bhargava et al., 2017). We could also draw from yogic and meditative practices to expand our repertoire of culturally contextualized interventions (Sinha & Chatterji, 2021). Adaptations of interpersonal therapy in Asian countries (Malaysia, China and India) have included goals and processes consonant with cultural beliefs and values (e.g., family cohesion, relational hierarchies and spirituality) and involved family members in therapy when needed (Patel et al., 2011; Stuart et al., 2021). Even as we consider these ideas about cultural adaptations, we must examine what this means in a culturally diverse country like India. There is a leaning towards Hindu philosophical beliefs and scriptures while discussing the incorporation of Indian concepts into practice (Avasthi et al., 2013), something that will not be relevant for persons from all religions. A reflexive stance calls for us to choose adaptations that are responsive to the cultural framework of the client in front of us. This critical engagement with context can guide us on the choice, translation and adaptation of theoretical orientations, so that we can use them more intentionally and flexibly in our therapeutic work.

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Influences on Our Choice of Theoretical Orientation The process of finding or choosing a theoretical orientation could probably be better seen as a journey rather than a single decision point, with a range of factors that influence therapist choices along the career path. Research on personality traits that led people towards specific theoretical orientations offers some pointers, though findings are inconclusive. Research sought to identify particular constellations of traits which were associated with dynamic and cognitive behavioural therapists. The cognitive behaviour therapist is seen as more active, rational and assertive, and the dynamic therapist as being intuitive, thoughtful and comfortable with ambiguity (Arthur, 2001). While creating this picture may be an interesting exercise, such stereotypes may be limiting both to ourselves and the profession. Even where certain personality traits were clustered around a particular orientation, these were not watertight categories (Ogunfowora & Drapeau, 2008). Findings also vary depending on therapist experience levels and types of personality measures, and most studies do not examine other possible influences and their interactions with therapist personality, indicating that these links are tentative and inconclusive. We would suggest reflecting on the ways in which our personalities may interact with our orientation of choice. Therapists can shape their orientation and its techniques to their own personality, resulting in a complex amalgamation over time (Ciorbea & Nedelcea, 2012; Heinonen & Orlinsky, 2013). We may also reflect on how our ways of being and relating in therapeutic interactions make lasting changes in our personal and relational spheres outside the room. More recently, the search for distinctive personality traits that predict choice of orientation has waned and newer studies examine the therapists’ personal philosophies, learning style, value systems and interpersonal style (e.g., dominance and affiliation) as determinants of their choice of theoretical orientation (e.g., Fitzpatrick et al., 2010; Tartakovsky, 2016). For instance, students who preferred a feel and watch learning style tended to choose the psychodynamic orientation,

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while those who gravitated towards a think and do style chose the CBT paradigm (Heffler & Sandell, 2009). We may all be able to identify aspects of self that resonate very well with our orientation and some that feel more discordant. Our personal life experiences may also lead us towards certain orientations. As therapists, we may recognize ourselves in different theories; and approaches that have proven effective in our personal lives may be the ones we believe in. We may make these connections quite readily, for instance, a couple therapist who recognizes that growing up in a family that emphasized gender equality shaped her affinity for feminist therapies. However, the influence of life experiences may also be implicit and complex, representing a search for answers within the theoretical framework. For instance, the choice of a psychodynamic orientation has been linked with a higher likelihood of mental illness in a family member and conflict with families of origin (Rosin & Knudson, 1986), more negative past experiences and higher motivation for personal development (Messina et al., 2018). Perhaps training within a psychodynamic orientation holds the promise of deeper self-exploration and a joining of dots between the past and present. Personal therapy is another significant life experience, and we may choose to practise within the orientation we have experienced as clients, particularly if that has been a positive experience. Clearly, the personal and the professional are intertwined, even in our choice of theoretical orientation. Reflecting on the influences of our values and personal experiences can be an interesting exercise and could illuminate the path towards more congruent theoretical orientations. These reflections can help us to anticipate, understand and respond more quickly to a lack of harmony and belongingness in our work as well as recognize when we feel a sense of comfort and resonance. Our training and professional setting also influence our choice of orientation. Therapists may choose to work with models that are empirically supported and seen as effective, those that have credibility in the professional community or are experienced as responsive to client needs (Roth & Fonagy, 2006). The overall orientation of our training institute, influential teachers, influential supervisors,

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theorists, ideas or books we have admired can all influence our preferred orientation. This choice is often intertwined with nature of the contexts in which therapists train and begin to work. For instance, a therapist who encounters many disempowered and marginalized persons during training may strongly align with social justice frameworks. While we may develop an affinity for a particular model during our training, we could also encounter pressures to adhere to another approach in our work settings. Client needs and preferences, as well our experiences of what works with different clients, may pull us towards certain orientations. Clients may come in with their own notions of what therapy is, what they want to talk about and how they wish to approach themselves. So, sometimes, even if a particular theoretical orientation resonates with us, we may adapt or change it to fit the needs and realities of clients. For instance, dynamic therapy may become briefer to fit the needs of clients who do not have the resources for long-term therapy. Or a therapist might notice that her clients are more accepting of the CBT format when there is less emphasis on homework. Some clients are more equipped to work on their own, while others may need more support. Some clients may resent the therapist taking charge or pushing for change, while others may feel too lost with inadequate structure and goals. So it is useful to not see our orientation as a one-size-fitsall solution that can be copy-pasted onto each client. Therapists who are sensitive to client needs and responses and can modify their own responses accordingly are more likely to be effective. Therapists also need to reflect on the scope and limitations of their preferred theory, to come up with these modifications. If we experience a repeated pattern of our orientation not working for our clients, we may need to rethink it and modify certain aspects. For instance, while systemic therapies typically endorse conjoint sessions (Simon, 2015), through repeated experience, therapists found that certain tasks are easier to accomplish in individual sessions, and faster progress could be made this way (Shah & Satyanarayana, 2011). When it comes to exploring determinants of theoretical orientation, it may help to understand the complex interactions of multiple factors,

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rather than focus on a single pathway (Poznanski & McLennan, 2003). Our awareness of these myriad influences can make us active participants in our professional journey and help shape our work lives to the benefit of ourselves and our clients. We can consider all the factors that might have influenced our choice of theoretical orientation and depict them in a pie chart. This can help us reflect on how these influences played a role in our initial choice of theoretical orientation. We can also consider if and how the strength of these influences has waxed and waned over the course of our career. In this process of exploration, we may find that that there is both an element of choice (what is the kind of practitioner I want to be?) and an element of discovery (what is the kind of practitioner I am inside?).

Me and My Orientation: An Evolving Relationship There is a difference between selecting a model that works well for a client’s particular concern and having a model we commit to and believe in. It is an important task in the journey of a therapist to select a model which informs their work, one that they are in tune with, enthusiastic about and allegiant to (Blow et al., 2007). This sense of conviction and commitment to a theoretical framework can manifest in increased levels of tenacity, enthusiasm, hopefulness and skill in our practice (Davis & Piercy, 2007; Blow et al., 2007). Congruence between the self of the therapist and the theoretical orientation can create a powerful synergy for change in therapy. The search for a shoe that fits is a process of self-exploration, as much as an exploration of diverse theoretical orientations. When we feel natural and comfortable with what we are doing in the therapy room, when we use the language that resonates with us, we can be more genuine and effective as therapists (Messer & Gurman, 2011). Choosing or discovering the theoretical framework(s) we believe in is certainly not a linear process. There may be some therapists who have no strong attachment to theory and others who find their theoretical home quite easily. There are some who may be ‘true believers’ or ‘purists’ and have a strong adherence to one theory, often in

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combination with active rejection of others. Ideological purity allows for a deepening of mastery and competence (Castonguay, 2005), perhaps emphasizing depth over breadth. Other therapists may have a deep commitment to one model while being open to other ways of thinking and practising. Therapists may also find themselves transitioning from one framework to another, or combining different approaches over their years of practice, based on what they find helpful or effective. Most therapists may struggle along the way, trying two or three orientations before settling on one that fits (Arthur, 2001). Even after we have worked successfully using one theoretical orientation, there may come a phase when it is no longer satisfactory. Perhaps it does not help us understand our client concerns or does not equip us with the techniques to manage client difficulties; and we may want to experiment to expand our repertoire (Rihacek & Danelova, 2016). This can lead us to realign to another model; the process involves questioning orientations, reflecting on what we are comfortable and uncomfortable with, and whether we are leaving space to explore other orientations. Whatever we choose, this involves a process of immersing in theory, making efforts to understand ourselves and our clients and reflecting about issues relevant to training, practice and research in psychotherapy. However, at some stage in our career, there comes a moment when who we are, what we do in session and what works with our client align. We may feel a ‘click’—a thrill—and release a breath we did not know we had been holding. When that moment occurs, we can catch it and cherish it. It is one of the most wonderful moments of our career. Of course, this journey may not always lead us to a single orientation. And we may set off to explore again. A Therapist Speaks: What Feels True… We invited Ms Malika Verma, a clinical psychologist and psychoanalytic psychotherapist who is currently in private practice in Melbourne, Australia, to describe her personal journey as she sought her true theoretical home. ‘The modality of psychotherapy that we choose to practise is very much about what is the best fit with our own personality, what feels

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true to us. Psychoanalytic psychotherapy suits me best. My thoughts here are not about the nature of the various therapies but rather about how I have experienced them. I initially trained as a CBT therapist and enjoyed my work very much. It made me feel very competent. I always had the right words, the right answers, a solution. I wore them like an armour suit. The avoidance of pain and reality is an aspect of my personality. I feel that being a clinical psychologist allowed me to be an expert, someone who will never be in the position the patient was in. I saw my patient’s struggle as an illness and a pathology of which I could cure them. I worked mainly with severe, chronic and complex mental health conditions but I never felt ruffled or frustrated. The truth was perhaps closer to the fact that I felt omnipotent and had no real understanding of the patient’s pain or their reality. One must wonder what made me leave this for psychoanalytic psychotherapy. I think it was starting my own therapy. For the first time, I really knew what my patient’s experience was, because I was one too. I knew now what it felt like when I said I was going on a break, or that we don’t need to meet weekly anymore, or that we must now end. For the first time, I could allow myself to be real instead of competent. I didn’t want the body armour anymore. I trained in interpersonal therapy alongside the psychoanalytic training and never felt attached to it. Both CBT and IPT now felt constraining and rigid. I felt that neither allowed me a real relationship with my patients. I enjoyed the rigour and demand of psychoanalytic training at Tavistock Clinic, UK. My own analysis, five days a week for five years, was invaluable to me both personally and professionally. Now I only practise psychoanalytic psychotherapy and psychoanalysis. I am often lost for words, but I can share with my patients the silence to convey that for which there are no words. I don’t have solutions, but I have the capacity to bear with my patients that which feels unbearable and intolerable. I work with aspects of my patients and with patients that others would not wish to work with. I fail often, and the patient is not the only one in the room who has failed and is floundering, and so we continue. Not all psychotherapists will want this. Not all patients will want this. Whatever feels true to you.’

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Developing a Personal Theory of Change The best school of therapy for us may be the one we have developed ourselves (Rogers, 1986). During training, it might often seem as though there is a theory ‘out there’ (Rogers, 1986, p. 9), a guiding map that already exists that we need to embrace, but the truth is that all of us have a theory within us (Fall et al., 2017), even before we begin any formal training. During and after training, though we may have adopted a particular theoretical lens, we also continue to evolve a more personalized approach (Horton, 2000a; Spruill & Benshoff, 2000). McLeod (2004, p. 45) mentions that this ‘personal framework for understanding is always more than any single theory of therapy can provide.’ Psychotherapists actively make meaning of the models taught, and select ideas, techniques, stances, etc., not only from their primary theoretical orientation but also from a range of theories. These amalgamate with their own wisdom, knowledge, life experiences and values to create a personal and idiosyncratic model of doing psychotherapy (McLeod, 2004; Rihacek & Roubal, 2017b). The development of a sense of connection and flow as we grow into a theoretical orientation has been described as a process of ‘metabolizing’ theory, a personal endeavour that happens ‘inside’ the therapist, and in the interactions between the therapist and client (Betan & Binder, 2010; Rihacek & Roubal, 2017b). As Carere-Comes (2001, p. 107) put it, ‘We have almost as many psychotherapies as psychotherapists.’ A search for our ‘embedded’ orientation, one that fits with our personality, values and world views (Arthur, 2001), may not be easy during the training phase itself. As trainees, we may not know enough about our ‘selves’ or theory to speculate on the possibilities of resonance or incompatibility with diverse theoretical orientations. Our anxieties about our new role might cause us to stick to the orientations we are most familiar with or trained in. When there is space for reflection on our own ideas about ‘helping’ and change, and our experiences with clients during this formative stage, it facilitates the emergence of a personal theory of change (Guiffrida, 2005; Spruill & Benshoff, 2000). This approach reduces the pressure to completely emulate a particular model and allows for a better fit between the person and the emergent

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model of practice. As we gain a more in-depth understanding of theory and practice, we may also find it easier to allow our personalities and world views to enter the room. A psychotherapist’s personal theory of change can be viewed as an extension of the self. Our belief system is an important influence on the adoption and individualization of our theoretical world view. We carry certain notions about the nature of human beings, seeing people as inherently good or bad, our behaviours and personality as more determined by our biology or shaped by our environment. We may see the role of childhood experiences or current social context as crucial and have differing views about the role of free will. We also carry ideas about what it means to be mentally healthy and how dysfunction develops. We may define our own mental health in terms of our feeling good about ourselves, being well adjusted with our context, being able to carry out our roles and tasks or being similar to others—most often some combination of the above. When we are unhappy, poorly adjusted, dysfunctional or abnormal, we may attribute this to various internal and/or environmental factors. This is related to our beliefs about if and how people may change and where within the spectrum of individual to collective determinants we place responsibility for this change. The way we view human nature as well as mental health/ illness of course deeply impacts the goals we may have for therapy. Whether we are stimulated to reduce distress, change behaviours, challenge thought patterns, modify relational patterns or reauthor stories and whether we focus on the past, present and/or ‘here and now’ are influenced by our belief system. Finally, our beliefs about the relative roles of the therapist and client impact the way we conduct therapy and the nature of the therapeutic relationship. Who needs to decide what the goals of therapy should be? What is the role of the therapist and the therapeutic relationship in helping clients change? Are there personal and professional characteristics that make us more effective as therapists (Horton, 2000b; Fall et al., 2017; Spruill & Benshoff, 2000)? Some of us may have clear answers to these questions, but our underlying beliefs are often implicit and not immediately accessible. We may also find that our views change with context or that we find

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it difficult to commit fully to any one perspective, as all of them seem to have value. A critical awareness of our own belief system is crucial for the reflective therapist. Coming up with a personal theory is never an easy task, and nor is it a one-time exercise. At times, the ideas may seem disjointed and incomplete, and we might find it hard to pull the theory together. We can start with an existing theory and make small changes in that to include certain ideas and techniques from other models that make sense for us, gradually extending this through personal reflections and experiences. It is a bit like learning a new language; as we synthesize, assimilate and transform this knowledge, things may begin to happen implicitly and almost automatically in therapy sessions. In this process, we also learn to tolerate ambiguity when theory does not offer ready answers. When we are more receptive to learning from our therapeutic encounters, we take the time to explore rather than prematurely applying theory to explain our client’s experiences. Over time, an awareness of the alignments or misalignments between theory and our personal style, beliefs and values may lead to a closer integration between our ‘self’ and our orientation. We also add another layer to our theoretical orientation, our own relatively stable therapeutic style that we imprint on our work (Rihacek & Roubal, 2017b). Fernández-Álvarez et al. (2003) proposed five dimensions that can capture the distinctive ways in which each therapist ‘does’ therapy: whether we have a relatively broad or narrow focus in therapy and how receptive we are to what our clients share; how flexible or rigid our regulation of the therapy setting is (e.g., schedule, fees and tasks); the distance or closeness in terms of the emotional communication and engagement with our clients; our level of engagement reflected in how involved and committed we are to our clients in relation to other aspects of our lives; and the degree to which our interventions are spontaneous or planned. As we develop our own style, it becomes clearer that our theoretical orientation does not entirely define the kind of therapists we are. The practice of therapy involves more than dipping into a compendium of skills. Our intuitive, flexible and nuanced responses and actions during sessions can feel akin to painting or composing a symphony, and it

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is these creative and artistic elements of our work that allow us to connect deeply with human experience. Over our years of professional development, we can add our accumulated wisdom to our theory, and the process of integration becomes more and more sophisticated. Looking back, experienced therapists can recognize the gradual shift from a detached understanding of theoretical ideas and techniques to a feeling of belongingness and integration (Råbu & McLeod, 2018). As practitioners gain experience and wisdom, they may reflect more deeply on their thoughts and feelings about theory itself—its tenets, application or even the role of theory itself (Råbu & McLeod, 2018). As our careers evolve, we can periodically check in to understand the relevance of our chosen theoretical orientation. The client groups we work with, our work contexts or our own personal growth can lead to a shift in what we desire from our theoretical framework. While models of therapy certainly inform and become integrated into our practice over time, we may recognize that all answers do not lie within one or even any theory. A rigid adherence to theory can limit the space for the client’s experiences, the development of our relational skills, and our capacities to accept and accommodate limitations, vulnerabilities and uncertainties within the encounter (Råbu & McLeod, 2018). Therapeutic wisdom may lie in a nondogmatic appreciation of theory, allowing for diverse truths and uncomfortable questions. No model can tell a therapist exactly what to do, or how and when to do it, and instead only provides a framework to structure our psychotherapeutic work (Blow et al., 2007). If we look at theoretical orientation as a ‘framework and not a straitjacket’ (Casement, 1985, p. 4), this leaves room for clinical intuition, flexibility and our personal styles to emerge in the therapeutic process.

Perspectives on Training and Development Should Training Centres Expose Trainees to Diverse Theoretical Models? In a word, yes. There is evidence that early exposure to multiple theoretical orientations has a positive impact on professional growth trajectories (Orlinsky & Rønnestad, 2005). Trainees can benefit from

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learning the language of diverse theoretical models through formulating clients’ stories from multiple perspectives. Case conceptualizations and discussions using different theoretical models can provide an initial exposure to the links between theory and therapy, even if therapy training is not as broad-based. Where possible, we recommend opportunities for critical engagement with more than one orientation during clinical rotations and internships. Some training institutes are defined by their allegiance to a specific theoretical orientation, and this allows for an immersion into its philosophy and methods. Even when training is focused in this way, it is important to espouse institutional pluralism, where other perspectives are valued and discussed (Govrin, 2014). Should Eclectic-integrative Approaches Be the Mainstay Early in the Training Phase? Some contexts offer more focused training on integrative practices, with this stance clearly incorporated into the curriculum, learning objectives, resource materials, case conceptualization frameworks and intervention methods. Other training contexts offer training that is specific to a certain model, and we do see country-specific trends as well. The concept of integration may also be conveyed implicitly and through exposure to different models trainee therapists experiment with and understand how to put them together (Aafjes-van Doorn et al., 2018). With many therapists shifting towards eclectic-integrative positions as they move along their career trajectories, there are proponents for an early initiation into integrative approaches (e.g., Consoli & Jester, 2005). However, Castonguay (2005) argues that integrative practice should be preceded by a deep understanding of the theoretical, clinical, empirical and epistemological bases of different orientations. Trainees may struggle to grasp the nuances and complexities of diverse orientations, and the common threads and combinations across these orientations, all at once. Additionally, all training sites may not have the resources to provide the theoretical knowledge and therapeutic skills reflected in each orientation. We believe that training contexts need to provide some theoretical anchors and help trainees build a foundation from which to explore and integrate further. We also

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advocate for training in change processes and pathways, above and beyond specific theoretical orientations (Ablon et al. 2006; Goodman, 2013; Heatherington et al., 2013). How Should We Build Supportive and Reflective Supervisory Spaces? Supervisors need to build time and space for reflections about theoretical orientations where trainees can be encouraged to articulate their philosophies about human suffering and change, and their experiences with theories and interventions. Process notes, candid disclosures and open discussions about the fit between theories, personal values, client needs and institutional processes can facilitate their tentative explorations (Fitzpatrick et al., 2010). We would recommend that supervisors make their own orientation/stance known but still leave room for trainees to question and debate about theory and techniques. How Should We Explore and Consolidate Theoretical Orientation/s throughout Our Career Trajectory? Practitioners who are committed to one orientation can strengthen their skills by seeking out specialized training and supervision at different points in their career path. While some of us might seek deeper immersion in our chosen model, others may look for training in alternate frameworks. There are several emergent therapeutic models that are blends of different approaches (e.g., mentalization-based therapy and emotion-focused therapy), and this may appeal to practitioners who are leaning towards integrative therapies. How Should We Engage with Key Questions and Debates about Theoretical Orientations? The movement towards cost-effective short interventions continues to influence what research is funded, what therapy services receive insurance coverage, what types of training are available and eventually where the field moves. This could edge out longer and more intensive psychotherapy formats. As practitioners, we do need to stay

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updated about the evidence for the effectiveness of various therapeutic approaches. However, there are attendant concerns about the narrowing of theoretical orientations at training sites and the overdependence on empirically supported treatments (ESTs), which are more often validated through randomized controlled designs rather than in naturalistic settings (Ablon et al., 2006; Heatherington et al., 2013). As trainees and practitioners explore the world of theoretical orientations, their options may be constrained by the dominance of time-limited and empirically supported therapies (Addis & Krasnow 2000). The growing popularity of treatment manuals, mobile apps and online web-based programmes are other trends that do not easily encompass all theoretical orientations. We can reflect on what we might gain or lose from this type of focus, and how we wish to use this evidence base in our practice. We also recommend that practitioners continue expanding their theoretical frames to incorporate social justice and human rights paradigms. This may involve a reflexive process of questioning our theories and their underlying values and assumptions (Singh et al., 2020). It can be an unsettling experience to realize that our theoretical lens might not be adequately responsive to the inequities in our clients’ lives and experiences. Our training may not always equip us to recognize and address the change required in institutional and societal systems. We hope that pedagogies and practices in counselling and psychotherapy will include these perspectives more uniformly. How Do We Build Practice–Research Networks and Collective Resources? Partnerships between practitioners and researchers can inform more meaningful and practice-friendly research on theoretical orientations. Our understanding of theoretical orientations in practice—what we listen for, what we do, why and how we shift our lens and even how we integrate across theories—can be quite limited if we depend only on randomized controlled trials and quantitative methodologies. While both quantitative and qualitative approaches have value, there is an underrepresentation of psychotherapy case studies in both journals

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and professional forums. Case studies can help us engage deeply with the therapeutic process and the complexities of the decision-making process (Grinfeld, 2009). We urge the development of shared resources and archives to share this wisdom within the professional community.

Conclusion While reflective processes may be more central to the therapeutic process in certain orientations, their value is being increasingly recognized across a range of therapeutic approaches. As we reflect, we can use the same language and methods that define our work with our clients. So narrative therapists may explore their own life scripts, dynamic therapists may try to recognize their counter-transference reactions and CBT therapists may track and document their own information processing styles. Our orientations also suggest tools or ways of reflecting. For instance, while personal analysis is integral to the psychodynamic tradition, systemic therapies advocate the use of ‘reflective teams’ and humanistic therapies offer experiential activities such as sculpting, art and role-plays (Dallos & Stedmon, 2009b). As psychotherapists, it is imperative that we locate ourselves on the complex map of theoretical orientations. As we move along our professional trajectories, we build our toolbox, explore and understand, reshuffle or strengthen our alignments. A reflective and flexible stance that allows room for irreverence ‘towards dogma, our own sacred cows and accepted truths’ (Hedges, 2010, p. 13) is valuable. This can leave room to continue our search within one orientation or explore divergent models and practices.

Chapter 5

Connecting with Clients and Building a Therapeutic Alliance

We all seek that one moment when we feel connected with the other, whether it is the whirling dervishes dancing to seek oneness with the universe, the musician reaching the flow state or the mother who tunes out the world to be with her child. Seeking attunement and connection is also what lies at the heart of the client–therapist relationship. The therapeutic alliance (also referred to as working alliance or helping relationship) has been recognized as key to facilitating therapeutic change across theoretical orientations (Bordin, 1979). The therapeutic relationship helps build a collaborative environment to work on client concern, sustains client motivation for therapy and reduces dropout (Ardito & Rabellino, 2011; Horvath et al., 2011). Several meta-analytic studies have found a consistent and predictable correlation between the quality of therapeutic alliance and positive therapy outcomes (Karver et al., 2006; Martin et al., 2000; Shirk & Karver, 2003). Of course, clients and therapists may experience the depth of the alliance differently, and it is our clients’ perception of the alliance that has the most powerful impact on the gains and changes in therapy (Castonguay et al., 2006).

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Connecting with our clients is not a one-time event but a process which is replayed session after session. In this chapter, practitioner narratives have been used to capture the almost intangible essence of what is it to be with a client and reflect on some of the ways to deepen this experience. We start by focusing on how therapist presence can build attunement with clients and then move to examining how to repair that connection when the inevitable ruptures occur. We then reflect on the vital facets of managing countertransference and balancing power between a therapist and a client, and finally look at the joys and sorrows of termination.

I’ll Be There for You: Presence and Attunement in the Therapeutic Relationship Implicit in the therapeutic contract is the idea that we will ‘be there’ for our clients. It means that we will not just be there for the client, but also that we will be present with the client, tuning into their minds, feelings and bodily experiences (Geller, 2013)—and not just in a generic way, but very specifically, in the moment of the experience. Therapeutic presence then is ‘a way of being with the client that optimises the doing of therapy.’ (Geller, 2018, p. 108; italics in original). Presence also implies being with ourselves, being aware of and using our history, sensitivities, needs, and personal and professional encounters to enter empathically into the client’s world (Erskine, 2011). Being present enables us to attune with our clients. In this two-way process, we connect with the internal world of the client, through kinaesthetic and emotional sensing, and communicate this back through words and gestures (Erskine, 1998). The client in turn sees their own mind in that of the therapist and ‘As one person “feels” the other, the recipient feels “felt”’ (Bruce et al., 2010, p. 85). Both presence and attunement are pan-theoretical constructs that underlie the therapeutic relationship and are seen as prerequisites for the work of therapy (Geller, 2018; Siegel, 2020). Various neural processes have been postulated to underlie this synchrony between two human beings, including mother–child attunement and the

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capacity for affect regulation (Schore & Schore, 2008), interpersonal neurobiology, which looks at the connection between ‘the social and the synaptic’ (Siegel, 2020, p. 9) and polyvagal theory that looks at the neural mechanisms underlying the experiences of safety, danger and life threat (Porges, 2011). As therapists, we can tune into ourselves by noticing our embodied experience, non-verbal reactions and feelings, as well as our knowledge, professional skill and wisdom (Geller & Greenberg, 2012; Geller, 2018). We can build on our overall self-awareness and presence by engaging with practices such as mindfulness, chanting, music, yoga, centring and grounding exercises, as well as paying attention to our well-being and relationships (Geller, 2018). Before we start the day, we can take a breather from the morning rush to open our thoughts, gather space, feel nourished and set an intention to be present through the day. During the session, we can tune into our embodied state by becoming aware of our breathing or the relaxation/tension in our muscles. A mindfulness exercise or ritual in between sessions to let go of the previous client and welcome the next one, perhaps with an inhalation and an exhalation, can also be useful (Geller, 2018). As therapists, we often have busy days, where we are rushing from session to session. On a typical day, is there anything specific you do to enhance your presence and centre yourself? Are there any other practices that you would like to integrate into your routine? Importantly, we might also reflect on whether our clients are feeling our presence as we intend, for it is our client’s experience of therapeutic presence that is linked with the strength of the alliance and the outcomes of therapy (Geller et al., 2010). As clients feel the relaxed, open, intentional presence of the therapist, they can open the space to be present with themselves. They feel safe, met and understood and are freed to explore the depth of their experience (Geller, 2013; Geller & Porges, 2014). During sessions, we can attend closely to our client’s emotional state, as manifested in their words, facial expression, gaze, head gesture and prosody. This helps us sense how safe or threatened our clients are feeling and respond more effectively to their internal states (Geller & Porges, 2014). We show our clients that

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we are attuned to them through the quality of our listening (without interruptions), by maintaining eye contact and matching the rhythm of our breathing, tone and prosody with theirs (Geller, 2018; Håvås et al., 2015). As distressing feelings come up, the therapist needs to sense when to let them flow and when to step in to soothe or regulate (Dales & Jerry, 2008). When we identify our client’s emotional state, it can help to demonstrate the reciprocal affect, for instance, attentiveness in response to anger or protection in response to fear (Erskine, 1998). We not only tune into what our clients are experiencing but also what they seem to need from us. Over time, such encounters can build the client’s capacity to self-regulate as their neural systems entrain with that of the therapist, through a right-brain to right-brain connection, which can occur without our conscious awareness (Dales & Jerry, 2008; Geller, 2018; Geller & Porges, 2014; Håvås et al., 2015). Finally, in this emotionally regulated state, clients can strengthen their capacity to mentalize or form beliefs about the mental states of themselves and others (Bateman & Fonagy, 2013). A Therapist Speaks: The Girl in a Locked Room One of the authors (Poornima Bhola) reflects on her experience of attunement in the therapeutic process. ‘Some of our deepest learnings emerge from experiences of our struggles to connect with our clients. I remember a young woman Maya,1 a reluctant client, angry with her family, herself and with me. Sitting with arms crossed, she would talk about being detached from everyone and everything and being attracted to darkness and the imagined possibility of death. Often quoting from the Japanese novelist Haruki Murakami, she spoke of the futility of human attachment and was clearly angry when she realized that I had read his books too. Maya reminded me of the girl in a locked room, from Murakami’s book Norwegian Wood. Most often I was outside the door, tentative and uncertain or trying to knock and get her to open. There 1

Name changed to protect client identity.

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were fleeting moments of connection and progress during sessions, but at other times she looked out of the window or laughed at my “weird” facial expressions. She kept coming for sessions, always five minutes early, but the therapeutic alliance certainly did not seem on firm ground. During one session, I spontaneously shared how I experienced her internal struggles and our time together. It was a visual metaphor about a bird, something that had just popped into my mind. Maya narrowed her eyes and asked angrily, “Did you read my diary” Reaching into her bag, she opened a page in a journal and showed me the same metaphor, a line in a poem she had written about herself. We sat in silence for some time. This shared experience opened a space for us to work together in the next few sessions. This brief but powerful encounter helped me learn many things about connecting with clients. Clients will often tell us how they have experienced relationships, what they yearn for and what they fear. This may need to be understood through the way we relate with each other. We may be too eager to close the distance and open closed doors—we may be ready (even anxious)—but our client may not. This therapeutic experience has stayed with me and reminds me that empathic attunement between the client and therapist can occur silently and slowly. It is also interesting for me that the two of us could connect and resonate in this way only when I stepped back from struggling with her and entered a more reflective space.’ Attuning to Attachment Needs As therapists, we need to reflect on the process of attunement and the meaning of the closeness and distance we feel with our clients over the entire course of therapy. This process can be more challenging with clients who are primed for dysregulation and heightened threat perception because of their attachment histories or traumatic experiences (Geller & Porges, 2014). Individuals with insecure attachment may perceive themselves to constantly be in danger, respond defensively or aggressively even when there is no risk, and stay closed to potential soothing by others. Our anxiously or ambivalently attached clients may

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have a hyperactive need for proximity and a magnified expression of distress and could look to us to consistently reassure and soothe their emotions (Mallinckrodt, 2010; Wiseman & Atzil-Slonim, 2018). Our clients with a more avoidant or dismissive attachment style may have a deactivated need for proximity and find it easier to regulate their emotions when on their own. Indeed, staying with their emotional distress in the intimate presence of another own could be harder for them (Mallinckrodt, 2010; Wiseman & Atzil-Slonim, 2018). As you can imagine, each client can have quite differing needs from their relationship with their therapist. Clients who seem to need more than we can give often leave us feeling overwhelmed and inclined to protect ourselves by drawing stronger boundaries. On the other hand, clients who seem not to need us at all can raise our anxieties and cause us to try moving closer, almost insisting on a connection. Mallinckrodt et al. (2015) suggest that with clients who are anxiously attached, we can start by actively offering some of the comfort and care that they need, leaving them feeling gratified. As the client grows to trust that our care is consistent, their ambivalence and anxiety in relationships gets reduced. Conversely, our clients who are avoidantly attached need to know that we have space for their avoidance and self-protection. We can offer them the safety of distance, letting them know that we are willing to meet them within their comfort zone. Our connection can be built by consistently tuning into their feelings, without necessarily asking them to share or pressurizing them to change (Håvås et al., 2015; Mallinckrodt et al., 2015). As the client starts to feel safer, we can experiment with changing our stance. With an anxiously attached client, we may occasionally refrain from offering comfort or soothing (for instance, helping clients search for their own solutions rather than providing them). The client may initially feel frustrated, as we are not immediately meeting their implicit or explicit needs, but could slowly learn to tolerate these feelings. We can gently increase this behaviour as the client grows more confident in their ability to manage their emotions. On the other hand, with an avoidantly attached client, we may begin to gradually push for more emotional exploration, discussion of distressing material or of the therapeutic relationship itself. The client may initially feel anxious

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but could gradually feel more comfortable with less distance in the relationship. In this way, the therapist is not only able to sense and match the client’s style but also alter it (Mallinckrodt, 2010). The task of the therapist here is not just to find the correct ‘attachment box’ to put their clients in. Rather, we need to be sensitive and flexibly responsive to interpersonal patterns and expectancies, sensing both where the client wishes to go and the optimal distance/closeness needed in the moment (Kietaibl, 2012). Each client is likely to have a unique goal of how much connectedness or distance they wish for in their relationships, and this could be based on their cultural value system as much as their childhood experiences. As therapists, we also tune into clients’ cultural locations, interpreting their behaviours through this lens. For instance, in India, the therapist may be referred to as ‘akka’,2 indicating that we have been given the position of a respected but approachable family member. Clients may invite us to participate in family rituals and celebrations, underlining that they accept us as part of the family. This is usually not intended as a boundary violation and can be viewed as a culturally acceptable style of relating with healers, rather than an indicator of attachment vulnerabilities. Our reflections can help us stay present and attuned, enabling us to forge the therapeutic connection and carry out the work of therapy.

Responding to Ruptures and Repairs in the Therapeutic Alliance Relationships are always unfolding, and this is true for the interactions between therapists and clients as well. It can be disturbing to experience periods of tension or a breakdown in communication with each other. We each respond differently to relationship disruptions. Think about a disruption in your personal life, perhaps a misunderstanding with a friend or a relationship conflict. How did you feel and respond? What might have helped to resolve the strain? Rafoogari, the traditional art of darning from India and the subcontinent, involves the repair and preservation of torn, frayed and fragile 2

Akka means elder sister.

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heritage textiles. Darning is a powerful metaphor about healing, which ‘honour(s) the place, significance and act of visible and invisible “darning” in the fabric of any life’ (Mehra, 2018). Rafoogars are like artists, who mindfully suture, strengthen and restore the ‘injured’ fabric, often using threads extracted from the original cloth. In the warp and weft of psychotherapy too, there are frictions, injuries and ruptures, which have the potential for repair and transformation. While ruptures have been linked with therapy dropout, successful repairs can improve therapy outcomes (Stiles et al., 2004). Of course, we also need to remember that some disruptions are minor and a normal part of human interaction and need not be treated as ruptures (Eubanks et al., 2015). Ruptures or strains in the therapeutic alliance can arise out of disagreement on one or more dimension of working alliance (Bordin, 1979)—the goals of therapy (e.g., the therapist wants to focus on understanding deeper emotions, while the client wants to improve their organizational skills), the tasks of therapy (e.g., the therapist recommends mindfulness to become more aware of thoughts and emotions, while the client prefers a more structured approach) or the nature of the therapeutic bond (e.g., the client experiences the therapist as unavailable or too demanding). We may be alerted to relational issues when our client appears tentative, reluctant, withdrawn or hostile at the beginning of the therapy. An early positive therapeutic alliance does not mean that the relational trajectory will be smooth or that the alliance will not falter later in the process. We also need to monitor for shifts in the level of connection, even when it seems strong and seemingly stable in the first few sessions. Ruptures can have varied manifestations and underpinnings as they emerge at different times in the therapy process. The tensions might be subtle and transient or much more intense and prolonged. The more obvious manifestations are when our client directly confronts us, expressing anger or dissatisfaction with the therapist or the activities, interventions or pace of therapy. These confrontation markers, for example, a client storming out of the session or rejecting an intervention, also have more direct and obvious impacts on the therapeutic process, often evoking confusion, ambivalence and intense negative feelings within therapists (Coutinho et al., 2011). This can

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be a challenging experience for therapists who may find it hard to deal with a client’s anger, disappointment or other feelings while remaining open and empathetic to their experience. Withdrawal markers, such as long silences, changing the topic, rambling storytelling or appearing unconcerned while describing difficult experiences, are easier to miss (Samstag & Muran, 2019). Our clients may not voice their sense of disconnection and might even become overly deferential or acquiescent when they sense a disturbance in the relationship. Sometimes, the complete absence of strain, conflicts or rifts in the relationship can reflect a hesitation to enter more challenging aspects of therapeutic work or a reluctance to endanger the relationship, and therefore difficulties in the depth and quality of the alliance. In these ways, our clients may either move ‘against’ or ‘away from’ the therapist and the work to be done together in therapy. As therapists, we may experience both types of markers in the same session, with a client initially being more hostile or challenging and later being more withdrawn or quiet, as if they have given up on getting us to hear them. The way a client expresses their dissatisfaction with therapy and their understanding of the causes of this dissatisfaction is likely to evolve. As our clients grow more secure with themselves and the relationship, they may become more flexible in their understanding and negotiation of interpersonal difficulties both within and outside the therapy room. For the therapist, staying attuned to the microprocesses in therapy and recognizing often subtle relational disruptions require a lot of focus and effort. Even where we do recognize our client’s discomfort, we might attribute these behaviours to something that belongs only to the client, skirt around the conflict or impasse, hoping that it is transient. Our assumptions about therapy, therapists and clients or our reticence in recognizing our own errors or misjudgements can all pose barriers to the reflective process. So while we learn to recognize ruptures, we might also reflect on the reasons why we may not recognize or attend to them. We may need to be more sensitive when our clients have attachment vulnerabilities, since ruptures in our relationship with them may

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be more frequent and intense (Miller-Bottome et al., 2018; Schenk et al., 2020). The recognition of disruptions in the alliance is also more complicated in couple, family or group therapy, where there can be splits in the strength and quality of the alliance with different members of the system (Coco et al., 2019; Swank & Wittenborn, 2013). The Rupture Resolution Rating System manual offers guidance about how we might recognize subtle and more evident markers of withdrawal and confrontation from our clients’ behaviours during sessions (Eubanks et al., 2015). When we notice a potential or ongoing rupture, we may pause to focus on the alliance, explore these experiences together with our clients and initiate the process of repair. The art of repair involves the creation of a shared reflective space where the rupture can be named and anchored to what is happening in the present. Based on Safran and Muran’s (2000) description of the stages of attending to ruptures, we can expect this process: The therapist may draw attention to the interruption in connection by asking the client what they are experiencing right now or what they are feeling about the present interaction. This enables the client to examine their experience and bring it to the table. Our acknowledgement of the client’s perspective needs to be expressed in a non-defensive manner; for instance, saying ‘Yes, I can see how ignoring your story about your boss was being disrespectful of your struggles at work,’ will be better than saying ‘I can see that you felt disrespected.’ The therapist can then both explore what the client needs to heal the current interaction and explore the meaning of the experience and connection with other patterns in the client’s life. Clients may also be reluctant to bring up their negative or conflictual feelings, and the therapist may need to work a bit harder to invite them in. They may ask the client, ‘What is it that you are finding hard to express right now?’ The conversation may move between exploring client’s reluctance to express their feelings and exploring the feelings themselves as they emerge. Central to different repair strategies is the creation of a safe and validating space for our client to express and explore their emotions and needs (Eubanks et al., 2018). Immediate repair strategies

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involve clarifying misunderstandings or revisiting therapeutic tasks and goals. Think about how you might respond to a client’s anger or disengagement. Would you respond immediately and directly? Would you ignore it and hope that it goes away? When faced with a rupture, stepping in with our own perspectives, quick-fix solutions or interpretations run the risk of leaving our client feeling that they have not been seen or understood. When we slow down and reflect on the rupture, we can become aware of how we might have misunderstood what was important to our clients, misjudged the timing of an intervention or not spent enough time to discuss the rationale for a therapeutic task. Expressive strategies involve ‘therapist metacommunication’ or being mindful of the interaction as it unfolds and communicating about it (Muran et al., 2021). We may choose not to address larger disconnections immediately, if we feel that the timing is not right or our client is not ready. We might also decide to respond to many smaller ruptures together instead of attending to them immediately (Eubanks et al., 2015). We may only notice a rupture later when we are reflecting on a session or writing notes, or when our client brings up an experience from a previous session. It can be useful for us to go back to the experience, perhaps asking our client, ‘The last session felt different from the usual for me. Was it something I did? Would you like to talk about it?’ The way in which a rupture plays out may be reflective of the tension between the need for agency and the need for relatedness (Safran & Kraus, 2014; Safran & Muran, 2000). Clients who value agency may be willing to confront the therapist and risk losing the relationship. Such a rupture can be resolved by helping our client progress towards getting in touch with their feelings of hurt or disappointment, and accessing their vulnerability and need for nurturance. Clients who value relatedness might withdraw and keep the relationship safe rather than express their dissatisfaction. By requesting our client to express their needs and feelings, we create space for them to articulate their discontent and assert their needs. This process of exploring our client’s needs and feelings around the rupture can help them acknowledge and clearly express their needs,

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creating a corrective experience that can be very therapeutic (Muran et al., 2021). For instance, an immediate response to noticing that a client is growing increasingly uncomfortable with a line of exploration and going into avoidant storytelling may be to respond to their unspoken needs and slowdown that exploration (Eubanks et al., 2015). However, communicating openly about the discomfort, acknowledging possible therapist contributions for the same and exploring possible reasons and patterns around it can help our client understand and accept themselves better. The therapeutic relationship is strengthened when clients can feel that the therapist cares about their feelings and is willing to address their needs. Every disagreement or disconnection need not mean that the relationship itself is endangered. As clients learn to negotiate the relationship with the therapist, and grow to trust that ruptures can be repaired, they can also take this learning to their other personal relationships. Clients may be able to use these experiences to navigate and build trust in other close relationships. Missteps in the therapeutic interaction create possibilities to recognize what the client is trying to communicate in therapy and to understand their possible reactions to relational conflicts outside therapy. When we work towards resolving ruptures, it demonstrates the value of addressing differences in relationships rather than remaining silent or passive. While it ‘takes two to make a rupture’ (Nof et al., 2019), the therapist needs to take the first step to work towards resolution. Our readiness to take ownership for our actions and recalibrate therapy tasks and goals can strengthen the therapeutic bond and even operate as a powerful mechanism of change. A Therapist Speaks: Warp and Weft Dr Susan Howard, a visiting lecturer at the Department of Psychology, University of Surrey, UK, shared her reflections on repairing ruptures in the therapeutic relationship. ‘Sophia3 came in with difficulties in her relationship with her twoyear-old son, Hugo. Our early work in repairing this relationship could 3

Name changed to protect client identity.

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not be done without reference to Sophia’s own difficult experiences of being mothered and her troubled relationships with others. Sophia’s early transference was dominated by idealization—of my ability to help her with Hugo and my knowledge and qualifications. I had gently challenged this idealization to avoid a catastrophic rupture once I (inevitably) did something to upset or disappoint her. The first major rupture came after Sophia mentioned being pregnant. She had previously spoken of her dissatisfaction with the marriage and had discussed ending it. My surprise was evident, and she immediately accused me of not being pleased for her. I understood this accusation as the projection of her own negative feelings about the pregnancy and realized how desperately she needed my support. As I paused to think carefully about my response, Sophia said, “I knew you didn’t approve. I could see it in your face.” As her therapist, she felt that it was my job to be pleased for her. It required considerable effort to remain in touch with Sophia’s underlying fear and anxiety and refrain from defending myself from such an unfounded and vitriolic attack. I took a direct approach, which both confirmed and challenged her reality: “You were right about seeing something in my face. But what you saw was surprise—I hadn’t known that you were thinking of having another child. But surprise isn’t the same as disapproval.” We did enough work to repair the rupture and continued to discuss this and Sophia’s own feelings about the pregnancy over later sessions. She became open to thinking about how difficult my disapproval would have been and what my active support meant to her, given the poor relationship with her mother. I was better prepared when the next significant rupture occurred a year later, at a time when overseas teaching and illness had kept me away from my practice more than usual. When we met after some trouble rescheduling a therapy session, Sophia averted her eyes. I recognized this as a sign of both her anger and a potential rupture. She began by saying that this would be her last session; I was too unreliable, and she was now used to managing without me. I knew that Sophia struggled being dependent on me and with the inherent power differential in therapy—illustrated by my ability to change sessions when she could not. My reflections showed me that she had a legitimate

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complaint—I had not given her enough opportunity to complain about my recent absences. I began by addressing her feelings about me as an unreliable object. Initially, this unlocked a torrent of anger, but I did not defend myself. I also shared my hypothesis that she had come to the session wanting to find a way of staying rather than leaving. My apology for not being sufficiently attuned to her feelings and this open acknowledgement of my own contribution to the rupture deepened our therapeutic relationship.’

