Using the metaphor of the porcupine to launch the book (in groups, porcupines struggle to huddle as their spines poke each other), Luepnitz draws out the tension we experience between getting close and feeling rebuffed, independence and reliance, a desire for intimacy yet fear of what this may mean (vulnerability and exposure). She uses many other metaphors elegantly, and does wonders at introducing some of the harder analytic concepts (from Freud and Lacan included) with ease and humility – there’s no definitive conclusions or ‘curing’ going on here (which therapy can never do, but sometimes authors can drift into claiming). She also makes a quiet case for therapy – how it can help us understand and act upon our possibilities and potentials, while accepting our limitations with respect and self-compassion.

An Introduction to Counselling and Psychotherapy: From Theory to Practice

I was pre-disposed to like this book. I have followed Andrew Reeves’ writings with interest, and greatly benefited from a training day about suicidal presentations he delivered years ago. It is therefore of no surprise that his latest book is so engaging to read – all 450 pages of it. This is a mightily ambitious book, and one I would have probably hugged on discovering a decade ago, as I muddled my way through the difficult decision to re-train as a therapist.

It’s not just the sheer volume of information that the book contains that is impressive, but all the generous thoughts and ideas that go with it – chapter overviews and plenty of re-caps, further online and offline reading suggestions, discussion points, skills practise sections, case vignettes and even a companion website offering power-points for tutors. Naturally things are left out that you’d like and others included that you may not. I wondered about a lack on arts-based therapies, alongside the fairly fine detail of how UK laws are created (rather than just knowing the laws that do affect us). But this still has to be the most comprehensive look at the state of the two professions today that I’ve come across. Being up-to-date, mindfulness and compassion-focused work are included and a penultimate chapter explores research in some detail, with a clarion call for us all to face imagined fears of incompetence and get involved.

‘Setting the context’ section looks at definitions and a history of the counselling and psychotherapy professions, along with ideas to weigh up in choosing where and how to train. The main theoretical models (and skills) are explored – psychodynamic, humanistic, cognitive-behavioural, with a good, and repeated, look at the ‘purism vs pluralism’ debate. Other therapies are mentioned too, with no particular theory or training seemingly favoured – this clearly chimes with a desire for the professions to avoid our tribalistic tendencies.

The section on the ‘therapeutic relationship’ goes into presenting issues, the therapeutic frame, potential challenges and a discrete chapter on diversity and difference. Reeves does a thorough job in contextualising all of this too, referencing ideas with potentially different work settings – private practice vs organisational work. ‘The professional self’, the final section, discusses self-care, professional boundaries and supervision – including a look at the main supervision theories, which was particularly useful for a non-supervision trained therapist like me.

Ultimately it achieves what it sets out to be though, ‘a book about practice, by a practitioner’ – and one I’d highly recommend to anyone lured by the idea of a career in talking therapy.

This review first appeared in Private Practice, the quarterly journal of BACP Private Practice, which is published by British Association for Counselling and Psychotherapy. BACP holds the copyright to the review and it is reprinted here with their permission.

I write book reviews for Private Practice Journal  – the journal of the division of the BACP for private practitioners. This is one.

When I was in training, I often struggled with an intense desire to know what to say or do when clients were particularly challenging. A book like The Therapist’s Answer Book would have seemed a God-send, especially given the curiously long number of problems it attempts to provide answers for. It’s author, Jerome S. Blackman has an impressive CV after 40 years in psychiatry (downloadable on his website), with a particular following in China and Romania. Intrigued by his obvious success, I really wanted to like his latest ambitious book (this follows in the wake of 101 Defenses), but it did prove tough at times.

Maybe a culture clash explains some of my discomfort. Blackman writes from his experience of American therapy, where clients are funded from insurance plans, and perhaps the therapist is more embedded in the collective psyche as a professional helper. Secondly, although Blackman emphasises his multidisciplinary approach and takes ‘something from the best ideas that each theory has to offer’, he leans heavily toward Freudian analytic thinking – with little reference made to more recent relational and attachment work or indeed mindfulness-influenced theories and practices. A chapter When CBT Alone Is Not Working also makes me wonder about this integration.

As a US psychiatrist practising psychotherapy, ‘treatment’ and ‘diagnosis’ are core to his thinking, especially around decisions to prescribe medications. This writes off the relevance of some chapters for us, including – When to Use Medicine and When Not To or When People Demand Medicine, What If You Opt Out of Medicare? Other chapters could be seen to reflect a more professionalised culture too, such as People Who Date Your Secretary or People Who Fall Asleep in Your Waiting Room, or indeed Elevator Phobics Who Must Take an Elevator to Your Office.

There are other problems phrased in slightly toe-curling ways: Passive, Wimpy People or Wiseguys or, my least favourite: Self-Centered People Who ‘Need a Spanking’. I also struggle with Women Who Wear Ultra-Short Skirts and/or See-Through Blouses as a ‘problem’, although Blackman does explain that ‘women who wear sexually provocative clothing cause overstimulation and conflict for heterosexual male therapists, no matter how the male therapist denies or rationalizes this.’ By offering a ‘short’ and ‘long’ answer as well as a case study or two means sacrificing a proper dig into theory, so this may account for his instructional tone.

Despite his apparent confidence in sorting people out, as his case studies largely testify, his honesty about some of his limitations are welcome – such as being unable to treat therapists who have seduced female clients. But I’m left wondering if those female clients wore sexually provocative clothing.

