The fundamental origins and nature of counselling psychology are set out in the first paragraph of Woolfe, Strawbridge, Douglas, & Dryden’s (2010) counselling psychology handbook as “… a particular approach to helping people, which proposed an alternative that challenged prevailing approaches” (p.1). Bridging the therapeutic practice of counselling and the science of psychology, with a distinctive identity founded both in the experience of being a ‘scientist-practitioner’ and a ‘reflective practitioner’, these active tensions lie at the heart of what it is to be a counselling psychologist. As a trainee counselling psychologist, I have particularly relished the opportunity to work and learn at the cutting edge of trauma, where recent advances in neuroscience research (for example, van der Kolk, 2014) and a growing evidence base for new treatment modalities such as EMDR Therapy (Shapiro, 2001) and sensorimotor
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healthcare. I believe we may, as a result, be facing a potential paradigm shift (Kuhn, 1970) in the 21st century as to how we work in a trauma-informed way with the significant and growing mental health challenges in our society (Cozolino, 2010; van der Kolk, 2014).
Historically, counselling psychology has been grounded in and inspired by North American humanistic thinkers, such as Maslow and Rogers, to value our understanding of the subjective worlds of both ‘self’ and ‘other’ as central to the discipline. I would argue that although as psychologists we have, rightly, devoted the focus of our clinical and research attentions to the well-being and outcomes of those ‘others’ that we treat, sometimes this has been at the expense of our own self and well-being. Woolfe et al. (2010) stress
“… the self of the helper is acknowledged as an active ingredient in the
therapeutic process. … [Like] our clients we are people, with issues and difficulties in our lives, and understanding how this impacts upon relationships with clients demands a willingness to explore our own histories, attitudes and emotional defences” (p.11).
In common with our clinical psychologist peers, the NHS is our biggest employer and we as clinicians are familiar with the ever-increasing pressure on resources and lengthening waiting lists. As departmental funding is cut, and teams are re-organised, it is vital that we attend to our own well-being both individually and systemically. As Herman (1997) memorably stated,
“It cannot be reiterated too often: no one can face trauma alone. If a therapist finds herself [sic] isolated in her professional practice, she should discontinue working with traumatized patients until she has secured an adequate support system. … The role of a professional support system is not simply to focus on the tasks of treatment but also to … insist that [the therapist] take as good care of herself as she does of others” (p.153; italics Herman’s own).
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In view of this, the dearth of literature or research enquiry until relatively recently by our profession into the well-being of those clinicians skilled in trauma-focused therapies, who daily risk indirect or secondary traumatisation whilst treating others, is quite surprising. As Figley comments, with respect to his theory of secondary traumatisation: “the most effective therapists are most vulnerable” (2015, p.1). He goes on to assert:
“At the heart of the theory are the concepts of empathy and exposure. If we are not empathic or exposed to the traumatised, there should be little concern for
compassion fatigue” (Figley, 2015, p.15; italics added).
At the heart of our clinical training as counselling psychologists lie person-centred concepts of empathy, unconditional positive regard and congruence (Rogers, 1951). These are viewed as necessary conditions and paramount for establishing a therapeutic alliance, which is considered the most healing factor in all psychotherapeutic work (Lambert, 1992), and
fundamental to working at relational depth with clients (Mearns & Cooper, 2005). The reparative nature of an empathic therapeutic relationship has been noted to be particularly important in working effectively with those who are traumatised and distrustful, having suffered abuse at the hands of others (Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004;
Meichenbaum, 2013; Parnell, 2013). However, as Figley (2015) cautions, in empathising with the accounts of the traumatised, we risk becoming traumatised ourselves.
There has also historically been an emphasis in trauma-focused treatments on exposure as a key therapeutic component, whereby both the client – and, inevitably, the therapist – repeatedly engage in detailed (and often harrowingly gruesome) accounts of the precipitating traumatic events (see, for example, Cloitre, 2009). All symptoms of traumatic stress have repeatedly been shown to correlate in their severity with cumulative exposure to traumatic events (Kolassa & Elbert 2007; Kolassa, Illek, Wilker, Karabatsiakis, & Elbert, 2015). Similarly,
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parallels drawn between the concepts of STSD, CF, and VT tend to link cumulative exposure to accounts of traumatic events with the risk of “profound changes in the core aspect of the
therapist’s self” (Pearlman & Saakvitne, 2015, p.152). Counselling psychologist Amirah Iqbal makes the important point that
“This implies a shift or change in the therapist’s perception of experiencing the self, others, and the world. If this affects the therapist’s relationships with others and their inner world this may have implications on the therapist’s ethical and professional practice” (2015, p.45).
Iqbal (2015) goes on to review the significant ethical considerations concerning the impact trauma work can have on counselling psychologists, which in turn can be harmful to clients. Both the BPS and HCPC codes of conduct, performance and ethics (BPS, 2009; HCPC, 2012) outline our full commitment to preventing client harm, which psychologist members pledge to uphold; the Division of Counselling Psychology professional practice
guidelines also outline supplementary best practice recommendations (DCoP, 2009). However, Iqbal (2015) points out that lack of training in awareness of the specific risk factors and
symptoms of STSD may mean trauma clinicians are inadvertently putting themselves and their clients at risk. Potential risk factors listed by Iqbal (2015) include the nature of the work, frequency of supervision, organisational structure, and the background, training (including education regarding awareness and normalisation of STSD symptoms) and access to personal therapy available to the therapist. The report concludes that there is a lack of research
exploring these factors and there are currently no guidelines available to counselling psychologists, or other trauma practitioners, to inform best practice in trauma treatment.
If our fundamental approach, both professionally and ethically, as counselling
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practitioners includes challenging prevailing approaches, perhaps it behoves us to examine how best we might ‘care for the carers’, by exploring our own experiences of delivering the
recommended trauma treatment protocols and looking rigorously at the personal and
professional costs that currently lie unexamined when supposedly evidence-based treatment decisions are made (Corrie, 2010). Given that, for counselling psychologists, the therapeutic relationship and use of self as a reflective practitioner form vital components of the fundamental ethos of our profession (Douglas, Woolfe, Strawbridge, Kasket, & Galbraith, 2016; Fouad, 2012), selecting a therapeutic modality which will protect and resource the clinician as well as the client may go a long way towards preventing the personal and professional costs of
compassion fatigue and reduce the risk of further harm to the already traumatised who seek our help.