The Third Space: Recognizing and Using Counter Transference Psychotherapy is an emotional enterprise, one in which both client and therapist experience and express positive and negative emotions and evoke them in each other. Images of the therapist as the neutral and controlled expert, or as a benevolent, ever-empathic figure are both caricatures. Just like clients, therapists also experience their share of emotional reactions during the therapeutic process. No therapist is immune, and we have all experienced countertransferential feelings of deep care and concern, inadequacy and helplessness, boredom or detachment, anger, envy or frustration towards our clients. Misch (2000, p. 192, italics in original) reminds us that ‘countertransference is always present, to a greater or lesser degree, in every psychotherapy and with every psychotherapist’. Although the concept of countertransference emerged from the psychoanalytic tradition, it is now considered a pan-theoretical idea, encompassing the entire gamut of conscious and unconscious sensory, affective, cognitive and behavioural reactions of therapists in the process of relating with their clients (Gelso & Hayes, 2007; Kernberg, 1965). Reactive countertransference (Clarkson, 1991) refers to feelings evoked by the clients and can help us empathize more deeply with the client’s inner world, for instance, concordantly feeling the same pain as the client, when the client is sharing a painful memory (Racker, 1953, 1968). A therapist might also react in ways that are similar to another person from their client’s life, thus recreating the client’s earlier relationship patterns (Racker, 1953, 1968). For instance, if the

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client behaves in ways that are rebellious, a therapist might respond in a critical controlling manner, closely mirroring the client’s early relationship with a parent (Kernberg, 1965). Within the object relations framework, transference and countertransference have also been explained through the defence of projective identification, where the client unconsciously projects into the therapist a self or object representation and then through subtle interpersonal pressure nudges the therapist to take on the feelings and behaviours characteristics of the representation (Gabbard, 2004). In this way, our emotional reactions to our clients present another way to listen to and understand their stories. As therapists, we also bring something to the relational table in the form of proactive countertransference or reactions that have roots in our own histories (Clarkson, 1991). For instance, a therapist who experiences the need to do more than usual to help an older client might recognize the roots of their behaviour and feelings in their own unresolved grief around loss of a grandparent. Another therapist’s intense feeling of powerlessness in response to a challenging client might stem from difficulties with authority figures in their own life. Reactions that have more to do with the therapist interact with what arises from the client, to create unique co-created patterns of countertransference which present opportunities to learn about both participants (BagerCharleson, 2018; Hayes et al., 2018; Holmes & Perrin, 1997). Although there are different ways of conceptualizing countertransference, all seem to converge in their understanding of these feelings, thoughts and ideas as creating a bridge between us and our client (Hedges, 2010). While countertransference is central to psychodynamic work, it has been gaining attention in the CBT tradition in the form of more conscious and accessible therapist schemata, for example, the detached protector and the hypercompensator (Vyskocilova & Prasko, 2013). This transtheoretical lens provides an accessible framework for therapists of all persuasions to tune into the meaning of their emotions in the therapeutic situation and use this understanding in the service of the therapeutic process. In its current avatar, countertransference is not seen as something to be feared, circumvented or eliminated but to be harnessed as a valuable

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reflective tool that can help us navigate the therapeutic process (King & O’Brien, 2011). The management of countertransference begins with an attitude of openness, tolerance and curiosity towards our emergent (and inevitable) feelings (Misch, 2000). Some experiences of countertransference are so direct, intense and repetitive that they enter our awareness more readily (Holmes & Perrin, 1997). At other times, however, our reactions may be more subtle, fleeting or disguised, and may elude awareness. The emotions that arise during the therapeutic process may at times be intense and confusing, creating substantial distress, and leading to self-protective avoidance. Such distress is more likely if we carry an idealized image of a therapist as someone who cannot or should not have negative feelings towards the client or are focused more on the ‘doing’ in therapy rather than the ‘being’. Our negative feelings may be reflected in our behaviour during sessions, even when we deny or minimize our feelings. We might have become less responsive to the client, withdrawn or overly task-oriented and directive, ending our sessions early or even wishing for termination of therapy. Our positive and protective feelings towards our clients can seem less problematic (Misch, 2000), but that is a comforting myth. Positive feelings that are parental or protective may indeed be less distressing for the therapist, but these feelings could also cloud thinking, constrain therapeutic possibilities and result in over-involvement or boundary violations. We may become too effusive and emotionally available and being preoccupied with clients’ lives and emotions in a way that their actual needs are not addressed. Our messianic zeal to help the client could fuel intense frustration or anger about the pace of change (Gait & Halewood, 2019), for instance, a young therapist who feels overly invested in pushing adolescent clients to achieve goals or make choices that she was unable to exercise in her own life or a therapist who feels reluctant to challenge a client she likes not wanting to hurt his feelings. Often, both positive and negative feelings towards our clients may be intertwined, and this can be challenging to recognize (Linn-Walton & Pardasani, 2014; Misch, 2000). Feelings of special closeness to clients could be enacted as countertransference love if they

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are not recognized, contained and constructively processed (Gabbard, 1994; Little, 2018). Therapists are cautioned to be mindful of possible boundary transgressions such as scheduling sessions outside the office, disclosure about personal struggles or a progression to sexual misconduct (Gutheil & Gabbard, 1993). At the end of the day, after you wrap up your sessions and gather your thoughts, focus on any client who evoked a strong emotional response from you. It could be someone you really looked forward to meeting or someone you struggled to empathize with. How did you feel just before your session with this client? Did you notice any emotions that stayed with you through the day? These reflections might alert you to the emergence of possible countertransferential processes. Sometimes we may need to listen to what our body is telling us and decode any sudden sensations of cold, heat or numbness, inexplicable drowsiness, muscle tightness, pain or suffocation during sessions (Stone, 2006; Zoppi, 2017). For some therapists, this embodied resonance emerges when clients are unable to express their intuitive feelings in words. This often occurs in the presence of those who have experienced early trauma, are fearful of strong emotions (Stone, 2006) and for whom ‘experiences are not remembered in words’ (Diamond & Valerio, 2018, p. 39). Diamond (2013) describes struggling to stay awake and feeling overwhelmed by boredom and disinterest during sessions with a client who lived alone and was seeking a partner. This was a powerful mirroring of the client’s internal experience, stemming from early parental neglect, where the client felt that she meant nothing to everyone. When the therapist was able to tune into this deep sense of nothingness, it deepened their understanding of the client’s relational experiences. All our emotions cannot be equated with countertransference; a therapist may well be irritated or distracted due to bad traffic or a long and tiring day (Gelso & Hayes, 2007). Holmqvist (2001) suggests looking out for exceptional feelings that arise with a specific client or during a particular session or phase of therapy, reactions that are unexpected or difficult to understand. We may also recognize repetitive patterns in our sessions, such as the desire to protect clients or a discomfort with clients’ risk-taking behaviours. We can tune into our

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reactions when they are ‘too much, too little, too positive, too negative’ (Gelso & Hayes, 2007, p. 37). This recognition is not always immediate and may occur only after we have been tangled in the experience for some time. Clearly, the recognition of countertransference cannot be a dispassionate intellectual exercise, and we need to be responsive and engaged in our sessions while staying aware of the various indicators of positive and negative countertransference. While feeling that something is not equivalent to enacting it, if we ignore countertransference manifestations, these unaddressed emotional reactions are more likely to be enacted in different ways and may deeply impact the therapeutic process and outcome (Hayes et al., 2018). This deep reflection on the meaning of our reactions can protect us from being sucked into the maelstrom of countertransference. Countertransference can work as a diagnostic tool and as a compass to direct us towards what is important and help us create a different relational experience for the client. While this is important in our work with all our clients, those who have experienced trauma, have certain personality constellations or exhibit suicidal behaviours are among those who may evoke more intense, challenging and characteristic patterns of reactions (Dalenberg, 2000; Ellis et al., 2018). As therapists, it may be helpful to anticipate and tune into our emotional reactions during the therapeutic process with certain clients. Reflections on the origins and intensity of our client’s emotions and on our own reactions can lead us to a deep understanding of their central vulnerabilities and the patterns in their relationships outside of therapy. However, one of the challenging tasks in understanding countertransference reactions is trying to locate which thoughts and feelings belong to the client and which belong to the therapist’s inner world. It may be easier to attribute our emotional reactions to something the client brings. However, our understanding of countertransference is incomplete if we do not turn the reflective lens on our own wounds and vulnerabilities. For instance, a therapist who recognizes an intense need to nurture, protect and go the extra mile for most clients can reflect on whether she has felt like this before, and if this pattern of relating reminds her of a previous relationship experience (Bager-Charleson, 2018; Tishby & Wiseman, 2014).

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Opinions about disclosure of countertransferential feelings to the client are divided. There are concerns that these feelings can be distracting and intrusive, appear confessional and serve to make clients feel responsible for their therapist’s feelings (Heimann, 1950; Holmes & Perrin, 1997). However, some argue that therapists’ reactions should not stay hidden, and direct disclosures of feelings in the here and now can be therapeutically useful (Zachrisson, 2009). Discussing countertransference reactions could potentially deepen the therapeutic alliance and counterbalance therapist–client power equations (Hayes & Gelso, 2001). Like all therapeutic disclosures, there are caveats regarding the degree, type and timing of such revelations. Most importantly, we need to reflect on whether sharing our feelings will be helpful for the client, whether the client has the resources to use this information and whether the alliance is strong enough to sustain the challenge (Hayes & Gelso, 2001). When the emotional reactions stem primarily from our unresolved difficulties, they are best bracketed and explored in the safe space of supervision or personal therapy (Gelso & Hayes, 2007; Heimann, 1950). At times, our countertransferential feelings can be so intense and difficult to resolve that we might even consider referring the client to another therapist. Managing countertransference can be complex and challenging for all therapists, and supervision and consultation are recommended as a safe space to explore our reactions and their triggers. ‘Countertransference is not an oracle’ though (Holmes & Perrin, 1997, p. 272) and is perhaps most useful as an invitation to therapists’ greater emotional awareness, responsiveness and reflection in the relational space. We work at the ‘intimate edge of authentic engagement’ in the therapy room (Stark, 2000, p. xii), and countertransference is a reminder that there are (at least) two people in this interaction, both of whose emotions impact the relationship. A Therapist Speaks: Do You Want to Switch Seats with Me? Dr Jyothsna Chandur, a clinical psychologist in private practice, in Bengaluru, India, who works primarily within the framework of long-term

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dynamic psychotherapy, shared her reflections on the experience and use of countertransference. Tara,4 a 23-year-old woman, came into therapy with severe dissociative episodes, an ambivalent attachment pattern and a long, complicated experience with psychotherapy. Through the first year, Tara spoke of her fears about trusting me, explicitly stating that my opinions of her do not count—I was only her therapist, being “paid” to just listen to her. Despite this, she was particular about attending every session and I could see that she felt safe in this space. Any attempt to provide comfort through validation or interpretation was received with sarcasm or irritation. This was followed by a profuse apology from Tara, accompanied by a palpable fear of abandonment. I was acutely aware of fighting intense anger, resentment and helplessness within myself during sessions. Although supervision helped me recognize how I was being pulled into an enactment, I was unable to find the words to take this forward. During one session, she expressed feeling completely isolated and angry at everybody over the week. Yet another attempt to connect with her and offer some reflections was met with sarcasm and annoyance. In exasperation, I revealed how I felt useless in our sessions, almost irrelevant. She was able to stay with my comment and not break out into a string of apologies, blaming herself. Perhaps this was because I was genuine in sharing my emotional reaction, and/or we had worked on building a therapeutic alliance that was strong enough to cushion the impact of this intrusion. I shared my feelings of anger and helplessness and how I dared not say that out loud, without feeling like this would crush her. She instantly identified with that feeling and said, “Hey, look at that. You turned into me!” She shared how she always felt like this around her mother, worried about saying something to tip the delicate balance. This honest exchange helped both of us reflect on our own experiences in the presence of the other in the room. Earlier, supervision and personal reflections had helped to see that my reactions to Tara 4

Name changed to protect identity.

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signalled that there was something she really wished me to know. However, it was only in this interaction that I could fully grasp both the depth of my reactions and their significance for Tara. Prior to exploring my own countertransference, my interpretations were more detached, intellectual and may even have sounded jarring and stilted. This was perhaps my way of protecting myself from the discomfort evoked in me. I am now able to slow down and stay with her, look underneath my immediate responses and find a way for us to connect, instead of forcing her to immediately ‘make meaning’ of her experiences. This has created space for more authentic and meaningful moments between us.’

Meeting in Difference: Power in Therapeutic Relationships There is no denying that therapists and clients meet in difference, but we still find ways to connect with each other (Altimir et al., 2017). Clients seek therapist-experts, who hear their stories, set session durations and charge for their knowledge and time. It is evident that ‘if a therapist positions themselves as the “hero” who rides into a client’s life on a metaphorical white charger, believing that they will resolve all of the client’s difficulties, this positions the client as a grateful recipient’ (Hedges, 2010, pp. 87–88). However, this view obscures the complexities of how power is constructed and operates in the therapy space (Zur, 2009). A starting point is to reflect on our relationship with power in the therapy room. The relative position of therapists does mean that we have more leverage in some aspects of the relational process. In acknowledging our knowledge and power as therapists, we become more accountable for the way it is used. Many of us are ambivalent about holding power and may view it as a potentially negative force. Power is often associated with domination or control, but it is important to distinguish between having power over someone and having the power to accomplish something (Göhler, 2009). While we do not wish to exert our power over our clients, we do wish them to have the power to change their lives. It is when therapy empowers clients and supports their inherent capacity to make decisions, change and grow

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that it is most meaningful. The navigation of the terrain of power between the therapist and client, how power is situated in theories and mental health systems and policies, and the experience of power/ powerlessness by both client and therapist inside and outside the therapy room, all these are issues that impact the development of the therapeutic relationship. Both therapists and clients bring knowledge, agency and power into the therapeutic encounter, and our task is to strike a balance between holding too much power and relinquishing too much to the client, ensuring that both voices are present in the conversation (Brown, 2007). Power can emerge in both overt and covert ways even when we think we are in an egalitarian relationship—in the seating arrangement in the therapy room, the way in which therapist and client greet each other and how they reach an understanding about the client’s story. Our tone of voice, where we linger in response to our clients’ words or emotions, what we skim over or ignore and the times we are silent, these are all subtle ways in which the therapist may direct the process of therapy (Totton, 2009). At times, we might withhold select information about how we understand clients’ difficulties (e.g., a diagnosis or formulation), albeit with a benevolent intent. As we open some doors and close others, this directs the process of therapy in specific ways. The power difference can also be more palpable in certain contexts. For instance, practitioners who see clients from rural areas in India might have experienced how some clients take their footwear off before entering the therapy room or touch the therapist’s feet to indicate gratitude and reverence. Have you ever felt uncomfortable or uncertain when your client asked personal questions? For instance, ‘Are you married?’ ‘Have you ever lost anyone you loved?’ or ‘Which political party do you support?’ What is your comfort level in sharing your feelings about the therapeutic relationship with your client? For instance, saying, ‘I feel some discomfort or tension between us today.’ Through our responses to these questions, we can understand our stance, comfort and experience with self-disclosure. Our position about what to share and what to withhold can impact the balance of power in therapy. Deciding about what to share as a ‘real

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person’ and what not to share as a therapist is challenging indeed. If we are inscrutable and completely closed to our client’s efforts to know us, this can create a sense of distance in the therapeutic relationship (Marks et al., 2019). Our revelations can add a human dimension to therapy, fostering attunement and creating a more equitable relationship. Conversely, this sharing could feel overwhelming, unhelpful or unwelcome, even increasing our client’s sense of vulnerability (Audet & Everall, 2010; Roberts, 2005). The decision to ‘let some aspects of themselves be known completely, others moderately, others slightly, others not at all’ (Farber, 2006, p. 200) can be a delicate balancing act for therapists. As therapists, most of us can remember clients who challenged our authority and the status quo in subtle or direct ways, making us feel confused, frustrated or powerless. Consider a client who slams the money down on the table after a particularly challenging session or an adolescent client who saunters into the therapy room, puts his dark sunglasses on and sits back with a nod to the therapist. The power play can be much more subtle and expressed in the way in which clients ask about therapist’s age or qualifications. Client resistance to our enquiries or efforts can signify their own sense of powerlessness and a need to reassert some control. At these times, acknowledging and understanding the meaning of these power struggles can be critical (Totton, 2009). We might find it easier to connect with this feeling and understand the role of power in our clients’ stories if we recollect times when we felt powerless in our own lives. Flexible responsiveness in our power positions can strengthen our ability to create a robust therapeutic alliance with a range of clients. Some of our clients may want more direction and guidance, while others seek a safe space to assert themselves and some are ambivalent or need both (Short, 2011). We may choose to shift and share power or continue to assert our position as a therapeutic strategy based on the stage or modality, our client’s needs or developmental stage and situational needs. In the early stages of therapy, the relational asymmetry can be freeing for the client, who can benefit from the therapist’s knowledge and skills without the obligation to reciprocate (Altimir et al., 2017). The balance of power often shifts as therapy progresses; our

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client may talk more openly about what is working or what else they need and begin to feel more empowered. The bond between client and therapist may be experienced as more authentic and equitable, and this levelling often has great meaning for the client (Altimir et al., 2017; Zur, 2009). However, it may be better for the therapist to remain on guard about slipping into an unequal relationship. Once we have suggested to our client that ours is the voice of authority in the sessions, it can be hard for us to change that pattern. Of course, there are times when our client is suicidal or in a crisis that we may take back the power to act in their best interests. When clients are ambivalent, wanting to be in control and yet asking the therapist to lead the way, Short (2011) suggests that we attempt to meet both needs by taking turns with who is in charge. These powerplays have their own value; as the therapist and client accommodate each other, the client learns that the world is negotiable and that it is composed of persons with separate subjectivities (Muran & Hungr, 2013). Think of a time where you shifted the power differential or shared power with a client. How did this impact the process of therapy with this client? We need to be particularly cognizant of issues of power and autonomy with adolescent clients, and they may need time to assess and feel comfortable in the space and in the relationship. It can help to provide a boundaried therapeutic frame for a sense of control and ensure that our young clients exercise power through actions such as setting the therapeutic agenda, expressing their opinions and making choices (Cook & Monk, 2020). In couple and family therapy, we deal much more directly with the issue of power, both in terms of the relationship between clients and between the therapist and client. Imbalanced power between couples, for instance, is seen as an impediment to a mutually attuned and responsive relationship and is a significant target of interventions. Resolution of power-related issues between the couple requires actively identifying power issues, as well as an effort to both engage with the more powerful partner as well as support the less powerful partner (Knudson-Martin et al., 2015). As therapists, we must be mindful of the boundaries of the therapeutic relationship and guard against potential misuse or abuse of the power we hold. The onus of responsibility is on us to avoid the

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slippery slope into friendships, romantic or sexual relationships with our clients (Gutheil & Gabbard, 1993). The larger canvas of social inequalities, stemming from client–therapist differences in class, race, gender, sexual orientation, caste or ability, can also create power imbalances and impasses during therapy. Clients from disenfranchised backgrounds may be at a heightened vulnerability to therapist exploitation due to increased power differentials, and as therapists we might need to be extra sensitive in balancing power with such clients (Capawana & Walla, 2016). While negotiating power in the therapeutic relationship is challenging, we also need to examine, question and redefine power that is embedded in our models of therapy, mental health systems and policies. Post-modern theories have engaged most deeply with issues of power in therapeutic relationships and privilege the client’s personal power and vantage point (Sanders, 2011). We see this position reflected in their therapeutic processes and methods; for instance, in Tom Andersen’s innovative reflecting team approach in family therapy (Andersen, 1990), families are invited to switch places with therapists and observe and join the reflecting team’s discussions about the therapy process. No matter what our theoretical lens are, we need to look more carefully and critically at power and control dynamics within the therapy relationship (Proctor, 2008). Going beyond orientations, we are also aware that mental health systems and policies themselves could act as either enabling or constraining frameworks, privileging either clients or therapists. Interview: Power, Policy and Practice We interviewed Dr Soumitra Pathare, a consultant psychiatrist and the director of the Centre for Mental Health Law & Policy, Pune, to discuss the role of power in mental health work and care. This is an excerpt from the interview: ‘Q. How does power play out when a client interfaces with the mental healthcare system? The therapist–client/doctor–patient relationship is inherently unequal. It’s better to acknowledge this inequality, because then you

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can try and address the power dynamic. We are an extremely hierarchical society where people are culturally attuned to say, “Since you know more than me, you should make the choice.” The most common thing therapists say is “Well … my client prefers it that way, so shouldn’t I then do what my client prefers?” Q. What would your advice be to therapists on negotiating power with clients? I think you just need to make an effort. You need to put it back to them and tell them that I will give you as much as information as you need, in a language that you can understand, and answer your questions, but I want you to make the choice. Often people get into healthcare settings because they like to be in a position of power to decide for people’s lives. There is no space in our training for clinicians to reflect on that because our role models are all based on this notion of the “benevolent patriarch”. Paternalism in healthcare has nothing to do with gender—it is a style, and women in healthcare can be as paternalistic as men. Somehow, our training does not actually challenge that and, in fact, medicine and all of healthcare take pride in being paternalistic. Young therapists need to reflect, “Am I being paternalistic and is that a good thing for anybody, including me? Am I beginning to enjoy this?” Q. How could mental healthcare initiatives with communities address the issue of power? While working with communities, the rule is to try and make it as participatory as possible. This means listening to the community and understanding what they feel is likely to help them, and then presenting your point of view. It’s a matter of dialogue—not as a tick box to be completed or a focus group discussion. Q. You were part of the Policy Group appointed by the Ministry of Health and Family Welfare, Government of India, to draft the National Mental Health Policy. How did you handle these issues of power during your mental health policy work? There are no easy answers to that question. A certain degree of honesty is required from everyone who is engaged in that process—a

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bureaucrat, an activist or a representative of the professional community. In negotiating policy, you are trying to do the greatest good for the greatest number of people. One’s role as an honest broker in that policy process is to try and create a level playing field while ensuring some philosophical, moral and ethical basis to these actions. At the patient level, the notion of a “nominated representative” reflected the voices and concerns of two disadvantaged groups: women’s groups saying, “I don’t want the usual system where the husband makes decisions for me” and the LGBTQI groups saying, “I don’t want anyone in my family to make decisions for me; I want to choose who should make decisions for me when I can’t make decisions for myself.” Going down that route was obviously criticized as against our Indian culture, where the family decides and knows what is best for you. Let us say that in a room full of 10 people, if 9 people agreed on everything, that does not necessarily mean that it’s the right thing to do. Democratic policymaking requires taking care of the needs, wishes and fears of the minorities, as much those of the majority. This requires time and effort, and it ends in a slightly messier solution, but is more inclusive. Everyone leaves the table thinking that I did not get everything I wanted, but I got quite a few things and I didn’t get anything less than what everybody else got.’

The End Game: Termination of the Therapeutic Relationship Termination is an inevitable part of the therapeutic process, sometimes mutual and planned and at other times forced or unilateral. A good-enough termination allows for the exploration and validation of emotions about ending the relationship and resolving any ruptures, a review of pivotal moments and changes in therapy, and a sense of looking ahead for both the client and therapist (Knox et al., 2011; Norcross et al., 2017). Perhaps a good beginning for our reflections is to think about how we view the termination of therapy. Do we look at it primarily as a loss of the relationship with the key task of separationindividuation or as a transformative bridge that can facilitate growth and development (Quintana, 1993)? Do we tend to see termination

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as indicating the permanent end of the therapist–client relationship or as a phase for processing a relationship that endures in our memories? These views will impact what we feel at the end of the therapy, the way we understand and respond to our clients’ feelings and how we make sense of these experiences. Session endings can be microcosms of therapy endings, and we need to be finely tuned to what our clients might communicate in the space between the chair and the door (Gutheil & Simon, 1995). While some of our clients may struggle with the ‘little endings’ within each session, manifested in abrupt closures or in efforts to extend session time (Moursund & Erskine, 2004), therapists could also encounter difficulties as the session draws to a close. The end of the therapy session can feel abrupt or awkward, and the emotional transition from deep caring to ‘I will see you next week’ can be a hard one to make. Our experiences at the edge of the therapeutic hour show us how comfortable we are in saying, ‘Our time is up’ (Gans, 2016, p. 413), especially in the face of emotionally intense communication or unexpected disclosures from our vulnerable clients. If we often find it difficult to end our sessions on time, our reflections can tell us what we need to work on. Is it about the role we wish to play in our client’s life? How we think therapy is supposed to work? Or our discomfort with not being liked? Negotiating session endings can also provide a practice ground for closing words and rituals and prepare both the client and therapist for the eventual termination of therapy (Sher, 2014). These endings are not sacrosanct, and the therapeutic frame does not have to be an unyielding fence (Gans, 2016). Some flexibility in extending the session time is warranted for certain clients and contexts, for example, in a crisis, and therapists may do this selectively. Termination of therapy can mean different things to different clients, and creating the space to discuss this can protect against assumptions about our client’s response (Macneil et al., 2010). Clearly, some terminations might be more difficult than others, with vulnerable clients who have a history of previous losses and attachment vulnerabilities or when therapists are more sensitive to endings. Our understanding of clients’ attachment styles can help us anticipate their approaches to termination and tailor our responses accordingly. For

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instance, clients with an avoidant style may deny the importance of termination or of the relationship and slip back into their comfort zone of detachment. It is important to help them stay connected with their feelings and those of others and encourage them to draw on learnings within the co-created emotional space in therapy. For an anxiously attached client, possible feelings of anger, anxiety, grief and abandonment may be overwhelming, and the therapist would have to step in more actively to structure the process to help them work through their intense cognitive and emotional responses (Zilberstein, 2008). In response to developmental considerations of work with children, therapists may take the extra step of tangible reminders that can be revisited, such as creating an album of the therapy work done together. Talking about what the child would want to remember and how they would be remembered by the therapist can also help the child at a later developmental stage. Termination with children does not have the same finality as working with adults and can allow for ongoing connection or a later return to therapy (Zilberstein, 2008). Since ‘termination is always about two people saying “goodbye”’ (Marmarosh, 2017, p. 4), therapist attachment styles and emotional responses to therapy endings also need attention. Therapists with secure attachment styles may engage more deeply with the process of termination (Ledwith, 2011). The therapist who tends to be avoidant may stay in the safe zone of positive emotions and discuss therapy gains, without tuning into or processing the messier emotions experienced by the client. Termination might even be brought forward to minimize dependency and deeper relating between the therapist and client (Holmes, 1997). The therapist who is sensitive to relational separations may experience a range of difficulties during termination, and these feelings may overshadow the client’s reactions and needs. As feelings of sadness and guilt arise about abandoning the client, the termination of therapy could be pushed forward. As therapists, we need to reflect on our early relational experiences, how we are in our current relationships, and our feelings about distance and intimacy. Reflections on our personal experiences with losses, transitions and endings; travelling to another country on vacation; a change of school; a breakup; or the death of a family member can increase awareness of our comfort with separations, change and ambiguity. We know

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what we need to do at the culmination of this shared journey, but if we are uncomfortable with termination, we might miss doing this, or even hesitate to call an end to ongoing relationships with our clients. We need to act intentionally in a way, which is responsive to client’s attachment style, be careful that our own needs are not being played out and try to address any of our vulnerabilities during this phase. Handling the termination more carefully with clients who have attachment injuries, by preparing early for termination, and allowing time to work through their feelings can mitigate some of the complicated and ambivalent reactions (Juul et al., 2020). It may be more meaningful to view the final phase of therapy as consolidation, replacing the finality of the word termination (Maples & Walker 2014). In a similar vein, Zilberstein (2008) recommends a change in how termination is understood, one that emphasizes connectedness rather than separation, allows for ways to remember the relationship and accepts that there may be a knock on the therapy room door again. Therapeutic endings may have different meanings but deserve attention in both time-limited and long-term therapies (Mander, 2000). The awareness of the inevitable endpoint makes termination the central issue in time-limited therapies and possibly accelerates the pace of change. The circumscribed time frame means that we must assess if clients have ‘places to land’ (Smith, 2002, p. 463), with adequate resources and supports, as their journey continues without the therapist. We need to be aware that inflexible endings impose constraints on the amount and nature of therapeutic work that can be done. Even though termination may not come as a surprise, it is important to explore our clients’ feelings about this predetermined closure (De Geest & Meganck, 2019). In some time-limited therapies such as cognitive analytic therapy, goodbye letters are used to take stock and share feelings, with planned follow-up sessions to monitor and support change (Ryle, 2005). In long-term psychotherapy, we need to attend to the tasks and processes of termination while guarding against dependency in the relationship and an ongoing search for a ‘perfect’ ending (Juul et al., 2020; Mander, 2000). The reasons for ending therapy and the context of termination— forced, client-initiated or therapist-initiated, planned and collaborative

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or unexpected and unilateral—all influence how we understand and process the experience. During our training years, much of the focus is on how to build and sustain our connection with clients, and relatively less on the emotional demands and challenges of saying goodbye. As trainees, we often experience interruptions and forced terminations, due to the structure of placements and internships. There is no turning back and little opportunity to prepare for these endings, adequately process our emotions, such as sadness, guilt, anger and relief, or critically reflect on these endings (Zuckerman & Mitchell, 2004). Later in our careers, we could experience difficult feelings evoked by therapy endings due to events in our personal lives, for example, job changes, pregnancy, illness and retirement. Through our reflections on these interruptions and cessations, both therapists and clients can be prepared and supported during this transitional period. Most therapists will encounter abrupt and ambiguous therapy endings during their careers. Sometimes these are initiated by our clients, but we have all experienced moments when a client leaves us feeling so confused, depleted and inadequate that we wish for the end of these interactions. We might also weigh this option of terminating therapy when progress seems blocked or the relationship seems to have broken down irretrievably. When such strong emotions seem to be fuelling our thoughts and decisions about termination, we could reflect and seek consultation or supervision to find direction and closure. It can be particularly challenging when clients terminate therapy without discussions with their therapist, leaving unanswered questions and complex emotions in their wake. Such experiences could impact our sense of self, our personal lives, and the ways we manage distance and intimacy with future clients (Ogrodniczuk et al., 2005). We may protect ourselves by focusing on client-related factors, attributing the premature departure to their psychopathology and factors that emerge from therapist; the therapeutic relationship and the context may not be recognized as easily. An understanding of our own emotional reactions and contributions and the probable reasons for termination may emerge only after deeper reflection and scrutiny (Piselli et al., 2011; Schaeffer & Kaiser, 2013). The onus is on the therapist to engage in a reparative process where needed, for the benefit of future clients

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and for one’s own professional growth. Looking back, we can ask ourselves various questions: Did I prepare my client for therapy at the start, and discuss what therapy is about, how long it might take and the potential difficulties and processes? Did I have the required skills and expertise? Did I tailor the therapy process to my client’s needs? Could I have done something differently or at another time? Was I too inflexible? Did I miss the signs of an alliance rupture? Did I slow down the pace of therapeutic work and attend to the therapeutic alliance when needed? Did I seek and incorporate feedback from my client? Did my emotional involvement in the therapeutic interaction or my difficulty in relating to the client play a role? Of course, we must consider our own contribution to termination, but we cannot lose sight of the range of factors that can influence client-initiated termination—many that are not directly related to the therapy process. Client dropout may well stem from the affordability and accessibility of treatments and varied life situations and constraints. Indian therapists discussed how premature terminations may occur when the family controls access to therapy and may also be more likely among disadvantaged clients (Chakravorty, 2020). We need to guard against self-criticism or lingering feelings of shame when our clients leave us prematurely. This need not be a solitary journey, as our peers and supervisors can provide support, perspective and learnings from shared experiences. Each ending may be different and is a time and opportunity to learn something about ourselves, our clients and the process of therapy. We may also need to accept that things do come to an end, especially therapy relationships. And an ending is not necessarily a bad thing. For the client, it can mean an end to suffering or an end to a bad phase in their life. Therapy endings usually mark the beginning of new possibilities. It could be so for the therapist as well. A Therapist Speaks: On Letting Go Dr Dharani Devi, a clinical psychologist and private practitioner who specializes in working with individuals with borderline personality vulnerabilities, shares her experiences of an abrupt discontinuation of therapy.

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‘I began seeing Mira,5 a single woman in her late 30s with a mood disorder and personality vulnerabilities. Mira grew up feeling unsafe in a chaotic and unstable home, with experiences of sexual abuse, complicated relationships with her mother and brother, and a father who had completed suicide. Since childhood, she had experienced her mother as “pretending” to care for her while simultaneously being hostile and critical and failing to protect her from harm. She was now estranged from all family members and lived alone. Our relationship evolved over the course of four years. Her previous therapist described Mira as a “difficult patient” and cautioned me about “defending boundaries”. Over the course of therapy, I slowly had to relax some of my “strict” rules and boundaries, and she had to learn to follow some. Through the course of our work together, I alternatively felt proud of her, worried about her and her lack of social support, was frustrated with her and admired her resilience—much like a mother. She had become quite special to me. The termination of therapy occurred abruptly in the initial stages of what was later a clear psychotic breakdown. Entire sessions were dominated by her insistence that one of her colleagues was sexually harassing her, and I found it difficult to relate to her interpretation of her colleague’s actions. After one such session, Mira emailed me stating that she did not want to continue therapy. While I cannot say that this unilateral decision was totally unexpected, it still surprised me. The session seemed to have gone well despite our differing perspectives, and we had “agreed to disagree”. I tried reaching out to her, but she responded saying that she was okay and did not want to meet me. Accepting what I felt and staying with it opened the door for other thoughts and emotions: worry, anger, frustration, hurt and guilt. Had I let her down in the same way “everyone” else in her life had? Was it my fault and lack of competence that she felt this way, despite our long alliance? I also felt frustrated that this had happened just as we were making progress and she had remained stable for an entire year. I felt betrayed and was angry with her for not having trusted me “to know better”. 5

Name changed to protect client identity.

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In fact, it was an email from my client that brought things into perspective—she understood my concerns but wanted me to “let her go”. A few months later, I met her while she was recovering from her psychotic episode. She expressed that she had missed me and appreciated the therapeutic journey. It was not that she “didn’t care” but felt that we had achieved everything we could have together. She spoke of her anger at feeling unsupported at a crucial point in her life but believed that my intentions were good. She wanted to resume therapy, just not with me. This experience uncovered my hidden beliefs regarding “successful” therapy and therapists and the role of power and control. Gradually, I appreciated how Mira had come a long way and had exercised her sense of agency in the relationship. Termination is the client’s prerogative—this was one of the most important lessons for me.’

Perspectives on Training and Development Training and Frameworks for Relational Skills Training programmes need to incorporate frameworks that focus on competencies for creation, cultivation and maintenance of the therapeutic relationship. Focal areas could include transtheoretical training in the identification of critical relational markers and resolution of ruptures (Eubanks et al., 2015) and strategies for recognizing and addressing countertransference (Cartwright et al., 2018). Research findings have highlighted that therapist qualities of self-integration, empathy, self-insight, anxiety management, or conceptual skills and the ability to mentalize about their own feelings, needs, beliefs, reasons and processes (Barreto & Matos, 2018; Bhola & Mehrotra, 2021; Van Wagoner, Gelso, Hayes, & Diemer, 1991) can aid in the awareness and management of countertransference. These findings tell us what to integrate into therapist training and address through transtheoretical models of countertransference management (Cartwright et al., 2018; Gait & Halewood, 2019). Staying in tune with emergent research about alliance-focused training and relational skills training modules

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is recommended. Trainees experience difficulties with their clients due to premature terminations and case transfers during their clinical rotations/internships, and both incoming and outgoing trainees need more support with such relational transitions and skills to reduce premature terminations (Ben David-Sela et al., 2020; Schwartz et al., 2018; Shaharabani Saidon et al., 2018). The recent advent of tele-psychotherapy warrants training in both technical (e.g., placement, lighting and distance from the screen, and secure encrypted connections) and relational aspects (e.g., attention to ostensive cues) to facilitate presence, attunement and safety in the digital therapy space (Geller, 2020). Our training modules need to be cognizant of cultural constructions of relationships, and how this can impact the nature of the alliance. In collectivistic cultures like India, client expectations about roles and responsibilities as well as the frame of relationships can be different, and trainees will benefit from being taught about how they can be responsive to this. Relational Skills and Supervision When trainees experience disruptions in the therapeutic relationship, an exploration of the role of one’s own attitudes, biases and assumptions, personal issues or interpersonal skills needs a facilitative supervisory space. Trainees learn not just from the course content but more significantly from the attitudes and stances they see in their trainers. When our supervisor can attune with us, and soothe us with their presence, we experience the power of co-regulation first-hand. Where our supervisors and trainers attend to ruptures in our relationship with each other and do so respectfully and caringly, we experience that those relationships can be rebuilt and strengthened in the process. We can learn how to connect with clients when our teachers connect with us. Effective training in relational skills can only occur in a sensitive and safe training environment in which we learn that all therapists encounter relational challenges, feel comfortable in sharing our experiences and emotions around therapeutic relationship difficulties and strengthen our repertoire of skills.

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Measurement of Relational Quality and Processes in Therapy The use of various tools to measure alliance or presence through the course of training could also be helpful in sensitizing trainees to examine, process and use this perspective more effectively in their work. The interested trainer can consider tools such as the Working Alliance Inventory (Horvath & Greenberg, 1989),6 which assesses the bond and the agreement on tasks and goals of therapy from client, therapist and observer perspectives.

Conclusion With every client, a new journey begins—to know and be known. Both the client and therapist discover parts of themselves as they meet another person with their own perspectives, values, experiences and feelings. Although the therapeutic contract may end, and the therapy process may be terminated, the therapeutic bond remains as the client and the therapist live on in each other’s minds.

6

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Chapter 6

Understanding Personal and Professional Values

Values are beliefs that represent what is important to us and guide how we live our lives. We develop our value systems over time, imbibing influences from varied spaces including family, social networks, educational experiences, community, sociopolitical affiliations and our cultural context. A lawyer who pushes for justice, a photographer who is motivated by creativity and passion, a social worker who speaks of the importance of compassion and altruism, a priest who addresses the congregation about religious guidelines and family bonds—these examples depict the deeply held convictions that people live and work by. Values are at the core of who we are and influence (a) our thoughts (I believe that each human being should be treated with dignity), (b) our feelings (I feel very strongly offended when I see people being rude to poor or disempowered individuals) and (c) our behaviours (I am always polite to wait staff at a restaurant). Considering how central values are in our lives, it becomes imperative to ask ourselves what role they play in our psychotherapy practice. The traditional analytic stance of the therapist being a ‘blank screen’ (Eagle, 2000) and the ethical mandate to avoid the imposition of therapist values, attitudes and beliefs on clients together represented a position where therapist values were seen as irrelevant or even

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harmful when brought into the therapy room. The aim was to keep the therapeutic space safe for clients to share their thoughts and feelings, choose their goals and make decisions without having to necessarily adopt the therapist’s value lens. This value-free or value-neutral stance perhaps reflected the pressures on psychotherapy to be a scientific discipline and disregarded the ambiguity, irony and paradox inherent in practice (Holmes, 1996). However, over time, theoretical models acknowledged the inevitable interplay between therapist and client values, and complete value neutrality was no longer considered either tenable or desirable (Jackson et al., 2013). The focus has now shifted to the awareness and navigation of values in the therapy room, considering that values are implicit in the work we do and the theoretical orientation we adhere to (Fife & Whiting, 2007). By being reflexive, we may also develop an understanding of our client’s beliefs and values and gain a deeper appreciation of their context and world. This process of looking at the world through another person’s eyes is difficult, and this can be harder when people seem different from us. An interesting initiative on building empathy is an international travelling participatory art project. In the Human Library exhibit, we can ‘borrow’ a person for conversation, someone whose values and experiences may be quite different from our own. Visitors to the A Mile in My Shoes travelling exhibit are invited to literally walk in someone else’s shoes while listening to an audio story about the actual shoe owner’s life. These immersive experiences provide an understanding of stories and lives we may know little about: a sex worker, war veteran, neurosurgeon, refugee or prisoner turned artist. This process of reflexive listening illustrates how empathy and perspective taking are core values in our therapeutic encounters with diverse clients. What personal and professional values do we hold? How do values enter our therapeutic space and how do we make choices around them? When do we speak about them and when do we guard against them influencing our clients negatively? This chapter presents perspectives to engage with these questions that we might have grappled with at various points in our careers and discusses pathways for therapists to negotiate value conflicts that emerge in therapy.

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Values and the Practice of Psychotherapy The profession of psychotherapy itself is based on certain values such as autonomy and empowerment, along with notions of what a healthy or good life is (Jackson et al., 2013; Jadaszewski, 2017). Some of us may come into the profession because these professional values deeply resonate with the personal values we hold and believe in. For instance, we may choose to become a therapist as a way of expressing the core value of altruism. As we train and enter the field of psychotherapy, we naturally internalize many of these professional values. Both professional and personal values further guide what we expect of ourselves and what we hope for our clients. For instance, we might gravitate towards models that align with our core value system and provide us an opportunity to express the values we hold (Tartakovsky, 2016). McLeod (2010, p. 154) highlights how ‘if aesthetic/artistic values are highly significant for you, then this may imply developing a theoretical approach that makes space for creativity’. Of course, immersion in a particular psychotherapeutic model may in turn also influence our values and world view (Carlson & Erickson, 1999). Our values—both personal and professional—influence our therapeutic work in many explicit and implicit ways. Pause to think about the values that are central to your preferred theoretical orientation/s. As therapists, we might seek congruence between our defining personal values and our work by choosing our practice settings or by making clients aware of the values embedded in our practice. For instance, a therapist strongly committed to feminist values may start a community organization which engages in advocacy and offers services for women experiencing intimate partner violence. Another practitioner might explicitly state the values that inform her therapeutic practice on a professional website. Our value choices are reflected in various aspects of our practice, for instance, how we charge for sessions, the typical number of sessions we see our clients for and whether we encourage inter-session contact. Our values determine how we

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approach diagnosis (e.g., do we see it as a useful tool or a harmful label?), how we conceptualize clients’ concerns (e.g., do we see a client who wants to stay single as someone who values independence or is avoiding intimacy?) and the nature of goals we set (e.g., do we encourage a client to risk an alternative career or value the security of a regular job?). In fact, our values lay the template for our entire stance and way of being in therapy. Carlson and Erickson (1999, p. 70) emphasize that ‘Whenever a stance is taken, certain values are favored over others.’ For instance, therapists have shared their reflections on how their personal values such as honesty, compassion, tolerance, respect and equality impacted the way they approached the therapeutic process and how they shared power with their clients (Duggal & Sriram, 2021a). As therapists, if we miss examining our own values, we may not just be blind-sided when it comes to our own stance but also struggle to provide a supportive context for clients to examine their values (Corey et al., 2011; Williams & Levitt, 2007). Therapists who are more reflexive about their values may be more open to engaging in meaningful therapeutic conversations about them (Fife & Whiting, 2007). This is particularly relevant in the context of current psychotherapy practice. Aponte (1985) discusses how times of accelerated social change often led to active questioning and negotiating of values, leading to value confusion. With the growing influence of media, technology and globalization, we are experiencing tremendous social transformation in India. Ways of parenting, gender relations, sexuality and attitudes towards work and family are all evolving, resulting in a range of value dilemmas that clients might feel safest bringing up in therapy. When clients come to us with questions around their values, it can be tempting to respond by sharing our own; and therapist and client values may become more similar or converge over the course of therapy. Perhaps this is better termed value conversion, as it is usually the client’s values that become more akin to the therapist’s (Tjeltveit, 1986) As therapists, we need to exercise restraint and ensure that clients’ values are not influenced, either overtly or covertly, against their wishes or without their consent (Jadaszewski, 2017).

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As we progress along our professional journey, we may find an increasing resonance between our personal and professional values, and this can help us contribute meaningfully to the field (Rangarajan & Duggal, 2016). If we stay connected to what we stand for early in our careers itself, we may be better positioned to make choices that allow the personal and professional to align.

