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Seeking counselling particularly for the first time, can be a daunting process. Engaging in counselling can be both supportive and challenging, so it is understandable it is often experienced as alarming, disturbing, disappointing when you are told the service is closing or the waiting list is so long the service is no longer accepting referrals.

What do you do if you find yourself in this scenario?

It can be so difficult not to give up and give in to those thoughts that perhaps tell you no one can help or there isn’t any help or support, what is the point. It has taken courage to get to the position of asking for or receiving support, this experience can be understandably disheartening.

The reality

Sadly this is happening all over the country in statutory and non-statutory services. The cost of running a therapy service has increased so much that many services find they are not viable, or they have to pass the cost on to the clients to such a degree they become unrealistic for most. Therefore, the few services that do offer true low-cost or affordable counselling or therapy become flooded with demand and quickly find themselves having to close their door and limit their services.

On the other side of all of this are services that do offer more affordable therapeutic services often rely on donations and volunteers to keep their costs down for the clients, but still remain viable. Both these resources are in scarce supply in the current climate. Why am I spelling this out? Because all too often, when someone experiences a service closing while they are in treatment, or being turned away at the door, it can feel deeply personal. It isn’t, it is the brutal reality of the world we are living in and although this also brings up difficult feeling,s it can also be helpful to keep this reality in mind.

What can you do?

There are a number of things you can do. Firstly, ask the service that is closing or has closed their waiting list, if they can recommend similar services. Speak with your GP or GP receptionist and ask them to signpost you not only to NHS services, but other local resources. Your local library will likely hold a directory of services and your local authority website will too. Many online directories have a filter you can opt for “reduced cost” “affordable” or “low cost” counsellors or therapists. Go on to the accrediting bodies websites such as BACP, BPC or UKCP and again search for therapists and counsellors who are offering low fees or affordable prices in your area or online.

Although they are very limited, affordable services do exist and if you are reading this, you have in fact found one in Highgate Counselling Centre. We actively work to have a waiting time of a maximum of 6-8 weeks from the first point of contact. We offer counselling for a contribution agreed with each individual based on their income to ensure it is sustainable.

Sustainability is the final aspect I will leave this piece on. Wherever you find yourself receiving support, if you are paying for it, ensure you can sustain paying the fees. It is not just services being suspended or closing that brings peoples’ much needed support often to an abrupt, unhelpful end. This can also happen because a client has not been realistic with themselves as to how they can really manage the fees. If you do find yourself in this position however, always talk about it with your counsellor or therapist. They will also want to find a way not to interrupt or end the work if possible don’t just assume nothing can be done.

An initial consultation is the first step into psychodynamic counselling at Highgate Counselling Centre. Over many years of working as an initial consultant, I have met people of all ages and backgrounds, each bringing something different, but usually sharing a wish to be heard. In this piece, I reflect on how I approach these meetings, what I am listening for, and how decisions about suitability for psychodynamic counselling are made.

My Background and Clinical Experience

I qualified as a psychodynamic counsellor in 2007 having already joined Highgate Counselling Centre as an external trainee in 2005. I became a staff counsellor on qualifying and began working as an initial consultant (IC) in 2008.  Since then I have met many prospective clients of all ages and personalities seeking counselling and all very different.  The one thing I feel that they have in common is a need to be heard, perhaps for the first time in their lives.

What the Initial Consultation Is —and Is Not

This is to assess whether a person is suitable for psychodynamic counselling.  They may be highly intelligent and qualified in their field of expertise but not necessarily be suitable for the counselling that we offer at HCC.  During a lengthy meeting – sometimes it take over two hours – I need to establish in my mind whether the person opposite me may benefit from this type of counselling.  It is important to say that we do not know the client.

It can take much courage for someone to apply for counselling in the first instance and we, as ICs on behalf of the Centre, have a responsibility to gauge their suitability.   We will obtain a lot of factual information in that meeting but we should also get a feeling of whether they are “right” for on-going work.  For this we depend to a very large extent on our countertransference, which is a key part of the report that we prepare for the allocations manager/director.  The latter provide support for the ICs, who do not make that final decision as to whether a person will be offered a place at the Centre.  However, the allocation is very much dependent on our reports.  We will make recommendations as to whether short- or long-term counselling is appropriate but we will also state our concerns, if any, on the basic premise of suitability for psychodynamic counselling.

What Happens During an Initial Consultation

So how is this done?  Although the report has a number of headings of information, each of the ICs in the team will have their own style on how to go about it. My own has been honed over many years of conducting these meetings and I follow the order of these headings. Unlike in private practice, where the assessment process may take a few sessions of normal length, we are required to write a report after having had one extended session.  These first sessions in private practice may be like any normal session, with the history unfolding within the transference, and it may be that notes are unnecessary.  I know that I will never remember all the detail in my meetings at the centre and I scribble throughout.    

At the outset, I welcome the prospective client introducing myself, telling them the purpose of the meeting and how it differs from a normal counselling session, including the length of the meeting.  They will have been told this by the receptionist when making the booking but people forget.  It is important to tell them that I will not be their on-going counsellor —although it can happen in rare circumstances— and that it may take some four to five weeks before they hear from their allocated counsellor offering them their first appointment.