He summarises what ‘integrative’ therapy means to him, and as I like the way he has put things, I wanted to reproduce them here. Not being a ‘purist’ (eg Gestalt therapist or CBT therapist) means I generally have to make great effort to convey what I do. There’s no neat ‘treatment’ that, say, analysts describe. Fonagy thinks there are three main ingredients to a successful psychotherapy: attachment, mentalising and compassion.

‘Attachment’ here refers to the trust any client must have in her therapist, which is clearly a difficult and counter-intuitive experience as she won’t know her/him from the off. This trust is sometimes described as the ‘therapeutic alliance’ or ‘collaborative stance’. Fonagy puts it in these terms: the therapist and client co-create this attachment relationship (which has infantile origins) via a number of subtle and important behaviours, that are mostly immeasurable by scientific standards. These include the therapist being emotionally ‘contingent’ in response to the client’s story and point of view. If you (therapist) take an interest in me, this creates, biologically, an attachment relationship between the two of us. I look to you to soothe my distress and this will elicit care from you (just as a mother responds to her child).

‘Mentalising’ is an ugly word but a sophisticated concept that Fonagy has written loads on. It involves a therapist being able to create in her mind some image of her client’s mind and is crucial for therapy. She must also communicate in such a way that the client is facilitated in organising her mental world. Experiencing anyone making sense of my thoughts and feelings help me organise myself – in distress I may even ask someone to think for me.

Lastly, but by no means least is compassion. This is another big and favourite topic of mine, written about here.

I agree with something else he says ‘I am totally signed up to psychotherapy regardless of modality’.

Grosz is an analyst, which means his training would have steeped him in Freudian ideas, subsequently topped up with many more (mightily complex) thoughts from the many post-Freudians. His book is delightfully light on theory however, making it readable to all. Writings about the mysteries of human behaviours, especially if unconscious, can often nudge into magical and poetic realms. It’s hard for me to know how convincing his ideas may seem to the un-initiated, as a veteran believer in the unconscious working problems through in adulthood. My bet is he’ll draw you in, his ideas are conveyed so well and so convincingly.

Working up to 5 times a week with ‘patients’ (not ‘clients’ as non-analytic psychotherapists would describe), over a number of years, clocks up a lot of therapist/patient time. Each of the 30 cases he describes here are distilled to a short, gripping story – rounded off with some sort of human truth or open-ended idea that doesn’t settle as neatly as a conclusion you half-crave. But sitting with the vague and not-known is the often the difficult stuff of therapy. We often want an answer from our therapist and have to bear the not-getting one. Sometimes we have to work things out, with or without our therapists well-thought through observations to guide us.

We meet a man who has tied his life up in knots through curious whopping lies, the disturbed child who spits in Grosz’s face each session, a man who faked his own suicide and another who bores everyone around him – including Grosz (interestingly, therapists write a bit about boredom in the therapy room). Each story reflects an aspect of each of us, or someone we know, so the book bears no weak link.

A very different book but also about the process of therapy that I like is Couch Fiction.

This is a very sad thing to learn and he’s right when he goes on to say the best thing you can do if you do see a counsellor (or indeed psychotherapist) is to check out their qualifications and professional registration(s). A therapist with a Bachelor’s or Master’s Degree in counselling or psychotherapy and a full member of the BACP/UKCP will have more training than someone with a certificate and no such membership. My colleagues and I have attempted to unscramble this for you more here.

The BACP also has more information on the status of regulating the profession.

It finishes on a positive note, having acquired a set of effective tools to manage his anxiety along the way – via therapy (cognitive especially), his mother, his brother and the love and patience of his partner. I’ve read a number of memoirs of anxiety but I reckon Smith articulates its pernicious hold particularly well. Lazily, I’ve reproduced a few lines that I liked:

… Anxiety compels a person to think, but it is the type of thinking that gives thinking a bad name: solipsistic, self-eviscerating, unremitting, vicious.

…(on reflecting of his mothers’ anxiety) Admit the anxiety as an essential part of yourself and in exchange that anxiety will be converted into energy, unstable but manageable. Stop with the self-flagellating and become yourself, with scars and tics.

…The hard work, you discover over the years, is in learning to discern between incorrect and correct anxiety, between the anxiety that is trying to warn you about a real danger and the anxiety that’s nothing more than a lying, sadistic, unrepentant bully in your head. The hard work is learning to step back and analyze the data dispassionately.

…All the potholes on the Future Road, all the risks distraction hides day to day from sturdier minds are, in the anxious mind, omnipresent and snarling. That is why therapists go to such lengths to urge their anxious patients away from intellectualization: The first step toward peace is disarmament.

…If you have ever been friends with a drama queen you know how taxing it can be. To have one in your head is enough to make you comatose.

…Anxiety is the stage a person has to pass through on his way to creating himself.

…On the one hand, your very existence means you can and will change things in your life and others. On the other hand, you aren’t God, so everything is always going to be drenched in uncertainty and doubt.

…Fear ……responds to fear by looking for fear, and the world being the world, it finds it. In this way, the merry-go-round of anxiety is fired up. The loop begins: fear to anxiety to fear to anxiety to fear to anxiety….

…In anxiety, there is no time to luxuriate in abstractions. It’s just you and your mind, which has fists and is using them. It  may be dualistic and logically untenable to posit the situation as You vs Head; it may not make sense philosophically. But in the throes of anxiety? In the cognitive shit? There’s really no other way to think about what’s going on.

The project is inspired by the idea that an individual’s reaction in a sporting context will mirror his reactions at school, home and on the streets. Sounds fascinating to me.