Unpacking Our Values As we examine our personal values and what they stand for, we can become aware of what we are committed to upholding. Because values reflect our understanding of what is good or bad, right or wrong, or important or unworthy, becoming aware of our core values can be a useful guide to examining our feelings, attitudes, choices and behaviours (Rokeach, 1973). Although values strongly influence our goals and behaviours, it is not always easy to give them a label or define them clearly. Examining a model of universal values such as the one given by Schwartz (2017) can focus and support our reflections on the relative significance that each value holds for us. The model represents 19 values (e.g., caring, tolerance and achievement) that are linked to our thoughts, emotions and actions. Values that are important to us could be compatible or conflicting with each other; for instance, behaviours and choices associated with caring are more likely to conflict with behaviours associated with achievement but could be compatible with tolerance. Sometimes our values only reveal themselves by how we respond or behave in different situations. For instance, we may not be aware of how much we value independence, until we are in a situation where that independence is challenged. We may also become more acutely aware of our values during times of crisis and rely on them to make meaning of our situation and take appropriate action. Reflecting on our responses during interactions with others can also clarify which values are more central to us; perhaps we feel closer to someone who demonstrates this value or get upset when anyone violates this value. We learn and imbibe many of our values from our family environments, often through interpersonal identification with parents (Podolskiy, 2012). This process may be implicit or explicit, and our

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childhood experiences can have a powerful influence on the values we hold as central during adulthood (Kasser et al., 2002). This process of delving deeper into how our value systems have evolved can help us examine similarities and differences between the values we learnt early in life and the ones that may have developed later as adolescents or adults. You could try these reflective exercises to map the values you endorse and prioritize. List out 10 things you value the most in your life—this could be a person, place or experience, and ask yourself what exactly you value about them. Organize your list in order of priority, with more important values coming first. Is there any value you would pick as central to you, and how do you express this in your life? Another way of understanding your values is to consider the life experiences around which they might have been shaped. Think of the proverbs or sayings that were often used in your family and reflect on the values they endorse. Reflect on any difficult time or crisis that your family might have gone through. What values did they hold on to (e.g., forgiveness and perseverance). Do you consider any of these values as important in your own life? We can also trace the genesis of our values through the groups and communities that we belong to, including educational institutions, sports teams, and religious and professional organizations (Grusec, 2011). Each of these social groups may set standards about the ‘right’ way to do things and have a set of core values which we might have internalized. Considering the extent to which our values are couched in culture, delving into how personal values interact with cultural and professional values becomes the next step. While our personal, professional and cultural values could be in complete tandem, at other times there might be tensions and opposing pulls. Cultural values in South Asian countries include collectivism, conformity to family and social norms, deference to authority figures and self-control (Kim et al., 1999). However, individuals within the same location, city, community and even family can have diametrically opposite views. So for each of us (both therapists and clients), the aspects of the Indian culture that we endorse may be different. While some of our personal values may be synchronous with cultural

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values and expectations, such as duty, tolerance, non-attachment and non-violence (Fusilier & Durlabhji, 2001), others may be dissonant or contradictory. Clients may bring concerns and conflicts related to marriage, divorce, childrearing, birth control, abortion, extramarital relationships, suicide and child abuse, which might stem from personal and cultural value positions. Becoming aware of our own value stance could help us work with clients when they present these concerns and help us take cognizance of how our values may be expressed in these moments (Fife & Whiting, 2007). The Delphic dictum nosce te ipsim/know thyself is perhaps the most central psychotherapeutic value of them all (Holmes, 1996). Being in touch with our values can aid in resolving difficult dilemmas, especially when they conflict with each other, or some need to be prioritized over others. When we recognize our values, we are less likely to become ‘therapist vigilantes’ and impose value positions on clients (Carlson and Erickson, 1999). Instead, we may be better placed to facilitate a similar process of exploration and awareness for our clients and enable them to make well-informed choices. Varied experiences in personal and professional spheres and cultural shifts may result in changes in our values. This only emphasizes the need for therapists to continue the process of self-exploration and reflection on their core values. This brings us to the understanding that deciding to reflect is also a value-based choice, one that prioritizes questions and embraces multiple perspectives.

The Elephant in the Room: Values in Therapeutic Interactions Values enter the therapy room through many different doors and in many different guises. Sometimes, their presence is explicitly and obviously felt, but often, values are expressed in subtle ways and can be easily missed, unless the therapist is alert to the possibility of their presence. We might gauge client’s values by being sensitive to their choice of words and the emotional intensity with which they describe their experiences or stance. This process often begins early in therapy while

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identifying the client’s goals and understanding the core values they represent. For example, it may be important for the therapist to parse out if a client’s stated desire to work on interpersonal skills is motivated by achievement and/or affiliation, as this will impact the focus and type of intervention. Therapists may make inferences from the appearance, clothing, setting and non-verbal behaviour of clients, and make (sometimes incorrect) assumptions about their value positions based on that. While it is true that certain groups of values tend to cluster together, it is not uncommon for values to appear in seemingly surprising combinations. For example, a conservatively dressed client can be very free-thinking, though she may not appear so. Sometimes clients prioritize values that may obstruct their own goals and even contradict the goals of therapy as well (Williams & Levitt, 2007). For example, if the client’s value of family cohesion and harmony prevents them from revealing family secrets, the therapist might find it harder to create a working relationship and establish shared goals. Therapist values enter the therapy room in complex ways as well. As therapists, we may not be aware that our values have been activated until we feel an emotional reaction that surprises us, especially when the reaction diverges from the norm or the therapeutic plan. Experiences of feeling bored or disengaged from the client, difficulty establishing a therapeutic relationship or creating a shared goal can suggest value differences. We may also feel an affinity towards a particular client because something they said or did resonated with our personal values. Holmes (1996) recommends a deliberate reflection on potential indicators of our ‘ethical countertransference’, which can help us become more aware of our values and how they affect our work. It might be helpful to ask ourselves: Were we too encouraging when our client spoke of reconsidering her decision to divorce her husband? Do we tend to align strongly with our adolescent clients when they resist parental demands and control? Were we too enthusiastic, curious or judgemental when our client shared about their usage of a dating application? Differences between therapist and client personal values may be the norm rather than the exception. Farnsworth and Callahan (2013) identified four types of client–clinician value conflict: pre-emptive,

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adjacent, operational and unarticulated. A pre-emptive conflict is an a priori value conflict which makes it difficult to engage in therapeutic work, for instance, a therapist who feels that they cannot work with a client seeking an abortion due to their religious belief system. Adjacent value conflicts arise when client values clash with the personal values of a therapist but do not necessarily interfere with goals of therapy. Operational value conflicts are those where the therapist and client share values, for instance, ‘forgiveness’, but do not agree on the associated behaviours. The client may want to show forgiveness by staying in an abusive relationship with their partner, but the therapist may wish them to show forgiveness by forgiving themselves for wishing to leave. Finally, unarticulated value conflicts are those where one of our less conscious values are being violated, where we may feel a sense of unease or disquiet but are not able to express or understand why. Women who wish to end their marriages or men who wish to quit their jobs may be issues around which our stated position and choice of therapy goals may remain value neutral, while our emotional responses may tell a different story. If a therapist feels a sense of unexplainable distance or ‘otherness’ from the client, it may be that they hold different values. Depending on how deeply one holds the value, the therapist can experience varying degrees of distress and emotional turmoil. We might need to check if the discomfort is arising from a prejudice or countertransferential reaction before considering if it is a function of a value conflict (Farnsworth & Callahan, 2013). Considering that value conflicts create emotional distress, it is not uncommon for clients to present with value conflicts which they bring up openly and explicitly, for instance, making a choice between looking after aged parents or going abroad for a higher education opportunity. At other times, the therapist identifies what the client is grappling with and frames this as a value conflict to further therapeutic work. Read this vignette and consider your perspective on the value conflict the client is experiencing: A married female client in her early 30s is unhappy that her husband spends less time with her and shows little interest in being physically intimate. He is otherwise a good provider and a stable human being. She comes to therapy, feeling very distressed

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and wondering how she should respond. Should she push for more intimacy? Or accept him this way? In this vignette, the client appears conflicted between valuing relational intimacy on the one hand and valuing stability and tolerance on the other. Therapists who value tolerance could be inclined towards ways for her to find acceptance, while therapists who value stimulation might first look at ways of building intimacy. Of course, therapists who value self-determination may put more effort into helping her decide for herself. Even where we do not verbally indicate a direction, we may convey our approval or disapproval non-verbally, by a nod or smile, or how welcoming we seem to the client’s ideas. When interacting with someone who sees the world similarly to us, we tend to like them, be supportive of their choices and perhaps gloss over their blind spots, offering less space to discuss contrary values or suggest possible changes. There are added complexities in couple and family therapy contexts, as we have the individual values of each person to consider as well as family values (Bloch & Harari, 1996). As therapists, we may align more easily with the spouse who shares our values of how marriage/ family should be (e.g., concerning sexual fidelity and the sanctity of marriage), leaving the other spouse feeling alienated or unheard. The alignment can be expressed by giving the favoured spouse more airtime or privileging their issues over the other spouse’s. This might reflect on how the problem is formulated, solutions are arrived at and the order in which they are addressed and how therapists hold space for all those who are in the therapy room.

Intersections between Values We are influenced by both personal and cultural values and may experience either compatibility or misalignments at these intersections and in their interactions with each other. The emotional impact of such value conflicts is illustrated in the Tamil novel One Part Woman by Perumal Murugan, where the protagonist and her husband were unable to conceive (Murugan, 2013).

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The societal pressure that holds the family’s highest purpose as that of having children, and places responsibility for conception on the woman, is tremendous. This pressure, both subtle and overt, intensifies, and she agrees to go against her value of fidelity to have a child, with tragic consequences on their relationship. As therapists too, we may experience inevitable pulls between what we value personally, the principles that our profession upholds and cultural ideas of what is good, right, just and desirable. Therefore, we need to understand where our values and those of our clients meet and where they diverge or conflict with each other. Value-related pressures and conflicts may be experienced even within ourselves, between two personal values (e.g., conformity vs self-direction), two professional values (e.g., autotomy vs beneficence) or two cultural values (e.g., independence vs relatedness). For instance, an adolescent wanting to individuate and leave home at the age of 18 years may be considered healthy in some countries, but potentially oppositional in India, where breaking away from the family fold may be seen as a violation of family bonds and duties. In such a context, an Indian therapist may wonder how the individual’s wish for autonomy can be negotiated in the context of the family values. These webs of values can interact in different ways, sometimes supporting and sometimes conflicting with each other. Both personal and professional values are influenced by culture or rather many different cultures, a situation that creates many complexities. Therapists’ personal values might mirror cultural and/or professional values or could be in strong opposition with them. For instance, coming from a patriarchal system, some therapists may not recognize intimate partner violence as a huge violation, while others feel disturbed by this position, as it strongly conflicts with the professional values of justice, human rights and dignity (Sinha et al., 2017). As therapists, we need to be aware of the dominant discourse and cast a reflexive gaze on our own positions, assumptions and biases. Key professional values or principles, for example, beneficence or autonomy, are culturally mediated and may be interpreted or prioritized differently across cultures and contexts. While client autonomy is privileged in Western contexts, the concept of ‘relational autonomy’

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may be more important in Asian cultures (Bhola & Chaturvedi, 2017). Family members are often involved in the help-seeking process and in key decisions made during the therapeutic process. This is often experienced as culturally congruent, not just by clients and their families but by mental health practitioners as well (Wasan et al., 2009). While it is important to understand values contextually, we also need to remember that all clients and all therapists who belong to the same culture need not share the same world view.

The Blind Men and the Elephant: Attending to Values in the Therapy Room There are different ways of addressing values, and all of them are equally relevant depending on the context of the therapeutic interaction. We reflect on how we can attend to the needs of the client and the therapy process while remaining integrated and genuine in the face of value challenges. Matching Client and Therapist Values Should therapists and clients must share the same world view and be aligned on important values? Matching therapists and clients on this basis may not be easy to implement; there are questions about which value or interconnected values should be matched and constraints related to the practice setting and the availability of therapists. Additionally, research results are inconclusive about the impact of client–therapist matching on therapy outcomes. While select client– therapist value similarities enhanced by therapeutic outcomes, so do certain value dissimilarities (Arizmendi et al., 1985). Kelly and Strupp (1992) demonstrated the ‘Goldilocks principle’, with moderate levels of value similarity, predicting therapy gains. Interestingly, Hogan et al. (2016) reported that patients’ perception of value similarity impacted the strength of the alliance, while actual value differences did not impact either alliance or outcome. The significance of a lack of a match in values may be particularly salient for certain values, such as those related to religious beliefs

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(Tjeltveit, 1986) or sociopolitical positions (Goldsmith, 2020). When political views are shared, therapists may feel more comfortable to disclose their political stance and even report a stronger sense of connection with their client (Solomonov & Barber, 2019). Both therapist and client may initially ‘feel around’ to sense the other’s position and experience a sense of relief and camaraderie if they are similar. Divergent or polarized sociopolitical perspectives carry the potential for detrimental effects on client–therapist interactions and the therapeutic process. A sensitive awareness of these differences and their possible impact on the relationship and therapeutic choices, as well as respectful dialogue, can help strengthen the alliance and resolve any ruptures (Redding, 2020; Solomonov & Barber, 2019). Similarly, sensitivity to client’s religious beliefs may be more critical than similarities in our belief systems. Pause to think about how you respond when ‘politics’ enters the therapy room. If a client expresses their political views during therapy, do you invite them to share further or do you feel uncomfortable with such discussions? If you feel offended by a client’s political views, what do you usually do? Do you consciously keep your political views out of the therapy room? Overall, the message for therapists is that difference and diversity are to be expected, and this is not necessarily an insurmountable barrier. In fact, differences are as important as sameness in relationships (Slife & Higgins, 2009) and as therapists, we learn to accept and appreciate the ‘otherness’ of our clients. Equally, clients’ acceptance of differences within the therapy room can help them extend this to people and contexts outside this interaction. Prioritizing Client Values in the Therapy Room A value-sensitive approach privileges clients’ values about goals and positions the client as the ‘expert’ (Heilman & Witztum, 1997; Williams & Levitt, 2007). As tourists in the client’s world, we can choose to keep client’s values intact, even if this means an incomplete resolution of their problems or a conflict with our own personal values. One of the methods advocated for therapists is bracketing, a self-reflective process of intentionally setting aside personal beliefs to focus more empathically on understanding the client’s world view

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(Jackson et al., 2013; Kocet & Herlilhy, 2014). We may also change or restrict therapy goals to accommodate to the value system and cultural context of the client. In the face of emergent value conflicts, Buddhist-inspired acceptance and mindfulness approaches recommend beginning with the acceptance that no two people can have the same values (Choudhuri & Kraus, 2014). Having a ‘beginner’s mind’ or an open and curious stance about the client’s value system (Suzuki, 1970), and the mindfulness stance of being neither accepting nor rejecting but observing things as they are, can create the space to try to transcend differences and look for similarities beyond. For instance, hearing a client express prejudice against people from a minority religious community, one that the therapist belongs to, can be an extremely disturbing experience for the therapist. However, accepting that there are multiple points of view, and that each person is shaped by their context, may help us see beyond client’s beliefs and access their conception of what a good person is. Perhaps there can be shared agreement that being a good person is a valid goal. This both/and approach, rather than an either/ or approach, allows for accepting opposing realities, without trying to change the client (Elliot, 2011). As therapists, we may wonder if it is possible to adhere strictly to a value-sensitive approach, where we ignore, bracket, accept or transcend the value conflict. If values are excluded from therapeutic dialogue, the interaction may feel inauthentic and superficial. Sometimes values need to be explored, examined, negotiated and even challenged during therapeutic interactions. Therapy itself is about creating possibilities for change, even metamorphosis and our values may not always remain isolated and static during this process. Working on Values in the Session We can draw clients into reflective conversations to help them clarify their core values or make these legitimate targets of change in therapy. Therapists can be viewed as authority figures, particularly if they represent a privileged social location, and clients may be reluctant to challenge therapists’ views. A gentle, sensitive stance can create

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openings for clients to share in a personally and culturally congruent manner. Helping clients identify their central values, addressing their value conflicts and connecting this thinking to their choices can make for a more meaningful discussion. For instance, after struggling with trying to get a client to be more emotionally contained, a therapist may realize that she values deep emotional experiencing more than she values emotional safety. This can lead to a whole different conversation. Our convictions also shape how we frame value conflicts to our clients. In framing a value conflict, it might be useful to reference a set of values rather than a particular one. For instance, ‘On the one side, we have autonomy, excitement, stimulation, exploration and on the other we have safety, security, prudence, “being smart” or playing along with societal rules. Is this how you would see your situation?’ When clients are aware of their value conflicts, these can be addressed directly by looking at underlying emotions and examining alternatives and consequences. Before initiating this, we can ask ourselves if the client will benefit from the discussion. Will it meet a therapeutic goal? Does the client want or need to know … or care? As the process of value negotiation begins, clients can be encouraged to explore alternate values through the route of behavioural change (Bonow & Follete, 2009). For instance, a therapist might encourage the client, ‘Why not try something else and see what happens?’ Discussions might centre on general societal values and look at personal implications for the clients in terms of specific actions and approaches (Aponte, 1985). While it might be easier to find agreement on the more general values, disagreement is more likely to arise over actual actions. While an adolescent client may share that honesty is a value that they endorse, a discussion on if, why and when they would reveal their recreational substance use to their parents might bare open the complexities of translating the value of honesty into action. This is a critical point to reflect on and find a way of working with values that is responsive to clients’ needs and goals. In some situations, we need to challenge client values more directly and advocate a re-evaluation of these values and their behavioural manifestations. This is recommended when client’s self-destructive, antisocial, or unethical acts or goals clearly obstruct change, contradict

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therapy values or impinge on the rights and safety of others (Bonow & Follette, 2009). For instance, while conveying an understanding of a client’s difficulties, a therapist would also explicitly challenge his use of violence against the partner during interpersonal conflicts. In some situations, therapists may need to communicate their inability to work with client goals that go against their strongly held professional values. For instance, several professional organizations across the globe contravene the use of conversion therapy to change sexual orientation even when a person approaches us with this request (Drescher et al., 2016), and similar position statements have been shared by professional associations of psychiatry, clinical psychology and psychiatric social work in India (Asia Pacific Transgender Network, 2020). While client values are ubiquitous in therapy, not all of them need to be examined or addressed. For instance, if a client’s disregard for the environment is not interfering with his therapy goals, this can remain out of the ambit of therapeutic work. A Therapist Speaks: A Room of Her Own One of the authors (Rathna Isaac) shares her experience of working with values in therapy. ‘As my client Lavanya1 spoke of her struggles to move into a home of her own, I felt increasingly disturbed and angry. I was aware of her difficult childhood, where her mother had died when she was not yet ten. Her father had been both physically and emotionally abusive, neglecting her basic needs for regular food, medicine when she was ill and not protecting her from sexual abuse. Lavanya felt unhappy and frustrated, as he remained both uncaring and irresponsible. She seemed conflicted between her duties as a daughter and the independence she longed for. This father challenged every value I ever held about parenting. As a systemic therapist, I valued reciprocity in relationships and her staying with her father seemed like a violation of the values of human dignity, respect and care. Still, having been socialized with similar cultural 1

Name changed to protect client identity.

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values as Lavanya, I also admired her self-sacrifice and willingness to put her duty above her personal goals. I shared these observations as well as my concerns for her safety and well-being. She appreciated this perspective and contrasted it with her extended family who believed that her place was with her father, and that as a single woman it was selfish to consider other options. Therapy became a space to explore her feelings and different views about choosing to leave home or continuing to stay. As we spoke more about duty and reciprocity, she recognized that what she felt was not a responsibility towards her father but towards her mother. Taking on her mother’s roles would keep her legacy alive, and this included looking after her father. Understanding each of the values and locating their origin (culture, individual beliefs and unique emotional experience) helped us discover a pathway. Together, we identified how she could balance her self-care with care for her father, thereby negotiating a balance between being her mother and being herself. My reflections taught me to slow down to explore rather than rushing to make a list of pros and cons and reach a decision. This helped uncover personalized layers and meanings, the blend of thoughts and emotions that drove Lavanya. While sharing my values opened a new conversation, it was placing my perspective as just one of multiple possibilities, which left her free to find her own answers.’ Therapist Disclosure of Their Values Therapists who seek to conceal their values should be aware that some of these can be inferred from their appearance, use of language, practice setting, as well as subtle non-verbal communication and emotional reactions. While these are inadvertent disclosures, we may also choose to disclose our values to clients as an opening to dialogue about values and their meaning. Some clients may seek a more authentic connection with their therapists and can find the active discussion of values a deepening and enriching experience in therapy. Clients may also be openly curious about the therapist’s values, particularly when they have doubts themselves or fear being judged. For instance, a client may ask, ‘Do you think it is wrong to be an atheist?’ or ‘Which political party do you support?’

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It may be more useful for us as therapists to share essential therapeutic values (e.g., depressive symptoms should be reduced), but idiosyncratic values (e.g., religious/political values) need not be transparent to clients (Strupp, 1980; Tjeltveit, 1986). We may be more cautious about self-disclosure in the initial phase of therapy, when both the therapeutic alliance and the understanding about the client’s needs and vulnerabilities is still evolving. Any sharing of our values must be preceded by reflection on the potential impact of these disclosures. Our response needs to be tempered by an understanding of the relevance to therapeutic goals, keeping beneficence and non-maleficence at the forefront of the decision-making process. Values are easier to bring up in more therapist-active modalities, where therapists share opinions, make suggestions and hold overt positions (Aponte, 1985). Some therapeutic approaches, such as humanistic, feminist and other post-modern frameworks, actively encourage the therapist to disclose and discuss their values, as this egalitarian position gives clients a freer choice about accepting or rejecting therapist perspectives (Crethar & Winterowd, 2012; Ziv-Beiman, 2013). Even if we decide to share our values, this needs to be a sensitive process that allows clients to feel safe to disclose their own values, without needing our approval or fearing censure. Using Supervision to Recognize and Address Value Conflicts The vignette helps you consider the fine line between a value conflict and a value difference: During sessions, Rama noticed that her client Anil constantly spoke about money—how to make more, his growing investments, and his properties and car purchases. He worked hard to make this money and was focused and driven. She believed that life must be about more than money and looked upon his behaviour as ‘greed’—in a country where so many have so little. Although she considered herself a non-judgemental therapist, their value differences made her uncomfortable. She could focus on the tasks of therapy—addressing his phobia of travelling by air—but found it harder to like him. Rama might wonder if anyone needs to change their values and beliefs in this situation, what to do about her strong emotions and if

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this is something to even mention to her supervisor. As supervisors, we need to provide a compassionate and conducive space by encouraging and legitimizing the discussion of values, value conflicts, assumptions or biases. This can help the therapist get comfortable about articulating values as they emerge in the therapy room, even in the absence of major value conflicts. The focus could encompass the therapist’s emotional experiences in addition to discussions about what to do. As supervisees, we may find that this helps us sustain a therapeutic connection, keeping us from withdrawing or getting angry with the client while working out how to respond. If we experience repeated value conflicts with one type of client (e.g., violent clients or restrictive parents), this pattern can be brought up in supervision. Supervision is also a good context to think about our theoretical orientation and whether it matches with our value system and assumptions about human nature. Making Decisions about Referral There is ongoing debate about the ethical ramifications of referral to another therapist in the context of ‘irreconcilable differences’ in values. It can be argued that referral may protect the client’s right to competent care and supports the moral imperatives of beneficence and non-maleficence (Tjeltveit, 1986). This is usually considered only in select situations when the therapist is unable to relate to the client’s position in any useful way, and not as a first-line method of resolution (Corey et al., 2011). As therapists, we need to first search for shared goals, try to build a connection with the client or consider options such as including a co-therapist to balance the emotions and values in the room (Kocet & Herlihy, 2014) and seek supervision and consultation. Our work is grounded in professional values such as justice and non-discrimination, and this mandates deep reflection and self-work before considering the referral route. Even when referral is deemed best for the welfare of the client after a careful assessment of potential risks and benefits, we have continued responsibilities as therapists. Farnsworth and Callahan (2013) provide guidelines for a sensitive and compassionate referral process; the clients’ values, beliefs or actions cannot be stated as the reason for referral, and the referral options reflect the client’s preferences. Subsequently,

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we may consider reflecting on our values and their impact on our practice through journaling, consultation or supervision. Strongly held sexual values, in which the therapist is heavily invested, may be extremely difficult to transcend; for instance, therapists may assess open relationship formats such as polyamory or consensual nonmonogamy as pathological, view their clients negatively and persuade them to change (Grunt-Mejer & Łyś, 2019). If we want to work effectively with clients who are in non-traditional relationships, reflections on our own feelings about sexuality, fidelity and commitment in relationships are critical (Girard & Brownlee, 2015). Take a moment and think about the value conflicts you might have experienced while working with clients. What are some of the ways in which you might have addressed these value conflicts? Which strategies did you find easier or helpful in resolving value conflicts with your clients? Which ones were more difficult or unhelpful? Imagine you needed to advise another therapist about ways to handle value conflicts—what would you tell them?

Perspectives on Training and Development Development of Value-sensitive Training Modules We need to create space to recognize and examine our values during training and supervision, with ‘value-sensitization’ components consciously built into these contexts (Carlson & Erickson, 1999; Jackson et al., 2013). Aponte (1985) suggested that this ‘delicate work’ of negotiating and working with emergent value conflicts could be done in a small-group format, where case vignettes and role-plays may provide trainees with the language and confidence to address values as they emerge in therapy. Training to Negotiate Value Differences in Supervisory Spaces Training initiatives that address supervisors’ needs and guide them on the negotiation of value differences between supervisees and clients as well as those that can emerge within the supervisory dyad will be

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useful. Supervisors may normalize these experiences and use a range of methods, for example, discussions, illustrative role-plays and vignettes, to encourage supervisees to be reflective (Dunn et al., 2017). Veach et al. (2012, p. 225) drew attention to value conflicts between supervisees and supervisors as ‘low frequency but certainly high impact’ events, many of which centred on cultural, religious and sexual issues. This process may be challenging for supervisors, as they seek to balance the needs for supervisee development and client welfare in addition to their own emotional reactions. While generic training related to value clarification and the recognition and resolution of value conflicts in both the therapy and supervision room are important, we recommend a deliberate focus on specific sensitive areas such as religion and sexuality.

Conclusion As we traverse the path of self-exploration during our professional journey, our values encounter ‘other’ values. Therapeutic wisdom may lie in the invitation of differences, openness to dialogue and shared and shifting perspectives. This idea is echoed in the words of the 13th-century Sufi mystic Rumi, ‘Out beyond ideas of wrongdoing and rightdoing, there is a field. I’ll meet you there.’ (Rumi, 1997b, p. 36).

Chapter 7

Engaging with Diversity in the Therapy Room

Each of us is different and has different ways of being in the world. The ‘culture’ we belong to makes us who we are and shapes the way we think, moulds our personal identities and gives us a sense of belongingness. This amalgamation of knowledge, beliefs, values, attitudes, meanings, experiences and practices acquired and practised by a group of people over generations binds us together and helps us reach individual and collective goals. There is an inherent multicultural fabric in the world we inhabit, and there exist cultures within cultures. India is an exemplar of a country with complex intersections of religions, ethnicities, socio-economic strata, castes, languages, literacy levels and rural–urban domiciles, indicative of ‘many Indias’ (Raguram & Bhola, 2019). With the advent of the fourth force of multiculturalism, there is a deeper appreciation of how cultural factors influence mental health and the theory and practice of psychotherapy (Jacob & Kuruvilla, 2012; Tseng & Stretlzer, 2004). Our cultural beliefs and practices impact our beliefs about health and illness and determine the way in which we understand physical and mental health, and how we express distress and make decisions about help-seeking. The therapeutic space is often viewed as a sanctuary, somehow insulated from ideas of difference that exist in the society. In reality, the ‘outside is inside’, and

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when the therapist and client walk into the room, they carry diverse personal, cultural and social values into the interaction (Sinha et al., 2017). Shared meaning and relatedness do not always emerge spontaneously between us. Every encounter between a therapist and client is potentially a multicultural encounter, one which calls for awareness, understanding and acceptance as we navigate the differences in our cultural beliefs, practices and identities. The nature and practice of psychotherapy have also been deeply moulded by cultural factors, such as the appropriate ways to communicate, establish the therapeutic relationship and so on. When Western psychotherapy models have been exported to other parts of the world, psychotherapists have attempted to include elements of their own culture into practice. Professional organizations recommend that we enhance our cultural competencies, cultivate an awareness of the lens through which we view the world and any distortions or biases we carry, and make a commitment to culturally sensitive practices (Liu et al., 2021). As reflective practitioners, we might need to be cognizant of forces that challenge the recognition, understanding and acceptance of diversity and its impact on therapeutic processes. Psychotherapy offers an opportunity to create a voice and a space for diversity, and perhaps this is more critical in the face of trends towards ‘othering’ in political and social spaces across the globe. In this chapter, we introduce concepts of multicultural competence, social location, intersectionality and privilege, and discuss their relevance to ourselves and to our psychotherapy practices. Practitioner narratives and experiential exercises illuminate the influences of class, caste, gender, sexual orientation and religion and their intersections. Through a reflexive lens, we bring these ideas into our conversations with ourselves, our clients, our supervisors and our supervisees, with the aim of facilitating culturally sensitive and affirmative psychotherapy.

Our Cultural Roots Roysircar (2004, p. 658) exhorts us, ‘Therapist, know thy cultural self.’ We can start by reflecting on the cultural groups we belong

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to and recognizing the beliefs and attitudes imbibed through these memberships. Looking at culture as something people ‘do’, rather than something people ‘have’ (Markus, 2008), can help develop a more nuanced understanding of what it means to be Indian, Muslim, Gujarati-speaking or African–American. Culture can be understood through visible and invisible markers, through our customs, what we eat, how we dress, how we relate to others, how we make meaning, and what we believe in, value and stand for. One of the most personal markers of our cultural roots are our names; both our first names and family names say something about where we come from and where we belong—our gender, class, caste, religion and community. Much about us is disclosed through our name, and we may be comfortable or uncomfortable with (parts of) our name. Some of us may change the monikers we are known by, perhaps when we immigrate to another country or in a professional sphere. Reflect on the memberships and locations implied by your name and the advantages or disadvantages these carry with them. The impact of our name can become powerfully evident when we consider what would change for us if our name were different. Exploring our cultural roots can also bring awareness of the ways in which they impact our therapeutic interactions. We tend to understand the world, ourselves and others through both sameness and difference. Social identity perspectives describe how we categorize people into ‘us’ and ‘them’ (e.g., man/woman, native/foreigner and English-speaking/ non-English-speaking), tending to view the members of our group as having more positive attributes, being more homogenous and distinct from the ‘other’ (Tajfel & Turner, 1979). The development of cultural sensitivity begins with deepening our awareness of our own and our clients’ realities, and consciously learning to value differences between our cultural identities. Creating a multigenerational cultural genogram can throw light on our ethnic, religious and other significant cultural identities (Hardy & Laszloffy, 1995). We can use it to trace intercultural marriages, migrations and other ways in which cultures blended, differed and were negotiated across generations. We could reflect on the cultural identities that feel similar or which we are comfortable owning, as well

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as who we consider as culturally different or ‘outsiders’. There may be some prejudices and stereotypes expressed within our families, both about others and ourselves. While some things may be valued and bring pride to our family name, others may cause shame. Through these reflections, we can understand which client’s cultural groups we might relate to and work with easily and which may pose more of a challenge. This would help us monitor the emergence of cultural countertransference, where our assumptions, biases and stereotypes could pose an empathic roadblock within the therapeutic dyad (Stampley & Slaght, 2004). When we encounter a difference in the therapeutic encounter, an attitude of cultural humility can help us adapt our therapeutic processes and work in a culturally responsive manner (Mosher et al., 2017). Culture is always in the room, even when unspoken, and reflective work provides windows to understanding our ‘cultural self’, engaging with the selves of others and building our cultural competence as therapists.

Understanding Intersectionality, Power and Privilege When we meet a new person, we often start by decoding various aspects of their identity. This is our way of making sense of where the person comes from, what their beliefs and values might be and how they might respond to certain situations. An individual’s social location is determined by the combination of all the groups that they belong to, based on their identities of age, gender, religion, race, social class, caste, sexual orientation, nationality and so on. Each of these locations brings its own privileges and disadvantages and influences how we navigate the world. It can determine our access to education, jobs and mental health services, and influences how others view and relate to us and how we see ourselves. The first step in developing diversity awareness is to begin with unpacking our own social location. A simple thought experiment can aid our reflections: Imagine that you woke up one morning to find that your gender, sexual orientation, race or religion had changed. Think about how this change would make your life different? Which opportunities

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would open or close for you? Would it impact how others perceive or treat you (Johnson, 2018)? We might belong to a socially dominant group regarding certain identities we hold while being a targeted minority group with others. While some of us may belong to many privileged groups, for instance, being educated and heterosexual, others may experience disadvantages across the various domains of their lives. These social positions are not static and fixed. Interestingly, the same identity can make us both an insider and an outsider; Gill and Choudhary (2019) describe this twin experience of both belonging and unbelonging among persons from the Northeast states of India as they migrate from their homes to live and work in mainland Indian cities. The intersectionality prism, first introduced by black feminist scholar-activists, helps us understand how the meaning of each identity shifts in relation to other identities (Crenshaw, 1989, 1991; Grzanka, 2014). This perspective allows us to embrace complexities and understand the unique effects of multiple marginalized identities; for instance, black women may encounter specific forms of disadvantage or discrimination that black men or white women might not. McIntosh (1989, p. 1) defines privilege as ‘an invisible weightless knapsack of special provisions, maps, passports, codebooks, visas, clothes, tools, and blank checks’. For instance, being part of middle– high-income groups brings with it many unearned rights, social benefits, immunity and favours, such as safety in the neighbourhood, access to culture and amenities, peer network, and the way people acknowledge and address us when we enter a room (Raheim et al., n.d.). Unless we develop an awareness of our own privileges, we may not be aware of the constraints that other people have in their lives, why people make the choices they do and why they live the way they do. We learn to recognize when we may have inadvertently imposed our own expectations, cultural ways or perspectives and failed to recognize our client’s struggles with systems of power. The Privilege Project is an initiative by a group of therapists, community workers and educators which advocates reflecting on social locations to build a multicultural perspective with a social justice lens (Raheim et al.,

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n.d.). They encourage individuals from majority groups to reflect on questions such as: How might your experience as a heterosexual person differ from the experience of a queer person in expressing affection and love towards their partner in public? How would you prepare to introduce your same-sex partner to your family of origin? What would it be for you to seek counselling if you were in a same-sex couple relationship? When we are hurried and do not pause to reflect on our work, we might be at a risk for enacting our privilege and silencing the voice of others. For instance, our interventions may suggest a certain ‘right’ way to parent or work, without considering the meaning and value it has for our clients or the resources available to them. Perhaps we have not checked if the images on the walls of our clinic depict only heterosexual couples and families or considered whether our documentation procedures are burdensome for low-literacy clients. Do we remain silent when a colleague makes a sexist remark, disparages a particular community or advocates conversion therapy? Once we become more aware of our privilege, we have the choice to either use this power to maintain the status quo or challenge it. Different systems (including mental health/therapeutic systems) might subject people to unjust treatment, narrowing their opportunities and creating distress (Adames et al., 2018). An individual may experience oppression in relationships (e.g., by having limited freedom to go out without permission) at the institutional level (e.g., not having access to quality care and services) and at a societal or cultural level (e.g., not being able to marry outside their caste). Through a process of ‘emancipatory reflection’ or questioning social norms, we become more aware of power structures and realize the potential for transformative action and change (Taylor, 2010). Pause and reflect on the different ways in which you connect to the lives of ‘others’. Do you engage with art, literature, film or music as pathways to widen your perspective? Also, consider the ways in which you engage with ‘culture’ in the therapy room. How often do you attend to clients’ cultural beliefs and practices? Do you feel you are open to receiving feedback on any of your remarks or behaviours that might not be culturally sensitive? How often do you use supervision

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and other reflective spaces to discuss how your clients (and you) are impacted by their multiple identities?

Unpacking Identity Dimensions The identity dimensions of class, caste, religion, gender and sexual orientation can be critical determinants of our experiences of privilege and marginalization. We deliberate on how these dimensions influence the experience and expression of emotional distress, determine mental health outcomes and impact help-seeking experiences, and reflect on how they influence our work. Social Class and Inequities in Mental Health Care For many of us, the essence of psychotherapy is the experience of an authentic encounter with another human being. We may want to be class-blind and preserve the ideal of an egalitarian balance in the relationship, but it seems inevitable that the realities of class differences will impinge on us and our therapeutic work. There are persistent inequities in economic position, status and access to opportunities across the world (Rodriguez-Bailon et al., 2017), with such differences even sharper in some countries. Despite the decline in poverty rates and a rise in the middle class, India is still home to 28 per cent of the world’s poor (United Nations Development Fund, 2019). Vahali (2015), a psychoanalyst, mused on her experience of distance between the ‘self’ and the ‘other’. She shared about a bus ride years ago, where a girl and her brother, both with matted hair and in ragged dirty clothes, got on and began singing songs. While they sang, some passengers smiled and looked at them with affection or pity, while others were indifferent, distracted or even hostile. The singing ended and the children asked each passenger for payment. Vahali went on to describe how she gave the girl a coin and instinctively touched her thin arm to draw her close. Although there were no words, the young girl moved away forcefully from this contact, with her eyes conveying anger and repulsion. While the two children slipped out of the bus, this encounter endured in Vahali’s thoughts and dreams. Reflecting

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on some moments in her life when she had felt insignificant and rejected, she tried to connect empathetically to the emotional state of the little girl, sensing how she must have experienced the world as an outsider. While therapists see themselves as sensitive and empathetic, for those who are economically deprived, mentally ill or homeless, the differences in class location may cast the ‘helper’ in the position of the historical ‘oppressor’. As mental health practitioners, this calls for us to be prepared to tolerate that which is uncertain and unknowable in human relationships. It takes effort to bridge the distance between ‘us’ and ‘them’ and engage authentically with those existing at the marginal spaces of the social world. Words may not always form a path to their experiential world; what is unarticulated may be powerfully experienced by the therapist as fears, anxieties, loneliness, anger and alienation. Uncomfortable questions may arise during our deep reflections, our own privilege and how we continue to maintain social inequalities. As therapists, we could begin by thinking about how we define ourselves in terms of social class. Of course, this may not always match how our clients perceive our class position. Markers of social class differences can be evident in the therapist–client encounter, even when not articulated or addressed in conversation. Assumptions are made from the way we dress, how we speak, and where we live, study and work. The impact of such differences is compounded when we are less aware of our clients’ class-linked experiences and world views, hold stereotypic assumptions or biases about the poor or the rich, and maintain silence about class issues in the therapy room (Appio et al., 2013; Trott & Reeves, 2018). If we operate under the assumption that class does not matter, then we may not engage with our clients’ daily struggles or experiences of classism (Liu, 2013), or we might give unrealistic suggestions that discount their limited resources or choices. Any assumptions we carry, either idealized notions about the well-resourced or beliefs that there are internal or dispositional causes for poverty, can influence the therapeutic relationship and processes (Rodriguez-Bailon et al., 2017; Smith, 2005). As therapists, we may wonder about the fit between psychotherapy and the needs and resources of our poor and disadvantaged clients. Is

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psychotherapy ‘as usual’, responsive to real-life contexts, where clients have no money for bus fare or food or cannot get admitted to a hospital because they will lose their daily wages? We may feel overwhelmed and powerless in the face of these immutable realities or believe that clients from economically disadvantaged communities do not value ‘talking’ treatments, lack the emotional or intellectual resources for therapeutic work and need material and practical solutions instead. These notions have been questioned and are seen as exclusionary (Mukherjee, n.d.; Sethi & Trivedi, 1982). Mukherjee (n.d.) examined the work in free or low-fee psychotherapy clinics in India, London and New York and stressed the need for mental health resources in low-income communities as part of a just and equitable society. We must also ask ourselves if we are othering certain communities as a powerless homogenized collective. Are we able to respect the inner lives, hopes and fears of all persons and recognize their capacities for resilience empowerment and change, irrespective of their class locations? When you look back on your sessions, do you recollect an awareness of the class disparity between you and your client? Do you think that this could have influenced your interactions and the process of therapy? Do you typically address such inequalities directly with your client? As you reflect on these questions, can you identify reasons why you might have brought up this experience or left things unspoken? This critical lens can be turned to the theoretical frameworks of many psychotherapy approaches. Often, the explanations for the emergence of distress and the onus for change are centred on the individual and decontextualized from the socio-cultural-political matrix (Kumar, 2012). Raguram (2016) narrated the case of a farmer experiencing depression, who encountered crop failure after a combination of delayed monsoons and being compelled to use genetically modified seeds that needed more irrigation. With rising debts and pressure from the local moneylender, he faced the impending loss of his land, his only source of income for the family. As a psychiatrist, Raguram (2016) wondered if addressing ‘negative cognitions’ of helplessness and hopelessness would be an adequate or appropriate intervention in this context of oppression and limited opportunities. As we work with economically marginalized or disenfranchised communities, our

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therapeutic frames would need to shift from insular positions and be more sensitive to structural inequalities. This reflexive process can evoke difficult emotions, such as discomfort and guilt about our privilege—this is perhaps one of the reasons why we refrain from engaging deeply with these issues. What can we do to make psychotherapy more equitable across class groups? Santiago et al. (2013) emphasize a flexible approach to session fees and schedules, locations that are closer to the communities, a focus on engaging and retaining clients, and education about the goals and processes of psychotherapy. Clients from low-income backgrounds value our efforts to build an egalitarian and caring connection and to integrate discussions about financial stressors, employment and related concerns into the therapeutic process. Our clients could be particularly sensitive to any signs of therapist indifference, disengagement and lack of empathy for their struggles with money and access to opportunities, and some react negatively to markers of therapists’ wealth and status (Thompson et al., 2012). There are larger questions about the organization of mental healthcare systems and delivery of services to the poor. In resource-poor countries with large treatment gaps and a shortage of trained mental health practitioners, it may be particularly challenging to provide psychotherapy services using traditional models. Three exemplars from India illustrate the importance of innovative integrated services within the community, interdisciplinary links, and the need to expand and contextualize our interventions. Rao et al. (2011) discussed their experiences in community-based group counselling for economically underprivileged women in rural India. Therapeutic support strengthened trust and reciprocity within their own social networks and directly targeted poverty and powerlessness through microcredit initiatives. Narasimhan et al. (2019) described the process of setting up The Banyan, a not-for-profit initiative which addresses the intertwined issues of poverty, homelessness and mental illness in urban and rural India. Their innovative care and recovery services, inclusive living options and community mental health programmes emphasized care which was co-located with primary health or community centres, involved grassroots workers and evolved through dialogue with clients.

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The non-profit organization Sangath has received global attention for their development of low-cost, scalable, culturally adapted effective interventions, using lay or non-specialist workers in settings with prominent income inequalities (Patel et al., 2018; Shinde et al., 2013; Singla et al., 2014). Through this work, they envisage an expanded role for mental health professionals in championing policies that reduce income inequities and mitigate risk factors which contribute to psychological distress. As therapists, we need to reflect on our own beliefs about money. What do you feel is the relationship between money and well-being? How much money is ‘enough’? Is it possible to have ‘too much’ money? As a therapist, what is the scope of your responsibility towards those who have limited resources? Do you experience difficulties negotiating session fees with certain clients? Our own beliefs and issues around money can also influence our ability to work with people who are wealthy. Ryan (2006) shared narratives from practitioners who experienced feelings of inadequacy, envy and resentment in working with clients from elite, moneyed backgrounds. Our internalized beliefs that wealth insulates people from difficulties could lead to a trivialization of their distress and interfere with empathic and compassionate responses in therapy (Hokemeyer, 2012). Clearly, classism can extend both ways. Even as we respond to these challenges and recognize that persons from all classes are unified in being human, the denial of class differences can constrain authentic engagement and responsivity to our clients’ needs. Caste and Mental Health Practice In India, there has been a history of social stratification and status differentiation based on fixed traditional occupations, creating hereditary groups of upper, intermediate and lower castes. Historically, individuals from upper castes within the social order have experienced many privileges, while individuals from lower castes (Dalits) have been socially and economically marginalized, oppressed and disadvantaged (Mosse, 2018). The practice of untouchability, where touch or contact with someone from the lowest caste order is considered polluting,

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manifests as restrictions against entry into places of public worship, access to community spaces or resources and upper-caste homes, acts of segregation in living, seating and eating and various other prohibitions. Despite the legal abolition of such forms of social exclusion and discrimination in 1955, the truth is that caste still matters in India, and caste as an identity can at times override all other identities (Deshpande, 2013; Krishnan, 2018). The practice of untouchability persists in varied forms in both rural and urban areas (Thorat & Joshi, 2020), with worrying levels of support for laws against inter-caste marriages and mixed responses to affirmative action policies for government jobs and higher education (Coffey et al., 2018). Untouchability is a lived experience of all people in India—either as survivors and challengers or as beneficiaries, perpetrators, bystanders and witnesses (Navsarjan Trust & Robert F. Kennedy Center, 2010, p. 3). In an interview with Hampapura (2020), Yashica Dutt, the author of the book Coming Out as Dalit, points out: ‘But most likely, if you can afford to say, “I’m so progressive that I don’t know my caste,” then you probably are upper-caste.’ Understanding caste as a social location in mental health practice calls for deep reflexivity about caste identity within ourselves, our families and in social spaces—our neighbourhoods, social media platforms, educational institutions and newspaper matrimonial columns. Including the narratives of individuals from marginalized caste groups within the mental health discourse in India can deepen understanding of the inner experiences stemming from this social location. Women belonging to the Dalit community are vulnerable to trauma through intergenerational caste abuse and present-day caste atrocities. Their relationships and academic or career achievements may be stereotyped, discounted and undervalued (Dhanaraj, 2018). Dalit persons may experience ‘double stigma’, being stigmatized both for their caste location and as recipients of state reservations and other provisions (Deshpande, 2015). The gaze of the upper castes may be internalized by Dalit persons, and this sense of powerlessness and undermining of personal dignity and self-esteem generates complex emotions of anxiety, fear, anger and a sense of psychological fragility (Jadhav et al., 2014). Persistent power inequalities and acts of discrimination and

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caste violence can have powerful impacts on the mental health of Dalit persons, increasing the vulnerability to anxiety, depression and suicidal attempts (Kohrt et al., 2009; Gupta & Coffey, 2020; Pal, 2015). As therapists, we need to engage with research that illuminates how these experiences of social exclusion and oppression lead to deep and lasting psychological wounds (Jadhav et al., 2016; Pal, 2015). We can become more effective and responsive to caste-based issues when we commit to an exploration of our own caste prejudices, motivations and commitments (Ramaiah, 1998) and reflect on how these might emerge in the therapy room. Taking a caste-blind stance is not recommended if we are to ensure that our client’s caste-based experiences can be duly voiced and acknowledged. Chakravorty (2020) documents a therapist’s narration of how the caste mismatch between her and the client eventually led to the client discontinuing therapy. The client expressed to the therapist how her experiences of being from the Dalit community were not understood even by her partner (who she described as a Savarna or upper-caste woman). Equally, supervision spaces also need to be safe spaces where power and privileges that come with caste positions can be explored and discussed. Exploring supervision in the Indian context, Duggal et al. (2020) described how a trainee therapist’s experience of feeling powerless was amplified in the context of the caste difference between supervisor and supervisee. Some supervisees shared how they valued the social justice lens and actively sought supervisors with a nuanced understanding of caste privileges and the intersections of caste with other marginalized identities. For individuals marginalized by their caste identities, the journey to therapy itself may have challenges; these include the lack of access to mental healthcare services due to geographical or economic disadvantage, discriminatory practices that deny entitlement to government healthcare benefits and the nature and quality of healthcare services received (Pal, 2015; Ramaiah, 2007). Concrete actions to increase access to services, such as providing transport cost for travel to health services in distant urban locations and having more community based and state-led interventions, can be helpful (Dhanaraj, 2018; Kohrt et al., 2009).