After finding out why they are seeking counselling and, very importantly, why now, I prepare the genogram. This can generate much emotion including, for example, shame and embarrassment that they cannot remember their grandparents’ names.  This is not a therapy session so I try to put the client at their ease at moments of distress.  Quite often I refer back to the genogram during the meeting to check a detail that I was unsure about.  On one occasion, the client referred to his wife later in the meeting whom he had not mentioned when I had been drawing up the genogram. I duly adjusted it and we spoke briefly about his forgetting to mention her which I highlighted in my report.  On another occasion, when preparing the genogram for a young man, I asked him for the names of his parents.  He said “Well, you know them!”  To say I was thrown is an understatement.  He explained who they were and then I remembered that my wife had worked with his father with whom I had played golf years earlier and that we had met them at a party perhaps 10 or 15 years ago!  They had spoken of their son but seeing his name on a registration form today all those years later had meant nothing to me.  I apologised and said that, because of this, I could not continue with the meeting and that we would rearrange it at no extra cost.  Fortunately for me, he understood and did not give me a hard time.  This has happened to me only once in over 300 meetings but one needs to be aware of the possibility.

Whilst obtaining details of their history, present circumstances, illnesses, previous counselling and therapy and any other relevant information, I have in the back of my mind how I am feeling as I sit with the client.  For instance am I interested in them and would I like to take them on as a client given the opportunity?  It is important to remember when one comes to complete the section on countertransference after the meeting that what you say are your feelings and not the client’s.

If I am unsure about whether the client should be offered a place, I tell them that, because, say, of their history, we might need to see them again to help us decide.  Usually they understand and happily this does not happen often.

I ask them what type of counselling they feel they would like, i.e. long or short term.  Some know but many do not.  I then tell them what I feel would be appropriate and why and generally we agree.  In obtaining their availability I mention that missed sessions have to be paid for.  This quite often leads to a discussion but hopefully they will remember this when their on-going counsellor reminds them.

Finally, I ask them if they have any questions for me. Quite often they ask what might happen if they do not get on with their counsellor. I suggest that initially they should speak to their counsellor about this to try to understand what might be going on which would probably be transferential. If the problem cannot be resolved they would be allocated another counsellor.

At the end of the meeting I thank them for coming in and show them the way out.

Final Reflections and the Reality of the Unexpected

One can never be sure who will come through the door but one needs to be open to anything.  More often than not, the people coming to the centre are not suffering from a mental disorder but have issues for which they need help. We do not offer cures or provide solutions; we do not offer guidance or reassurance.  So what do we provide?  We offer them a space to talk to enable them to gain insights and understanding into their difficulties and to help them manage their lives better.  I tell this to clients at the outset of the meeting so that they are in no doubt as to what to expect.  Their reaction will also help me to get an idea of their suitability.

One last story:  It is very rare that someone comes to the Centre with another.  I tell this story as it is, I feel, important to know who is seeking or wants counselling.  The following has happened to me just once:  The gentleman supposedly seeking counselling came in with his partner who remained in the waiting area whilst we undertook the meeting.  He was from a recent war zone and, from his initial words, it sounded as though he had been in the war and may have witnessed some terrible things. We were working on the genogram about half an hour into the meeting when he said “Stop. I don’t want to go on with this.  I don’t want you to write a report so tear that up.”  I am not sure if I did the right thing but, guided by my feelings, I tore up the report and put my pencil down.  I said “Okay, no report.  But we have some time left.  Would you like to talk a bit more?”  He said he would and I listened to some harrowing material.  At the end of the meeting I went out with him and his partner stood up looking at me as if to say, I felt, “Will you take him on?”  At the same time, I saw him shake his head to her as if to say “This is not for me.”  They left and I felt that it was she who had wanted him to have counselling whereas he was not ready to embark on it. I felt terribly sad as they left the building.

Written by Norman Mintz

What is supervision of psychodynamic counselling

Integral to the training and on-going CPD of psychodynamic counselling practice is clinical supervision.  This is where counsellors whether training or qualified bring their cases to an experienced supervisor of psychodynamic counselling and/or psychotherapy to present and discuss their cases.  All trainee psychodynamic counsellors are required to undertake 1.5 hours supervision per case a month.  At the Highgate Counselling Centre, trainees are committed to join a group of four members for weekly supervision of their counselling cases.  The trainee is allocated clients via the initial assessment process.  Once allocated a client, the counsellor begins a long-term process of once weekly psychodynamic counselling sessions.  In order to qualify for BACP registration, the trainee counsellor is expected to complete 100 hours of supervised clinical work.

How to Begin

It may sound paradoxical and not without thought that I start this conversation with advice I give my students as they begin the process of working with their cases.  How not to be helpful…. This advice may fly in the face of an altruistic vision, easily relatable to as the passage of a counselling journey begins, when often what might be uppermost in the mind of the trainee counsellor is I want to be of help.