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The Blue Dawn is a mental healthcare support group established to provide affordable and accessible mental health support and care through community healing to Bahujans (Scheduled Castes, Scheduled Tribes, Other Backward Classes, Nomadic Tribes and Decriminalized Notified Tribes across religions). Acknowledging that mental health services in India are limited to those who are privileged, and discount the experiences and realities of the marginalized, this initiative aims to connect clients to mental health practitioners who understand structural oppression (especially caste-based oppression), and who have an anti-caste, queer-friendly, disabled-friendly approach. Online support is provided for those who need a safe space and sponsored therapy sessions for clients who cannot pay for the services. Combining perspectives from anthropology and psychiatry can help us understand how caste and casteism impact inner lives, look at issues related to the stigma and disclosure of caste identity and perhaps move closer to learning how these psychological wounds can be healed (Jadhav et al., 2016). Knowledge about the historical struggles and current issues experienced by the Dalit community, an understanding of laws and policies using a human rights perspective and reflective work by students from all communities are strongly recommended in mental health training and practice (Ramaiah, 1998). While there are clear recommendations on how we can include caste sensitivities into our work, we strongly believe that a more deliberate effort is needed to avoid tokenism and integrate them meaningfully into our professional standards and practices. Religion in the Therapy Room Religion and spirituality are related concepts that share an appreciation of that which is sacred, transcendent or set apart from the ordinary. Our religious and spiritual beliefs offer a way of making meaning of our lives and provide motivation for our choices and actions (Hill & Pargament, 2008). Each of us have our own relationship with religion, spirituality and God, either central or peripheral to our way of being in the world. Some of us may be spiritual rather than religious, while others may be more focused on the social and scientific, rather than the

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sacred. Beliefs, practices and ways of living are closely tied to spiritual inclinations and religious faiths in the Indian cultural fabric. In India, religion provides a cultural language that helps people explain and express emotional distress (Kakar, 1997). A range of idioms of distress such as mata aana1 and shaitan ki awaaz2 are linked to religious beliefs. Religious beliefs from the Indian dharmic traditions, such as karma,3 dharma4 and moksha5 also determine how people make sense of distress and seek well-being (Shweder, 2008). Emotional suffering such as sadness, worry and even severe mental illnesses have been attributed to religio-spiritual causes such as bad karma, offended deities, evil spirits, planetary positions and so on (Bhagwan, 2012; Deane, 2014; Ramachandran et al., 2005). Sometimes, a religion-based explanatory model can conflict with the clinician’s biomedical model, leading to spoken or unspoken tensions between the two (Peteet et al., 2016). When therapists connect to the emotional experience of the client, and respect the meaning they give to their symptoms, this can make them feel less anxious and more in control (Heilman & Witztum, 2000). As therapists, we may consciously attempt to engage with religion and spirituality in ways that are meaningful for our clients, but our training does not always equip us to navigate this territory with ease. Religious practices such as prayer, meditation, yoga, seva (community service and volunteering) and satsang (a spiritual discourse or a gathering for prayers) are part of everyday practices that can reduce stress, buffer against mental health concerns and foster spiritual growth 1 When the individual exhibits symptoms of spirit possession and when the spirit is considered to be of a Hindu goddess by the witnesses. 2 The voice of the devil. 3 In Hinduism and Buddhism, the sum of a person’s actions in this and previous states of existence or previous births are viewed as deciding their fate in future existences. The current experiences of distress and illness are often explained as an outcome of previous actions. 4 In Hinduism, it is regarded as a cosmic law underlying right behaviour and social order. Following dharma leads to happiness and adharma leads to misery. 5 Moksha means liberation from the world.

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(Sharma & Misra, 2018). In keeping with their religious beliefs, people may seek treatment for mental health concerns in dargahs6 and temples, often through healers or spiritual gurus. Formal efforts to bridge medical models of treating mental illness with religious beliefs have led to collaborations of healing systems, such as the government initiative, Dawa–Dua programme (dawa = treatment; dua = prayer/invocation), between faith-based healers and allied mental health professionals in Gujarat, India (Shields et al., 2016). Reflecting on the role that religion and mental health services play in people’s lives, we may observe that both are powerful healing traditions that can benefit human beings. The more we connect and combine forces, the more we can help our clients, without making them feel like they need to choose between two forms of help. Engaging with the religious or spiritual lives of clients can appear particularly important in India, the home of several religious–spiritual traditions. This does not mean that we open these conversations or infuse spiritual components in the therapeutic process with all our clients. When a client makes a passing or subtle reference to their beliefs or uses a religious metaphor, some of us may feel enthused by this information and respond by enquiring more deeply. At times, we could feel uncomfortable or unsure about what to say and retain focus on the client’s other emotional/interpersonal issues. When our client makes frequent references to religious or spiritual ideas or speaks of the centrality of these beliefs, these are cues for the therapist to delve further. We can enter our clients’ world views by asking where they draw their strength from or how they find comfort in times of suffering. When religious or spiritual beliefs seem important to our clients, we can explore more about the role of faith in their lives and how this can be integrated in their therapy plan. How much we continue to focus on the topic can be guided by our clients’ relationship with religion/ spirituality rather than our own (Josephson & Peteet, 2007). Some of our clients may seek more psychological inputs, preferring to keep their 6 A Persian word, meaning a shrine built over the grave of a revered religious figure, often a Sufi saint.

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faith, or the lack of it, outside the therapy room, while others might actively seek spiritual answers to their existential and moral questions (Gordon et al., 2010; Post & Wade, 2009). At times of personal crises, especially when dealing with trauma, suffering or end of life issues, both client and therapist could find religion/spirituality-related discussions more relevant (Peteet, 2001). Clients may find solace in their faith, and just bearing witness to their experiences can be valuable. It is equally important to meet our clients who are ambivalent about their beliefs and walk their journey of doubt with them. Helping them to clarify and recommit to their core values (both religious and otherwise) can help alleviate their distress and find meaning in their suffering. Just the way therapists choose therapeutic techniques that fit each client’s need, wisdom from religious texts can be introduced to discuss ways of being in the world, make possible reinterpretations of difficult experiences and seek meaning and comfort. For instance, teachings from the Bhagavad Gita, a central Hindu text, have been advocated for the resolution of inner conflicts through discussions on the inevitability of the birth and death cycle, the immortality of the soul and the performance of dharma (Pandurangi et al., 2014). Meer and Mir (2014) shared the use of religious texts to further discussions on gender and relationships or to develop confidence, by practitioners working with Muslim clients in the UK. While this approach may resonate with some of our clients, it requires therapists to have more than a superficial understanding of religious texts and spiritual concepts. Therapists who commit to a deep and critical engagement with both the words and the meanings of religious/spiritual teachings can use their knowledge with select clients in their practice. Therapists vary in their religious/spiritual beliefs and what they feel about religion entering the therapy room. While religious faith and therapeutic work can feel integrated for some therapists, others may not experience this confluence (Duggal & Sriram, 2021b). Some could be reluctant to engage with these ideas, perhaps feeling uncertain, uncomfortable or disconnected from such discussions. Therapists might choose a selective focus on the psychological implications of religious issues or the spiritual aspects, keeping other discussions out of the ambit.

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Imagine a meeting between a therapist who has found meaning and solace in the practice of yoga and meditation but finds engagement in daily prayer less relevant, and a client who finds meaning in daily prayer but dismisses yoga and meditative practices. What might this bring up for the therapist? Reflect on an experience where you might have experienced a divergence in religious/spiritual beliefs or practices between you and your client. How did you respond at that time, and would you like to do anything different in future encounters? As therapists, we often do not consciously acknowledge our religious/spiritual beliefs and their emotional significance for us, until we face them in the therapy room. When clients directly ask us questions about our belief in God, prayer, particular beliefs or practices, we may be thrown off balance, particularly if we sense a difference from our client’s perspectives. Religious values are linked to other social and political values and can evoke strong emotions when activated during therapy. Differences in religious values can be most disturbing in controversial areas such as suicide, abortion and euthanasia (Peteet et al., 2016) or when our client’s life choices seem constrained by their religious beliefs. During therapeutic conversations, we might try to bracket our own values and respect those held by the client. It can be an effortful process to refrain from questioning our client’s beliefs and assumptions, particularly if they seem harmful. In such sensitive situations, we need to reflect within an ethical framework—balancing individual rights with beneficence and non-maleficence imperatives (Gordon et al., 2010). Building a reflexive awareness of how religious and spiritual beliefs are experienced in our therapeutic practice is important (Vieten et al., 2013). The therapy room is meant to be a space that accommodates differences, but religious biases and prejudices can find their way in. Reflective work must begin with an inward look at our own responses to markers of our client’s religious affiliations and beliefs. It can be hard to acknowledge our potential biases and harder still to challenge them, but essential work for a therapist. Reflective engagement with religion as a social location calls for therapists to be sensitive to experiences of marginalization or oppression among clients from minority faiths. Without building this awareness and competence, we may

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come across as insensitive or ignorant of their realities. There can also be times when we feel hurt or triggered when clients overtly or covertly express their religious prejudices. We can allow ourselves to acknowledge these painful feelings and take them to safe and reflective supervision spaces. As we engage with religious and spiritual themes in a reflective manner, we can use the possibilities they offer more effectively in our therapeutic work. A Therapist Speaks: You Believe, I Believe, We Believe Ms Mehak Sikand, a clinical psychologist and research scholar from India, shared a reflective piece on the challenges and opportunities that arise from engaging with religion in the therapy room. ‘I am a woman in my late 20s who was registered as a Hindu at birth and grew up being respectful of all faiths and beliefs. As an adult, I chose not to identify with or follow any religion. During my training as a psychotherapist at a tertiary mental healthcare facility, I began working with a Muslim man in his mid20s. He believed that a jinn7 was enticing him to engage in “sinful” behaviour (masturbation) and struggled with overwhelming guilt and distressing psychosomatic symptoms. Early in therapy, he asked, “Are you a Muslim?” None of my clients had ever asked me about my religion, but I did realize that ignoring the difference between us would not work. It felt like my one answer would determine the level of comfort and safety in our relationship and impact the entire course of therapy. Pausing to take a breath, I answered, “No.” In that moment, my client smiled and looked down. Taking the conversation further, I enquired about how he was feeling at that time. His response suggested disappointment and hopelessness about my ability to ever understand the gravity of the issue he was facing. It was As per the divine scripture of Islam, jinn (also known as djinn) is one of Allah’s creations. The Quran states that they were created from smokeless fire before the creation of mankind and were given choice and free will. While some of them are believers, the disbelievers or the devils are believed to misguide or punish mankind. 7

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true; I did not know much about his belief system. However, I knew how deeply distressed my client was and wanted me to understand his concerns as he understood them. Our differences were not erased, but a space was created for him to share religious beliefs without quick interruptions or alternative “psychological” or “biological” causal frameworks (which I was more inclined to believe in). My readings about Islam and jinns helped me connect more deeply with his experiences of guilt and fear of punishment from these diabolical creatures. This helped me find a language to speak about this in sessions. Gradually, the space expanded to incorporate both our models, and we were able to delineate and work on goals that could be managed by a mental health practitioner. None of my endeavours were made with the assumption that I could know all about Islam or all about my client’s distress. It was merely an effort to put one block at a time while building a bridge between us.’ Gender and Psychotherapy Gender-related cognitions, attitudes and behaviours are acquired and maintained through our social relational contexts (parents, peers, teachers and media) and the existing social structures in our culture (Leaper & Friedman, 2015). Our socialization into gender determines the roles we adopt and impacts our relationships and world views. Culture provides a blueprint for how to ‘do’ gender, and this is embedded and institutionalized in our social systems. The rules for gender persist even in the face of sociocultural changes, and these continue to reinforce ideas about difference and inequality between men and women (Ridgeway & Correll, 2004). Understanding how gender operates in the therapy room involves a process of reflection and self-discovery. When working with our clients, we become aware of their exposure to different stressors because of the gender roles they play, and different vulnerabilities stemming from their gender identities (Eagly et al., 2012; Gilligan, 1993). How our clients reach therapy and the nature of care they receive are also influenced by gender (Undurti, 2020). Gender can be seen as categorical or fluid, and this inevitably influences how we view it in

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our therapeutic work and within mental health systems (Hyde et al., 2019). Further, if we assume that persons who identify as women, men or non-binary experience the same sociocultural realities, we may not pay adequate attention to the roles of upbringing, culture or context in determining human experience and behaviour (Wester et al., 2002). It is only when therapists actively reflect on their gendered beliefs and build awareness of any gendered biases and blind spots that we can empower our clients to examine how gender impacts their identity and behavioural choices. Gender disparities and gender-based disadvantages have been documented across the globe (World Health Organization, 2020). We discuss how these experiences are linked with increased vulnerability to mental health difficulties, with a focus on the Indian context. In patriarchal societies, women are often socialized to assume subordinate roles with limited autonomy to make decisions. Gender discriminatory practices limit women’s access to education, employment, financial literacy, freedom of movement and independent decision-making, further impacting their mental health (Ram et al., 2014). If we are to engage with the lives and stories of our female clients, we might need to recognize how gendered expectations (e.g., role definitions as mothers, sisters and daughters and emphasis on caregiving), imbalance of power and privilege, experiences of discrimination, dowry-related harassment, and abuse and violence may serve to increase risks and lead to poor mental health outcomes (Bhattacharya et al., 2019; Chandra & Satyanarayana, 2010; Malhotra & Shah, 2015). Gender-sensitive practice involves the acknowledgement of gender as a powerful determinant of client realities (Stone, 2020). Our beliefs about gender can impact how we understand, interpret and diagnose client behaviours. Clients often present with emotional distress, and we may respond differently to the emotions of male and female clients. You could take a moment to contemplate and respond to these questions: Do you find it disturbing to see a man crying in a therapy session? Does aggression feel more distasteful or inappropriate coming from a female client? Is it more intimidating to see aggression coming from a male client? Do you think your own gender influences how you feel and react?

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Women are perceived as more emotional in nature, whereas situational attributions are more likely for similar emotions expressed by men (Barrett & Bliss-Moreau, 2009). This suggests that when a woman shows sadness, this may be attributed to her personality, but when a man shows sadness, we search more actively for reasons in the environment. Women are also three times more likely to be diagnosed with borderline personality disorder than men, and this could be influenced by clinician bias and even reflects biases in the diagnostic criteria themselves (Bjorklund, 2006; Ussher, 2013). Engaging in reflective practice may help us uncover our definitions of what is normal or abnormal based on socially constructed ideas of gender. There can be subtle and insidious manifestations of our gender biases in the therapy room. Do we direct questions related to finance to our female clients or to male family members? Are we likely to gloss over a comment from a client that she needs to seek permission from her husband to visit her natal home? Seemingly ‘benevolent’ beliefs about the virtue or innocence of women, or those that suggest that women need to follow more traditional roles to be well adjusted and gain male protection and affection, can also be harmful (Glick & Fiske, 2001). The restrictiveness of such beliefs might be harder for us to identify in our own lives, our client’s lives and in the therapy room. The issue of interpersonal violence, a prominent risk factor for women’s mental health, can bring gendered beliefs into sharp focus. In honour cultures (prevalent in some parts of India), it is acceptable for men to control behaviours of women that are perceived as challenging the honour or status of the men in the family, with violence if necessary (Vandello & Cohen, 2008). Violent behaviours may be minimized, seen as a private issue or viewed as ‘culturally accepted’, thus strengthening existing gender power hierarchies (Bhate-Deosthali et al., 2013; Sinha et al., 2017). Therapists’ action or inaction in working with female clients in these situations could stem from their own beliefs, which may be unexamined and unarticulated. Some therapists may experience intense feelings of anger about the constrained choices of women in unequal and violent relationships. These emotions might blind them to the complexities of decision-making in such situations and lead to actions that undermine the goals of healing

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and empowerment (Lancaster et al., 2018). Other therapists might feel quite anxious if a client decides to leave the coercive situation and urge her to ‘adjust’, automatically fearing the consequences of women making unconventional choices. Therapists with more traditional gender beliefs may see the woman as complicit in her victimization and suggest that she monitor and alter behaviours that ‘provoke’ violence from the partner (Thapar-Björkert & Morgan, 2010). Gender power structures in the society are reflected in our mental healthcare systems and training frameworks. As therapists, we need to be aware of how a psychiatric diagnosis may result in significant discrimination and stigma for women. Dhanda (1995) documented legal cases of divorce on the grounds of ‘insanity’ when the woman deviated from prescribed gender norms, for instance, putting too much salt in the food, not greeting the husband’s relatives adequately or refusing to consummate the marriage on the night of the wedding. Sometimes women are brought for psychiatric evaluation when the husband wishes to remarry or when the family wishes to dispossess them of property or inheritance. Being sent back to the natal family, separation or divorce, abandonment in mental institutions, abuse and neglect or homelessness are all exclusionary and coercive experiences which increase vulnerability and constrain women’s choices (Dhanda, 1995; Lacroix & Siddiqui, 2013; Moorkath et al., 2018). Dominant biomedical models have been critiqued for their tendency to medicalize and label the lives and suffering of women. Through her analysis of textbooks used in psychiatry training in India, Davar (2005) highlights how women’s mental health is neglected and sometimes misrepresented, with little attention to the social determinants of mental health. If the locus of distress is situated within the individual, then this suggests that it is the woman who must change. However, if we adopt gender-sensitive social models of health, then a range of preventive and promotive mental health initiatives can target the social determinants of women’s mental health (Undurti, 2020). A critical self-reflexive stance can help us recognize how the gender power structures that are institutionalized in the society enter the therapy room. This can sensitize us to systemic social inequalities and help us integrate concepts of social justice, advocacy and empowerment in our practice (Yu, 2018).

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Gender role expectations impact both men and women and influence the way we evaluate and diagnose male clients. For instance, depression is seen as a more feminine disorder, so when men show symptoms of depression, it violates gendered expectations (Liang & George, 2012). This suggests that we may be slower to recognize depression in men, and when we do see it, it could make us more uncomfortable. It is important to reflect on the needs, sensitivities and preferences of male clients in the therapeutic process. Adherence to traditional masculine norms can deter both mental health help-seeking and the expression of emotions and vulnerabilities during therapy (Addis & Mahalik, 2003; Vogel & Heath, 2016). Male clients may exhibit scepticism about the value of talking and self-disclosure (Deering & Gannon, 2005). As we reflect on how to change therapy to better fit men and boys, it is important to remember that men and women do not differ in all aspects, and of course, that all men are not the same (Liddon et al., 2019). Clinical experience suggests that male clients can value the opportunity to be comfortable with their vulnerabilities and explore their emotional needs in a safe space. It is recommended that practitioners use a gender-sensitive approach and recognize that male clients might have fears around being seen as failures and instead focus on strengths and resources, perhaps involving positive aspects of masculinity, for example, selfreliance, heroism or fatherhood (Seidler et al., 2018). When men find it difficult to express emotions, the therapist could help them develop their affective vocabulary. As therapists, we might need to pace our introduction of emotional language with men who have a history of not being connected to or labelling their feelings. A collaborative relational style, with an appropriate use of self-disclosure and the normalization and validation of discomfort, or hesitation regarding therapy, can facilitate their engagement. Other men-friendly adjustments to practise include the use of relatable humour, metaphors and analogies that men can relate to, and a more concrete problem-solving approach (Mahalik et al., 2003; Seidler et al., 2018). Male clients’ preference for short-term, solution-oriented structured approaches has also been reported by Indian therapists (Kallianpur, 2018). Studies also suggest

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that interpretive therapies, which focus on emotions, might provide new methods for male clients to express and process their emotions (Deering & Gannon, 2005; Ogrodniczuk et al., 2001). A nuanced and contextualized understanding of the range and impact of various expressions of masculinity calls for reflections on our own beliefs and biases about men and masculinity. Imagine that your recently married client wanted to discuss their intention to take a long-desired sabbatical from work, so that they could focus on their emotional growth. Consider if (and how) your responses might differ if it were a male or female client. Did you discover anything new about your relationship with gender through this exercise? The dynamic between a male client and a female therapist can sometimes be an advantage. Some men might be more comfortable in expressing their intimacy and dependency needs to a woman (Deering & Gannon, 2005). Discussions about the nature of the therapeutic relationship could help male clients understand the emotional closeness they might experience with a female practitioner in a more productive way. Unpacking the dominant discourses around gender roles, masculinity, power and how they perpetuate notions of being strong, self-reliant or achieving at work can be useful during therapy (Joshi, 2015; Stone, 2020). The online resource for men with depression, HeadsUpGuys, is an exemplar of a gender-sensitive approach that uses men-friendly messaging and male role models, builds a laddering approach to normalize help-seeking and strengthens pathways to self-management (Ogrodniczuk et al., 2018). Understanding their relationship with gender is also important for male therapists. Currently, a minority in a field that is almost a poster child for the ‘feminine’ qualities of communication and emotional caring, male therapists can sometimes feel isolated. They may struggle to find space for their masculinity in the therapy room and their femininity outside of it. At times it may be difficult for male therapists to break through gender stereotypes to be emotionally attuned and care for their clients. It might also be hard for clients to approach male therapists due to stereotypes that they may not be gentle and approachable enough (Kallianpur, 2018).

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The costs of non-conformity to binary notions of gender are high; individuals from the transgender community often live on the margins and experience intolerance, stigma and discrimination (Kalra et al., 2010). Therapists who have heteronormative identities may have a limited understanding of the difficulties and constraints encountered by individuals who identify as the ‘third gender’, including emotional, physical and sexual violence and limited educational opportunities, often resulting in poverty and homelessness (Agoramoorthy & Hsu, 2015; Shaw et al., 2012). These cumulative experiences of stress, alienation and lack of a sense of control increase the vulnerability to mental health difficulties, self-harm and suicidal risk (Pandey, 2018; Thompson et al., 2019; Wandrekar & Nigudkar, 2020). Many of these difficulties remain invisible and untreated, and mental healthcare facilities may be unaffordable or experienced as exclusionary. When an individual from the transgender community experiences further discrimination from a mental health professional, their distress is compounded. This increases barriers to quality mental healthcare and support (Wandrekar & Nigudkar, 2020). Although the World Health Organization (n.d.) has declared that gender incongruence will no longer be classified as a psychiatric disorder, practitioners need to make this shift as well. Therapists can reflect on whether they themselves might have imbibed some of the misinformation, societal prejudices and discriminatory practices. It has been recommended that cisgender therapists understand gender as a nonbinary construct, develop awareness of cisgender privileges and increase awareness on how experienced stigma and marginalization impact the mental health of transgender and gender non-conforming (TGNC) clients. Practitioners could focus on using trans-positive language, staying updated with best practice guidelines for gender-affirmative surgeries and understanding how trans-persons can be supported on their transition journeys (American Psychological Association, 2015; Sathyanarayan & Bhola, 2016). Gender-sensitive practices include not relying only on our clients for information on transgender issues (education burdening), being careful about not focusing so much on gender that we exclude other important aspects of our client’s life (gender inflation) and watching out for our assumptions that all transgender individuals are the same (gender generalizing; Mizock & Lundquist, 2016).

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As therapists, we need to be aware of how we process gender and remain fluid and responsive in our treatment of women, men and non-binary individuals in our therapy rooms. Rather than looking at matching the gender of the client and therapist, it could help to understand whether the client prefers a therapist of a particular gender and, if so, explore the reasons behind this preference. We need to walk the line between recognizing the unique context that gender identity creates for our clients while, at the same time, not viewing them only through this lens (Mizock & Lundquist, 2016). A Therapist Speaks: Reshaping Conversations about Women’s Lives We invited Dr Prabha S. Chandra, Professor of Psychiatry at NIMHANS, Bengaluru, to share her reflections on being a spokesperson for women’s rights in mental health. ‘Roxane Gay, a feminist author, wrote, “There is anxiety in being yourself, though. There is the haunting question of ‘What if?’ always lingering. What if who I am will never be enough?” These lines just about sum my professional life. As a woman psychiatrist in a male-dominated speciality in India, I do not think I had any doubt that women’s voices needed to be heard in the mental health space. Yet after 30 years, I still think it is not enough. My role as a mother and woman has always defined me in my work, and I have remained authentic, sometimes at a cost. Talking to trainees about the intersection of gender, caste and other inequalities and encouraging them (especially the men among them) to think contextually about what a mental illness actually means to a woman is an interesting journey. I have seen them gradually emerging out of their metaphorical “strong” cloaks to actually revealing stories about their mothers, sisters and girlfriends, and being vulnerable about their own helplessness when they felt they couldn’t do much. Motherhood has been the most challenging and rewarding experience for me as it probably is for so many of us. My strong connections to my body when I was pregnant with my daughter and then later to see her grow—part of me yet not entirely—has been a magical journey.

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It was early in my residency that I realized that the experience of motherhood was different for most women I saw in the hospital. I heard stories of early marriages, unwanted pregnancies and being torn away from everything that was familiar and supportive, and then having to care for your baby, when all you needed was someone to care for you. With my team, I started the first perinatal mental health service and mother–baby psychiatric unit in Asia, where the mother–infant dyad is provided holistic and multidisciplinary care at a vulnerable time in their lives. Training psychiatrists, obstetricians, ANMs8 and ASHAs9 in gender-sensitive care and maternal mental health have been a critical part of the process. It was not enough to provide a hospital bed or antipsychotics, the healing process required so much more. One had to dig deep into the women’s confused conversations and into oneself to have the patience to unravel their lives. Long conversations on patriarchy and the power imbalance have, I think, yielded some sensitivity among trainees (men and women alike). I often worry that I get too agitated when sweeping statements are made about women’s sexuality, their “mad and emotional” behaviour or their responsibility to keep themselves safe in an unsafe world. I vacillate between the personal, political and medical to try and get it all together into a coherent gestalt—sometimes failing, but often succeeding.’ Sexual Orientation and Affirmative Practice Although the mental health landscape related to same-sex sexuality has seen shifts over the past few decades, there is an undeniable history of discriminatory and harmful practices such as conversion therapies to ‘cure’ homosexuality (Narrain & Chandran, 2016). While some mental health practitioners and organizations in India have been actively An auxiliary nurse midwife (ANM) is a female health worker in India’s National Rural Health Mission, who is based at a health sub-centre or primary health centre. 9 ASHAs are an all-female cadre of community health workers in India’s National Rural Health Mission. 8

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advocating for the rights of the queer community, the movement for committed action towards systemic and policy change is ongoing (Kottai & Ranganathan, 2019). The inclusion of queer perspectives and affirmative practices continues to be uneven in mental health curricula, training, practice and supervision. There may sometimes be limited opportunities for therapists to examine their own attitudes, experiences and expressions of sexuality. Unexamined positions might lead to subtle, covert and unintentional forms of therapist bias that can be experienced as microaggressions by queer clients. Such exclusionary and invalidating messages might problematize non-heterosexual orientations and insidiously damage the therapeutic environment (Shelton & Delgado-Romero, 2011). Constant reflection by therapists may increase awareness of any homonegativity and help in the understanding of minority stress and heterosexism experienced by members of the queer community and of their journeys (Ranade, 2019; Ranade & Chakravarty, 2016). Having a gay friend or considering oneself as ‘gay-friendly’ may not be enough; therapists who are not part of the queer community may need active efforts towards being ‘gay-informed’ (Kelley & Flaherty, 2015; Kort, 2008). This includes becoming familiar with inclusive language, cultivating an openness to learning about their unique life stressors and experiences and how it is to navigate the world with this identity. For straight therapists who are unsure about their acceptance and effectiveness with clients from the gay community, Holtby (2004, p. 13) shares, ‘Maybe the key is being open to and knowledgeable of differences, as well as utilizing those things which are fundamentally the same for all people like intimacy, loss, self-esteem, and the impact of our personal and family histories.’ Sensitive and contextually relevant models which address the diverse needs of queer clients, especially those that are linked to the queer identity (e.g., decisions about coming out, internalized homonegativity, family of origin relationships and self-esteem) have been proposed (Wandrekar & Nigudkar, 2019). Decisions about ‘coming out’ need to be understood within social and familial contexts that can differ across cultures. Importing Western frameworks to understand queer identities, experiences and choices may not adequately capture

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the complexities of growing up and living as a queer person in other cultures and contexts. As therapists, we could reflect on our own positions about issues such as self-disclosure (implicit or explicit) about our sexual orientation (Kronner & Northcut, 2015; Moore & Jenkins, 2012). While some research has indicated that queer clients experience their queer therapists’ disclosures as helpful (Kronner & Northcut, 2015), the decision could vary across therapists. Training in queer-affirmative practices can help build an inclusive practice with the required knowledge, attitudes and skills to effectively work with clients from the queer community. A Therapist Speaks: Learning Queer Affirmative Counselling Practice We invited Ketki Ranade/KP, faculty at the School of Social Work, Tata Institute of Social Sciences, Mumbai, to share their perspectives and work on queer-affirmative practice. ‘The Queer Affirmative Counselling Practice (QACP) course has been developed by queer and trans-identified mental health practitioners, for practising mental health professionals in India. The course development and execution are supported by the Mariwala Health Initiative, and we have trained 100 mental health practitioners from across 10 cities, between 2019 and 2020. Why this course? With increasing visibility and rapid socio-legal changes on LGBTQIA+ issues, mental health practitioners are increasingly acknowledging the gap in their training and are eager to learn about queer and trans mental health. We felt that it was important to take the lead in creating a curriculum that is rooted in our lived realities and that can critically engage with mainstream mental health praxis. What we do in this course? We begin by looking at the complex ways in which societies construct normative gender sexuality. Understanding the confusion between ‘normative’ and ‘natural and normal’ is the starting point of this course. Participants, particularly those identifying as heterosexual and cis-gender, engage in a range of self-reflexive

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exercises tracing their own life journeys—when, where, from whom and how they learnt about appropriate gender roles and sexuality and how these have shaped their experiences. Participants reflect in groups on social privilege, power and ways in which it is connected to gender sexuality and in turn linked with well-being, distress and access to services and support. We also build an understanding of lived realities of queer and trans persons, minority stress experienced by them as individuals, in intimate relationships and with families of origin. The mediums of films, lived experiences/narratives of queer and trans persons, as well as case vignettes derived from clinical practice of the trainers help build this understanding. Group exercises using a queer-affirmative lens offer powerful experiential learnings. Tenets of queer-affirmative counselling, and ways in which a neutral approach differs from an affirmative one, are discussed using case examples. Participants are encouraged to apply the queer-affirmative lens to their knowledge of popular models of counselling, such as person-centred, cognitive behavioural, family systems and narrative therapy, through group activities. This interdisciplinary course draws from sexuality and gender studies, sociology, critical psychology and mad studies. Trainers occupy multiple loci of being trained mental health professionals/practitioners/educators, identifying as queer/trans themselves, and as activists associated with the queer movements in India. These positions, as both trained experts and experiential experts, are unique to the QACP course. Self-disclosure from these multiple loci has been often used by the trainers as a pedagogic tool to enhance both authenticity and empathy in the training room.’

Across the Intersections As we look across the intersections of various social locations, it becomes clearer that these cannot be compartmentalized. Our privileged and marginalized identities are interlocked and continually shape our lives and therapeutic interactions, strategies and goals. The client may bring questions about therapist and client’s social locations into sessions and wonder if their realities can be heard and understood by

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the therapist. We need to create a space where such articulations are not just possible but also invited by the therapist. To incorporate an intersectional perspective in our work, we need to ‘ask the other question’. Feminist scholar Maria Matsuda (1991, p. 1189) explains this approach: ‘When I see something that looks racist, I ask, “Where is the patriarchy in this?”’ Using an intersectional lens can strengthen the therapeutic relationship and support clients to process how oppression impacts their lives and build skills to recognize and respond to inequitable social structures. The ADDRESSING acronym coined by Hays (2016) can guide therapists to remember the multiple seen and unseen identities that impact their interactions and work with clients: Age and generational influences, Developmental disabilities and Disabilities obtained in later life, Religion and spiritual orientation, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin and Gender. Of course, the ADDRESSING acronym may not capture all relevant intersections and we may need to incorporate some identities, such as caste, which are unique to certain cultural contexts. As we reflect on this relational intersectionality resulting from similarities or differences in therapist and client identities, we must situate this in social, political, cultural and ideological contexts (PettyJohn et al., 2020).

Perspectives on Training and Development Assessment of Social Identities and Cultural Experiences Practical methods and tools can help practitioners keep culture at the centre of their therapeutic work. An assessment of social identities and cultural experiences through instruments such as the Patient Social Identity Assessment (Dadlani et al., 2012) is recommended for all clients, not just those from marginalized or minority groups. In this process, therapists can reflect on the social identities which were prominent or relatively hidden during the initial therapeutic exchange. It sets the stage to explore any biases or assumptions related to each

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social identity intersection and not just those associated with each social identity in isolation. While doing this assessment, therapists can think more deeply about how clients might also make assumptions about therapists’ own obvious identity markers. Therapist subjectivity is a key factor even when structured evaluation methods are used. Multiple therapists may enter through the same door but reach a different cultural formulation with the same client (Aggarwal, 2012). Training Methodologies for Diversity and Social Justice Guidelines and tools for cultural competence may sometimes be difficult to translate into practice. Experiential and reflective methodologies which are embedded in clinical settings and supervision and adopt an idiographic perspective are recommended (Benuto et al., 2018; Etengoff, 2020). Systems-level interventions towards cultural competence include attention to workforce diversity, building service delivery systems which support equitable access, using of inclusive terminology, culturally sensitive assessments and interventions, and workforce training to build competencies (McCalman et al., 2017). Incorporating a social justice lens into therapeutic work can seem challenging. Winter (2019) recommends making a concrete start through reflections on power and privilege in our experiences and narratives, and by ensuring that interactions and communications with clients convey relational equality and collaboration. Therapeutic formulations must be expanded to include sociopolitical contributors to distress so that our clients do not feel that both the ‘problem’ and the ‘solution’ are located within themselves. Training frameworks that engage with social justice also value and emphasize the role of community resources and actions outside the therapy room. Interrogating Psychotherapy Models Guidelines and assessment methods are only the beginning of our engagement with the complexities of cultures. Pon (2009) cautions us that a simplistic view of cultural competency as a set of skills to be mastered and applied can protect us from the more difficult work

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of self-reflexivity. When we engage with issues such as racism and colonialism and both historical and contemporary processes of marginalization, we are compelled to examine how we (and our professions) are implicated too. As teachers and trainers, we need to reflect on whether our psychotherapy models adequately reflect sociocultural issues. These can include migration, health policies and laws, social landscape, as well as the diverse realities of our clients’ lives. Another critical question centres around if and how therapies developed in Western contexts can be transplanted or translated to Eastern cultural contexts. Integrating Critical Consciousness as an Educational Pedagogy Critical consciousness as an educational pedagogy, developed by Freire (2005), recognizes that internalized and structural oppression contribute to individual distress and social dysfunction and that each of us has the agency to individually and collectively take action towards a socially just society (Jemal, 2017). Thus, a collaborative effort is needed from all stakeholders in the education system, including trainers, supervisors, students and administrators. Only then will the mental health training include these components in the curriculum and provide opportunities for trainees to work in diverse contexts with marginalized populations (Brown & Perry, 2011; Hernández, Almeida, & Dolan-Del Vecchio, 2005). The degree of organizational and systemic support and shared viewpoints with colleagues and teachers can vary and this can make it more challenging to deepen our critical awareness and actions. While for some of us these deliberations might begin during our training years, for others it might happen as we work with diverse communities in our practice. Building Competencies for Advocacy As therapists we can be advocates for clients inside and outside the therapy room and become active agents of social change by empowering others and ourselves to challenge systems of oppression and

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seek social justice (Brown & Perry, 2011; Ratts & Pederson, 2014). The American Counselling Association (Toporek & Daniels, 2018) outlines advocacy competency domains that are linked to acting with and acting on behalf of the client and outline a range of interventions within and outside the therapeutic space. Advocating within the therapeutic space includes identifying the strengths of the client, how issues of oppression impact their well-being and growth, and equipping clients with skills for self-advocacy. Outside the clinical space, it is important to build awareness about community initiatives, organizations that promote client rights and reach out through technology, media and policy advocacy. It is not enough to reflect on social realities, we also need to follow it up with transformative action.

Conclusion One palace, one million doors Countless windows in between From wherever I look The Beloved is before me. (Virmani & Rikhi, 2019) This verse by the 18th-century Sufi Shah Abdul Latif Bhittai is the central motif of a meandering journey through the white desert sands of Kutch in eastern India during Shabnam Virmani and Vipul Rikhi’s search for mystic songs in remote villages (Virmani & Rikhi, 2019). Shah Latif’s words span both sides of the border between India and Pakistan and reflect diverse literary and spiritual influences:; the Qur’an, Rumi and Nath Panthi yogis. Virmani speaks of finding songs and stories from the Bhakti, Sufi and Baul oral traditions that ‘cross borders without visas’, reflecting the intermingling of voices from different religions, languages, geographical locations and different time periods. Each tradition is unique, speaking the same truth about human experience—with different words but in a shared language. We can see parallels with psychotherapy practice, where when we talk about engaging with diversity, we are actually talking about the possibility of connection. Although we may enter through different

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doors or look out of different windows, it is possible for a shared perspective to emerge. Diversity in our therapy room, community and world is an inescapable fact of life. As therapists, our willingness to immerse in and critically reflect on the structures underlying the society can open new doors in the minds of our clients as well. Conversely, our silence on issues of such significance for our clients can itself perpetuate and support existing disparities. When we engage openly and honestly with issues of diversity, it is no longer a threat but an opportunity for growth. It is through meeting the other that we can truly meet ourselves.

Chapter 8

Learning from Clients

When psychotherapists across the world were asked to reflect on the strongest influence on their professional growth and development, the resounding verdict was their experiences with clients (Orlinsky et al., 2001). As therapists, we can experience a series of reality checks, where our theory and technique let us down. At these times, our clients may lead and take us along in their journey. When we understand and integrate these experiences, we become more humble and less sure of our power to heal; but conversely, we can also become more confident and competent, as we come to see our role more clearly. No two therapeutic encounters are the same, no two paths of self-discovery are similarly mapped and no two sessions are alike. With each client we discover new ways of listening, relating and being, and somewhere along the way we change as therapists. In the fantasy novel The Lord of the Rings (Tolkein, 1994), we leave the safe and familiar Shire and journey on a long and dangerous quest with Frodo, the Hobbit. When Frodo is uncertain and reluctant, Gandalf the powerful and wise wizard helps him get started and is a constant guide and mentor. Along the way, Frodo has many challenging encounters, experiencing inner struggles and powerful enemies, facing difficult choices and enduring a series of tests. He persists on a quest to destroy the One Ring and save Middle Earth from the Dark

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Lord Sauron, saying ‘I will take the Ring, though I do not know the way’ (Tolkein, 1994, p. 264). Gandalf encourages him to have experiences outside his comfort zone and appears, when needed, to lead him to safety. Gandalf is a central figure in Frodo’s transformative journey. But really, Frodo is the hero. Even Gandalf is impressed with Frodo’s will and choices, perhaps more than the mighty deeds performed by kings, knights and even himself. In a similar vein, Duncan and Miller (2000, p. 173) remind us, ‘It is time to recast the drama of psychotherapy, to retire the star therapist and place the heroic client in the leading role.’ As trainees, we usually enter the world of therapy through the doors of teachers, courses and books. It is no wonder when we first encounter clients that we may believe that we know far more than they do and want to share our insights, knowledge and understanding with them. In this rush, we sometimes might not heed what our clients are trying to tell us about themselves and their lives. Over time, most of us realize that like Frodo, our clients are on their own journeys, motivated by their own purposes. They have chosen to recruit therapists to help them with part of the way, but it is their desire to heal and grow that provides the real energy of therapy. Rather than seeing therapy as a process where treatment/therapist operate on the client to create change, Bohart (2000) suggests that we need to see the client as operating on treatments and theories to produce effects. Clients do come to therapists for expertise and support in meeting their goals, but they are to be ‘joined with’ rather than ‘acted upon’ (Williams, 2020, p. 530). Wise and experienced therapists can hold both the client’s framework and their own professional one, using both to guide the change process (Levitt & Piazza-Bonin, 2016). It seems that for therapy to work well, both client and therapist need to be actively engaged, mutually respectful and willing to learn from each other. In this chapter, we reflect on the various ways we can enter the clients’ world through enhancing our sensitivity to the language they use, responding to client preferences and drawing out their theory of change. Routine outcome monitoring (ROM) and methods of eliciting and processing client feedback are examined. We bring a focus

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to client voices outside the therapy room as well, attending to client narratives about their therapy experience and seeking lessons from the user–survivor movement. We end with discussing how therapists also grow and change as persons through their work with clients.

Stories That Teach: Learning from Client Narratives Listening and learning from client narratives might seem something we do all the time, but it is reflecting together that helps us learn how therapy works for the client in front of us and for those who are yet to come. As therapists, we need to engage with our client’s problems, through their words, metaphors and idioms of distress and through what they do not say. The material might be brought in non-verbal ways as well, a visual metaphor in a drawing, an image in a dream or the placement of objects in a sand tray. Metaphors are likely to have different meanings for each of us and can express emotionally rich and complex life experiences, or bodily felt emotions that are hard to define or fully articulate (Angus & Scott Mio, 2011). In describing her turning a blind eye to her husband and son’s ways of managing the business and money, a client shared how she felt like ‘Gandhari’.1 She used this culturally powerful metaphor—of being blindfolded by the choice so the deeds of others were not in our view—to communicate her situation to the therapist. The exploration of this metaphor opened possibilities for the client to reflect on her choices. The therapist could ask reflective questions about how her gender, family values and life experiences might have contributed to her being in this position. Together, they explored the alternative ways of responding which seemed possible, and what choosing to open her eyes would mean. Sensitive exploration of the story and context in which metaphors are couched open doors into the emotions that could underlie them and create a stronger therapeutic bond (Angus & Scott 1 Gandhari is a character from the Indian epic The Mahabharata, who chose to blindfold herself through her life when she found out that her to-be husband was born blind.

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Mio, 2011; Wagener, 2017). Each exploration we take with our clients into their expression of experiences like the anxiety that lurks as a bear in the cave, the relationship that feels like a tattered dress or therapy that feels like a promise of water on Mars expands our awareness to new dimensions of understanding human experience. We can support therapeutic change by asking clients to imagine how their metaphors could be transformed or even introduce metaphors to the client (Wagener, 2017). For instance, if a client describes their experience of depression as dragging a black hole behind them, we can ask what it might feel like for them to put that burden down or step away from the hole. Angus and Scott Mio (2011) tell the story of a couple who used the metaphor of armour to describe how the wife protected herself. The therapist shifting the metaphor for protection from armour to soft pillows enabled the husband to see how he could gently move them away one by one, rather than having to poke his way through, thus paving the road for better intimacy. Such discussions can help the therapist learn how to tune into the client’s lived experience and create powerful change opportunities. Engaging with the Client’s Theory of Change Over years of practice, therapists also learn to engage with each client’s theory of change and use it to determine therapy goals and processes (Bohart, 2000; Duncan & Miller, 2000). Some clients might have already thought through aspects of their concerns, while others might use the therapy space to discover and crystallize their understanding. While therapists might initially impose their own understanding and conceptualizations, over time they may learn the process of how to lead from half a step behind. When clients enter an often-unfamiliar therapeutic space, they may wonder what to talk about, worry if their problems are legitimate or feel emotionally inhibited and vulnerable (Klieven et al., 2020). Checking what they know about the process, listening with curiosity and respect and then adding information from our professional knowledge build ‘scaffolding of shared understanding’ between the therapist and the client (McLeod, 2013, p. 58).

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Attention to client experiences and preferences may be particularly useful in the early trust-building phase of therapy (Hovland et al., 2020). In traditional hierarchical societies like India, the notion of inviting such discussions may be harder to accept (Bhola & Chaturvedi, 2017). We may need to work more consciously to ensure that clients feel comfortable sharing their preferences about therapy methods or techniques, foci of conversations, preferred therapist style and goals of therapy. We can begin this active dialogue by first explaining what is on offer and what we would need from clients (McLeod, 2015). It is around the frame of what is possible for us as therapists to do that clients can make meaningful choices. This experience of choice can be an empowering experience, one that helps clients shift their frame of reference from ‘I need help’ to ‘I am learning how to help myself.’ Using measures can also help frame and kickstart conversations around client preferences in the therapy process. Some examples include the Therapy Personalization Form (Bowens & Cooper, 2012), the Psychotherapy Preferences and Experiences Questionnaire (PEX-P1; Berg et al., 2008) and the Cooper–Norcross Inventory of Preferences (Cooper & Norcross, 2016). When we reflect with clients on their preferences, it opens possibilities and, most importantly, creates hope that things can be different (McLeod, 2013). The client no longer tries to find the right answer and can be freed to find the answer that works best for them. We can respond immediately to micro choices like ‘I would like you to ask me more specific questions about my relationship’ or ‘I wish you would smile at me more often.’ While we do not acquiesce to every request, for example, a request for increased session frequency, we do remain respectful of it and try to explore the reasons and meanings behind it. While clients appreciate their therapist’s responsivity, they may also wish for guidance when they feel stuck or are avoiding issues (Levitt et al., 2016). Finally, constantly asking clients what they want or prefer can leave them feeling irritated or concerned, perhaps seeing the therapist as too hesitant or lacking confidence (Burnham, 2005). We invite you to ponder on how you engage with your client’s needs, preferences and experiences during the therapy session. At the start of the therapy hour, do you ask your client how they would like

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to use their time with you? At the end of the therapy hour, do you encourage them to share how it went for them and if they would have liked anything different? During your conversation with your client, do you enquire about their previous efforts at change, and the strategies they would like to continue with? Do you directly enquire about the client’s comfort with the therapeutic relationship? How frequently do you review which interventions your client found most and least useful? How likely are you to change or modify your therapeutic approach based on this feedback? As the client evolves their theory of change, we become more aware of what motivates them, their emotional landscape and their explanatory models. Some clients might see their current distress as stemming from their family experiences, for example, being made to feel guilty for asking for what the family could not afford. Another client may relate their difficulties to their religious notions of lacking commitment during the fasting period. Some clients might use the frame of cultural values that to bear and tolerate is desirable rather than fighting to change or confront. When we ask the client, ‘In what ways do you see me and this process helpful to attaining your goals?’ (Duncan & Miller, 2000, p. 181), we not only elicit the client’s story of how they can change but also the role they would like us to play in this process. Where therapist formulation and intervention fit with the client’s own model of distress and connect with their strengths and previous efforts to understand and help themselves, treatment can be more effective. The skill of the therapist lies in finding the model that matches best with the client’s world view and offers continuity with their life stories, and that activates the client’s own theory of change and self-healing capacities (Bohart, 2000; Duncan & Miller, 2000). The Feedback Loop Noticing the smaller moments in therapy and our clients’ immediate verbal and non-verbal responses is one way to know if the client and therapist are on the same page (Oanes, Anderssen, et al., 2015). The immediacy of the therapist’s noticing what is happening with the client in the session and addressing it can leave clients feeling heard and validated. An intentional seeking of feedback, a non-defensive

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response, open discussion of differences and subsequent modulation of our actions can contribute to better therapeutic outcomes (Timulak & Keogh, 2017). Asking clients to respond to these questions about their experience can help us make changes in the therapeutic process and set the agenda for future sessions: What are my feelings about the session? What did I learn? What did I not like? What did I wish would have happened (Haber et al., 2014)? We might need to make a deliberate effort to seek feedback from all our clients, specifically clients from disadvantaged socio-economic groups and marginalized or minority communities. Innovative and developmentally appropriate measures, for example, the Dialogical Feedback Tool (Rober et al., 2021), can be used to attune to the experiences of young children in therapy. There is an array of feedback measures that use qualitative or quantitative approaches, are personalized or generic, and vary in their focus on select symptoms, a broad range of outcomes, relational aspects or the overall experience of therapy (Prescott et al., 2017). Pragmatic considerations such as time, cost, human resources and relevance for our practice may influence which measures we use and how frequently we do so. Regular tracking of our client’s symptoms and concerns, using structured measures at multiple points, can lead to a shared understanding of the ‘problems’ throughout the course of therapy. ROM allows us to graph and track each client’s trajectory of change, identify those who are ‘not on track’ and use this feedback to modify therapy goals and processes, rather than following a fixed evidence-based protocol (Reese et al., 2013; Shimokawa et al., 2010; Winklejohn Black et al., 2017). There are a range of structured feedback systems being used across various theoretical orientations and formats of therapy. While there are variations in the scope, length and targets of assessment, measures are typically brief to allow for repeated use. Two exemplars are the Outcome Questionnaire (OQ-45; Lambert et al., 2013) and the Partners for Change Outcome Management System (PCOMS; Miller & Duncan, 2004). The OQ-45 tracks symptoms related to distress, emotional states, interpersonal relationships and social roles. This can be used in combination with a clinical support tool, the Assessment for Signal Clients, which measures in-session

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experiences such as alliance and motivation, as well as outside therapy experiences of social support and life events (Lambert, 2015). The PCOMS includes the Outcome Rating Scale and Session Rating Scale and is used to monitor treatment outcome, therapeutic alliance and client views on progress, with specific guidelines for how to intervene with clients who are improving, not improving or deteriorating (Reese, Nosworthy et al., 2009). Personalized measures like the Psychological Outcome Profiles (Ashworth et al., 2004), which require clients to describe and rate their problems, functioning and well-being, can place more demands on them than ‘tick the box’ forms. But this can be worth the effort, as they allow clients to share what is important to them that may not be covered by standardized assessments (Alves et al., 2020). Learning about our client’s world in their own words can open the door to an exploration of sensitive, hidden and important issues at the outset of therapy. When initial conversations introduce feedback as the building of a partnership and share information about what it will be used for and who has access to the data, our client will probably be more committed to the process (Börjesson & Boström, 2020). We need to create conditions so that feedback is integrated into the therapy process; each session could begin with examining feedback from the previous session, noting areas where the scores are particularly low and discussing this with the client (Reese et al., 2013). When client feedback is more specific (for instance, ‘I would like to talk more about my childhood experiences’), it makes it easier for therapists to discuss and apply the feedback in the next session itself (Brattland et al., 2018). While information from a feedback tool can be used by the therapist alone, to interpret and apply (De Jong et al., 2012), using it as a basis for therapist–client discussions is a much more useful approach. The therapist also has an opportunity to reflect on their own contribution to the client’s experience, perhaps with a supervisor. The filling of forms and the use of numbers and statistics to understand what is going on in our therapy rooms may be daunting for the therapist and client alike (Reese, Usher et al., 2009). Therapists may also be inhibited because of their discomfort with technology, complex representations of the feedback and time and resource constraints

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(Gleacher et al., 2016)). The structuring of therapy can feel like a third entity in the room, which challenges our identity as practitioners of the fluid ‘art’ of therapy (Oanes, Borg, et al., 2015; Reese et al., 2013). Perhaps, we like to think of ourselves as the experts in the room and are reluctant to expose ourselves to feedback that may not match our expectations or impressions. We may question the client’s feedback or look for reasons outside therapy to explain the findings (Brattland et al., 2018). When we feel questioned by clients, we will need to work extra hard to manage our emotions and defensive reactions and keep the focus on their needs (Levitt & Piazza-Bonin, 2016). Therapists are still the gatekeepers who decide how much session time is spent on discussing feedback, and so we need to be clear about our feelings about using this methodology (Hovland et al., 2020). As we understand the theory (and research) behind feedback and begin to seek and use it more regularly, we can realize its value, both for the client in front of us and for others in the future. The amount of organizational and leadership support for the usage of client feedback systems has a significant impact on therapist’s willingness to do so, as well as clients’ attitudes about the value of feedback processes. If you were setting up a group practice, what would you do to implement and evaluate a client feedback system? Getting quantitative feedback enables us to develop a metaunderstanding of therapeutic process and practice, offering a scaffold to help us move beyond our theory or comfort zone. Importantly, using a feedback tool opens the door for clients to describe their needs, which they might be reluctant to do face to face. Qualitative explorations with clients indicate that feedback tools are experienced as helpful in identifying sensitive issues like therapist–client relationship (Hovland et al., 2020). Overall, tracking progress can be empowering as clients learn the language and skills to express their needs (Oanes, Borg, et al., 2015). When therapists are alerted to indicators that clients are not responding as expected, they can course correct and prevent further deterioration and dropout (Lutz et al., 2015). While the use of feedback can result in immediate positive shifts among those that are ‘not on track’, therapists do not always initiate conversations on progress trends with these vulnerable clients who need it most (Hutson

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et al., 2020). Feedback does not universally improve therapy outcomes, suggesting the need to weigh the costs and benefits of implementing resource-intensive feedback systems. There have been fewer encouraging results in psychiatric settings with a larger representation of persons with severe illness manifestations (Østergård et al., 2020). It seems important to adapt feedback systems for use in diverse clinical and care setting and for specific client characteristics and needs. From an exploration of clients’ perspectives, we learn that the focus on measuring symptoms and risks was perceived as too narrow (Moltu et al., 2018). Our feedback measures may need to be recalibrated and contextualized to what is meaningful and important in our clients’ lives and recovery journeys. For instance, tracking depressive symptoms tells us how our client is feeling, but how they are doing in interactions with their spouse or children might be more relevant for them. We need to examine if our feedback systems allow clients to articulate what was experienced as helpful or hindering, whether they felt understood and safe with the therapist or if they felt free with disagree. A feedback tool by itself does not have any power and can ‘only be as good as the therapist who uses it’ (Miller et al., 2015, p. 452). As therapists, we need to commit time towards this critical reflection on client feedback and remember that all of us can open such conversations with our clients, even if we do not use formal feedback measures.

Learning from Client’s Voices When we step back and see therapy (and therapists) through our clients’ eyes, rather than through the lens of expert-led research or theory, there is much to learn about the ways we play our role as therapists, the gaps in how we provide therapy and what is valued by clients in the therapeutic experience. Rather than therapists’ perceptions, it is our clients’ perception of the therapeutic relationship and the helpfulness of the session that contributes most significantly to therapy outcome (Swift & Parkin, 2017; Timulak & Keogh, 2017). If our clients’ voices are not heard and psychotherapy occurs within a closed system, we may remain oblivious to the fact that therapy can sometimes be harmful or ineffective.

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What the client finds meaningful in each therapy session may not be what the therapist notices as significant. This is beautifully described in the book Every Day Gets a Little Closer: A Twice-told Therapy, where both the therapist and the client describe their experience of each therapy session (Yalom & Elkin, 1974). Reflecting on the experience, Yalom notes, ‘Often she values one part of the hour, I another’ (Yalom & Elkin, 1974, p. 351). There is ample evidence for what he calls the subterranean life of the client, that is, that clients do not share all their experiences, thoughts and feelings with the therapist. Ginny (the client) agrees with this saying, ‘At times I acted in his office, deliberately subduing my spirit to coincide with the therapy hour’ (Yalom & Elkin, 1974, p. 378). A Client Speaks: Musings on a Partnership Ms Suman Bolar, a Bengaluru-based writer, communications consultant and school administrator, shared her experiences as a psychotherapy client, reflecting on what makes for an empowering partnership. ‘I vividly remember my first visit to a therapist. After I’d explained why I was there, I was instructed to lie down and clench and unclench my muscles from head to toe. I was irritated. I’d expected and wanted to be asked questions, hoping that a professional would help me understand my pervasive, inexplicable sadness. Instead, I was doing isometrics! When I left, I knew that I wouldn’t return. I now know that the therapist was trying to relax me prior to therapy. But to me, it was the equivalent of a first date with someone who orders on your behalf without being asked to. It might have felt different if there had been an effort to explain, but there wasn’t. I struggled through several different therapists before I found one who was right for me. What made her different? She seemed to recognize that we were in a partnership. In any partnership, clearly articulated expectations and boundaries are essential: What is each one’s role? Like dancers, each partner must learn when to step up and when to step back. Above all, each partner must earn and keep the other’s trust. My therapist trusts that I will be

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punctual, stay committed and pay promptly. I place faith in her professional ethics, trusting that she will pay attention, try to “get” what I’m feeling and push me (but not too hard!) when necessary. But this is not an equal partnership; only one partner (me) is making themselves completely vulnerable—and the imbalance is at first deeply unsettling. Over time, we have grown into this partnership, coming to trust, like and perhaps even admire one other. We’ve come to understand and appreciate each other’s words, silences, patterns and rhythms. Whenever we’re in sync, sessions are fruitful and productive, with actionable outcomes. Things are trickier when our priorities differ. I’ve learnt to pay close attention when my therapist veers off to something seemingly irrelevant. Sensing something that I haven’t, she has seized the wheel, gently confronting me with uncomfortable truths or pushing me into expressing something I’ve been suppressing or avoiding. Even though I rarely understand where she is going or why, I’m able to acquiesce to her agenda because she always acknowledges that she’s taking charge. Such sessions are exhausting, for both of us. There’s no immediate payoff and I’m sometimes restless or agitated for days. But eventually, some tiny nugget shifts or widens my perspective, helping me respond to life experiences with composure and equanimity. We’ve both learnt to be patient with the therapeutic process, trusting that a planted seed takes time to sprout and longer to flourish. A partnership cannot be one-sided. As a client, I offer my therapist access to a wider set of human experiences, more emotional high notes, low notes and octaves to draw from, and the chance to hone her craft. But more than anything else, I think that I contribute to giving her the one thing we all need as human beings: the sense that she matters.’ Perspectives from the Consumer/Survivor/ Carer Movement We might hear individual voices or a chorus of voices from clients who have formed a movement, urging us to take a critical perspective on psychotherapy, its place in our client’s lives and in the mental healthcare systems, and on ourselves as psychotherapists. This may be

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accompanied by a shift in terminology, where the terms user or consumer refer to people who are receiving mental health services (Daya et al., 2020; Samudre et al., 2016). From this vantage point, we view clients as consumers, people who have rights, who expect high standards of service and who do not wish to be controlled by the systems that are meant to be serving them (McLeod, 2015). The term survivor is owned by persons who critique and oppose the traditional mental health paradigms as damaging based on their experiences (Sweeney, 2016). We also need to privilege the voice of carers, persons who have had close encounters with the mental healthcare systems, through the experience of caring for family members. Users/survivors/carers speak from varied standpoints, depending on how much they experienced treatment and care as helpful and affirming and where they note areas for change (Daya et al., 2020). Some users might embrace the dominant mental health language, speaking of themselves as ‘patients’, with diagnoses such as ‘borderline personality disorder’, or work as advocates within existing frameworks. Others may go further to question psychiatric labels and the biomedical discourse, uncover serious inadequacies in systems of care and push for self-determination. This paradigm shift requires us to shift our gaze to reflect on our own value positions and on the larger mental health system that our clients encounter. Do we see our role as therapists to fix problems (and people)? What is our position about diagnostic criteria and categories? How much do we know about user–survivor perspectives and experiences with psychotherapy? An awareness about user/survivor movements, both locally and around the world, can help us engage with the needs of several marginalized groups. User/survivors from low- and middle-income countries (LMICs) face difficulties related to access, affordability of treatments and associated loss of livelihood, in addition to mental health stigma. When these factors combine with the power differentials between users and service providers and the limited opportunities for decisionmaking, there are monumental barriers to working towards rights and advocacy (Samudre et al., 2016). It requires persistent and committed effort to overcome these barriers, but community-led programmes do exist and thrive around the world. The Seher initiative is an exemplar

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of an urban community mental health initiative in India, which is embedded within a human rights framework. In an interview, Bhargavi Davar, the director and co-founder of The Bapu Trust, shared how Seher evolved into a holistic care model which encompasses self-care, recovery and healing. Davar spoke of asking questions to understand the needs and perspectives within low-income communities: ‘What does support mean? What does psychosocial distress mean? What is worry? What is tension? When does it become unbearable and people need support? What are the kinds of supports? What are the community arrangements that are acceptable to them’ (Davar, 2019)? The language of psychosocial disabilities, in place of psychiatric terminology, allows for deeper engagement with experiences of distress and social determinants of well-being. There is a recognition that traditional mental health systems offer pills and psychotherapy, but communities also have needs for nutritious food, employment, safe spaces or legal aid. The principles of agency, choice and inclusion are reflected in the central role of peer and therapeutic support groups drawn within the community. Another initiative from India It’s OK To Talk is an example of a co-design process including young people with mental health challenges. Broken but not beautiful, It’ll be okay. If not, that’s okay too and Orange uniforms… are among the narratives, videos, artwork and poetry about lived experiences and paths to self-acceptance, self-care and recovery. Interestingly, though young people could choose to be anonymous, most owned their stories and revealed their identities on the website (Gonsalves et al., 2019). A related initiative Mann Mela is a digital and travelling museum of young people’s mental health stories from India, with animated depictions of their recovery journeys, developed through a participatory process. As therapists we can find ways to learn from and contribute to the user/survivor movement and advocate for meaningful change. Therapist–survivors who have been through psychological distress themselves can be uniquely positioned to connect with their clients’ experiences and to think more deeply about the kinds of therapists and therapy that are needed. With this shared experiential knowledge, therapist–survivors ‘no longer have the luxury of setting up simplistic

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us-versus-them dichotomies—they are us and them’ (Adame, 2011, p. 335). This journey is for all therapists, and we can operationalize the aims of the survivor movement through more humane approaches in interactions with our clients, through an openness to expanded notions of healing and recovery and by creating inclusive spaces in society (Adame, 2011, 2014). We can also learn about what is valued, needed or missing in therapeutic spaces from two rich veins of knowledge— survivor research and mad studies—and lend support to the needs and agendas of our clients in their communities (Beresford, 2020; Faulkner, 2017). Our willingness to look at these spaces, question the paradigms we work within, engage in dialogue and then look within ourselves can help us and our profession evolve.

Completing the Circle: Client Contributions to Personal and Professional Growth Working closely with clients as they change and grow transforms therapists in many ways, for how can we continue to stay the same ‘in the presence of so many who are changing’ (Kottler, 2010, p. x)? Our everyday activity of putting ourselves in the shoes of many different people can broaden our perspectives and encourage us to explore different ways of being (Kahn & Fromm, 2001; Kottler & Hunter, 2010). Each of us may be able to recall at least one experience when something our clients said or did led us to challenge our assumptions or modify our practices. The times when we have been stuck, have an emotionally charged session, experience a breakthrough with a client or lose a client to dropout—all offer potent opportunities for reflection and learning. Eminent therapists often describe how responding to challenges in therapeutic work helped them grow beyond what they knew and discover something new in therapy (Kottler & Carlson, 2006). The building of the therapist self happens bit by bit, as we learn to hone our skills or techniques, pay attention to our feelings and derive a realistic acceptance of the nature of change, through our experiences with clients (Stahl et al., 2009). As we witness our clients’ journeys through pain and suffering to healing and growth, it stimulates deep reflections within us and forces us to not just expand our professional

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capacities but also confront our ‘selves’ and larger questions about life and meaning (Freeman & Hayes, 2002; Hatcher et al., 2012). When we sit before a client having thoughts of self-harm, we might say that we learnt how to assess for risk, how to create a safety plan and how it could be individualized. In those moments, however, we also learn to sit with distress, how anchoring it can be to be in the presence of another, that it is okay to talk openly about death and dying, and how amid distress we can find the courage to go on. Pause here to recollect the interactions with any one of your clients who had a significant impact on you. This could be someone who you met years ago but will never forget or someone you saw more recently. Reflect on what you have learnt from this client as a therapist, and as a person. Perhaps the most interesting question you can ask yourself is: In seeing the client change or not change, did I change anything myself? Being a therapist requires us to think deeply about ourselves and reflect on how our feelings and experiences impact the process of therapy. Through this work, we discover and use different parts of ourselves. Some parts of us are challenged and others reinforced, and over time, we crystallize our sense of self (Kottler & Hunter, 2010). Though our limitations and blind spots are likely to get exposed through the process of therapy, we may learn to accept ourselves better through journaling, supervision and other reflective paths. As we understand that we need not be perfect in order to help our clients, we may be able to develop more realistic standards in other areas of our life as well (Stahl et al., 2009). This growth may then feed back into our work with our clients, deepening our appreciation of what it might feel like to struggle with ourselves, face a challenge we feel overwhelmed by or celebrate small victories. There may be major transformations in our world view when we encounter clients grappling with existential challenges like finding meaning in death or loneliness (Kahn & Fromm, 2001). Deliberations on existential themes with our clients might trigger personal reflections on how we view our own life and make meaning of our existence and give us strength to look beyond our own defences. We can learn to accept limitations, ambiguity, uncertainty and incompleteness as a part of life while simultaneously becoming aware of unexpected possibilities

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and choices (Bugental, 1991). We may notice something new or different in our lives, appreciate our blessings or become more open to new experiences. Sometimes when our personal struggles parallel a client’s difficulties, their responses or courage may inspire us to try something different. In helping them deal with their concerns, we might begin to reflect on how we are dealing with our own. Kottler describes this experience beautifully: ‘The more I confronted my clients about the ways they were inflicting misery on themselves, the more I had to look at the ways I was doing the same thing’ (Kottler & Hunter, 2010, p. 10). We may feel inspired by our clients’ resilience and humbled by what our clients achieve despite myriad challenges, and this might motivate us to be stronger as a person and strive harder with our goals. Our interactions with our clients may have a strong impact on our relational selves as well. Therapists have described how they were able to value relationships that offered love and care, acknowledged their own need for support and found new ways to relate to their children and grandchildren by expressing previously suppressed parts of themselves and showing more interpersonal courage and positivity (Hatcher et al., 2012; Råbu et al., 2016). In seeing our clients and their struggles in relationships, we may also learn what not to do. Therapists have described learning the value of communicating effectively after witnessing the distress experienced by couples in conflict or becoming more assertive and independent after seeing the challenges encountered by their clients with dependent patterns (Mishra, 2016). Being more aware and accepting of individual differences and being able to speculate on why a person may have made a particular choice enable therapists to feel less anger or blame in interpersonal situations (Dahl Tyskø & Lorås, 2017; Råbu et al., 2016). Clients may also teach us to view the world in different ways. In inviting us into their lives, they may expose us to new ideas, asking us to read about spiritual or self-care practises they may be interested in or telling us about ideas, activities, podcasts, books or resources they might have been influenced or inspired by. As a therapist, we may meet people we would have otherwise never met, from different cultures, social backgrounds, occupations and communities. This might help us cast off our prejudices, experience the value of diversity in religious and

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spiritual beliefs or life choices, and develop a nuanced and informed lens on how we position ourselves in the world. While there may be no real map on how to integrate our clinical experience with our personal growth, we may benefit from reflecting on how our clients touch our lives: who we become in their presence and what that makes possible for us outside the therapy room. Sometimes we may gather understanding through intentional reflections and, at other times, our learnings may emerge as a spontaneous aha moment. Pause to consider your experiences with clients over the years of your practice and reflect on your biggest learnings about life and what works in therapy. Having platforms where master therapists share the wisdom and life lessons that they have learnt from their interactions in clients could inspire many of us to reflect on our experiences more intentionally. We certainly do not have to wait years before we look back on what we have gained from our clients and begin to reflect on the intersections and amalgamation of the personal and the professional. These, sometimes, ineffable learnings from our encounters with clients begin from the first day we sit in the therapist’s chair, and some of our earliest experiences may have powerful and memorable impacts. Perhaps if more therapists spoke openly to each other about what they absorb from clients, the flow of learning between therapist and client would feel more natural.

Perspectives on Training and Development Development of Therapist Skills and Systems for Integrating Client Feedback Encouraging comprehensive assessments that focus on clients’ preferences, strengths and resources might foster a stance of learning from clients. Training programmes and practice settings can promote guidelines and systems for eliciting and incorporating client feedback. We recommend the use of client feedback methods to augment supervision and track needs for additional supervisory inputs. An examination of trends in client outcome patterns across clients could also help supervisors support each supervisee in their development (Swift et al., 2015).

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Building a Stronger Research Base on Client Perspectives about Psychotherapy We advocate a greater focus on the client in psychotherapy research and agree with Fuertes and Nutt Williams (2017, p. 370) that ‘clients’ experiences matter because clients do the bulk of the work in therapy.’ Through an exploration of the psychotherapy process in all its complexities, we may come closer to understanding why therapies and techniques work differently across clients, how therapeutic change occurs and the ways in which it may be obstructed. Goldfried (2019) recommends that we attend to a range of key client variables such as awareness of their difficulties and possible change pathways, motivation for and expectations from therapy, and use this to build empirical evidence that can inform therapeutic practice. The use of diverse research designs to examine clients’ perspectives and lived experiences, including qualitative approaches and observational studies, can narrow the gap between research and practice (Williams, 2020). Therapist Engagement with User–Survivor Perspectives, Movements and Advocacy We strongly recommend an exposure to user–survivor perspectives and movements as a part of the curriculum and training processes across the mental health disciplines. Training programmes can incorporate resources such as best practice guidelines for user and carer involvement in mental health services (Sheldon & Harding, 2010) and encourage trainees to join conferences and other spaces where they can share and learn from clients as stakeholders. If we are to engage more meaningfully with our clients’ lives and realities, we must understand their distress beyond symptoms and diagnostic labels and look outside the therapy room into their sociocultural-political contexts and systems. A range of reflective, creative and experiential approaches, both within classroom and real-world community settings, can support trainees’ engagement with advocacy and social action. Trainees can be sensitized to issues of social justice, power and context in their case conceptualizations and therapeutic interactions. Our commitment to advocacy and social action could

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involve working closely with civil society organizations, connecting clients with needed resources (e.g., legal and economic) or investing time to support legal and policy changes that address systemic barriers and support client rights (Burstow, 2004). In our professional trajectories, we could choose to engage with advocacy from within traditional mental healthcare systems or apart from them. Involvement of Service Users in Mental Health Education and Training At one level, engagement with service users can provide an understanding of lived experiences that are not represented in textbooks. There is potential for various levels of involvement: curriculum consultation, development of learning material, teaching and educational roles, trainee selection and assessment of training courses and modules (Lea et al., 2019). Inclusive models that embed voices of service users and carers in mental health training are certainly not universal practices and can require a revisioning of training frameworks. Dedicated time and effort will be needed to transcend ‘us and them’ thinking, avoid tokenistic initiatives and reflect on any personal or systemic barriers to implementation (Hatton, 2017; Lea et al., 2016). Engaging Service User Knowledge in Psychotherapy Research User-led or survivor research, user-controlled research and service user involvement in research are important emerging trends. We note a shift from brief involvement or consultations to one of co-production, where mental health service users may be involved in multiple ways in an equal partnership, from defining research priorities to designing and implementing the study and to the dissemination of findings (Rose & Kalathil, 2019). As researchers, many of us require training to increase our familiarity with participatory frameworks and iterative processes in co-designing interventions (Bevan Jones et al., 2020). The Eurikha project2 is an exemplar of user-controlled research, actively 2

www.eurikha.org

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initiated and directed by users, survivors and persons with psychosocial disabilities. This seeks to map knowledge created though user-led mental initiatives and movements, advocacy and rights-based activism across the globe. Building a democratic and participatory research process comes with multiple challenges, including deeply embedded power dynamics and structural barriers. These challenges may be accentuated in countries with hierarchical social structures and high mental health stigma and where user–survivor movements are still mobilizing. Even in contexts where the voices of service users are heard, we need to reflect about whether marginalized perspectives within user groups are included and valued (Rose & Kalathil, 2019). If mental health practitioners want to co-produce research with user–survivors, this requires introspection on how democratic we are in the therapy room, the ways in which we attend to client priorities and empowerment and how much we typically engage with structural and systemic contributors to distress (Spong & Waters, 2015). These reflections can clarify our capacity-building needs, illuminate any assumptions and biases, and prepare us for equitable and meaningful partnerships in the research process (Telford & Faulkner, 2004).

Conclusion Learning from clients implies seeing them as equal participants while taking responsibility for our role as co-travellers on the path of therapy—sometimes guiding and sometimes following. This perspective has already led to the development and shifts in how we view therapy and how we offer services, and we look forward to next steps in this area.

Chapter 9

Supervision and Reflective Practice

Supervision is an avenue to strategically withdraw to meditate, contemplate and think about our therapy practice. Through this ‘respectful interruption’, we learn from the work we do—we sit at the feet of our experience and allow our work to become our teacher (Zachary, 2000, p. 13). Supervision facilitates the use of reflection as a tool and helps us explore how to use our experiences as a ‘springboard for further learning’ (Caroll, 2009, p. 40). Supervision allows for the process of reflection to unfold at the deepest levels, so we can deconstruct our experiences in therapy, observe what transpires between us and our client, and explore our own thoughts, feelings and actions in the presence of a supportive other (Senediak, 2014). The focus of the exploration moves back and forth between existing theories and personal experience, sometimes being more analytical or critical and sometimes more intuitive and personal. Conversations we may have only had with ourselves, our half-formed thoughts and impressions, may become clearer to us as we attempt to think through our experience with our supervisor. The reflective self-awareness that emerges can help us move beyond didactic knowledge and get closer to the essence of the therapeutic encounter. Didactic methods in supervision focus on providing knowledge and skills, and monitoring processes and procedures. While helpful

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and much needed particularly during training, these methods may not be adequate in furthering the professional growth of the practitioner. Creating a safe space in supervision for active engagement in the process of reflecting on experiences as a therapist can be valuable. However, reflective supervision requires time, and institutions that wish to encourage this process also need to consider how to make provisions for the same. While reflective supervision involves going deeper within the self and sharing what is found, it differs from personal therapy. The purpose of supervision is the professional development of the supervisee and not therapeutic support. When personal and emotionally laden material is shared in supervision, both supervisor and supervisee might find it helpful to separate the supervisee’s emotions from those of the client. Having made this demarcation, they can decide whether the feelings need to be addressed in supervision or may be better addressed through personal therapy. In this chapter, we highlight the role of supervision in providing the structure and support required to facilitate reflective practice. Readers can identify their needs and expectations from supervision, consider the supervisee–supervisor relationship, and explore the methods, tools and processes of reflective supervision. We address both supervisor and supervisee perspectives, as they engage with the process of supervision.

The Reflective Journey: Being a Supervisor and Supervisee Being a therapist involves a high degree of responsibility; we need to appear competent in the session, regulate our own emotions and be cautious about using the right words at the right time. Sometimes we need a space where we can be unsure, or unguarded, trusting that someone else will look out for us. This is a space supervision may provide, with supervisors holding the frame for us and creating safety in which we can share our strengths and vulnerabilities and in the process learn how to be more effective as therapists. Supervision is also where we learn to reflect on how we apply theory and technique in sessions with our clients. The supervisor and supervisee undertake the journey of supervision together, bringing a readiness to co-reflect and learn together.

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Framing the Supervision Contract The initial conversation between supervisor and supervisee usually focuses on what the supervisee is looking for and establishes both the supervisory contract and the nature of the relationship. The supervisor seeks to understand the supervisees’ stage of professional development, nature of practice, their needs related to knowledge and skills and, of course, their expectations regarding reflective processes and methods (Orchowski et al., 2010). Initially, novice supervisees may want to know what reflective supervision is about, while more experienced therapists may need to clarify their assumptions and expectations about reflective work. The frame may need to be occasionally renegotiated as supervisee needs evolve. Setting up a supervision contract, where the goals, individual responsibilities, meeting schedules, documentation methods, boundaries, confidentiality and payment (if any) are discussed and listed, can ensure clarity (Ellis, 2017). We need to commit to defined and protected time for supervision sessions, so that they are not rushed or narrowly focused on what is to be ‘done’ in the next therapy session. If we are affiliated to an educational institute, the programme requirements for supervision (e.g., supervision hours and documentation) could inform the structure of sessions. As both supervisors and supervisees, we also need to be aware of what we bring to the table, our strengths, needs and foibles. Think about what your counterpart might need to know about you so that you can work effectively together. Preparation for Supervision When we first enter supervision, there may be a mix of anticipation and anxiety. There is eagerness to learn, but this may be accompanied by fears about potential evaluation. Novice and expert supervisees may have different anxieties, as the implications of the potential evaluation are different and consequently the levels of shame or openness may also vary. The supervisor and supervisee can arrive at a consensus about how feedback will be sought and the pathways to address difficulties that arise during supervision. Some may prefer more guidance, with a

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clear structure and well-articulated goals, while others may be looking for a partner to explore with. As supervisees, we need to consider what kind of material we bring into the supervision session. While on-the-spot reflections have their place, using process notes or audio/video recordings carry certain advantages. These detailed narrative accounts are best documented soon after the session in a ‘She said, I said’ format (Wideman, 2019). Discussing process notes might help get an in-depth understanding of the therapeutic process—the content of discussions and interactions as well as the therapist’s internal feelings, thoughts, desires, fantasies and bodily reactions. Although maintaining process notes can be time-consuming, they bring us closer to understanding inner and relational processes, becoming more aware of moment-to-moment choices, actions and reactions that could further our reflective work. While it is the supervisor’s responsibility to guide supervisees towards methods that lie closer to their goals, supervisees can maximize the benefits by completing some preparatory reading and listing specific questions and learning goals (Crocker & Sudak, 2017). In terms of knowledge inputs, we might have questions like ‘Could you tell me how I could develop a safety plan for a client experiencing intimate partner violence?’ or ‘What theories could I read to understand more about my client’s grief reactions?’ Skill-based queries may include ‘Could you review my session transcript and provide feedback on how I have used Socratic dialogue to challenge this cognitive distortion?’ or ‘What reflection could I have used here?’ Reflecting on challenging situations, particularly with reference to the relationship with the client or emotions the session triggered within us, may help us understand the therapy process (Orchowski et al., 2010). Some examples of reflective questions would be ‘I wanted to discuss this, because I feel termination is difficult for me.’ ‘Can you give me some ideas about how to avoid giving advice when clients keep asking?’ ‘Could you help me explore the anger that I am feeling towards the client’s parents?’ and ‘A client brought a gift for me and I just could not say no’. As supervisors, we can ensure that all three aspects are covered while prioritizing what might be important for our supervisees. Our needs as supervisees are dynamic; sometimes we may require more

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hand-holding and at other times encouragement to try things out or explore what is unfamiliar (Bhola et al., 2017). In a reflective account, Ahluwalia (2019) describes how her supervisor did not see beyond her façade of confidence as a trainee therapist and therefore offered less direction. This allowed her to stay protected and unchallenged as she remained on the surface of the relationship with her client. In a later experience with another supervisor, this was gently challenged, and a space opened for reflections on her ‘self’, her theoretical leanings and the emotional complexities of therapy. As we grow as therapists, we learn to tolerate ambiguity, observe sessions from more than one perspective and formulate questions around inner processes (Young et al., 2011). With more advanced supervisees, supervisors may look more deeply into emotional experiences and their explanations, pose constructive challenges or provide meta perspectives that encourage reflection and growth (Ladany et al., 2013; Wilson et al., 2016). It is useful to match the learning environment to the needs of different supervisees, the changing needs of a particular supervisee over time, in different domains of work or even within a session (Borders, 2014). Years of training or experience are not necessarily linked with a specific developmental level, and supervisees at the same level might have varying reflective capacities. An ongoing assessment of competencies and needs can place supervisory inputs within the supervisee’s zone of proximal development (Vygotsky, 1978). Further, when supervisee and supervisor theoretical orientations match, then reflection might be focused on ideas specific to the model. If supervisor and supervisee are aligned to different theoretical orientations, they may discuss how space could be created for multiple perspectives. As supervisors, we can also benefit from reflecting on our own cultural background, along with that of the supervisee and client (when possible), and determining what style of supervision might be a better fit (Orchowski et al., 2010). Belonging to a particular community influences our lived experiences, and being aware of our religious affiliations, class and caste privileges will ensure that we are sensitive to differences that might arise in the reflective discussions. Similarities, differences and bridges between supervisee and supervisor

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positions can be explored mutually and openly. While the onus is on the supervisor to create space for these discussions, it is up to the supervisee to engage in them non-defensively. Pause and review on one of your better supervision experiences. Describe your supervisor’s approach and what they did to make it work for you. As a supervisee, what did you bring to supervision that made it a positive experience? Our own experiences in supervision deeply impact if we continue to seek supervision over time and how we supervise others.

A Safe Space for Reflection Everything begins with the relationship, in supervision as in therapy. As the heart and soul of the supervisory encounter (Watkins, 2014), it is the alliance that creates a safe space that acts as a container for the uncertainties, anxieties and questions brought to supervision (Bordin, 1983; Watkins, 2014). There is evidence for a link between the strength of the alliance and trainee satisfaction with supervision, self-efficacy, comfort with disclosure and even client outcomes (Basa, 2017; Mehr et al., 2015). When the inevitable vulnerabilities of supervisees intersect with a supervisory stance which is experienced as unsupportive, distant or evaluative, the worries about being judged as inadequate (both as a person and as a therapist) can block progress in supervision. Supervisees might share only superficial stories about how well therapy is progressing and skirt around what is emotionally meaningful, choosing not to disclose information that reveals missteps and negative experiences (Duggal et al., 2020; Ladany et al., 1996). As supervisors, both supervisees who seem completely withdrawn or those who tell us only positive stories can make us pause to question the relationship. We might try to be persistent or insistent in getting supervisees to share openly, or we might try to hold space for them to come to terms with mistakes or vulnerabilities and hear that they are not alone in this experience. When we respond with empathy, maybe even sharing a story about our own difficulties as therapists, our supervisees might circumvent feelings of shame and be more open to being vulnerable

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(Curtis et al., 2016; Hahn, 2001). The potential for feeling ashamed or inadequate works both ways and, as supervisors, we may also block certain supervisee questions or reflections that take us into territories where we feel unsure. This vignette presents how a supervisor can use their self-reflection to help supervisees: Rajesh had recently experienced a series of worrying dropouts and brought these concerns to Kavitha, his supervisor. ‘Dropouts do happen, even when we try our best,’ she said ruefully. Speaking about her own experience, she shared, ‘My client was frustrated by her struggles with making small changes in her life and was desperate to make more of her career. I tuned into how she repeatedly beat herself up so much that she felt too exhausted to make any changes she wanted. Looking back, I can see that she was trying to convey something more. Perhaps lulled into the comfortable rhythm of interacting with a long-term client, I assumed that she was talking about her relationship with her boss. I can see now that she was probably talking about the therapy relationship. I am quite sensitive about being liked … so when my clients seem to like me, I assume that therapy is going well. This time though, it was because she liked me that my client found it hard to express how sessions were no longer meeting her needs—a nuance that I clearly missed. Reflecting on our experiences help us learn and grow, Rajesh, and this makes us better therapists. Perhaps we can review and learn from these experiences together.’ The culture of supervision is embedded in institutional, professional and societal hierarchies, and power inequalities are perhaps most prominent during the training phase. This could be exacerbated by the fact that the supervisors might also be teachers or evaluators. Since avoiding the dual relationship is difficult in training settings, supervisors may need to work extra hard to clarify how the roles and relationships will be kept distinct. The supervisee might not just see the supervisor as a figure of authority but may also be acutely aware of other social and class-based hierarchies that exist between them. While power imbalance exists around the world, cultural notions of deference towards authority figures in collectivistic cultures like India can mean that the supervisory relationship tends towards the formal.

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As supervisors, we can address this inherent hierarchy explicitly and aim to create an environment where trainees can question perspectives, express contrary opinions and admit vulnerabilities (Bhola et al., 2017). The need for a culture that encourages conversations about power in supervision has been emphasized by trainee supervisees (Duggal et al., 2020). When supervisor and supervisee expectations are at odds, or there is a sense of disconnection in the relationship, it is our openness and humility that can help us take reparative measures to repair ruptures in the alliance (Watkins et al., 2016). Collaborative relationships between a supervisor and supervisee can make it possible to express disagreement and provide feedback both ways, strengthening the bond and creating a valued relationship (Duggal et al., 2020). As supervisees, we can reflect on what we need from the supervisory relationship, identifying supervisor behaviours and words that helped us feel safe, as well as those that discouraged us from speaking. As supervisors, we can think about what we do to help our supervisees feel safe and the extent to which we have our finger on the pulse of the relationship. A Supervisor Speaks: Supervision Is about Creating Safety We invited Dr Maitri Chand, a systemic family therapist and supervisor, and clinical assistant professor at MUSM, Macon, USA, to share her reflections on the supervisory process. ‘Supervision is not teaching, and supervision is not making a young therapist a clone of yourself. Supervision is about creating safety for therapists to become comfortable with “not knowing” so that they may cultivate an open learning stance. This helps them to figure out who they are as therapists and helps them take steps towards what may appear as scary in the therapy room as well as in their inner worlds. Early in their career, therapists feel overly concerned about helping their clients “feel better in therapy” or ending the session on a particular note (whatever that is). Sitting with our own discomfort around client stories and emotions, as well as our own emotions in the therapy room comes from experience that the supervisor can encourage. In my supervision work, I encourage my supervisees to explore this discomfort,

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especially in their own families of origin. For instance, we consider when and where in their families of origin they feel the need to “fix” things and/or people. Or when and how they (or are expected to) help people feel better. These are challenging questions and reflecting on them in supervision is a safe way to build supervisees capacity to remain with their clients’ emotional states during sessions. When supervisors express a curiosity about their supervisees, it enables supervisees to do the same for themselves, and for their clients. Whatever the tools and skills may be, I cannot emphasize enough how none of it matters if the supervisor is unable to first create a safe space. Beyond any supervision methods, a supervisor must support their supervisee’s vulnerabilities and help them figure out who they want to be as therapists.’