Of course, the inclination to want to help is strong.  Yet in practice, psychodynamic counselling and the work we do in supervision, invites a more complex kind of helping, one that involves thinking, feeling and allowing space to unknow.

The purpose of supervision

Supervision of psychodynamic counselling at the Highgate Counselling Centre is where trainee counsellors, often alongside staff counsellors, bring their cases to unpick, explore and understand a dynamic between counsellor and client presented by the unique peculiarity of the therapeutic relationship.  This relationship as it begins and unfolds, may mirror something of the client’s relationships in the wider world.  This mirror helps counsellors to understand the relational patterns and how to address the ebb and flow of feelings and actions as they play out.

Navigating feelings in the room

As work begins with a client the psychodynamic counsellor is tested by their own feelings which may well intrude on the counselling space and a struggle unfolds.  This may take shape in a need to work out what feelings belong to them, the counsellor, and what feelings belong to the client.  This is a common and to my mind often an improbable task –  a concern nonetheless, brought to the supervision space.  While this concern may be real and true, it is helpful to understand that whatever is going on in the room between you and your client is actually about what is going on between you and your client.  Your feelings as counsellor are part of that relational field; they are responses to and relating with your client’s feelings in that session, they are a unique meeting of mind and feeling, in that space.  This is what we call the countertransference experience.

Transference and the meaning of the encounter

How we understand much of the client’s experience in the world, their view of themselves, their relationships, their historic family dynamics, what was then and what is now, is communicated in the room in its unique and peculiar form which is the transference.  Because the psychodynamic counsellor brings only their presence and their active listening skills, the client hopefully develops a sense of reflectiveness and awareness that what’s on their mind is delicately reflected back to them, as well as an independent mind of the counsellor, who may interpret a meaning of what the client’s unconscious feelings communicate.

An example: The Late Client

In supervision of psychodynamic counselling for example, we might explore why a client is repeatedly at least 10 minutes late for their sessions.  Over the weeks there may be numerous reasons, traffic, delayed trains, work demands, children requiring attention.  Each explanation is plausible.  Yet as the pattern repeats, it invites reflection, leading us to think about why the client can’t have the whole session time of 50 minutes.

The counsellors in the supervision group might take this on at several levels. A distinctive transference response from each group member may vary.  We can, of course, take the lateness at face value as each week the reason for lateness is just as plausible as the previous week. But we might also ask–could there be another communication hidden within this behaviour? Is it possible that behind the reasonable reasons there’s another communication?  This is how we can broaden our thinking about what the client may be trying to tell their counsellor and how each group member might also be having a different response or reaction to what the client is communicating. As each counsellor in the group responds to the client’s actions, each member might be holding different aspects or even conflicted perspectives emerge–what we call a parallel process to the clinical work.

This allows for a way to think together about different ways to approach and present to the client an understanding that doesn’t undermine the defence, the conscious reason for their being late.  Equally, the counsellor can also suggest that there may be another important communication here…. Might it be that the client wants to convey an unhappiness, a grievance to the counsellor–I need to keep you waiting.  I need to know that you will wait for me.  I need you to think about me while you’re waiting for me.  Grievances, time lost, losses, may all have meaning in the client’s past story.  Here there could be links to multiple ways of communicating an indirect dissatisfaction.  I reject you before you reject me, for example.

Through such reflection, as a supervision group, we begin to think beyond behaviour and towards meaning – we consider how the counsellor can bring understanding to the client without undermining their client’s conscious defences.

Sitting with the impasse

I’d like to return now to how this conversation began when I said that an important learning for the psychodynamic counsellor is how not to be helpful.  One of the hardest tests in this work is how to sit with an impasse or a feeling of being stuck where anything the counsellor might offer or say is rejected.  It is not unusual that the client who wishes for change is equally resistant to change.  This may seem both paradoxical but also relatable to, when we pause and reflect. For the counsellor it can feel deeply uncomfortable, especially when the counsellor’s predisposition is to carry knowing and how to facilitate change. Yet in supervision the psychodynamic counsellor can be reminded that such resistance is not a failure but a communication–a potential for greater understanding of how to withstand not knowing.

The paradox of change

Here is the paradox of the work and how the internal conflict of the client presents in the psychodynamic counselling relationship.  Change is sought while might also be fought against.  In supervision of psychodynamic counselling our endeavour is to find ways to name and accept the spaces between where the client is and where they hope to go and what might be obstructing them to get there.

In closing

Supervision of psychodynamic counselling at the Highgate Counselling Centre is not a guide to right or wrong answers. It is an essential, shared exploration toward safe therapeutic practice. It offers trainees the opportunity to think, to feel and to grow into the reflective stance that underpins all good therapeutic work.

The purpose of the supervision group is a reflective holding space for counsellors to bear uncertainty, tolerate frustrations and to cultivate their curiosity rather than forge a need to solve.

Learning to bear how not to be helpful is, paradoxically, one of the most helpful things we can do–for our clients, our development as psychodynamic counsellors, and for the integrity of the therapeutic process itself.

———Written by Kate Hardwicke, a psychoanalytic psychotherapist and psychodynamic supervisor.  She is one of the supervisors at the Highgate Counselling Centre.