The Supervisor’s Tool Kit Reflective supervision is a process of questioning, and the questions we ask ourselves and each other can come from many places—from clients, peers, supervisors and supervisees. Reflective supervision is a slow process, a time for contemplation and long pauses with few immediate answers to our questions. Davys and Beddoe (2009, 2010) provide us a reflective learning model, beginning with identifying the event to be considered, moving on to the process of exploration, followed by experimentation in the session and ending with a shared evaluation. Tell Your Story A supervision session usually starts with the question: ‘What should we talk about today?’ Focusing on a key priority area, question or concern is useful, as ‘boundary-less reflection’ (Davys & Beddoe, 2009, p. 932) can be anxiety-provoking or can feel pointless. These could be trigger events or experiences that present a new situation or evoke intense emotions in the supervisee, something which was surprising, confusing or felt like a breakthrough. As supervisors, we begin with helping the supervisee find their voice and share the story—in their own words and from their own perspective. We listen carefully for who the central characters are (this can also be the supervisee) and where in the story the supervisee lingers and where the gaps are. We note the gaps in the

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story; perhaps the father is missing or the emotions are missing in the narrative. This process of retelling and reexperiencing the session in the presence of a witness is most useful when supervisors do not rush to discount, explain or soothe in response to what is shared. The way we listen influences the story that is told. Playing with the Story The exploration stage is a time to zoom in and reflect on the personal impacts and meaning of the issue for the supervisee and then pan out to understand any influences from the professional, organizational and sociopolitical contexts. This is when supervisors are most active—scaffolding supervisees by providing affirmation, reassurance and support, teaching theory and skills and suggesting therapeutic approaches, or opening the door to reflective discoveries. The supervisor can choose among a range of methods to help supervisees reflect on difficult moments in therapy, connect with their emotions and understand the impact of their personal experiences on the therapeutic process. The timing of reflective explorations is important—we may need to wait if the supervisee (or supervisor) is too distressed, angry or defensive and respond to their immediate needs for support and direction. A series of reflective questions can stimulate the supervisee to identify the need for change in the way they are interacting or what they are doing in sessions (Senediak, 2014). Pause to consider how you can build reflective awareness in a supervisee who is struggling and feeling ‘stuck’ with a new client. While the client acknowledges their diagnosis of depression, they appear hesitant to share their feelings or discuss their difficult relationships they seemed trapped in. They comply with therapeutic tasks, but each session seems just like the last one. As supervisors, we may begin to explore the experience, for instance, by asking ‘What were your expectations from the interaction?’ or ‘What was the emotional tone of the session?’ The initial exploration questions could prompt the supervisee to become aware of more subtle aspects of session experience and note any discrepancies. This might guide the supervisee to note the disconnect between seemingly

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productive discussions on workplace tasks and targets and the flat emotional tone of the session. Such explorations can help supervisees see how their personal style, expectations and assumptions might impact the session interactions. For instance, the supervisee might wonder if their high-energy style might feel overwhelming for this client. This could prompt a slowing down of the process, perhaps using a more sensitive and gentle way of exploring the client’s experiences. When supervisors prompt supervisees to shift their lens, for instance, looking at the role of gender, age or religion in their client’s story, this can create new openings in the therapy process. Through this reflective review, both supervisor and supervisee can explore the directions and possibilities for the next session. Often, therapists’ difficult personal experiences and histories are seen as red flags, blind spots or something that gets in the way, particularly when there is a resonance with what emerges in therapy (Timm & Blow, 1999). Because of this, supervisees may not be ready to acknowledge or bring in their vulnerabilities directly into the conversation. As supervisors, we may need to listen carefully for the emotions that supervisees describe or display while discussing the session, as this opens the door to their inner experiences. Inviting supervisees to share their feelings can foster the reflective process: ‘It seems like you are feeling deeply about working with X? Could you share what you are experiencing?’ The supervisee then gets a chance to share their affective responses, which could include feeling angry because the client was late again or anxious when the client disclosed using an addictive substance. Both the supervisor and supervisee may wonder together about the emotional reactions, name them and explore how the anger, sadness, impatience, excitement or confusion might be entering into therapeutic work (Heller & Gilkerson, 2009). These supportive conversations can help the supervisee talk about the sources and implications of these emotions, thereby sharing their personal vulnerabilities or life experiences. It could be that the supervisee response has to do with their own life experiences, perhaps struggles with addiction in their families of origin. While the supervisee’s life experiences can be potential obstacles in the therapy process, they can also be a strength, lending them a

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sensitivity that another therapist might not have (Timm & Blow, 1999). As supervisors, we could validate their experience and facilitate exploration through resource-focused questions such as: ‘How do your life experiences help you to be more compassionate to your clients? How do your life experiences allow you to understand your clients on a deeper level? How can you use your previous life experiences to inform your work?’ ((Timm & Blow, 1999, p. 334). When we see our personal lives as neither good nor bad, but as experiences that make us who we are, we can be more balanced in how we use our experiences in therapy. And having a good supervisor is key to this process. When supervision discussions and explorations focus very closely on micro processes in the session, this supports a deeper level of interpersonal and intrapersonal awareness. Methods of such examination like interpersonal process recall (IPR; Kagan, 1976) are quite timeintensive. In IPR, the supervisor and supervisee review segments of recorded therapy sessions together. The supervisee is encouraged to enter a reflective space and connect with their covert thoughts and feelings before the session and during the interaction while pausing and listening to the recorded segments. As supervisors, we stay in the background, non-judgemental and non-directive, resisting any urge to provide feedback or interpretation. Instead, we try to listen empathically, entering the therapy room with the supervisee and generating a series of reflective questions to enquire about their experiences, perceptions, expectations and preferences (Cashwell, 1994; Ivers et al., 2017). We may begin with looking into the experiences of the supervisee, exploring the bodily sensations or images evoked in the session, what they were feeling and what they were thinking about their clients or therapy process. A deeper exploration of session interactions includes looking at expectations and perceptions that therapist and client may have had of each other, enquiring ‘What do you think your client wanted from you?’ ‘Do you think your client was aware of what you were feeling at that point?’ or ‘Do you think that your client would describe that interaction in the same way as you?’ Some forms of understanding may come to us only when we give time to considering various smaller moments and meanings. For instance, asking about unstated agendas like ‘Was there anything that you wanted to say to

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your client but did not?’ can help the supervisee uncover new layers of the interaction. Even if we are not able to record sessions, the discovery-oriented, process-focused stance of the IPR approach is one that we can use to help supervisees go deeper into their experience. In a recent extension of the IPR method, Ivers et al. (2017) outlined a series of questions that can be used to enhance supervisee’s multicultural awareness. These questions address issues of cultural differences between supervisor and supervisee and any cultural assumptions and biases held by the supervisee, and bring a focus to the role of cultural factors in the client’s story, for instance, asking about the supervisee’s reactions to indicators of the client’s social location (e.g., accent, religious beliefs and skin colour) or exploring their perceptions about the client’s comfort in discussing their experiences of injustice and discrimination. Our awareness of the role of culture and context on our client’s experiences allows us to piece together and integrate aspects of our client’s story. Supervisees value culturally competent supervision which fosters self-awareness and supports sensitive and inclusive practice with culturally diverse clients (Soheilian et al., 2014). Some frameworks for reflective conversations are anchored within specific theoretical models. An exemplar is the reflective communication and questions method (Gray & Smith, 2009), which draws from solution-focused or narrative models to frame exploratory questions. The supervisor could ask the miracle question: ‘Imagine for a moment that in your next session with your client all of the current problems and conflicts you are having disappear. You know, the session of your dreams. Tell me, what would that look like?’ (Gray & Smith, 2009, p. 164). Other questions that draw from narrative therapy could help identify the source of any disabling narratives in the supervisee’s social and cultural landscape while keeping the focus on supervisee strengths. We all know that we need to step into our client’s shoes, but it can be difficult to access our awareness of what the client is experiencing or how we are coming across to them while we are in the thick of the session. In the prismatic dialogue approach, Bird (2006) proposes capturing this experience in the quieter space of the supervision session. In this practice, the therapist plays the client, while the supervisor plays

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the therapist, asking relational and circular questions to uncover their relationship patterns. Once the exercise ends, the supervisor checks: ‘How do you think this might help your next conversation with your client?’ Entering so completely into the client’s shoes, without also needing to think like a therapist at the same time, can open us to aspects of their experience we may not have seen before. Moving Forward The supervisee next moves to the stage of experimentation and application of possible actions and solutions in the therapeutic process. This is positioned as something to try with the client and not as a definitive path. When the supervisor and supervisee decide to move forward with a plan, for instance, to try the empty chair technique with a client, they also need to consider if the supervisee has the necessary support and resources. The supervisor might share some reading material, involve the supervisee in a role-play and discuss any apprehensions about how this will be received by the client or if it will work. In this stage, we put our reflections to test, applying them in the real-world situation, aware that every move we make is based not on a fact or a certainty but on a hypothesis to be verified. Revisiting the Story This last phase is an opportunity to review what has been learnt through these reflections and allow space for new questions to emerge in supervision. A supervisee might begin thinking about their work with certain types of clients or contexts, their development as a therapist, an ethical conundrum or wonder about the role and value of therapy. Together, the supervisor and supervisee can plan when to explore these questions and address these learning needs. Instead of waiting for difficult moments to occur in therapy and then reflecting on them, we could also anticipate these challenges to prepare for reactions that are likely to occur (Moffett, 2009). This model of reflective supervision privileges supervisee experience over supervisor expertise and sees reflective processes as having the potential to transform therapists. The evaluation and feedback stage completes the reflective

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loop, though, in truth, the process is never complete. Rather, we may move back and forth through stages, asking new questions and arriving at new answers.

Reflecting Together: Supervision in Group Formats Group formats leverage the advantages of multiple voices to nurture reflexivity and focus on the process of meaning-making undertaken by the group. As group members, we need to reflect on our approach to therapy. Are we more critical or more curious? Do we feel that there is one right way to do things or that there is something to be learnt from each perspective? The use of more tentative and open-ended styles of enquiry and sharing, for instance, ‘What struck me when I heard her talk about the incident’, ‘This brought up my own experience with...’ or ‘I wonder what might happen if they traded roles for a day or two’, expands possibilities for all group members (Paré et al., 2004, p. 122). In the group reflective case discussion model, one supervisee is invited to share a therapeutic experience and observe the groups members’ responses. The supervisor plays a less active role but keeps the discussion focused and ends by consolidating the reflective learnings (Edmund, 2012). The interacting–reflecting training exercise (Rober, 2010) uses a similar format with an interesting blend of experiential work in small groups. Metaphorical images are used to describe the client and the supervisee (e.g., a train leaving a station, a tree with strong roots or a flock of seagulls in flight). Room is created for supervisees to experiment and take risks with their reflections, delving into inner conversations that are not easily acknowledged or expressed in sessions. The polyphony of group members’ voices is valuable in guiding future therapeutic work, and the focus is not on reaching a consensus or searching for the ‘one truth’. We can try de Bono’s (1999) Six Thinking Hats problem-solving technique as an innovative group supervision technique to think about a therapy situation collaboratively (Li et al., 2008). All group members are invited to ‘wear’ one hat at a time, perhaps starting with the White Hat, which asks, ‘What do we know?’ With the Red

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Hat, group members shift to expressing their feelings and intuition, without having to provide reasons or justifications. The Black Hat poses critical questions about potential problems and what does not fit. While wearing the Yellow Hat, group discussions centre on ‘What could happen?’ using a positive, optimistic stance. This reminds group members to focus on what is feasible, beneficial and wished for. Next, the Green Hat encourages group members to think differently and out of the box. The supervision session ends with everyone wearing the Blue Hat to create space for reflections and blending all the ideas generated. We also have the opportunity to reflect if we tend to use some hats more than others. While group work can enhance reflective thinking, it is important to ensure group safety and coherence and address any difficult group dynamics (Heffron et al., 2016). The role of the facilitator is to keep the space safe and reflective as therapists share difficult experiences in sessions or struggle with clients. Being hit by a series of critical or searching questions, or not being given room to think or process their experience, can leave group members feeling defensive, shamed or angry. The facilitator needs to see to it that questions, comments and feedback come at a pace and style that the supervisee can handle, in order to stimulate reflection. Peer Supervision Groups As we begin to test our wings after training, creating a group with our peers can offer a space for continued supervision, where we have a feeling of ‘being in the same boat’. Peer supervision can be a particularly useful resource for both novice therapists and experienced therapists who work independently and have limited access to professional networks. A space with less prominent power differentials can be freeing but, like all other groups, a cohesive and sustainable framework is helpful. Peer supervision groups can vary in the way they define their scope and focus, for instance, on personal issues, case conceptualization or skill development, and whether they align with a specific theoretical orientation. These groups are not necessarily leaderless and may have varied formats for leaders, moderators or observers, which can

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involve rotating roles. Although there are few studies that examine the effectiveness of peer supervision (Borders, 2012), this format is increasingly valued as an adjunctive approach which allows us to engage with multiple perspectives (Golia & McGovern, 2015). A Supervisor/Supervisee Speaks: A Work in Reflection We invited Ms Hargun Ahluwalia, a clinical psychologist and reflective practitioner currently practising in Australia, to share her transformative experiences in the peer supervision space. ‘For the longest time, as a therapist I have thought of myself as a work in progress. Progress, which is “onwards and forward movement”, has meant learning new techniques and modalities in psychotherapy— like building storeys on a skyscraper and adding pages to resumes. More recently during the lockdowns in the pandemic, I wondered if onwards and forward was the way to be. The social realities of the pandemic began to creep up on me. The news of thousands of deaths, lost jobs, the migrant worker crisis and the systemic challenges, which I had deftly drowned out, began to get louder. I felt shame at my ignorance and privilege and wondered if other psychologists thought about and felt for the world outside of academia. I brought these ideas into my online peer supervision group and realized that most of my peers felt deeply uncomfortable bringing their personal feelings into this intellectual space. I remember doing with their discomfort what I did with my shame—tried to understand it, first silently and by discussing together. The group evolved into a smaller one, where there was some comfort in looking into our histories and acknowledging difficult emotions. We talked about the world around us by understanding how it made us feel. After the brutal gang rape of a young girl belonging to the Dalit community, a few of us cried and some of us reflected on our emotional distance. We asked, “Had we always been deaf to the horrors around us?” “What purpose does our ignorance serve for us?” “Do we feel safe this way?” In the safety of this reflective group, we could experience unsafe feelings. We supported each other’s uncomfortable journeys through

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gentle questioning and sometimes by just letting the question be. I carried these questions outside of the group and into therapy sessions with my clients: “Do I distance myself from my clients’ social realities?” “Am I really empathizing if I’m trying to remain safe by not allowing myself to feel discomfort?” Reflecting on my emotions and reactions made me learn more about who I am, what I value and what I need. In turn, I became more attuned to my clients and better able to guide them to discover parts of themselves. Peer supervision has become a profoundly life-changing experience. I have learnt that progress isn’t about moving onwards and forwards but inwards and maybe even backwards, where I look at my past. I’m not as interested in building storeys as I am in examining the foundation. In this space, I can look inwards without judgement, be vulnerable in front of others, allow myself to be taken care of and learn from others.’

Reflecting on the Supervision Process As a system that is already integral to the life of a psychotherapist, supervision is easily adapted to nurture the practice of reflection. Each reflective supervision framework or method has its own flavour and focus, and we may be inclined to use some more often than others. What we lean towards also depends on our preferences, demands of our work and available time. We can deepen or shift the focus of our reflections by incorporating approaches we are unfamiliar with or use diverse methods and modalities. While there may be a range of methods available to us to further the supervisory process, it might be critical to reflect on how the methods are aligned to our supervisory goals and if they are enhancing the learning and growth that we envisaged. Before we start working together with a new method, collaborative discussions about supervisee and supervisor’s expectations and the learning goals and growth pathways can allow both to feel agentic. What we learn from discussing one client during supervision can help us understand what we can do differently with other clients. We can also have retrospective aha moments when we look at a previous therapeutic interaction with new eyes. When both supervisors and supervisees are committed to the reflective process, it creates a deeply enriching and satisfying space for both.

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Relational reflexivity encourages practices that allow both parties to reflect on how the supervisory conversation and interactions are experienced (Burnham, 2005). The supervisor could initiate questions such as: ‘Is this going okay for you?’ ‘Is this what you want us to discuss first?’ and ‘Does my style of listening work for you?’ Regular discussions about the learnings from each session, the cumulative changes in knowledge, skills and attitudes, and identifying what could be better will ensure that the supervisee becomes comfortable with reflection and will not be thrown by a sudden deep question. As supervisors, we may also reflect aloud on how the process of supervision is going for us and how we might be experiencing our role, again modelling the process of reflection for supervisees (Curtis et al., 2016). Advanced supervisees might also welcome discussions on the parallel process in supervision, on how the client–therapist interactions might reflect in the supervisee–supervisor interactions (Borders & Brown, 2005). As supervisor and supervisee reflect together, it may also balance the power differential in the relationship, teaching supervisees how they can do the same with clients. Introspection can also help supervisors recognize if they are avoiding reflective work by throwing questions back at supervisees or frequently referring them to theory and textbooks. Our reflections on how we construct the supervisory relationship, understand the impact of our challenging and positive experiences, and the nature of our commitment to reflective work and the supervisory role can feed back into more meaningful supervisory dialogues.

Building Our ‘Internal Supervisor’ and ‘Internalized Supervisor’ As we experience our supervisors, we begin to develop an ‘internalized supervisor’ or an internal representation of our supervisor’s voice, in various combinations of visual, auditory and felt presence experiences, which contains and guides us in our engagement with our clients (Watkins, 2018). It is possible that we incorporate both positive and negative voices of our supervisor, eventually leading to a ‘good’ or ‘bad’ internalized supervisor. If our supervision experiences have not been

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reflective enough and exclude our personal reactions and histories, this can impede the development of confident, reflective inner voices (Mammen, 2020). When we imagine a compassionate supervisor, it develops our capacity to soothe ourselves and be less self-critical (Bell et al., 2017). It is the supervisor’s approach, presence, supportive statements and guidance that get represented and are resources to be used later while working with a client. Holding the supervisor in the mind helps us handle difficult moments, further our work with our clients and grow as therapists. While the internal representation of the supervisor plays a crucial role in our early professional development, Casement (1985) proposed the idea of an ‘internal supervisor’. This could be imagined as a mental space where we reflect, explore and monitor our work from a supervisory perspective (Bell et al., 2017). It involves spontaneous reflection, where we can look at our own work and what is happening between us and our client, something that stands apart from the internalized supervisor. This internal supervisor has its origins even before we receive any formal supervision. As we progress, the island of intellectual contemplation—‘a mental space within which the internal supervisor can operate’ (Casement, 1985, p. 28)—develops and what eventually becomes possible is the dialogue between the internal and external supervisors. Both the internalized supervisor and the internal supervisor support our development as reflective practitioners, so that dialogue and perspective taking become part of our everyday practice. We invite you to engage in a visualization exercise. Picture how your internalized supervisor looks. Do they seem calm and confident or worried and unsure? Do they sound more critical, compassionate or perhaps dispassionate? End your reflections by considering whether the two of you speak often enough?

Room to Grow: Developing as a Supervisor As therapists, we may enter a supervisory role because it feels exciting and is a natural progression in our careers and/or a job requirement. Quite often, we may be expected to step into the role of a supervisor soon after training to become a therapist. Finding our own feet as

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professionals and having to guide others at the same time can leave us feeling unprepared and even like an imposter. Doing supervision, or undertaking the tasks of supervision, can be differentiated from being a supervisor or assuming the identity of a supervisor (Burnham, 2012). We may do supervision for years, before we can say with confidence that we are supervisors. Being a supervisor requires more than therapeutic and reflective skills. We also need to draw on our love for teaching as well as our sense of responsibility towards the profession. Supervision is a complex process, and ‘supervisory-mindedness’ requires attention to several layers of functioning and reflection (Watkins, 2013). We need to put ourselves into the shoes of our supervisee and their client(s) while simultaneously remaining firmly in our own. We need to be in touch with the ‘self of the therapist’ that lies within each supervisee but also be careful not to slip into casting them as clients (Borders, 1993). As novice supervisors, we may strongly wish to succeed in this new role and be liked by our supervisees. We may recall stressful experiences with our own supervisors and be committed to being warm and supportive with our supervisees. It can be difficult to respond adequately to both the relational and technical aspects of our interactions with supervisees. Our uncertainties about integrating evidence-based therapeutic models and techniques and our own intuition and personal stance can combine with these factors to make us reluctant to challenge our supervisees or to provide them with adequate structure and guidance. We also need to balance power, introducing our perspectives and insights while leaving room for our supervisees to develop their own relationship with psychotherapy. The skill of adjusting our expectations and inputs to match our supervisees’ needs and level of development requires constant reflection. Although we can feel anxious and sometimes even demoralized at the thought of these tasks, we may be reassured by knowing that this is part of the developmental journey for all supervisors (Watkins, 2013). As powerless or unsure as we may be feeling, we need to remember that our supervisees are feeling even more powerless (Goodyear et al., 2014). Frustration that we may feel from them is often frustration they are feeling about themselves or their therapy, rather than with us. As we reflect openly on what we

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feel from our supervisees, they may also develop the ability to reflect more accurately on their own experiences. Regularly checking in on our goals and processes as supervisors can help us resolve these tensions. While it is hard work to be a supervisor, it is also an extremely rewarding experience. As we reflect with supervisees on their therapy experiences, we may come to see perspectives and ways of approaching therapy that we would not otherwise have considered. Working through another therapist’s struggles can also bring our own blind spots and strengths to the forefront. As supervisors, maintaining supervision notes can help us track the overall development of the supervisee, as well as review our own progress (Bernard, 2014). We need to keep checking with ourselves about our comfort with asking reflective questions during supervision and commit to building this skill over our professional journeys. Ultimately, becoming a supervisor is one of the fastest ways to grow as a therapist, and being a good supervisor is a very significant way to contribute to the profession. It can take time to develop a conviction about the value and meaningfulness of psychotherapy supervision (Watkins, 2013). As we grow more confident about our skills and the value of our work, we develop a style of supervision that works for us (Goodyear et al., 2014). Undertaking this journey in a reflective and deliberate manner and accessing a range of promising models and guidelines for supervisor development can be useful, particularly for novice supervisors (Tangen et al., 2019). Spaces that nurture supervisors are vital to the process of supervisor development, as they can offer access to resources as well as a platform to connect with other supervisors. A Supervisor Speaks: Rahbar—A Supervision Initiative As we reflect on our own journeys as supervisors, we may connect with what drives us to take on the supervisory role. One of the authors (Chetna Duggal) shares her journey as a supervisor and her reflections on starting a supervision initiative. ‘Very often our journeys are about the movement from playing a role to becoming one with it. When I began supervising trainee

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therapists and counsellors, it was about taking on a role. It was not an easy journey—there were enough times I wondered if I was up to this role or not. Through my reflections on what was transpiring in the supervisory space and through the dialogue with my supervisees, I discovered the values and perspectives that guided my supervisory approach. To build and own the supervisor identity took work and courage, and it took time before I could call myself a supervisor. As I heard more about experiences of compassion fatigue and burnout among young practitioners due to lack of supervisory support, I felt convinced that something more needed to be done. It was with the vision to advocate for supervision and co-create responsive, supportive and culturally sensitive spaces for training and supervision that I conceptualized Rahbar (a field action project of TISS to promote supervision in mental health practice). Since 2019, Rahbar has been offering spaces for supervision, training and reflective practice. The supervision process is designed to build knowledge, skills and perspective, and at Rahbar, we ensure that supervisee needs and voices are valued. A needs and expectations assessment helps develop the plan of supervision in a collaborative manner. We promote reflection through experiential activities, reflective dialogue and frequently checking in with the individual supervisee/group. Practitioners are invited to share their experience of supervision through an anonymous post-session feedback form and share any suggestions for subsequent sessions. Through this process, the process, agenda, content and facilitation style of supervision are further evolved and adapted. Especially curated readings and resource material are shared after each session, based on the needs articulated by practitioners. With the acute pressures on mental health professionals during the pandemic, the Rahbar team began offering pro bono supervision in April 2020. While practitioners reported gains in knowledge and skills, what was valued most was the safe relational supervisory space. Our new directions include active efforts to make supervision and training for mental health practice accessible (especially for those in resource-constrained settings), help organizations develop supervision practice guidelines and training manuals, and most importantly, we are now offering a formal training for supervisors.’

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Perspectives on Training and Development Supervisor Development Frameworks and Training Competency frameworks that outline the necessary technical, relational and ethical supervisory skills may need to be introduced early; however, exposure to supervision competencies is not uniformly accessible across training contexts (Falender, 2018). We advocate use of competency frameworks and best practice guidelines to focus attention on supervisor development in psychotherapy training, along with an intentional focus on reflective processes in supervision (Border, 2014). The success of implementing reflective supervision components in training programmes depends on circumventing barriers due to competing academic and clinical demands and support from leadership and key stakeholders. Initial and ongoing training opportunities in the form of courses and workshops in generic supervision competencies, or specific methods such as use of IPR or genograms, are critical to support supervisors’ growth. For an understanding of what supervision looks like in different theoretical orientations, we recommend the American Psychological Association video series that showcase 10 approaches in addition to competency-based frameworks.1 This spans multicultural/ feminist, accelerated experiential, emotion-focused, systems, critical events, integrated developmental, cognitive behavioural, integrative, relational–dynamic and experiential perspectives. Supervision in Resource-constrained Contexts The availability of supervisors and access to supervision are limited in India, particularly post training. Peer supervision, group formats and tele-supervision can be useful, and these opportunities need to be created, strengthened and promoted in resource-constrained contexts (Bhola et al., 2017; Carson et al., 2009; Malik & Grover, 2014). When supervision is a part of multiple organizational roles and commitments, there is increased risk of lower engagement and effectiveness in the 1

www.apa.org

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supervisory role (Mondal et al., 2021). While therapist burnout and compassion fatigue are much discussed, supervisor workload and support need more attention. Developing an Ethos of Supervision for Lifelong Learning and Development Seeking supervision is positioned as important for all practitioners, regardless of their level of experience. This can deepen our skills and engagement with therapeutic work and protect against burnout. As supervision is not always mandated and regulated, seeking it depends more on a supervisee’s inclinations or on the resources of time, money and available supervision opportunities. We note significant crosscultural variations; while only 17 per cent of a sample of psychotherapists in India reported formal supervision after training (Kumaria et al., 2018), the rates are far higher in several other countries, even among more experienced practitioners (Grant & Schofield, 2007; Orlinsky & Rønnestad, 2005). We recommend that professional associations in contexts like India create resource networks for ongoing supervision and emphasize this as a priority for continuing development.

Conclusion The supervision process belongs equally to the supervisee and supervisor and requires commitment and investment from both for it to succeed. With reflective supervision, both stand to learn from each interaction, mutually stimulating personal and professional growth as they reflect together on the experience of being a therapist.

Chapter 10

Being in Personal Therapy

Visitors to the National Gallery in London walking past the iconic painting ‘The Ambassadors’ by Hans Holbein are suddenly confronted with the image of a skull on the canvas. How does an indeterminate oblong shape on the canvas transform into a skull only when viewed from a particular angle? The artist used the technique of anamorphosis, where an image viewed from a different angle or position, or through a special device, makes something visible which was concealed or could not be seen. Just as changing the vantage point makes it possible to see something new, therapists who have experienced being in the client’s role in personal therapy may be able to access a unique and layered understanding of the therapy process that may not be possible from the therapist’s chair alone. We are all part ‘therapist’ and part ‘client’, with different parts being dominant at different times. It is the reflective process of reworking this figure and ground which aids our search for professional sensitivity (Berman, 2005). We can feel more congruent if both identities mutually inform and enrich each other rather than remaining disconnected and isolated, or competing for dominance within us. In keeping with this perspective, we use the term ‘therapist-client’ to denote therapists in personal therapy.

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The earliest form of training in psychotherapy involved mandatory and regular analysis for the practitioner, as it was believed that only a therapist who was aware of their own unconscious could help the client become aware of theirs (Freud, 1915/1958). Personal therapy continues to be intrinsic to the psychoanalytic and psychodynamic orientations, with practitioners from the psychodynamic and humanistic schools of thought being most inclined towards this choice (Bike et al., 2009; Orlinsky & Rønnestad, 2005). Its influence has percolated to practitioners of varied persuasions, and engagement with personal therapy continues to be a strong tradition. Carl Jung, Marsha Linehan and Irvin Yalom are part of a community of therapists who have sought personal therapy at various stages of their career, in response to mandatory training requirements, to learn more about therapy or to heal and grow. In The Gift of Therapy, Yalom (2002, p. 41) describes his ‘odyssey of therapy’ over 45 years of clinical practice, drawing attention to its role in tuning the therapist self, our most valuable instrument. While personal therapy is not an imperative, many therapists view it as a rite of passage, and as critical to their personal growth and to the development of a therapist identity (Curtis, 2011; Orlinsky et al., 2011). The global footprint of personal therapy was mapped across six countries in North America, Europe and Australasia, which showed that an overwhelming majority (almost 87%) of psychotherapists reported engaging in personal therapy at least once (Orlinsky et al., 2011). Personal therapy is the most direct route for working on the self of the therapist, possibly making us more aware, congruent and better functioning (Malikiosi-Loizos, 2013). It also sensitizes us to client experiences, and many therapists report that they feel that it has enhanced their alliance with their clients (Rake & Paley, 2017). Some clients also view personal therapy as an important resource for building therapist self-awareness and empathy (Elkins et al., 2017; Ivey & Phillips, 2016). Through these impacts, we can assume that it also improves client outcomes, though this has been harder to prove through research (Gold et al., 2015; Norcross, 2005; Orlinsky et al., 2011). The intangible effects of personal therapy are perhaps best understood through our own experiences and the shared reflections of other therapists.

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As therapists, each of us may have questions on the need for personal therapy or how to best use this therapeutic space. In this chapter, we explore how and why personal therapy is accessed, break down how it influences our personal and professional development, and address other pertinent questions about the personal therapy experience. We end by examining the challenges and rewards of being a personal therapist.

Why Seek Personal Therapy? In her candid memoir Maybe You Should Talk to Someone, therapist Lori Gottlieb (2019) invites us into the therapy room to see her both as a therapist and as a patient. She chronicles her transformative personal therapy experience, which began after the end of a relationship and lasted longer than planned. Her journey is juxtaposed against the stories of four of her patients—a woman diagnosed with terminal cancer; an abrasive, self-focused Hollywood producer; a woman struggling with alcoholism and relationship difficulties; and an older woman searching for meaning. In this process, Gottlieb connects her reflections and process of self-discovery in both roles and rooms. As therapists who are contemplating or undergoing personal therapy or perhaps looking back on our experiences, we may learn from and relate to this narrative. We witness her difficulties in getting started, choosing a therapist and gradually immersing herself in the therapeutic process and her journey of self-discovery. Despite our belief in psychotherapy, we may hesitate to make the time and financial and emotional commitment that therapy calls for. Even when we feel quite certain of its value, the shift from ‘taking care of’ to ‘being taken care of’ is not necessarily an easy one. Just like our clients, we may experience that moment in time when we realize that even though we have been coping quite well, our resources are being overwhelmed. We might seek therapy to deal with early life experiences, adult life issues, life stage concerns, a relationship loss or a physical illness. Experiences of stress, depression, anxiety or substance use, which are impairing professional functioning, could prompt some of us to reach out (Schoener, 2005). We may also seek

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to grow further, develop healthier relationships, learn new skills or become more congruent as individuals. We may wonder: ‘Why was I feeling the way I did with this client?’ As therapists, we may find our emotions and memories being triggered by session content. Even when we take this to supervision and consultation, we may still feel the need for deeper reflection or resolution. We may also be stimulated by our overall professional experience; for instance, in response to experiences of stagnation in our work, we might ask ourselves: ‘Is this all I have to offer clients? Is this as far as therapy goes? Is there something more I need to understand about myself or people that can help me go further?’ These are all relevant reasons to seek personal therapy. Our attitudes and emotions of shame at needing help, doubts about the helpfulness of therapy, worries about confidentiality and fears of giving power to a therapist are possible barriers to seeking help. The anonymity and freedom that our clients experience may not be available to us since we are part of the same profession. There might be concerns about how a trainer or colleague might judge us if our inner struggles are revealed. The culture of our training institute and our professional milieu also tends to shape our views on personal therapy. If our training institutions, teachers and colleagues do not consider personal therapy as important, we are less likely to seek help. Of course, the same is true if we ourselves do not see it as valuable or an essential requirement for being good practitioners. We do know that practitioners in India ranked the experience of personal therapy as last on a list of 10 potential positive influences on their professional development (Kumaria et al., 2018). A range of contextual constraints, such as large caseloads and fewer trained professionals, have been noted as barriers to seeking personal therapy in LMICs like India (Bhola et al. 2017; Thomas & George, 2016). Given the large mental health services gap and large caseloads, institutions may not have the resources for personal therapy programmes for trainees. Trainees themselves may not be able to afford therapy and even if they can, finding a personal therapist who can commit the time or offer subsidized rates may not be easy. The mental health community may not be large enough to avoid dual relationships, and we may worry about issues of confidentiality and stigma as well. The

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increasing availability of online therapy over the last few years is a welcome development, as it vastly increases the pool of available therapists. Finally, therapy is ultimately a personal choice, and we may not be experiencing distress or feeling like we need therapy. We may be coping well, have enough social support or might prefer to draw from supervision, reading or professional interactions for our development. Each experience we have—a class, a workshop or a chat with a friend—is valid and useful in its own way, and a lot depends on how we engage with and make meaning of our life experiences. Take a moment to consider what you might gain from personal therapy or what might keep you from trying it. If you are not in personal therapy, do you wonder if there might be anything you are missing out on?

Experiments with Clienthood Over the last 20 years, the focus has shifted from whether personal therapy benefits therapist-clients to how it benefits us. The process of reflecting on personal therapy experiences and integrating the learning into our professional repertoires is a key pathway to gaining from personal therapy. For those who decide to take the plunge and seek personal therapy, there are many possible rewards. Getting in Touch with the Self The first gift from this dedicated hour to reflecting and talking about ourselves every week is an increase in self-awareness. This is one of the fundamental purposes of personal therapy and is frequently reported as its primary benefit by therapists (Pope & Tabachnick, 1994; Rizq & Target, 2008). While we may never know ourselves completely, the process of searching can build what Wigg et al. (2011) call ‘extended reflection’. They use this term to identify the benefits of long periods of therapy that address various issues as they emerge for the therapist-client. This idea is also reflected in the theme of ‘prolongation’ identified by Murphy (2005), where trainees reported that personal development and growth happen when personal therapy is extended beyond the requirements of training or presenting issues. Therapist

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self-awareness is not a state but an ongoing process which requires constant self-curiosity. Therapist-clients describe how revisiting their therapy experiences later helps them to reconnect, update and synthesize to reach a new level of understanding (Råbu et al., 2021). Personal therapy can help us to be more aware of our emotional world, identifying, accepting and managing our emotions better. This in turn can help us to tolerate strong or uncomfortable feelings from our clients, and as we accept them, they can grow to accept themselves (McLeod, 2013). Therapist-clients who become aware of their blind spots and get comfortable with their vulnerabilities through personal therapy can use this awareness to respond to client’s emotions more effectively and better distinguish their own feelings and reactions from those of the client (Noble & Rizq, 2020; Wiseman & Shefler, 2001). Learning through Experience Personal therapy is an opportunity to learn how to be a therapist. Going through personal therapy can bring theoretical frameworks to life and also help us reflect on the concrete tools of the trade (Probst, 2015a). We may experience the power of insight, the strength that comes from being truly accepted or the thrill of feeling that we now have a strategy we can use to help ourselves in any situation. This ‘experiential’ part of personal therapy is likely to have the deepest impact. Åstrand and Sandell (2019, p. 6) noted how personal therapy helped trainees in understanding therapy by saying, ‘You can’t just learn by reading, you have to feel it.’ The therapist-client may remain with significant experiences in personal therapy, first experiencing as a client, then turning it around and looking at it as a therapist. As we connect both perspectives to theory, we may experience both personal and professional growth (Råbu et al., 2021). The personal therapist could be an important role model, especially for trainees and novices (Grimmer & Tribe, 2001). As therapistclients, we may make constant comparisons between what we do and what our therapist does, thereby learning the subtleties of what makes therapists effective. Thinking about what triggered us positively or negatively in the session, or what left us feeling closer or further away

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from our therapist, can also be a pathway to understanding ourselves and our work. We may also learn from the missteps of our personal therapists, and their readiness to acknowledge their own mistakes can have the added benefit of helping us recognize and accept our own mistakes in therapy (Bellows, 2007; Probst, 2015a). Those of us who are in personal therapy could reflect on our experiences as a client. Take a moment and ask yourself if there was anything your personal therapist did that made you feel: ‘Yes, I want to be like that as a therapist.’ Or ‘No, I don’t want to do that as a therapist’? Has this influenced you to adopt or avoid any of these behaviours with your own clients? Experiencing therapy (especially when it helps) can also help us develop a deep-seated belief or conviction that what we are doing is meaningful and will help the client. Subsequently, when we speak to our clients about therapy, and how and why it works, we can speak from our own beliefs and experience. Deepening Our Connection with Clients Sitting on the client’s chair, we can become aware of a range of subtle experiences that we have not encountered before. We can become more sensitive to our client’s vulnerability and what might be painful or difficult for them in sessions; or we might recognize how much courage it takes to come into therapy every week (Åstrand & Sandell, 2019; Probst, 2015a). This might lead to a deep sense of respect for our client’s struggles and a reduction of our own sense of omnipotence. Experiencing what it is like to be spoken to as a client may also stimulate us to think more carefully about how we speak about and to our own clients. Did we enjoy hearing our intimate experiences described as ‘symptoms’? If we were diagnosed, did that label capture our experience? Can therapy be meaningful without using this language? The area of greatest impact and perhaps the most significant contribution of personal therapy to professional development seems to be in terms of building relational depth and interpersonal competencies (Rake & Paley, 2017; Taubner et al., 2013). Intimacy with our personal therapist can build self-acceptance and help us to become aware of, understand and experiment with our intimacy levels (Legg

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& Donati, 2006). As we reflect on what helped us build an alliance with our personal therapist and what they did to foster the relationship, we can also become aware of how we can build a better alliance with our clients. Our learning may also be specific and nuanced. In our personal therapies, the experience of silence in the therapy room may sometimes evoke safety and holding and at other times distance and aloneness. Such experiences can sensitize us to the use of silence with our own clients and what it might mean to them (Anonymous, 2011). Growing into Our Own Style As we experience personal therapy, we may notice how each therapist is different and has a unique style. We can use these insights to reflect on the style or stance that fits with our personalities, aspects of orientation or technique that we resonate with and the languaging that feels both natural and effective. In this way, we can move on from blind imitation to creating our own identity, thereby growing as therapists (Wiseman & Shefler, 2001). This process can even help us develop our own techniques and theories, as it did for Pinsof, who developed integrated problemsolving therapy. He says that the most profound influence on model development was his experience as a person and patient, describing that ‘It is a model that I can sell, because I have bought it. I know it from the inside as well as the outside’ (Pinsof, 2005, p. 146). Of course, such integration requires that we observe the way theory and technique are used, experience its impact on ourselves and use this to feed back to what we understand of theory. Every Silver Lining Has a Cloud Of course, not every experience in therapy is one of affirmation and growth. Personal therapy can be a mixed bag, especially when it is mandatory or introduced in the training phase. When trainees allow us a glimpse into this intensely private space, we learn that personal therapy may be perceived both as a ‘safety net’ and as ‘risky business’ (Moller et al., 2009). While many trainees have testified to the transformative power and value of personal therapy (Edwards, 2018;

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Von  Haenisch, 2011), there are some divergent voices. Trainees undergoing mandated therapy have described a gamut of negative responses, from a lack of readiness, a sense of being disconnected from the process or just ‘ticking a box’ to anger and resentment and feeling like there was a gun to the head (Rizq & Target, 2010; Von Haenisch, 2011; Wilson et al., 2015). An immersion in personal exploration can be distracting or overwhelming, making it difficult for trainees to focus on developing skills and connecting with their clients’ needs (Kumari, 2011). Some of us may be vulnerable, particularly if we have not had secure attachments or our reflective functioning is compromised due to past trauma (Rizq & Target, 2010). A trainee’s life may be filled with assignments, evaluations and new learning, leaving less time to process or resolve the difficult issues that personal therapy may bring up (Moller et al., 2009). It seems like many tangible and intangible things can happen in the corridor between the therapy room with our personal therapist and the therapy room with our client. By enhancing our attachment security, personal therapy improves reflective capacities and mentalization, thereby allowing us to think more effectively as therapists (Rizq, 2011). Thus, intense self-experiences in therapy can create greater self-reflexivity. Wigg et al. (2011) derived a literature-based model on how personal therapy impacts the development of reflective practice. The authors identified areas of reflection: (a) reflections on the self as a person or personal reflection, which includes both awareness of and acceptance of self, and insight into client experiences; (b) professional reflections, which include understanding how to boundary the self in the therapy room, learning what you wish to do or not to do by modelling the therapist, and validating the benefits of therapy; and (c) meta reflections, which include a developing comfort with a more authentic use of self and becoming more coherent and integrated. Personal therapy can primarily be seen as a reflective space, encouraging growth, keeping us motivated and deepening our engagement with work. More than anything else though, personal therapy is a significant form of self-care for therapists—a space to feel at home, put down our burdens and let somebody else carry the load for an hour.

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A Therapist Speaks: Therapist on the Couch Ms Nupur Dhingra Paiva, a child and adolescent psychotherapist, and author of Love and Rage: The Inner Worlds of Children, shared with us her varied experiences of being in personal therapy. ‘I have been a client in psychotherapy in different ways (individual and group; twice-per-week depth therapy, weekly therapy and intensive dynamic therapy consultations) with different therapists over an 18-year period. The most powerful, memorable and effective were when I was invited to be an active participant, instead of on the couch or as an anxious–silent group member. While on the couch, I wanted to see my therapist’s reaction to what was shared, to look at her face and perhaps to keep an eye on her. I have always been tuned in to how others respond to me, but it took years to realize how this was a core part of my character structure. In group therapy, I was overwhelmed by anxiety, wanting to become invisible and disappear. Simultaneously, I wanted the group leader to be a benevolent, giving, leading presence. I was again keeping an eye on her, to see how she reacted to me. Clearly, I was placing myself in a needy, passive, helpless child position to this powerful figure, and I constantly needed her validation. This is ironic because helplessness in others, especially women, has always been a source of irritation when it enters the room in my patients. Yet here I was, doing exactly the same. So it becomes easy to see how it was a disavowed part of myself which I could see and reject in others but not see in myself. When my therapist reacted positively, I would be emboldened to continue. When she reacted with impatience or dismissiveness to my contribution, it would sting, leaving me wounded and enraged. I wanted her permission and encouragement—I wanted her approval the way I wanted my father’s approval. This personal therapy journey made a big impact on my interactions with my patients, most of whom are adolescents with emotional and relationship difficulties. I am very aware of the tone of my voice ever since I heard myself speak on a video-recorded session; I was horrified

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to find how strict and clipped I sounded—not empathic or gentle at all. I am now more aware of the relationship patterns that the patient invites me to fit into: Do I become active when my patient is passive and helpless? Do I do the hard work when my patient is detached and disinterested? Whose therapy is it—mine or the patient’s? So who needs to be doing the hard work? How do I respond when there is veiled aggression, sarcasm or devaluation? These are a few tricky aspects of the quality of the relationship which only became evident to me by having been a patient repeatedly.’

Personal Therapy: A Matter of Choice Psychotherapy can take many forms, and no one knows this better than a therapist-client. Taking the time to reflect on our options and preferences, perhaps even trying out a few different approaches, can help identify the therapy that works best for us. If you are in personal therapy, pause and reflect on what contributed to this decision and what factors influenced your choice of therapist. Who Is the Best Therapist for Me? Once we decide to take the plunge and seek personal therapy, it begins with making the critical decision of who to see. As therapists ourselves, we may be much more particular in picking the therapist we want to see, as we know enough about the field to know the difference the quality of therapist can make. While some therapists may find senior professionals or colleagues more accessible, others may prefer to seek therapists who are not part of their professional circle due to issues of confidentiality (Norcross, 2005). The therapist’s reputation, our belief in the treatment being offered and feeling that the therapist is professional and experienced, all influence the choice of therapist (Oteiza, 2010). Of course, it is the match between personal therapist and therapist-client that matters the most, and we usually pick a therapist we feel comfortable with. It could well happen that it does not work out with the first therapist we try. Both our early experiences of personal therapy as well as our growing

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professional knowledge can help clarify what we are looking for and refine our choice. Staying Home or Going Out? Another choice that the therapist-client needs to make is whether we wish for therapy in our own theoretical orientation or contemplate trying something different. We may feel that we can learn more from modelling a therapist who works in the same orientation as us or from one who practices from an orientation we are interested in finding more about. While psychoanalytic/dynamic therapists were the most likely to stay close to home and choose a therapist from their own orientation, those from other orientations were more varied in their choices (Norcross, 2005). In fact, cognitive behavioural therapists have been known for seeking personal therapy outside their orientation (Laireiter & Willutzki, 2005). Choosing a therapist from a different orientation can be an interesting experience, providing the opportunity to have our personal material examined through the language and philosophy of another school of thought. Curtis (2011, p. 804) shared how the ‘experiential multiplicity’ of seeing therapists from different orientations enabled her to appreciate both directive and non-directive work. Working from a different orientation may also help us de-focus from theory and enter our experience rather than intellectualizing it (Brown, 2005b). A positive personal experience with another orientation can also impact the way we view our own. CBT trainees described a tension between the manualized protocols they were learning as students and the more relational therapies they were experiencing as clients (Noble & Rizq, 2020). When novice therapists experience therapy in their own orientation, it can feel less confusing and help in crystallizing theoretical concepts (Laireiter & Willutzki, 2005). However, later in one’s professional development, exposure to other orientations of therapy can broaden or deepen their skills and competence. It depends perhaps on the reasons we seek personal therapy and the role we see it

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playing in our lives and professional development. Is it a tool to learn techniques? Or a means of understanding the therapeutic alliance? Or a pathway to explore less explored parts of the self? Therapies of various modalities can be impactful, and we can give ourselves the freedom to experiment. Are We There Yet? There is no one right time to seek personal therapy and no one recommended duration of therapy. For some of us, personal therapy may represent a brief mandated stint during training. For others, it may be one of our important pillars of support that we cannot imagine doing without. As reflected in the choice of orientation, many therapists seem to prefer long-term therapies and are also more likely to be recommended the same by their therapists (Norcross et al., 2001). However, this is not to say that only long-duration therapies are helpful. Hoyt (2011) speaks about how a single session of hypnotherapy helped him prepare for a surgery he required. A long duration of therapy does not necessarily mean seeing the same therapist, week after week, for years. We may stay in therapy as we need, attending to different issues and trying different therapists and modalities. Several factors other than duration likely determine the impact and value of personal therapy.

Helping the Helper This vignette explores what it might be like to be a therapist for other therapists and illustrates some of the questions we might have about this role: Nasir, a seasoned therapist in his 40s, was asked to be a personal therapist for the first time. While he was initially flattered and felt recognized by his professional community, he wondered how to proceed. Is personal therapy different from ‘regular’ therapy? How would he prioritize and balance the twin goals of personal and professional development? Would a therapist-client be easier or harder to work with than a regular client? Would he feel more relaxed talking to a colleague who understood his language, or would he feel more

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tense at being open to evaluation by a peer? What would he do if he ran into the therapist-client outside the session? He felt the need to focus his reflections and to consult someone with experience as a personal therapist. If you were in Nasir’s shoes, what would you have wanted to know? Easing Therapist-clients into the Other Chair When they first enter the therapy room, therapist-clients can bring different expectations and vulnerabilities with them. Some may feel eager to finally have their personal therapy experience, some may fear being judged by their colleagues and others (often trainees in mandatory therapy) may feel pressured into this role and may be unsure about whether they need it at all. As personal therapists, we often start by exploring what personal therapy means to our therapist-clients and addressing any apprehensions they might have about the process. In particular, we need to be aware that our clients may feel especially vulnerable and unsure, struggling to follow in a room where they usually lead. Openly exploring what it might feel to be in the ‘other chair’ and responding to their questions and concerns by discussing our approach or plan can create a more equal partnership. Sharing our own vulnerabilities can also help them feel more comfortable with expressing theirs. We ourselves might feel intimidated by having this ‘expert’ client who speaks our jargon, enquires knowledgably about our approach or declares clearly what they want and do not want from sessions. We may wonder if they are as confident and friendly as they appear or if they are feeling nervous and exposed and trying to establish their own competence. Are they expressing their needs and feelings or attempting to take over the session and determine what is to be discussed? As personal therapists, we can reflect on what our therapist-clients may be experiencing and why. The use of a shared language could be a way of drawing us closer and sharing inner worlds, or it could be a way of keeping distance and ‘intellectualizing’ issues. A reflective openness to possible meanings and an interest in their underlying experience are important in creating a healthy therapeutic alliance.

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Attending to the Personal and Professional We know that each client takes a different journey to the therapy room, with specific hopes and goals of what they wish for themselves or how they want to change their lives. In personal therapy as well, the focus emerges primarily from the needs and experiences of the client, and we need to spend time to understand what these goals are. Therapist-clients may dismiss some of their own goals as too insignificant and worry about revelations that are too painful. They might wonder: ‘How can I as a therapist actually need help with parenting? How can I admit that I am having an extra marital relationship or that I am dependant on substances?’ We may need to give them explicit permission to have both small and big goals and emphasize that we are not expecting them to function better just because of their profession. We try to provide them the respect of treating them like fellow professionals, without ever forgetting that they are also vulnerable human beings. Asking the ‘why now?’ question can help them connect with their immediate experiences around entering therapy. Along the way, we can also enquire about their motivations to join or continue in this profession, exploring the connections between their personal and professional experiences and understanding implications for their functioning (Fleischer & Wissler, 1985). Therapist-clients might value the opportunity to discuss their professional choices and build congruence between their personal and professional selves. Sometimes, therapist-clients may wish to discuss their work-related difficulties, describing a session with their own clients. As personal therapists, we strive to keep focus on the inner life and needs of the client in front of us, and as they talk about their lives and work, we need to keep in mind that they are really talking about themselves. In this way, we can use their professional experiences as a pathway into understanding their personal values, concerns or difficulties. What Makes the Therapist-client Unique? Having a client who is also an ‘expert’ on therapy can be both deeply satisfying and uniquely challenging. We may feel friendlier and warmer towards our therapist-clients and experience sessions as livelier and

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more natural. Personal therapists report that they enjoy sessions more and are more likely to discuss research or matters relevant to the profession with their therapist-clients as compared to other clients, creating a feeling of intellectual closeness (Norcross et al., 2001). A pre-existing knowledge of therapy can work as a shortcut, as therapist-clients often require less psychoeducation, and their intellectual knowledge of concepts makes the shift to the emotional level much easier (Beck & Butler, 2005). There can also be a sense of shared camaraderie and experience, with both therapist and client being aware of the highs and lows of a therapist’s life. However, as personal therapists, we may wish to be appreciated or acknowledged by our clients and can therefore feel put on the spot, with each of our actions and reactions being closely reviewed by a fellow professional. If our therapist-client tells us that they do not feel accepted or that they wonder if therapy is going anywhere, it can be hard not to feel defensive. Therapist-clients might be hoping for a magical transformative therapy experience and feel let down or be critical when this does not happen. This duality of experience can make the therapist-client ambivalent about both therapy and the therapist (Fleischer & Wissler, 1985). Perhaps it is experiences like this that have led many personal therapists to describe therapist-clients as more challenging or critical (Geller et al., 2005b). Therapist-clients may feel that as therapists themselves, they ought not be treated as ‘regular’ clients (Fleischer & Wissler, 1985) and can experience boundaries (for instance, around extra session contact) as rejecting. As personal therapists, we may need to be extra sensitive to boundaries and how they may be interpreted by our therapist-clients. Therapist-clients might push us to treat therapy like a regular conversation between colleagues, wanting to contact us after hours or seeking career advice. While we might occasionally choose to shift between the therapeutic frame and regular life, it is not useful to do so at the behest of the therapist-client, as this can make therapy feel like less of a safe and certain space (Probst, 2015b). However, overall, they seem to appreciate being treated like regular clients, in terms of keeping to the structure of therapy, appointment schedules or ending sessions on time (Daw & Joseph, 2007).

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The likelihood of extra session contact is far greater with therapistclients than with other clients, as we may share the same professional spaces. We can try keeping such contact to a minimum, but where this is unavoidable, we need to explicitly negotiate around client preferences (King, 2011; Norcross et al., 2001). For instance, we might directly ask, ‘What would you like to do if we run into each other at a conference?’ Reflecting together about the meaning of these experiences can also be useful. Too Much Information: Dealing with Disclosures Sharing a common world also means that our therapist-clients may discuss professional colleagues and contacts, making us privy to information which we do not know what to do with. Of course, our clients need to feel safe to talk about their feelings and difficulties with the people in their lives, and we may need to reiterate the confidentiality contract to ensure that they do feel this safety. Such communication can evoke feelings of fascination, curiosity or horror about colleagues or professional ‘rivals’. We may also feel protective or defensive if we feel our therapist-client is being negative about someone we value. We need to consider if and how we can continue our personal relationships with colleagues, without allowing this secret information to colour our interactions. Anticipating such disclosures can help us reflect on how we can respond to them. We may also feel disturbed when therapist-clients bring in information about ethical violations they engaged, either deliberately or unintentionally. For instance, they may make a passing reference to receiving an expensive gift from a client or holding a session in a coffee shop. As personal therapists, we may be unsure if this ethical breach should be brought to the therapist-client’s notice, and how this might impact the therapeutic relationship. If we discover a more significant breach, are we supposed to report them? What would be the implication of hearing such a revelation from a trainee therapist? Would the context impact our obligations? These are complex questions with no simple answers, and consulting with peers and reflecting on the possible outcomes of each of our choices can help

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guide us meet our obligations to the therapist-client, their client and the profession. In conclusion, while there are several unique aspects to seeing therapist-clients, we would recommend Laura Brown’s advice to remember that ‘…the therapist-client is a client, first, last, and in between’ (Brown, 2005b, p. 280).

Perspectives on Training and Development Debates about Mandatory Personal Therapy during Training A compelling argument for making therapy obligatory is the initiation of a strong foundation for self-exploration and reflective work. However, personal therapy is not necessarily intrinsic to psychotherapy training worldwide, and there are significant variations across countries, mental health disciplines and training programmes. For instance, while training programmes in Germany have stringent requirements (minimum 120 hours) for licensure (Taubner et al., 2013), in the USA, only analytic training institutes and select graduate programmes specify any personal therapy requirements (Geller et al., 2005a). The Rehabilitation Council of India (2016) does not mention personal therapy in its guidelines for clinical psychology training, although a few graduate programmes have incorporated a brief personal therapy component (Thomas & George, 2016). While personal therapy during training can be a valued experience, concerns about potential negative effects for some trainees and infringements on their autonomy are being expressed more openly and stridently (Chaturvedi, 2013; Kumari, 2017). The economic and time costs of mandated therapy could exclude disadvantaged persons from considering psychotherapy as a profession (Rizq & Target, 2008). We recommend that while available options for personal therapy can be discussed, the elements of choice are important— to seek therapy, decline or withdraw, or even defer the decision. As trainers and supervisors, we need to reflect on our position on

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personal therapy for trainees and consider whether and when we would recommend it. Best practice guidelines can be helpful for training contexts that encourage, recommend or continue to mandate personal therapy. These can support trainees in making informed choices, engage safely with the process and learn to use personal therapy in a meaningful way. Training courses need to have clarity about the aims and rationale for this form of experiential learning and share this with trainees in advance (Moller et al., 2009; Murphy et al., 2018). Space for dialogue, choice regarding the therapist, therapeutic orientation, duration and frequency of sessions, or even discontinuation of therapy are advocated (House, 2007; Malikiosi-Loizos, 2013). Information about therapists who provide care at reduced fees may be particularly important for trainees. An authentic engagement with personal therapy and assimilation of its potential benefits can be fostered by reflective processes to help trainees integrate their therapy experiences and convert these learning into more effective work with clients (Edwards, 2018). Attunement to the trainees’ experience and commitment to their safety and well-being are paramount with clear pathways for support and redressal for any difficulties with the personal therapist or other negative experiences (Edwards, 2018; McMahon, 2018). Multiple Pathways to Personal Development There is an emergence of training recommendations which call for introducing trainees to a range of reflective and experiential activities rather than personal therapy alone (e.g., European Association of Psychotherapy, 2017). The inclusion of personal development components such as experiential groups, supervision spaces and journaling could provide scaffolding in training contexts where personal therapy is not easily available, accessible or affordable (Thomas & George, 2016). Personal practice frameworks, which are shorter and perhaps more contained than personal therapy, are gaining research and theoretical support. Each of these spaces offers different reflective possibilities that we might find useful as therapists.

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Conclusion Entering personal therapy calls for ‘courage, being able to stay with the unknown’ (Loewenthal, 2019, p. 3). But this is a space that can reward our courage with reflective opportunities for personal and professional transformation. It is when we are compelled by our own reasons and choose to engage deeply with this form of personal exploration that personal therapy may be most valuable. It plays a unique role in the lives of therapists because the only way to truly experience what it is like to be a psychotherapy client is to be a psychotherapy client.

Chapter 11

Investing in Self-care and Growth

The Pause is a practice initiated by a nurse, after the experience of losing a patient to cardiac arrest. The nurse requested the team to ‘pause’ and honour the life of the individual, before continuing with their routine. When team members collectively pause, this encourages empathy during critical moments and an acceptance of their own difficult feelings (Ducar & Cunningham, 2018). Taking a moment to reflect and get in touch with ourselves and our clients and acknowledging what is shared and difficult for both can be a grounding experience. When is the last time you needed a ‘pause’? When did you ignore your need for a pause? As therapists, we share our ‘self’ and use our feelings, experiences and strengths to foster a deep connection with our clients. This emotional investment in the relational process often brings deep satisfaction, rewards and meaning to our lives (Radeke & Mahoney, 2000). However, therapeutic work is not easy and is often marked by unexpected challenges and uncertain endings. Our work also involves emotional labour (Hochschild, 2003), where the ‘rules’ direct us to show empathy and consciously mask and regulate our own difficult and intrusive emotions. We may also experience the pressure to do the right thing and constantly watch out for our

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clients, and these responsibilities may take a toll on our well-being. Being a psychotherapist involves going through a repeated cycle of caring, which includes the phases of engaging with clients (empathic attachment), caring for and working with them (active involvement) and then separating from our clients at the end of each session (felt separation). The fourth phase in the cycle of care is the time to pause for reflection, restoration and re-creation of the self (Skovholt & Trotter-Mathison, 2016). As an ethical imperative, therapist self-care has been positioned as an individual responsibility, in response to personal difficulties that cause impairments in the professional sphere (e.g., American Psychological Association, 2017; National Association of Social Workers, 2017). Practitioners are urged to ensure their competence and prioritize the well-being of their clients, taking remedial or corrective action if required. Drawing on concepts from positive psychology, which emphasizes the sense of flourishing, can help shift self-care out of a stress-coping framework. This involves a deeper engagement with positive emotions and our values, a focus on growth and generativity, along with building relationships and resilience (Wise & Reuman, 2019). ‘Caring for others requires caring for oneself’ (Dalai Lama, 2003, p. 125), and it is vital that self-care be valued as integral to our professional work. Self-care practices can then become a part of our everyday routine, much like writing session notes or consulting with supervisors. We further advocate that self-care also be acknowledged as a systemic responsibility, integrated into our institutional and organizational structures, and cultivated from the point of entry into the profession. The societal construction of therapists as ‘poster people for healthy emotions’ (Van der Merwe, 2019, p. 38), and as role models equipped with all the answers, can be restrictive. This has been evident during the COVID-19 pandemic, where therapists responded to increased mental health vulnerabilities among clients and other front-line workers and made rapid shifts to remote work, sitting at their screens— often tired, anxious and trying to help (Geller, 2020; Mcbeath et al., 2020). During this time, therapists were (again) positioned as ‘people who cannot, or should not, be fellow sufferers also doing their best’

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(Lee, 2020, para 3). In conforming to this image, therapists might portray themselves as impervious to stress and vulnerability and even feel ashamed about needing support. This problem is compounded when organizations and institutions also operate from this position, expecting therapists to draw on their own resources without questioning the systemic status quo (Stiles & Fox, 2019). In this chapter, we look at how self-care and resilience-building can become a more valued and visible part of our work life and emphasize how this is both an attitude and a practice. This is discussed in the context of workspaces (e.g., palliative care), challenging experiences (e.g., client suicide), losses and transitions in a therapist’s personal life and organizational practices. While self-care is important at all stages of our career, we bring a focus on trainees and the training phase, a critical time to learn to prioritize self-care. We also share diverse paths to build a personalized toolkit to nourish and sustain ourselves and find meaning in our work.

The Matrix: Clients, Therapists and the System Becoming aware of the interplay of stresses that emerge from therapeutic interactions with our clients, from the person of the therapist as well as the organizational and structural context, can guide us towards better self-care. A good experience in one area (a great session with a client) can buffer us from stress in another area (a difficult experience with a department head). Of course, negative experiences can also be cumulative in their impact, and experiencing stress in more than one area can really stretch our resources. Difficulties with Clients: A Part of the Territory As busy practitioners, working with diverse clients, we may feel quite tired by the end of each day. Their stories and emotions often linger on with us long after the session has ended. While this churning of ideas and impressions at the back of our minds can be useful, triggering reflection and planning for the next session, it can sometimes become intrusive (Bimont & Werbart, 2018; Schröder et al., 2009).

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Take a pause to recall a client who ‘followed you home’—in your mind. Perhaps thoughts and emotions from sessions with this client colour your day or frequently enter discussions with supervisors or peers. Reflect on why this might be happening. Ponder on whether there are certain clients or concerns that that you find harder to leave behind? Or whether you as a therapist find it hard to disconnect from many of your clients? We experience strong interpersonal connections and emotional reactions in our work, but this can exact a cost, impacting our personal relationships. When we are full with the lives and emotions of our clients, we may feel a need to withdraw from our social connections (Råbu et al., 2016). It may be difficult to shrug off the therapist identity and have healthy relationships where both partners are equal in power and vulnerability (Farber, 1983). Our sensitivity to the possibilities of negatives can cause us to be anxious or exacting partners and parents, or more cynical and mistrustful of people (Hatcher et al., 2012; Kottler & Hunter, 2010). The nature of concerns our clients present may be more consistently linked to the sense of emotional exhaustion than the number of clients we see (Yang & Hayes, 2020). Engaging with clients who have presentations such as challenges with addictions or personality vulnerabilities can exacerbate stress and deplete our emotional resources (Bourke & Grenyer, 2013; Oser et al., 2013; Simpson et al., 2019). Bearing witness to stories of trauma, displacement and loss can deeply impact therapists. The experience of feeling the client’s pain can lead to indirect trauma (Knight, 2013), an umbrella term that encompasses manifestations of secondary traumatic stress (Figley, 2002), vicarious traumatization (McCann & Pearlman, 1990) and compassion fatigue (Figley, 2002). Therapists who work closely with clients with trauma histories may be vulnerable to anxiety, hypervigilance or numbing and re-experiencing of their client’s trauma – all experiences that are analogous to post-traumatic stress disorder. Cumulative exposure to stories of trauma can also lead to potentially permanent and pervasive changes in the cognitive schemas and the self of therapists (McCann & Pearlman, 1990; Pearlman & Mac Ian, 1995). When our client’s worlds are devoid of trust, safety or control, we may feel a lack of

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the same in our worlds. These experiences can also lead to compassion fatigue when we find it difficult to access our most fundamental tool—empathy for our clients. Some work settings may be more challenging than others. When we provide compassionate care in spaces such as palliative care, close encounters with death and dying, interactions with grieving families and constant existential questions can leave us feeling depleted (Mills et al., 2017). In contexts like these, without adequate and conscious efforts at self-care, it can be difficult to hold on to meaning and satisfaction from our work (Sansó et al., 2015). A Therapist Speaks: ‘Self in a Profession That Only Cares for Others’ We invited Ms Hiba Siddiqui, a senior psycho-oncologist at Max Healthcare in Delhi, India, to share her reflections on taking care of herself as she works with clients diagnosed with cancer. ‘In my work in the oncology unit of a private tertiary care hospital in India, I form a deep connect with patients in their long and arduous journey of battling cancer. Parents helpless for their children, unable to stop the deterioration; a senior citizen, desperately holding on to his dying wife; a patient with no social support who may not be able to pull through the harsh side effects of the treatment—what can I possibly say in this situation to make them feel better? Such moments test my ability to remain calm and composed while interacting with them. Many times, the pressure is draining, causing me to break down at home or outside the workplace. Self-reflection and dialogue with team members and peers allows me to process my sessions, find peace with troubling conversations, deconstruct complex emotions and gain a fresh perspective on my chosen therapeutic trajectory. It helps to make a conscious effort to share my journey with those close to me (while maintaining confidentiality) and guard against isolation from friends and family. In so many ways, my patients become a part of me, a part that is often lost and grieved for. My own weekly psychotherapy sessions help me define and make sense of my grieving process. Having worked in oncology

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for more than nine years and having been a caregiver for someone with cancer earlier, I realize the importance of self in a profession that only cares for others.’

Self-care in the Face of Client Suicide Therapists working with trauma and suffering can collect both beautiful and painful memories, which deserve time and attention to process and integrate. One experience we all hope never to have is that of losing a client to suicide. While we may be able to accept that not all clients will get better, the finality of suicide can hit us hard, both as individuals and as professionals. Many therapists start their stories of client suicide by describing how they got the news and recalling their first discussion with their supervisor (Knox et al., 2006; Spiegelman & Werth, 2004). A minimal or dismissive response or, worse, a critical or blaming one may have long-term implications for how well we are able to come to terms with our client’s suicide (Knox et al., 2006; New Zealand Psychologists Board, 2017). Intense feelings of shame, guilt, anger and loss can jostle with self-doubt about our skills and fears of being judged incompetent or unfit for our chosen profession. Mourning for our clients, dreading facing their families and worrying about legal or institutional repercussions only compounds our emotional turmoil (Sandford et al., 2020; Schupman & Goss, 2020). We may need a time to retreat, but as we grow to accept our own limitations and those of our clients, we can come back as more resilient and sensitive therapists. This is perhaps one path that we cannot walk alone, and our friends, family, colleagues, supervisors and institutions, all have their role to play. As therapists, we may be unsure how to mourn or for how long to mourn. Our feelings of distress can impact our practice for several years, with upsurges of grief at odd moments or flashbacks of experiences with the client (Onja & Michel, 2005). Some therapists experience a distancing from clients, while others may feel engulfed by anxiety about their clients. If we avoid or minimize our emotional reactions, we may stop seeing clients in crisis, avoid discussions around

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the event or work mechanically to cope with our feelings (Knox et al., 2006; Whisenhunt et al., 2017). Anxious therapists may worry more about at-risk clients, making frequent risk assessments, referring for medication or admission more quickly, and being hypervigilant for signs that clients might take their lives (Sandford et al., 2020). This carefulness and greater sensitivity to client’s pain is not always a negative, but discussions with supervisors can help distinguish between honing our skills and practising too defensively (New Zealand Psychologists Board, 2017). Conversely, therapists might exert subtle pressure on clients to be better or happier, seeking reassurance that they are doing well (Baba Neal, 2017). While it is okay to deal with our feelings at our own pace, deal with them we must. Losing a client to suicide forces us to consider questions of responsibility and choice about life and death (Sanders et al., 2008). We might need to remember that we are just one of the multiple factors impacting the client’s life, and that clients ultimately do have some control over their own lives and choices. The combination of diverse risk factors, the limited sensitivity of available tools and the reality that our clients could conceal their suicidal ideation and plans, all come together to make it difficult to predict and prevent suicide (Blanchard & Farber, 2020; Kessler et al., 2020). What is expected of a therapist is to do the best we can. Connecting with other colleagues who also knew our client and sharing both our victories and failures may be a big part of therapist healing (Sherba et al., 2019). Immersing in the narratives of other therapists who have had similar experiences (such as those available from the website of the American Association of Suicidology’s Clinician Survivor Task Force (n.d.) may also help us feel less alone and show us a way forward. Supervision may also provide a supportive space for therapists to process their grief, articulate their feelings and questions about what they could have done differently, and create a meaningful narrative of their experience (Schultz, 2004; Whisenhunt et al., 2017). As supervisors, we may also share our own stories of losing clients to suicide and help supervisees feel that they are not alone. When we use ‘we’ language when discussing the suicide (New Zealand Psychologists

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Board, 2017), and remind our supervisees that we discussed the case together, and neither of us was able to prevent the suicide, this may create a shared sense of responsibility (Spiegelman & Werth, 2004). We may also help in decision-making around the supervisee’s need for additional support or personal therapy, their readiness for work or the type of case load that would be appropriate in the immediate future. It can be challenging for us as supervisors to ‘hold it together’; we could be impacted by our own loss history and experiences with client suicide and bear the additional burden of worrying that we have failed our supervisees. Room for supervisors to process their own grief and more conversations about required support and guidance are much needed. Learning to care for ourselves and embrace life in the face of its uncertainties and vicissitudes are important lessons for us as therapists. Pre-emptive discussions about the possibility of client suicide during training, expanding the focus beyond risk assessment to looking at philosophical aspects, secondary trauma, feelings of failure and the need for self-care can help therapists prepare for and traverse this difficult terrain (Sanders et al., 2008; Schupman & Goss, 2020). When individuals and organizations support therapists and provide time and resources for self-care, this may mitigate the negative and persistent impact of client suicide. The creation of support networks for practitioners outside academic and organizational settings, for instance school counsellors or therapists in private practice, is also important (Christianson & Everall, 2008; Finlayson & Simmonds, 2019).

The Personal Lives of Therapists The personal qualities and experiences of psychotherapists have an inevitable presence in therapeutic work, as positive contributors to our craft, but also as vulnerabilities that make us more susceptible to work-related stress. An inflated sense of responsibility for our clients’ outcomes can lead us to do too much in sessions, overlooking how ‘the more the therapist does, the less there is for the client to do’ (Kottler, 2010, p. 193). ‘Perfectionistic’ therapists are not ‘perfect’; exacting standards can be linked with poorer client outcomes (Presley et al., 2017). Sometimes the same qualities that make us good at our jobs

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may also hinder our self-care. Attention to detail may easily lead to rigidity and emotional openness to emotional vulnerability, and our early maladaptive schemas such as unrelenting standards and self‐sacrifice can make us more susceptible to burnout (Richardson et al., 2020; Simpson et al., 2019). Reflections on our personal self can bring awareness about the intrapersonal factors that limit us as therapists and offer directions for change Even a well-functioning therapist can be temporarily laid low by stressors or life events, relationship or financial difficulties, challenges to health or personal losses (Adams, 2014; Barnett et al., 2007; Nash & Chapman, 2019). While some may be transitory events, others, like caring for a child with a neurodevelopmental concern, may require continual adjustment. For female therapists, becoming pregnant is a life event that adds a new identity as a mother and a new bond to build. Clients might resent sharing us, and therapists might have mixed feelings, sometimes resenting our clients for taking us away from our baby, and sometimes resenting our baby for taking us away from our work (Waldman, 2003; Way et al., 2019). Negative life events like divorce or death of a loved one are intense experiences that inevitably spill over into our work as therapists, with possible negative impacts on our ability to build and sustain the therapeutic alliance (Nissen-Lie et al., 2013). Our personal experiences of past trauma can also set the stage for emotional disruptions and a sense of depletion (Yang & Hayes, 2020). We may want to protect and rescue our vulnerable clients, but this can connect sharply with our own pain and lead to retraumatization, a re-experiencing of difficult memories and the connected feelings. We all have personality traits, burdens and even trauma, but these need not prevent us from being effective therapists. While it is true that we need to acknowledge our difficulties and work through our past experiences, we can also learn to work with our ways of being and doing and use our wounds to empathize with our clients. As therapists, it may be hard for us to acknowledge that we can experience personal difficulties, suffer or fail, just like everyone else, but ‘adversity busts that whole thing wide open’ (Comstock, 2008,

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p. 183), and there are times when we can no longer keep our therapist selves separate and intact. Acquainting ourselves with therapist narratives of personal adversity and coping (e.g., Lubner & Luca, 2019; Murray-Swank, 2019) can help us acknowledge and respond to our struggles. It helps when our supervisors demonstrate that neither they nor we are ‘above’ psychological stress and act as our role models for self-care. Therapists often speak of a reluctance to ask for help from their colleagues, fearing their judgement or evaluation—a fear that is not completely unfounded. However, when we are sensitive to our colleagues’ distress, we can step in to support them at a challenging time, perhaps preventing an escalation of their difficulties. We may also need to be more willing to suggest and consider emotional support or therapy and be more open to flexible work roles or reduced responsibilities, as required by us or our colleagues. This can create a generation of therapists who accept the intersections between personal and professional lives and are not so reluctant to help and be helped. Therapists may choose to continue working, hoping that if they ignore their distress, it will go away. Work can also feel like a welcome refuge, a place we can feel competent, relevant and needed. The key factor is our evaluation of our ability to work versus our need for time to heal and cope. Speaking about bereavement, Adams (2014) notes that we may need time for grieving, completing the rituals of death and finding our personal strength. ‘Using’ therapy to help us feel better could tilt the focus towards our own needs or put undue pressure on clients to make therapy gratifying for us (Adams, 2014). Being only half there in session or struggling to build an empathic bridge with our clients are clues that we need time for resolution (Horwell, 2019). It can help to discuss our thoughts about taking time off and about returning to work, with a friend, colleague or supervisor. As always, institutions and systems that are willing to give us the space to be human, perhaps through supportive policies and provisions, can support our individual efforts. When we do return to work, we may find that our experiences have altered us and added a rich layer to our work as therapists. There is a sense of shared humanity with our clients, and we may

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no longer feel like we are from ‘different worlds’ (Adams, 2014, p. 107). There is also something about the experience of pain that leaves us open and raw, perhaps breaking through our usual defences and professional walls. Horwell (2019) described a cyclical process, where talking to others about her personal experiences contributed to her therapy work, and reading and reflecting on therapy helped her come to terms with her loss. When we transform as therapists, we may experience changes in the way we relate with our clients, for how can a new therapist have the same old relationship? Waldman (2003) describes how communing with her baby helped her to get in touch with the wholly positive mirroring and loving gaze that her client needed from her. Murray-Swank (2019) describes how he began to use more self-compassion and experiential methods in his therapeutic work because of how valuable it was in his own difficult times. Our own experiences can not only influence the therapeutic process but the outcome of therapy as well.

Role of the Organization in Therapist Self-care Our hours of work, work setting, case load and number of roles we play are weighed against satisfaction with our work, whether we feel appreciated or validated for it, our sense of growth or control and of course the income we generate (Bakker & Demerouti, 2007; Maslach et al., 2001). As therapists, we may be left with little time to recuperate in between sessions, tasks or responsibilities, leading to an accumulation of several smaller moments of stress. Work culture often demands that we are busy caring or working all the time, and that we do not rest until the work is completed. When we are lower down the ladder, we have much less control over our workload or time. As we go higher, we have more responsibilities that demand our attention. Those who work in organizations may experience less autonomy and control over the quantum and type of work than those in private practice, leading to more potential burnout (McCormack et al., 2018). The larger context of the organization, including hierarchies, operating rules and values, resources and facilities, all add up to a sense of a reciprocal contract between employee and employer. If

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this contract feels unfair or imbalanced, then our job satisfaction may be threatened (Maslach et al., 2001). We may feel a lack of fit with the frameworks and policies of our organization, for example, wanting to do more therapy work but being expected to do more research. If the organization is rigid in its policies and offers less space for negotiation and compromise, we may wonder if we belong and should stay. In India, work overload, lack of resources and poor organizational structure have been identified as stressors for clinical psychologists (Rao & Mehrotra, 1998). Counsellors can feel underpaid (Bhargava & Sriram, 2016), and the usual advocated avenues for professional development like peer supervision or consultation and personal therapy may be scarce. For psychotherapists, it may be particularly hard to draw a line between our work and personal lives, and this is accentuated by the constant interference from our use of technology. We can feel that our privacy is being intruded with pressure to be constantly available over mail or chat. As therapists, we can protect our time by having a social media policy that regulates contact with current and former clients or having a standard time to responding to email communication. Of course, what is even more important is our ability to mentally ‘switch off’ from online work-related communication during weekends or vacations. Therapists who play multiple roles can take great joy in their sense of competence and benefit from having different types of work to focus on (Kottler, 2010). However, when we are therapists, trainers, supervisors, teachers, researchers and part of the administrative team, these diverse roles can lead to role conflict (Lee et al., 2020; Norrman Harling et al., 2020), making it hard to prioritize our activities or plan our day. Reflecting on which is our salient identity and what gives us the greatest satisfaction as well as which role we find the most troublesome (of course, both can be the same) can help us navigate these choices. We spend a significant part of our day at work, and the interpersonal atmosphere we operate in can impact us. A work environment that feels unsupportive or aggressive, with more interpersonal conflict or rivalry, can create immense stress (Lee et al., 2020; O’Connor et al., 2018). Founders and leaders of organizations have a significant

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role to play in ensuring a safe workspace for all, which is inclusive and affirmative and provides necessary mentoring and growth opportunities. Actively creating reflective spaces and fostering a culture of openness to discuss personal vulnerabilities and challenges need to be spearheaded by the leadership. Interview: Organizational Self-care Frameworks—The RAHI model We spoke to Anuja Gupta (Ashoka Fellow, Executive Director and Founder) and Ashwini Ailawadi (Co-founder and Creative Director) to learn about the self-care practices and systems at the pioneering non-profit RAHI (Recovering and Healing from Incest) Foundation, India’s first incest/child sexual abuse response organization. Gupta and Ailawadi emphasize that being in touch with one’s emotions and being willing to reflect on and deal with personal issues are the very cornerstones of work with issues of trauma. This deep engagement can be potentially triggering or bring up vulnerabilities of different kinds. This is true for everyone: those on personal healing journeys, those involved in support, advocacy and rights-based initiatives, communication and outreach through awareness and capacitybuilding programmes and even administrative work. At the recruitment stage for volunteers and staff, there is an assessment of coping abilities and support structures. Gupta remarks, ‘At RAHI, there is a very high quotient of it being personal. We have systems to take care, but it is also important for people to have some external support structures. In our experience, if they have both, they have done well, else it is difficult to sustain in this work.’ An employee welfare scheme provides low-cost psychotherapy services for staff members, which is co-paid by RAHI. There are processes to build a ‘culture of sharing’ about stories of abuse, with guidelines to support safe sharing in small group team meetings. The founders speak of the dangers of a ‘them and us’ split in the team and emphasize that reflective work and support are required by all members—survivors of abuse as well as those who are impacted by working closely with trauma or are struggling with other vulnerabilities. Close mentorship

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is provided to survivors, with a special focus on those who need to work with unresolved childhood trauma. Ailawadi speaks of engaging with personal definitions of ‘strength’ and ‘weakness’, as these can impact survivors’ journeys of healing and self-care. Social action is seen as an important tool for self-care and growth among survivors through the Firebird project. Before a survivor engages in the sharing of personal testimony, ‘We constantly judge if it is going to enhance their recovery,’ says Gupta. Apart from self-care practices of ‘meditation, doing fun things, not having very strict working methodologies’, and drawing boundaries to protect personal time, Gupta speaks of the sustenance and meaning drawn from witnessing recovery and transformations. ‘One of our peer educators recently said that she is going to have a child and wants to name it “Rahi”. Something we are doing right … this is why we still do what we do.’

Working towards Well-being Often, the stress we experience is manageable, and the joys and rewards of our work nourish and sustain us. At other times, this stress can manifest in different ways, and periodic attention to our self-care status and needs can help us to pick up early signs of impending burnout: overwhelming exhaustion, feelings of cynicism and a sense of ineffectiveness (Barnett et al., 2007; Maslach et al., 2001). Research indicates that emotional and physical exhaustion are the aspects of burnout most often seen with psychotherapists (Simpson et al., 2019). Psychotherapists can also reflect on whether they are experiencing meaning burnout, which occurs when our work no longer has meaning for us and feels routine, boring or valueless, or caring burnout, which occurs when our ability to care gets eroded, leaving us disconnected from clients and their concerns (Skovholt & Trotter-Mathison, 2016). The Practitioner Professional Resiliency and Self-Care Inventory (Skovholt & Trotter-Mathison, 2016) offers a reflective opportunity for trainees and practitioners in the caring professions. We can track our experiences of vitality and stress in both personal and professional domains and reflect on what is going well and what is challenging for

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us. This shows us if our issues are more proscribed or pervasive, and whether we are maximizing our sources of strength. When we notice that we are not doing so well, we may feel disappointed or angry with ourselves for the situation we are in. Rather, we suggest an attitude of self-compassion, where we are understanding and forgiving of ourselves, talking to ourselves as we might to a friend (Neff, 2011; Nelson et al., 2017). A self-compassionate stance can be liberating, helping us to see troubles as a part of life and caring for ourselves as a natural and valid response. Our individualized self-care practices may be a combination of proactive and preventive steps that help buffer stress and emergency responses to mitigate acute stress or imminent burnout. Of course, the cycle is recursive, so beginning a yoga and meditation class as a response to current experiences of compassion fatigue may be preventive of having more such episodes in the future (Baruch, 2004). Basic lifestyle changes like attending to sleep, nutrition or exercise are always a good place to start. Too Much to Handle Malini is a recently qualified psychiatrist who is feeling very rushed and tired. She wants more time to pursue her own research, which excites her, but her clinical load is extremely high. This is her first job, so she spends much of her time reading up and planning her work—her training certainly did not prepare her for everything. She feels frustrated and depleted, regrets having to drop her yoga class and spends more and more time dreaming of a holiday in the hills. This vignette of a busy therapist depicts the challenges of maintaining harmony between work and life. ‘Work–life balance’ and ‘me time’ are often heard terms but are among the hardest things to achieve. To get the time to do the things that matter to us, we need to negotiate with work or family. Not all therapists have the privilege of choice, and at times we may not be able to afford to reduce our workload or engage in a self-care activity like joining a gym or taking a holiday. We might need to visualize the best possible self-care within the context of our genuine constraints. Making the decision to take that morning walk, alter our sleep routine

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or turning off notifications on our phones in the evening are all intentional steps that may help with milder manifestations of stress. We need to gauge when our capacities are too stretched to accommodate more work and make the choice to say no when needed. We can begin by taking a closer look at how we plan our caseloads and organize our days, ensuring breaks between therapy sessions to gather our energies for the next interaction (Kottler, 2010). Reflecting on whether it is financial pressure, pressure from the workplace or our own work ethic that keeps us working long hours with little time to take care of ourselves might be helpful. We might need to remind ourselves that ‘passionate commitment to work does not mean overcommitment to work’ (Dlugos & Friedlander, 2001, p. 303). A change can be as good as a break, and planning some variety and diversity in our tasks may also be an interesting way to both stimulate and replenish ourselves. Time with clients may be balanced with time with students, books or supervisors. Planned vacations may bring transient relief but may be most effective when we mentally detach from work and use the opportunity for relaxation and recovery. As psychotherapists, our work life is very peopled, and seeking a degree of solitude may allow for contemplation and regulation of our emotions. Building practices of retreating into ourselves through brief visualization or mindfulness exercises or changing our physical environment may have sustainable effects. Sometimes, everything we do can feel like a chore, whether it is sitting with clients, reading, writing, learning or reflection. We can search for what excites or enthuses us and keeps us motivated. Since psychotherapy is serious business, when we engage with it constantly, we may forget that aspects of life can be fun or temporary. No one can, or should, be an intense professional at all times—laughing, giggling and allowing ourselves to be silly may also be hugely restorative. What Am I Doing Here? Raj has begun doubting his competence as a counsellor after three clients dropped out of therapy. He is feeling the need to update his skills and wonders if peer supervision will offer answers for his

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questions. He finds himself questioning his therapeutic decisions and being more unsure with clients. ‘Maybe I am in the wrong profession,’ he thinks. This vignette describes a therapist’s feelings of self-doubt about their competence. Self-doubt seems to be an inevitable part of a profession where both success and behaviours that lead to those successes are defined so loosely and differently. Our clients may get slightly better, or better just for a period of time. Even when we do our best, rarely do our clients say that they are ‘completely fine with all issues resolved’. At times when our client’s dissatisfaction with us becomes more visible through their dropping out or missing sessions, we can feel our doubts rising to the surface. We need to remember that our clients may not always be ready or motivated for change, and we may be working within the constrained possibilities of their lives. We need to have realistic expectations of what therapy, and what we as therapists, can do for each client. We may help a client accept their childhood experiences, but we cannot really change their past. There is a limit to how much therapy can change life’s circumstances—no matter how hard we and our clients try, some concerns remain. Reflecting deeply about our work may lead us to question many aspects of what we do. When we feel free to voice our doubts about our professional abilities and decisions and can sit with ‘not knowing’, this creates pathways for us to grow in our therapeutic work. While a self-reflective stance can facilitate problem-solving and course correction in therapy, it has the most positive impact when we are also more accepting and less critical of ourselves as persons. We also do have positive experiences as therapists and can savour these moments, allowing ourselves to experience them more intensely and for a longer period, anticipating or reminiscing about them and celebrating them with others (Quoidbach et al., 2010). Acceptance of our limitations may also motivate us to improve on our competencies. Each time we step out of our comfort zones, reflecting on clients who are frustrated with the pace of change, seem stuck or are deteriorating, we are likely to learn something we did not know before. We can track and build our skills with reference to professional

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competency frameworks (British Association of Counselling and Psychotherapy, 2020; Guerrero et al., 2017; Neimeyer & Taylor, 2019; von Treuer & Reynolds, 2017). Competency frameworks help us frame where we are and where we would like to go. We may also enhance our competencies by reflections on our learnings from academic activities such as reading, attending workshops and conferences, and translating this into specific and tangible changes in our practice. We may need to deliberately build our expertise, as the passage of time and experience alone may not help us build expertise as therapists. The process of deliberate practice involves setting incremental and personalized learning objectives that are just beyond our current abilities, with time allocated to repeatedly rehearse and refine specific skills (Rousmaniere, 2017). Keeping a learning log that tracks what we did and could have done, using therapy recordings, and asking for and responding to client feedback are all strategies that predict better client outcomes (Chow et al., 2015). We do not need to engage in this journey alone but can reach out to a supervisor who can walk with us and offer a space for regular reflection and course correction. Even master therapists who have been in the profession for a long time experience a sense of never having fully arrived (Skovholt et al., 2004). Perhaps what is most important is that we ‘learn how to learn’, a skill that can stimulate growth and mitigate stagnation and burnout. Art Making for Self-care Ms Deepti Guruprasad, a clinical psychologist and art therapist, practising in the USA, shared two art-based self-care exercises that she uses in workshops with therapists. The secret room: Engaging in a creative activity can help therapists get in touch with their emotions and express their inner wisdom. Maintaining an attitude of openness and playfulness while creating is important, as such exercises are designed for personal reflection rather than social comparison or public display. This art experiential is designed to help therapists ‘escape’ to a peaceful, quiet space, one

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that is their own and can be accessed at any time (adapted from Haeyen, 2018). Materials: Thick paper, paints, pastels, markers, coloured paper, magazines, scissors and glue. Instructions: Imagine a secret room and see what it looks like. It is a room in which you relax, to which you retreat when you feel overworked or drained. The door is closed to everything that might tire you out. The room is calming, pleasant and lovely. Make an image of this room using any materials of your choice. Reflection questions: How did you design your secret room? What elements were important in it? What makes it comforting? How often do you need this room? Was there a time when you needed it more? In your daily life, is there a place in your surroundings where you can feel this way? If so, do you use it? Your strength tree: How often do you review your strengths and appreciate your worth? You can identify your strengths through this creative exercise (adapted from Mehlomakulu, 2017), and these can serve as pillars of support in your journey as a therapist. Materials: A large sheet of paper, pastels or markers. Instructions: Lay your hand on the large sheet of paper such that a part of your arm is also on the paper and your fingers remain around the middle of the paper. Spread your fingers open and trace your hand including your arm, leaving the back of the arm and fingertips open. Your arm becomes the trunk of the tree, and the fingertips are the beginnings of your branches. Divide the base of your tree trunk into sections to indicate roots and divide each fingertip into smaller branches. Add leaves to the end of the branches. The leaves should be big enough to write words in them. There is no right or wrong way to draw the tree. List your core strengths or pillars of support in your journey as a therapist on your roots. On each leaf, list one special skill, unique resource, coping strategy or a contribution to your profession. Your relatively newer skills could be depicted on the smaller leaves, along with any skills you wish to add to your repertoire. You

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can complete this activity at one go or leave it open for additions and changes. As you grow as a therapist, you may deepen your roots or sprout more leaves. Reflection questions: How did you experience this activity? Was it easy for you to list your strengths? How active is your inner critic? How often do you reflect on your strengths and spend time appreciating yourself? You could keep this image as a reminder of your growth journey and use it at times when you feel less motivated or perhaps underappreciated in your environment. Feeling Too Much or Feeling Too Little? Meera is a sensitive social worker who works closely with young clients in a drug rehabilitation centre. Many come from disturbed homes, and she can feel their pain and empathize with their need for escape. She works hard to reach her clients, thinking of new ways to get them engaged, watching the videos they like and even learning to play online games. Recently, a teenage client started using substances again and left the centre. Meera was extremely disappointed with herself. She could feel herself getting angry with clients who were slow to progress and disconnecting from the more difficult clients. ‘What’s the point in caring?’ she thought, ‘Anyway I can’t make a difference.’ This vignette illustrates the emotional weight a therapist might need to bear. As therapists, we are expected to perform in an emotionally regulated and caring manner in both our professional and personal lives. From the beginning of our training, there is a tacit understanding that we do not discuss unwanted emotions about our clients. Anger, frustration, hopelessness or contempt can become unspeakable even in the privacy of our own minds. When we recognize these emotions as legitimate and valid reactions in therapeutic work and engage in informal sharing and venting with colleagues, this can offer us significant relief (Van der Merwe, 2019). Mindfulness meditation, acceptancebased techniques or other emotion regulation methods might also help us acknowledge our emotions without feeling overwhelmed by them (Rudaz et al., 2017; Miller & Sprang, 2017).

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Our resilience as therapists is closely tied to how we make meaning of our experiences. Religious or spiritual perspectives can offer tremendous scope for meaning making for those of us so inclined (Dlugos & Friedlander, 2001). Meaning can also come from making a difference or being in a respected profession (Skovholt & TrotterMathison, 2016). Witnessing the resilience and growth of our trauma survivor clients may also inspire our own growth in turn. Resilient therapists feel a sense of alignment between their beliefs and practices, remain strongly connected in both personal and professional spheres, and continue to be curious, self-reflective and self-aware (Hou & Skovholt, 2020). When we feel disconnected and disillusioned with our work, we can try to remember what inspired us to join the field or reconnect with what we valued the most about our work (Poslun & Gall, 2020). We can also balance the negative emotional space that we may sometimes find in our therapy rooms, by generating positive emotional spaces in other areas of our lives. When things are not going so well at work, it might be helpful to think of what could be restorative—perhaps spending time with family or seeking solitude in the mountains. A Therapist Speaks: Pan’nin Zaar Khudayas Waninn (Seeking Help from the Almighty1) Ms Asiya Niyaz, a consultant clinical psychologist at the Institute of Mental Health and Neurosciences, Srinagar, Kashmir, shared her reflections on how connecting with the divine helped her connect to herself and her clients. ‘Kashmir is called the Valley of Saints and is dotted with much visited shrines where people offer prayers. During my clinical practice, I have witnessed many of my clients using religious ways of coping, by reciting the Holy Quranic verses to ward off difficulties in their lives and seeking help through prayers. Since I share a collective unconscious with my clients, I also regularly visit the holy shrines or offer prayers alone at home, in order to find peace and cope with the stress 1

Translated from the Kashmiri language.

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and challenges of my work. This helps me to connect to my “self” and connect with my clients.’ The Lonely Road George is a thoughtful intellectual therapist who recently moved back to his hometown to take care of his ailing mother. He works in a busy community mental health centre, and his dedication to work leaves little time for friends or family. He finds it hard to share his experiences with his new colleagues who he fears may not understand him. He wants to get married, but where to find the right person? Although he spends his days engaged in intensely intimate conversations with clients, his evenings stretch out emptily in front of him. This vignette highlights how a therapist may feel isolated even amid deep connection. As keepers of secrets, we may box things and often not share stories of our successes or failures or even small everyday experiences with others. Building professional collaborations with like-minded colleagues may help us feel less isolated and more connected to a community that supports our goals. Often, it is merely the kind attention of a caring colleague that may keep us motivated and energized for work. Rokach and Boulazreg (2000) suggest that we develop competence constellations, circles of connection with colleagues who share our language, who can guide us in our work and even share self-care strategies that they have found useful. As mental health professionals going through similar stresses, we may be uniquely placed to recognize signs of work stress in each other (Norcross & VandenBos, 2018). Take a moment to think of your impact as a fellow professional: Are you a source of support or strain? Organizational atmosphere and leadership may play a protective role when we are under work stress. When leaders value the well-being of team members and foster cooperation and support, and make this explicit in their words and actions, others are likely to follow suit. Therapists are ‘experts at one-way caring’ (Skovholt & TrotterMathison, 2016, p. 162). While we recognize and endorse the value

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of close confiding relationships for our clients, we may not always have adequate access to resources that offer us emotional, instrumental or practical support. All of us need a web of relationships to carry us through life and meet our needs to be seen, acknowledged and valued by those around us. This could include someone to call when we are having a difficult time at work or someone to celebrate our success with. While some friends may meet our intimacy needs, others may offer us resources or information and company in our activities. Think about who you could call if you were feeling lonely or who might help you file your taxes. If you felt the need to strengthen your support system, where would you make a start? We may build networks by investing in and prioritizing relationships that are healthy and nurturant, reconnecting with old friends and family who meant a lot to us and developing new relationships where possible. Nurturing relationships with individuals from diverse backgrounds might give us new perspectives and varied contexts for mirroring and relating that bring out different aspects of our personalities (Guy, 2000). Letting go of dysfunctional relationships is an important aspect of relational self-care, and one that we may not often consider (Butler et al., 2019). Self-care and Resilience Action Plan Self-care is an ongoing need and requires consistent attention to gauge how well our strategies are working. Sometimes our self-care plan is more a set of dreams or intentions than an actual plan. We may make a start by committing to any one change we would like to make and list the steps that could help us translate our ideas into action. A Therapist Speaks: Sanctuary We invited Dr Pallavi Banerjee, a psychotherapist and teacher who is currently in psychoanalytic training, to share the personal and professional choices she made to further her self-care and presence with clients. ‘Often, the initial work in therapy involves just getting in touch with one’s intuition to recognize the need for rest (even just a relaxed

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moment sitting with a cup of tea), before continuing with the grind. Unfortunately, we therapists may be as divorced from self-care as our patients. I am a psychoanalytically oriented psychotherapist who works from her home-based office. I have been in stressful jobs, managing both my clinical practice and teaching, and this stress gradually showed up in therapy sessions. Minor signs like feeling bored in the session or feeling impatient with a resistant client. Nothing out of ordinary, right? We all have these feelings as part of the countertransference baggage that is so much a part of our work. But burnout is insidious, and that is what makes it a silent enemy. What alarmed me was the fuller presence that I would bring to the sessions when rejuvenated after vacations. The mental suppleness I would feel, my curiosity and a plethora of other deep feeling states that would tune me in to my patient. This, along with other life circumstances, motivated me to slow down in life and take the practice of psychotherapy as the primary function in my work life. The mind states I accessed during silent meditation retreats in the hills gave me the taste of a slow life with focus. Then there was no going back to the fast ‘10,000 to-do-lists’ kind of life. Along with my work as a psychoanalyst, I also teach part-time and provide supervision. Although I work from home, I take on patients for therapy only if slots are available during pre-decided work hours. That way, I have a uniform routine. As part of professional care, I take supervision from multiple spaces as part of my analytic training and in peer and group modalities too. Taking off during the weekend, my own psychoanalysis and my regular meditation practice also form a major part of my ‘soul care’. Being part of the Buddhist sangha, going for retreats, painting, reading books or spending a quiet evening listening to classical music helps me work through mental fatigue. My choices in the last few years have led towards making me more fully present in sessions with my patients, making each day of work something to look forward to. I won’t say that I have consciously made all these choices. Rather, the more I slowed down, the more my intuitions guided me to move in these directions.’

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Perspectives on Training and Development Integrating Self-care within Training Contexts Self-care can be fostered through the creation of formal learning opportunities for trainees to reflect on, and recognize and identify signs of personal distress, burnout, compassion fatigue and vicarious trauma. Lessons from positive psychology, such as recognizing and honing our strengths, aligning work with our values and investing in strong relationships, can enrich the self-care curriculum. Self-care can be approached from various angles, using a combination of didactic and more experiential and exploratory methods: assigned readings, guided discussions and self-reflection exercises (Thériault et al., 2015). A range of self-care opportunities within the campus/workplace, for example, mindfulness meditation, fitness activities, acceptance and commitment therapy techniques can broaden the repertoire of trainees and employees. Some enduring lessons can be imbibed from faculty members at training institutes when they model effective work–life balance and self-care (Zahniser et al., 2017). Ensuring that trainees devise concrete individualized self-care plans can serve to strengthen well-being, impact the quality of care provided to clients and set the foundation for restorative practices throughout their professional pathways (Posluns & Gall, 2020). Implicit and explicit messaging that positions overwhelming stress as a rite of passage for entry into the (invulnerable) psychotherapist’s role need to be interrogated and addressed (Thompson et al., 2011). Emerging research illustrates which self-care approaches work, whether they lead to change and where the impacts are felt. The increasing support for self-compassion and mindfulness strategies suggests that what we advocate for our clients and seems to work for therapists too (e.g., Boellinghaus et al., 2013; Christopher & Maris, 2010). Overall, trainees invest more in self-care practices when their training programmes emphasize self-care (Zahniser et al., 2017). However, self-care initiatives do not have to stand apart from training in other professional skills. Frameworks such as the POTT model, which focus on self-awareness and acceptance of our vulnerabilities, can foster self-care among clinicians (Kissil & Niño, 2017). While

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the evaluation of self-care initiatives can indicate which strategies are most impactful, there is no substitute for participatory dialogue and ongoing evaluation, where we ask trainees what they need, what is working well and what changes could further strengthen individual and organizational self-care cultures. Organizational Policies and Structures That Facilitate Self-care A commitment to student and faculty welfare requires that all organizational policies and practices be reviewed to examine their impact on self-care and well-being. This includes a critical review of the academic and training demands and schedules, workload, supervision time and work–life balance, workplace interactions and communication, and processes for grievance redressal. An assessment of felt needs and a feedback system can help organizations make more substantive and effective changes (Simionato et al., 2019). Trainees and employees need to feel that availing of designated time-off or advocating for needed changes is encouraged and valued in the organization. Training institutions and organizations can share their best practices and innovative approaches for professional development and well-being and facilitate the development of effective models for resilient workplaces. Role of Supervision in Supporting Self-care Supervision can play a vital role in normalizing early experiences of uncertainty and anxiety and developing self-care competencies during and beyond psychotherapy training. Regular discussions around supervisees’ personal strengths and needs, and their current levels of resilience, can facilitate engagement in self-care practices (Thompson et al., 2011). As supervisors, self-disclosure about our own stresses, struggles and solutions can help legitimize supervisee experiences and encourage them to work towards their own well-being (Thériault et al., 2015). At all stages of our career, reflective supervision can be a form of self-care, where we learn to look back on our practice experiences, note impacts on our well-being and move forward with greater

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skill and awareness (Glassburn et al., 2019). An intentional focus on supervisee wellness and the development of self-care as a competency falls within the ambit of normal supervisory responsibilities. Responding to Therapist Mental Health Vulnerabilities and Impairment Distress and vulnerabilities are universal human experiences, and the therapist community is not immune to mental health difficulties. Initiatives such as peer buddy systems and mentoring can help build networks of support within training programmes (Johnson, 2002; Salee & Sibley, 2019). Coverage for mental health services, supportive leave rules and employee assistance programmes are other organizational provisions that can support help-seeking (Nash & Chapman, 2019). In many institutions, trainees who may be experiencing emotional distress, personal crisis or burnout are recommended remediation and support and a break from the training as a backup option. The process and criteria for both remediation and discontinuation need to be clearly defined and the options offered to the trainee in the most supportive ways (Kallaugher & Mollen, 2017). Creating pathways to accessible and affordable care for trainees and employees who need mental health consultations is a priority, but these are likely to be underused if stigma and other barriers to help-seeking are not addressed. Therapists do enter the mental health system, and there are special considerations to keep in mind when working with ‘therapatients’ (Goldberg et al., 2020, p. 124). The treating professional may offer extra confidentiality in terms of opening a file or setting a more private meeting place and keep a special focus on a guided return to work and a future self-care plan (Goldberg et al., 2020). Role of Professional Associations in Supporting Self-care Professional associations can support the self-care needs of practitioners through various training opportunities to learn effective self-care strategies. Even brief experiential self-care courses can

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help practitioners acquire skills and use them intentionally (Guler & Ceyhan, 2020). They could take the onus of codifying the shifts within their ethical guidelines and competency frameworks to encompass notions about proactive self-care and the shared responsibility of individuals and professional communities. We recommend that professional guidelines related to supervision or mentoring be reviewed to check how self-care is addressed.

Conclusion Self-care is not limited to one domain of our life; it is an endeavour to nurture our self with deep commitment and love. We invited Mr Muzammil Karim, a practising clinical psychologist and couple therapist in Delhi, India, to share his reflections on self-care through his poetry. Khudkalami Dil ko ye samjhana hai Apna khayaal bhi rakhna hai

Self-talk2 I must counsel my heart To take care of myself too

Ghum ka lamba daur chale Dard ke qisse aur mile Mann to rooth jaata hai Dil bhi toot jata hai Thak haar ke ye zehen Soonch mai kahin kho jaata hai

When sadness stays for long And pain weaves more stories Mind spirals into sulking Heart find itself broken Tired and exhausted my mind Gets lost in endless worries

Pyaar se ghum sehlaana hai Dil ko ye samjhana hai Apna khayaal bhi rakhna hai

Love is the cure for sadness I must counsel my heart To take care of myself too

Kabhi hansi kho jaati hai Neend kabhi marr jaati hai Koi khalal pad jaata hai

Laughter is lost at times At times even sleep perishes Dissonance cuts through the soul

2

Translated from the Urdu language.

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Mann bhaari ho jaata hai Dil ke khaali kamron mein Ghum barf sa jam jaata hai

Heaviness weighs on the mind Within the empty rooms of the heart Sadness freezes like snow

Umeed ko dhoop banana hai Dil ko ye samjhana hai Apna khayaal bhi rakhna hai

Hope must bring new sunlight I must counsel my heart To take care of myself too

Reflective practice can contribute to the self-care of the therapist, and creating time for self-care can enhance our ability to reflect on our work. As psychotherapists committed to the idea of positive mental health, we need to strengthen our own capacity to love, work and play (Jahoda, 1958).

Chapter 12

The Reflective Path Integrating Reflection into Training, Practice and Research

Just as there are many roads to a destination, many models and pathways can guide us in our journey to being reflective practitioners. As we become more comfortable in using the reflective lens, we can uncover new ideas to use in our work as therapists. This is a good time to pause and reflect on the key ideas and reflective methods that you can take away from this book. Can you identify one change you would like to initiate in your practice because of your reflections. Consider what else you would like to learn about using reflection as a tool in your therapeutic work.

Keeping Our Head in the Air and Feet on the Ground In some ways, reflective practice seems elementary, as it asks us to think about what we do in therapy. While reflective practice models make it appear like a systematic, rational cycle of thinking about our work, we may also wonder if a meandering, uncharted process of discovery is closer to the ideology of reflective work. There are several seemingly opposing perspectives on reflective concepts,

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methods and processes, and these dialectics are perhaps inherent in reflective practice: • The art of being emotionally present and responsive vs the art of being intellectually reflective and analytical • The art of being spontaneous and authentic vs the art of delay and contemplation • Noting similarities and resonances with our client’s story vs recognizing our differences and separateness • Thinking from ‘inside out’ (based on our intuition, perspectives and strengths) vs thinking from ‘outside in’ (based on our client’s/ multiple stakeholders’ needs, priorities and feedback) • The value of exploration and discovery vs the power of repetition and mastery • Staying grounded in theories and models of therapy vs questioning our beliefs, assumptions and conceptual frameworks • Caring for others vs caring for ourselves • Accepting ourselves (and our personal histories) vs being open to change The energy of reflective practice can come from our awareness of and willingness to attend to both sides of these paradoxes in determining our immediate and long-term behaviours and choices. During the process of therapy, we may look through our client’s eyes but also through our own, shifting between imagining ourselves as similar to our clients and as ‘foreign’ or different (Flaskas, 2009). Neither of these positions is more important or better and each can offer something that the other may not. In the same way, there is room for both affect and cognition, reflection during and after sessions, acceptance, questioning, privileging the self and privileging the other. During our therapeutic work, there are times we tilt in one direction, perhaps so invested in our client’s well-being that we disregard our own emotional needs or so aligned with our beliefs and theories that other truths have no place. This signals the need to redress the balance or find a way to engage with both aspects. Curiosity can take us many places, and engaging with these dialectics can lead us to newer ways of thinking about and ‘doing’ reflective

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practice. We may also wonder about the purpose of the constant quest for surprise, newness and originality in reflective practice. Much of therapeutic work may seem repetitive: the same cognitive errors, selfdoubt, difficulty managing emotions in clients, and the same empathy, support and challenge from therapists. Moments of epiphany or transformation in both therapy and reflective practice are precious because they are rare. However, what seems repetitive still has potential for learning and growth, and sometimes our reflection tells us to keep doing what we have always been doing. And this is also valuable.

A Critical Appreciation of Reflective Practice Reflective practice is now an established facet of psychotherapy, and a critical consideration of issues around the conceptualization, application and evidence base is required. Inconsistencies in Conceptual Definitions and Models of Reflective Practice A core difficulty with the research and application of reflection has perhaps been inconsistency and uncertainty in its definition, operationalization and evaluation (Collin et al., 2013; Rodgers, 2002). There are diverse, often personal, approaches, even among practitioners who use and value the reflective lens (Fisher et al., 2015). This variability is understandable, given the broadness of the concept and the lack of a common language to facilitate discussion (Rodgers, 2002). Reflective practice has been approached from different perspectives, including processes (such as examining, thinking and analysing), foci (such as practice, theory, meaning and self) and rationales (such as thinking more clearly, thinking differently, improving action and changing self and society; Beauchamp, 2006). It might be easier to understand what one does in reflective practice, rather than what is reflective practice. While several models have provided a goal and focus for our reflections (e.g., Gibbs, 1988; Kolb & Fry, 1975; Schön, 1983), there are a few concerns about them as well. For instance, the atheoretical nature of many of the models has

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left them open to over-simplification, as though we just need to pause to think a little before acting rather than analysing, connecting to professional knowledge base or evolving something new (Thompson & Pascal, 2012). The way in which reflective practice is applied often leads back to a more technical, rational, step-by-step thinking approach, which does not always capture the artistry of the therapeutic professions (Hébert, 2015). Early models have been deepened by adding the element of thinking ahead or planning our actions, called ‘reflection for action’ (Thompson & Pascal, 2012, p. 317), or by engaging in critical social enquiry and being reflexive as well as reflective (Finlay, 2008). Reflective practice has also been interpreted through the lens of theoretical orientation, and models like SP/SR for cognitive behaviour therapists (Bennett-Levy, 2019; Bennett-Levy & Haarhoff, 2019; Thwaites et al., 2014) or POTT for family therapists (Aponte, 2016) have been integrated into training and supervision. We feel excited at the possibilities that reflective practice can offer to practitioners across diverse orientations, contexts and career levels. Evidence for Reflective Practice: Quoˉ Vaˉdis? What do we know about the actual impact of reflective practice? The emerging evidence base for reflective practice is skewed towards trainees and academic settings, with fewer studies involving practitioners and clinical settings. Some models like SP/SR (Bennett-Levy, 2019; Bennett-Levy & Haarhoff, 2019; Thwaites et al., 2014) or POTT (Aponte, 2016) are better researched, as are some specific methodologies like reflective writing (Roja, 2017) or reflective practice groups (Binks et al., 2013). Studies with trainees have primarily used qualitative paradigms to explore trainees’ experiential accounts of increased self-awareness and acceptance and a greater willingness to take risks or manage uncertainty. In this process, they reach a better understanding of their role, can relate and communicate with clients more skilfully and flexibly, and integrate their enhanced repertoire of conceptual, technical and practical skills (e.g., Bennett-Levy & Lee, 2014; Thwaites et al., 2015; Sheikh et al., 2007; Woodward et al., 2015). Family therapy trainees report feeling

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more confident about use of self in therapy, more aware of the process of connecting with their clients and forming a positive therapeutic relationship, as well as improved self-care (Kissil & Niño, 2017). There is also emerging evidence on the impact of reflective practice among practising therapists, who turn to this approach more to strengthen interpersonal understanding and skills than their conceptual or technical understanding (Bennett-Levy, 2019). They report being able to reflect on session interactions in the moment, recognize and contain their own emotions and countertransference reactions, and retain focus and empathic connection with clients (Carmichael et al., 2020; Davis et al., 2015; Fisher et al., 2015). Reflection seemed to occur almost organically and was integrated into the way they approached their work or dealt with challenges. It also helped crystallize their professional identities and enhanced their sensitivity to ethical issues (Fisher et al., 2015). Evidence indicates that reflective practice is clearly a promising area, with much to offer to both trainees and practitioners. The research process itself can be more reflective, with a greater focus on process and the role of the therapist and a deeper, qualitative understanding of the role of reflection in therapist–client interactions. A reflexive, reflective research paradigm may help us better capture the ‘complexities of the therapeutic hour’ (Zeldow, 2009, p. 3) and attend to the voices of our clients and diverse, marginalized groups as we plan and interpret our research. Research on the effectiveness of reflective practice will continue and possibly extend to include client outcomes and feedback, justifying the continued inclusion of reflective practice with psychotherapy training. However, we believe that reflective work is personal, and each therapist finds their own ways to use reflection. Such reflexive and critical engagement with our personal identities and the systems that we are part of cannot leave us or our work unchanged. These transformations are powerful and meaningful even when not quantified or documented, and it may be important to free the act of reflection from the kind of scientific and educational scrutiny that can stifle it. As therapists, we may often do something that ‘feels right’, without being able to articulate why, and the emphasis need not be on teasing

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out every detail of knowledge or thinking, but rather accepting that everything need not be known (Hargreaves, 2004). Reflecting Is Not Easy The process of introspection and discovery can be challenging, as we let go of certainties and venture into less known territories. In fact, reflection that brings in a new idea or perspective is inevitably accompanied by some stirring and discomfort (Hanson, 2011). We can be tempted to continue intense reflections and end up lost in distressing and negative ruminations about ourselves, particularly when we have difficult personal histories or a negative self-image (Yip, 2006). Reflective work might be particularly difficult, even exhausting, when we are experiencing concurrent stress or have less social support than we need (Bennett-Levy & Lee, 2014; Knight et al., 2010). One of the biggest issues with reflective practice seems to be the time and effort required. As reflective practitioners, we might be helped by keeping track of our own limits of tolerance and our vulnerabilities and develop our reflective skills at a pace that works for us (Yip, 2006). At times, we may need to turn our reflection off to protect ourselves, as reflection is a much more emotionally intense activity than learning facts or writing assignments (Ferguson, 2018). When we are curious, have a more objective ‘fly on the wall’ perspective of the issue and are motivated by wanting to learn or change, we might find reflecting as helpful and growth promoting (Lengelle et al., 2016). It makes sense to have some sort of target to reflect around and some rubric to identify when the experience is no longer productive. Reflective practice can focus on new and ‘strange’ experiences, the dialogue they open, and the emergent changes in therapists’ beliefs and practices. Trainers and supervisors can ask the therapist to choose what they wish to reflect on, perhaps a brief therapy segment where they felt surprised or moved, while remembering to reflect on strengths and positive experiences as well as challenges (Ghaye, 2011). Methods like this can ease us into the practice of reflection, reducing defensiveness and stress from the process. While there is no doubt that reflection can be most beneficial when we are busier and feeling stretched, we need to incorporate it into

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our regular routines in ways that are pragmatic and meaningful. Every action we take as therapists can be accompanied by some degree of reflection and over time, we might find a comfortable synergy between reflection and our work. Challenges in Training Reflective Practitioners Being reflective is not an easy skill to teach. Therapists and trainees could experience the shift from an academic objective knowledgebased paradigm to a more subjective emotion-based paradigm quite challenging. Training programmes and organizations would do well to instil a desire to be reflective, nurturing genuine curiosity about the nature of our work, the world and the self, and then offer needed support. How reflective practice is presented to students and linked with professional needs (e.g., through hearing how more experienced professionals use it) is also relevant. Models can be presented as examples of a way of thinking, rather than steps to be followed, allowing for more flexibility in response (Finlay, 2008). Trainees can be encouraged to express themselves, explore and test out new ideas at their pace (Binks et al., 2013; Finlay, 2008). These measures can make them feel more engaged with the process and take more responsibility for reflective learning. A positive experience in training is linked to having a feeling of interpersonal and emotional safety, within a clear structure. Trainees can feel unsafe in terms of worry about being emotionally overwhelmed by the personal material and about exposing themselves to their classmates (Bennett-Levy & Lee, 2014). The significance of having an active and warm facilitator in creating an ethos of safety and exploration cannot be overstated (Heneghan et al., 2014; Knight et al., 2010). Structure, boundaries and common goals seem to foster a sense of group cohesion and purpose (Freeston et al., 2019; Knight et al., 2010; Lyons et al., 2019). For practising therapists, the culture of their organization or work setting can influence the willingness to reflect. A non-reflective culture that focuses on quantum of ‘routine’ work, with little time or support for reflection, raises significant barriers for mental health trainees and practitioners (Heneghan et al., 2014; Wilson, 2011).

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Regardless of the training or work context, becoming a reflective practitioner requires an ongoing commitment. We advocate an adult learning paradigm where each trainee or practitioner brings their own motivations and expectations to the table. Approaches that emphasize self-direction, experiential learning through role-plays or simulations, and quick application to concrete situations are likely to be most meaningful (Woodward et al., 2015). Learning to use the reflective lens along with clinical work enables trainees to transfer and apply their learning from one sphere to the other. We may have varied goals and pick up different aspects of reflective practice at different stages of professional development. While trainees could experience larger gains in declarative learning, more experienced practitioners could benefit more in terms of refining their craft. Practising therapists may have clearer goals from reflective practice, for instance, wishing to explore particular human experiences or build cultural competence (Freeston et al., 2019; Thwaites et al., 2015). Evaluation of Reflective Abilities during Training Efforts to build reflective abilities in psychotherapists often involve making reflective practice a part of mainstream education curriculums. One of the most common ways of assessing level and quality of reflection is through reflective journals or written assignments (Mann & Walsh, 2013). These reflective portfolios allow trainees to crystallize and articulate their reflections within a defined space. As they access and integrate their inner experiences, they can also connect with their clients’ experiences and develop their practice (Bruno & Dell’Aversana, 2017; Sutton, Townend, & Wright, 2007). However, there are a few concerns with eliciting and evaluating reflection in this manner. It is often mandatory for the trainee to engage in personal reflection and share the results with faculty, leaving them feeling exposed and vulnerable (Ghaye, 2007). When the component of evaluation is added to the requirement to lower personal (emotional) boundaries, the issue becomes even more sticky. Reflective output can turn into a sort of confessional, where the trainee needs to produce the right kind of confession to please the experts (Swan, 2008). Certain forms of writing that fit the reflective script may be

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more accepted than others, for instance, stories of using reflection to turn an experience around and ‘win the day’ or of initially showing inappropriate attitudes but then redeeming oneself through reflection (Hargreaves, 2004, p. 200). Other stories, let us say of an experience which deepened prejudice or did not lead to growth, may not be as appreciated (De la Croix & Veen, 2018; Hargreaves, 2004). Reflective writing may become geared towards grades or faculty approval rather than understanding the self or therapy process better in a more honest way. When we ask students to write out their personal dialogues for an audience, and an evaluative audience at that, we are not likely to get their spontaneous and authentic reflections (Platt, 2014). Too much emphasis on reflective output during training can create ‘reflective zombies’ or students who have been conditioned to follow prescribed thought steps, rather than engaging in truly reflective behaviour (De la Croix & Veen, 2018, p. 394). Of course, the same is true for practising professionals as well. There is also the question of whether the ability to write reflectively or even think reflectively can be equated directly with the ability to act in a reflective and effective manner (Eaton, 2016). As trainers and supervisors, we need to consider what we can do to make the evaluation of reflective abilities more ethical and relevant. We can encourage trainees to represent their reflection as it feels meaningful to them (art, dialogue, video recordings, etc.) and base the assessment on understanding how they are progressing (De la Croix & Veen, 2018). When modes such as self-assessment are used, this encourages therapists to set their own goals and understand the processes they would like to engage in, increasing their motivation for actual reflection (Finlay, 2008; Ixer, 2016). External feedback and formative assessments can be useful in providing new perspectives but need to be dispensed with care. While inadequate feedback can leave trainees feeling anxious and unsure about what is expected of them, overly structured or detailed feedback may feel too judgemental or critical and can leave trainees feeling like they are doing it wrong (Binks et al., 2013; Bruno & Dell’Aversana, 2017). When reflective teaching is embedded within the discipline, with a more specific focus on the skills and concepts required for actual

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practice, it is likely to be more effective (Freeston et al., 2019; Platt, 2014). As we repeatedly go over the steps of both reflection and action in our therapeutic work, we can internalize these skills better (De la Croix & Veen, 2018). While reflection in action or being aware of their pre-existing beliefs, thoughts and feelings during the session can build therapist skills, this can also be emotionally and cognitively challenging (Priddis & Rogers, 2017). When therapists feel confident about their abilities and more emotionally contained, they can use their reflective skills better in response to challenges during therapeutic interactions with clients in the moment. However, when they are hesitant or uncertain, feeling overwhelmed by requirements to reflect on their feelings during the session, therapists could retreat into safe behaviours (Burgess et al., 2013; Ferguson, 2018). These findings raise questions about the role of training and what it needs to focus on and how we can best build therapist confidence and skills. We recommend beginning with reflection on action, where trainees can wonder about their own and client’s experience after a therapy session, with adequate supervisory support. It seems that reflective practice teaches therapists how to think about and approach sessions, but we need more focus on using reflection to manage difficult moments in the session. A model such as the objective structured clinical examination format, followed by reflective probes, can be useful, as it focuses on the application of reflective abilities (Bogo et al., 2011). Scaffolded feedback that first evaluates where the trainee is at the present time, and what their next step should be, and provides specific suggestions for growth, can help to address anxieties about in-session difficulties (Thwaites et al., 2015; Freeston et al., 2019). Training that allows for a personalized approach and a graded progression can strengthen reflective processes and learning from in-session experiences, both during and after therapy sessions. To Reflect Alone or in a Group Reflection is often seen as an intellectual activity that takes place when we are alone. Many of us may prefer to reflect alone, safe in the privacy of our minds, and this has its own rewards and comfort. However,

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when we are in the spaces of supervision and personal therapy, we are reflecting in the presence of another. Group processes are particularly suited to achieving the goal of deepening reflection, and reflecting with others allows direct access to fresh perspectives and ideas through the voices of the other participants in the group (Gillmer & Marckus, 2003; Heneghan et al., 2014). We may feel less alone in our experience and more likely appreciate our own thoughts as one perspective and not as ‘the truth’, thereby remaining open to change and growth (Hanson, 2011; Lengelle et al., 2016; Thwaites et al., 2015). By examining group dynamics, we get the opportunity to see how we impact others and how they view us. This is an important level of self-awareness and can also open our eyes to aspects of what may be happening between us and our clients (Kiff et al., 2010; Lavender, 2003). Interaction with other minds and creating conversational spaces and communities where reflections can be shared and contextualized can greatly enhance our output (De la Croix & Veen, 2018; Ghaye & Lillyman, 2000), and we advocate for therapists to actively seek opportunities to reflect with others in addition to their solitary explorations. Reflective groups are without their issues, however, as they can encourage confirmation bias and groupthink. One interesting response to this is to have a devil’s advocate in every group, who is tasked with challenging the group consensus, considering other possibilities, or taking an outsider perspective. Reflective questions can help participants identify groupthink processes and allow space for different voices to emerge (Lyons et al., 2019). Are we all pro reflection? Do we speak about our problems in a more emotional manner or a more stoic one? Do we question the facilitator or go along with her? Even when multiple perspectives emerge from group members, these are best considered as possibilities and not as ‘solutions’. Trainees in reflective practice groups can experience fears of being judged and shamed about their thoughts and feelings but often value the opportunity to speak and hear about experiences and remain committed to the process even when it is distressing (Lyons et al., 2019). In a Balint group with psychiatric trainees, larger group sizes and unfamiliarity with the theoretical model being used in the group made group members feel more lost and exposed (Graham et al., 2009).

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Defining the focus of reflections can reduce pressure on the person who is sharing; for instance, in Balint groups, one participant presents a case and then sits back while other participants discuss and reflect on possible meanings. In this way, the focus remains on the case and not the presenter (Douglas & Feeney, 2017; McKensey & Sullivan, 2016). Group discussions that focus on the process of reflecting rather than the content of personal reflections can help with emotional containment in groups (Freeston et al., 2019). Trainees are likely to benefit from individual support to process material that emerges from the group. This could be in the form of maintaining a personal journal that can be reviewed by the facilitator or spending a little time in the group to identify issues that can be taken to personal therapy, supervision or mentorship. Conversations with likeminded group members outside the session or finding individual spaces to reflect on experiences within the group were some of the ways in which participants coped with the demands of a reflective practice group (Lyons et al., 2019). Group facilitators will need to be sensitive to the impact of sharing on the trainee, as well as the overall group dynamics. It would be ideal if they had training in both reflective practice and work, as both sets of skills are required.

The Journey Continues… Reflective practice is a maturing field which is gaining traction as a powerful resource for psychotherapists who wish to engage more meaningfully with their work. There is a strong call for operational definitions of the concepts of reflection and reflective practice which spell out tangible steps to learn and rubrics to teach and evaluate (Kaslow & Ammirati, 2020). The development of standardized measures to assess reflection and its impacts can improve the quality and quantity of research evidence for both theoretical and applied aspects of reflection (Mann & Walsh, 2013). Together, this can guide the training and practice of reflection, allowing us to build a meaningful knowledge and research base. We see reflective practice as a means to bridge the scientist–practitioner gap, as it is in integrating theory and practice that we develop deeper understanding of our work (Kinsella, 2010). Reflection can help us hold both traditions of knowledge

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together and crystallize when to ‘go by the book’ and when to take a flight into the unknown. We see value in more creative modes of selfexpression and experience, using the imagination, art or movement to access layers of meaning and fresh perspectives. Reflective practice straddles many diverse disciplines and lends itself to the cross-pollination of ideas across professions such as education, nursing, business management and mental health. The resultant frictions and synergies, both within and outside the mental health disciplines, can stimulate the transfer and integration of knowledge as well as innovations and change (Kaslow & Ammirati, 2020). Several concepts from psychology can also be usefully applied to enrich reflective practice. For instance, cognitive neuroscience perspectives can clarify our conceptualizations of what reflection is and identify how to distinguish it from higher-order thinking (Lilienfeld & Basterfield, 2020). Perspectives like mentalization can guide us in understanding the level of reflection taking place by becoming aware of how mental states are referred to and interpreted. We also celebrate the increasing attention to critical reflection and the sociological context in which human interactions take place. Reflecting on what seems routine and accepted can throw light on our underlying assumptions about society and address issues of diversity, intersectionality, power, discrimination and oppression (Hébert, 2015). We can question mental health paradigms and support change by paying more attention to client voices. A deeper engagement with critical reflexivity, which emphasizes the impact of our ‘selves’ and our social context to the knowledge we create, needs to be fostered in therapeutic spaces (Thompson & Pascal, 2012).

Conclusion We hope that a critique of reflective practice and a recognition of its transformative potential will help us to use it more ethically and appropriately and keep the field alive and growing. In the best part of the tradition of reflective practice, we should question everything, including reflective practice itself. As the area continues to mature, we need

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to consider how much we should regularize reflection. When reflective practice becomes the convention rather than an anti-establishment movement, does it lose some of its potency? The more we research, structure, and teach and evaluate reflection, the more it becomes canon and perhaps engenders less original thought. This raises the question: What can we do in our own way to keep the field alive and relevant? We urge the building of a community of reflective psychotherapists. This book can help us navigate through still uncertain terrain with reflection and reflexivity as our map and compass as we make discoveries about ourselves and about therapy (Bolton & Delderfield, 2018). We can never be perfect therapists, but if we are dedicated to ongoing self-discovery and lifelong learning, we are likely to be ‘good enough’ (Cozolino, 2004).

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About the Authors

Poornima Bhola is Professor, Department of Clinical Psychology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India, where she completed her MPhil and PhD degrees. She has over 25 years of experience as a therapist and is currently the coordinator of the psychotherapy training programme in the department. She is deeply interested in training and has conducted numerous workshops for counsellors and psychotherapists on reflective practice, ethics and youth mental health. Her research interests include psychotherapy processes, training and development, youth mental health and personality dimensions. Chetna Duggal is Associate Professor, School of Human Ecology, Tata Institute of Social Sciences (TISS), Mumbai, India. She completed her MPhil (Clinical Psychology) from NIMHANS, Bengaluru, and PhD from TISS, Mumbai. Her research interests include psychotherapy practice, training and supervision, and adolescent and youth mental health. She has been in psychotherapy practice for over 15 years. In recent years, she has launched the School Initiative for Mental Health Advocacy (SIMHA), and Rahbar, an initiative for supervision. Rathna Isaac, PhD in clinical psychology, completed her training in NIMHANS in 2005 and is a private practitioner and supervisor with 20 years of experience. She is an external consultant and supervisor for the Couple and Family Therapy Programme at Parivarthan Counselling, Training and Research Centre, Bengaluru. She has created and conducted both basic and advanced training programmes on couple therapy and provides ongoing group supervision for couple counsellors. She has conducted several training workshops for counsellors and psychotherapists at all levels and is deeply interested in the psychotherapy process.

Index

ADDRESSING acronym, 174 advocacy building competencies, 177 strengths perspective, 37 aha moment, 196 altruism, 24–25 American Association of Suicidology’s Clinician Survivor Task Force (n.d.), 251 American Counselling Association (ACA) advocacy competency, 177 analytic psychodynamic tradition, 68 anamorphosis, 225 An Artist of the Floating World, 38 anxious therapists, 251 armour to soft pillows, 182 Assessment for Signal Clients (ASC), 185 attunement process, 90–92 Authentic Movement, 59 balance of power, 108 being reflective, 4 Bhagavad Gita, 159 biomedical models, dominant, 165 burnout, 258 caring burnout, 258 cases Lavanya, 137, 138 Maya, 89–90 Mira, 117–119 Sophia, 99 Tara, 104–06

caste mental health practice, 153–56 change psychotherapist’s personal theory, 79 client deliberations on existential themes, 194 interactions, 195 learning from voices, 188–93 listening and learning, 181 theory of change, 182–84 values, challenge, 136 world, different ways, 195 compassion fatigue, 249 confrontation markers, 93 connections, 248 consumer, 191 contextually relevant models, 171 conversations, 200 Cooper–Norcross Inventory of Preferences (C-NIP), 183 countertransference, 100 challenging tasks, 103 diagnostic tool, 103 emotions, 102 love, 101 management, 101, 104 countertransferential disclosure, 104 COVID-19 pandemic, 246 critical consciousness, 176 cultural countertransference, 146 cultural roots, 144–46 exploring, 145 personal markers, 145

Index  347

cultural values, 127 culture, 146 curiosity, 275 cycle involving six stages action plan, 12 analysis stage, 12 conclusion stage, 12 description, 12 evaluation, 12 feelings, 12 cycle of caring, 246 darning, 93 declarative–procedural–reflective (DPR) model, 5 declarative–procedural–reflective model, 6 Delphic dictum nosce te ipsim, 128 development, value-sensitive training modules, 141 dialectical behaviour therapy, 27 dialogue, 249 didactic methods, 200 diversity awareness, 146 training methodologies, 175 doing reflection, 4 dragging a black hole, 182 eclectic-integrative approach, 83 emancipatory reflection, 148 embedded orientation, 78 emotional labour, 245 emotional reactions, 248 ethical imperative, 246 experiential learning model, 12 expressive strategies, 96 feedback, 188 building of partnership, 186 loop, 184–88 Firebird project, 258 flexible responsiveness, 108 focal areas, 119

gender expectations impact, 166 psychotherapy, 162–69 gender-based disadvantages, 163 gender discriminatory practices women, 163 gender disparities, 163 gender power structures, 165 helpers attending, personal and professional, 239 challenge, therapist-client, 239–41 easing, therapist-clients, 237–38 therapist-clients, information, 241 ideas and impressions, 247 immediate repair strategies, 95 indirect trauma, 248 inner conversation, 47 inner self, 43 internalixed supervisor developing, supervisor, 219–21 internalized supervisor, 218 representation, 219 internal supervisor, 218 developing, supervisor, 219–21 representation, 219 interpersonal process recall (IPR), 211 interpersonal violence, 164 intersectionality prism, 147 intersections, 173 interview power, policy and practice, 110–12 interwoven tapestry, 10 Kashmir. See Valley of Saints learning from clients, 179–99 looking glass, 48 low- and middle-income countries (LMICc) face, 191

348  Reflective Practice and Professional Development in Psychotherapy me and my orientation, 75–77 meet in difference power in therapeutic relationships, 106–10 mental health care caste, 153–56 social class and inequities, 149–53 mental health education, service users involvement, 198 mental health professionals, 266 me time. See work–life balance mindfulness meditation, 264 models of reflection, 11–14 momentary awareness, 46 motherhood, 169 motivations in-session behaviour, 31 therapy room, 29–35 Multitheoretical List of Therapeutic Interventions, 70 Outcome Questionnaire (OQ-45), 185 paper mirror, 57 Partners for Change Outcome Management System (PCOMS), 185 pause, 245 peer supervision, 215 perfectionistic therapists, 252 personal development programmes, 20 personal iceberg metaphor, 43 personal self, impacts, 40 personal theory of change development, 78–81 personal therapist matter of choice, 235–37 therapist on the couch, 234–35 personal therapy, 20, 226–33 person-of-the-therapist perspective, 45

person-of-the-therapist (POTT) model, 60 positive psychology framework, 46 possible selves, 63 poster people for healthy emotions, 246 power, 106 negotiation in therapeutic relationship, 110 Practitioner Professional Resiliency, 258 practitioners, 246 prismatic dialogue approach, 212 privilege definition, 147 proactive countertransference, 100 procedural system, 5 professional self impacts, 40 Psychological Outcome Profiles (PSYCLOPS), 186 psychosocial disabilities language, 192 psychotherapists, 22 personal qualities and experiences, 252 psychotherapy, 99 gender, 162–69 models, 176 nature and practice, 144 values, 124 voice and a space for diversity, 144 Psychotherapy Preferences and Experiences Questionnaire (PEX-P1), 183 psychotherapy training programmes personal and professional responses to therapist, 36–37 perspectives, 35–38 selection process, 36 Queer Affirmative Counselling Practice (QACP) course, 172

Index  349

Rafoogari, 92 RAHI model organizational self-care frameworks, 257–58 reactive countertransference, 99 recognition, 103 re-creation, 246 referral, making decisions, 140–41 reflection intellectual activity, 283 places, 19–20 professional development, 16–19 reflection in action, 15 reflections, 1 context, 10–11 methods and tools, 14–15 origins and intensity, 103 purpose, 28 therapist self, 9–10 therapy process, 9 reflective communication and questions method, 212 reflective groups, trainees, 284 reflective practice, 7 challenges to practitioners in training, 280–81 energy, 275 evaluation during training, 281–83 evidences, 277–79 inconsistencies, 276 maturing field, 285 professional development, 1–20 stay honest, 274–76 systematic approach, 14 trainees in groups, 284 training programs, 16 reflective practitioners challenges in training, 280–81 difficult job, 279–80 reflective processes, 85 reflective supervision, 208 reflective system, role, 5 reflective teaching, 282

reflexivity, 2 relational self, 48–53 family, 49–50 therapist’s relational scripts, 50–53 relational skills supervision, 120 training and frameworks, 119–20 relationships, 92 religion and spirituality, 156 religion, therapy room, 156–61 religious practices, 157 resilience action plan, 267–68 resilient therapists feel, 265 retraumatization, 253 routine outcome monitoring (ROM), 185 ruptures, therapeutic alliance, 93 same-sex sexuality, 170 secondary traumatic stress, 248 self discovering, 42–48 expressive and experiential routes, 59 Indian psycho-spiritual tradition, 43 intentional use, 54 relational, 48–53 revealing and concealing, 53–57 self-as-therapist schema, 40 self-awareness, 45 self-care, 267–68 art making, 262–64 face of client suicide, 250–52 practices, 246 Self-Care Inventory, 258 self-disclosure creative pathways, 57–60 expressive and experiential routes, 59 reflective journaling, 57–59 therapist, 55 traditional perspectives, 55 self-discovery journey, 42–48

350  Reflective Practice and Professional Development in Psychotherapy self-doubt, 261 self-exploration, 23 self-of-the-therapist work, 45–48 self-practice/self-reflection (SP/SR), 13 self-practice/self-reflection (SP/SR) model, 60 self-reflection, 2, 249 self-reflective, 261 self-reflective skills, 8 self-schema, 40 self-therapists and meditations, 43–44 short movement visualization, 60 signature theme, 45 social justice, training methodologies, 175 socio-economic-political context, 8 suicide, 251 supervision, 200, 251 supervisor and supervisee, 201 exploration stage, 209 framing contract, 202 group, 214–15 peer supervision, 215 preparation, 202–05 reflection, 216–18 reflection, safe space, 205–07 safety, 207 supervisors, supportive and reflective, 83 survivor, 191 tele-psychotherapy warrants training, 120 termination, 112 The Lord of the Rings, 179 theoretical orientation, 69 client needs and preferences, 74 key questions and debates, 83–84 multiple, early exposure, 81 personality traits, research, 72 personal life experiences, 73 training and professional setting, 73

The Privilege Project, 147 therapeutic alliance.. See working alliance therapeutic interactions, 247 therapeutic presence, 87 therapeutic relationship, 86–92 termination, 112–19 therapists, 21 attachment style, 51 attuned to microprocesses, 94 disclosure values, 138–39 experts, 106 fears, 32 meditations on self, 43–44 mental health concerns, 55 mentalization ability, 62 motivations, 22–25 personal challenges, 27 personal lives, 252–55 preferred theory, limitations, 74 relational scripts, 50–53 relative position, 106 religious/spiritual beliefs, 159 self-awareness, 41, 230 self-care, role of organization, 255–57 self happens, 193 self-reflections, 9–10 survivors, 192 tracing motivations, 21–38 traditional analytic stance, 122 unaddressed psychological difficulties, 31 work as gatekeepers, 187 wounds, 27 therapist values, 129 matching client, 133–34 therapy, emotional neediness, 33 Therapy Personalization Form (TPF), 183 therapy process, reflections, 9 therapy room, 160 The Red Book, 14

Index  351

The Reflective Practitioner, 3 training and development distress and vulnerabilities, 271 integrating self-care, 269 organizational policies and practices, 270 personal development, multiple pathways, 243 personal therapy, debates, 242–43 perspectives, 81–85, 119–21, 174–76, 223–24 supervision, 270 treatment specific interventions, 69 use of self, 41 use of self-training frameworks, 60–61 supervision, 61–62 user-controlled research, 198 user survivor research, 198 therapist engagement, 197 Valley of Saints, 265 value conflicts, 130 Buddhist, 135 emotional impact, 131 supervision to recognize, 139–40

values, 122 client, prioritizing, 134–35 examining model of universal, 126 intersections between, 131–33 personal and professional, 124, 132 professional, 132 psychotherapy practice, 124–26 session, 135–37 therapeutic interactions, 128–31 therapist disclosure, 138–39 therapy room, 134–35 unpacking, 126–28 webs, 132 value-sensitive approach, 134 vicarious traumatization, 248 well-being, 258–67 withdrawal markers, 94 women, gender discriminatory practices, 163 work culture, 255 working alliance ruptures, 93 ruptures and repairs, 92–99 work–life balance, 259 wounded healer, 29