Dr Stuart Hannabuss is an honorary (humanist) chaplain at the University of Aberdeen and a volunteer counsellor for NHS Grampian.
One of the central assumptions in person-centred counselling is trust – the client trusts the counsellor, the counsellor trusts the client. This form of trust extends beyond the trust we expect in consumer and personal insurance contracts where both sides have a duty to get the facts right. It is a trust that starts by expecting personal information to be disclosed honestly and openly, but then goes deeper, where both parties agree about honestly and open-mindedly dealing with difficult and sensitive emotional feelings.
If it is not confidential and non-judgemental, it is nothing. However well and elaborately supported by administrative protocols, like data protection and liability arrangements, the central transaction in counselling lies between client and counsellor. Clients may be referred to counsellors by many others, including doctors and (in a university setting) tutors. Clients may also refer themselves, typically when someone enduring the grief of bereavement contacts Cruse. Either way, the success of the process begins with trust, and if effective it builds from there.
Trust cannot ever be presumed to exist …. it is brittle and can easily break.
The client’s view
Yet as with families and friendships, trust cannot ever be presumed to exist from the start. It is brittle and can easily break apart at any stage. Counselling is often offered or sought, in fact, when other forms of help have themselves been seen to fail. For many clients, counselling is challenging – admitting the need for it, asking how it works and who provides it, talking to someone who at the start is a complete stranger.
All this takes courage: it is for many a leap in the dark. It may not work. As many of us know from school, the happy memories (good friends, good teachers) are mixed with bad ones, and many clients seek out counselling after years of disappointments and unfulfilled expectations. Many clients, too, keep their visits to counsellors secret, above all from family and friends, because they are afraid of being seen to be weak or needy.
There is still stigma in not having perfect mental health.
For all the policy rhetoric in the field there is still stigma in not having perfect mental health. It is hard enough to face up to this in yourself, let alone admit it to someone else, however used we might be to telling our GP. Some clients also regard counsellors as forms of psychotherapists or even psychiatrists; professionals who treat people who are ‘mad and inadequate’. Many clients disguise their visits to counsellors as ‘going shopping’ or ‘seeing a friend’, and many are pleased that GP practices offer counselling because it’s easy to say you need medical (rather than psychological) advice.
The client’s needs
It is often difficult to be clear about what you really need in life, and what is really wrong. There are many times when you need a wise friend to tell you what you should do, and when you feel like a child looking for a parent’s help. This way of thinking encouraged the development long ago of transactional analysis, in which transactions or conversational exchanges between clients and counsellors can be asymmetrical (eg client as ‘child’ and psychotherapist as ‘parent’) or equal (equitable) i.e. both parties interact as confident and assertive mature adults.
Familiar though this model is, it continues to illuminate practice whenever professionals ‘decide to decide’, on prima facie evidence or presupposition or caricature, on what the client’s needs are. It also suggests at what truly effective counselling can be – a fully open and honest session where space and time are given for the client to face up to their difficulties and get non-intrusive agenda-free assistance in achieving that. An adult-to-adult transaction. But clients need help – and time – in order to confront their fears, to reflect on how they have tried to manage relationships and confused emotions, and to decide what they can possibly do about it.
Clients need help – and time – in order to confront their fears.
The client’s narrative
Professionals often say that they need the patient to tell their own story. To hear from the patient where the pain is and how bad it is, to learn the historical and lifestyle background to the visit to the surgery or hospital or counselling room. This story or narrative is likely to be richly-textured and personal, and often chronological; ‘I first felt unwell last Wednesday and then it got worse the following day…’ and teleological ‘I slipped on the ice and felt a crack in the small of my back’ or ‘I knew I ought to give up smoking’.
The narrative is an important source of two types of information; first, as an indicative account of what seems to be happening and how symptoms can be identified and treatment recommended, and second, as a way of discovering how the patient or client feels about it, their attitude to pain or illness or challenges they believe they cannot face. Material is revealing. A client may say that she has tried complementary medical products or acupuncture or prayer, or they believed they should simply grin and bear it and not make a fuss until things got too much. They might also be putting on an act and looking for sympathy and attention, where transactional analysis tells us they decide to play the role of ‘child’ believing that it will get them what they want.
They might also …. decide to play the role of ‘child’ believing that it will get them what they want.
Trusting the client
Counsellors and health-care professionals quickly learn to separate out the real from the false – actual rather than imagined symptoms, real rather than speculative causes, evidence-based explanations rather than psychological and medical myths. There are times, too, when it becomes clear that what the patent or client believes is categorically wrong (e.g. that peeing problems do not affect the kidneys, that stress at work is just for wimps) and so, to that extent, their narrative ‘cannot be trusted’, where the professional position is one of diplomatic re-framing attitudes and re-interpreting evidence.
There are other times, more common that idealists admit, when clients cannot be trusted because of an intention, sometimes unwitting but often knowing, to present a forged narrative. This is where honest self-knowledge and sombre reflection turn into ‘rhetorical deflection.’ This is how detective novelist Donna Leon describes an evasive witness for Commissario Brunetti in Earthy Remains.1 Clients, like witnesses in law and in fiction, can present themselves in devious and disingenuous ways, and this shapes the image they present.
Such rhetorical deflection involves two things. First, some familiarity with and mastery of the lexicon and mannerisms of the professionals they set out to meet, drawing often on extensive experience, and second, an intention to shape the facts in ways that characterise their own role in them as wholly laudable or innocent, as if fate has dealt them an unfair deal. ‘At least I’ve had seventy good years’ or ‘what can I expect with depression in the family?’ or ‘it was only a fiver on the horses’.
Deflection is where you …. role-play yourself into a parallel character that is not authentically yourself.
Deflection is where you attribute things to others, and role-play yourself into a parallel character that is not authentically yourself. It is commonplace in counselling, something that often brings clients to counselling in the first place, and a matter that effective counselling has a chance of resolving. Yet both client and counsellor have to want it to work. It is an adult-to-adult responsibility. Sadly, however much faith clients put in counsellors, and however much trust they seem to show in sessions, outcomes often fail, with two results. One is that clients look promiscuously for help. And the other is that counselling itself, for all the public talk about mental health, is ineffective.
Without active mature trust on all sides, we cannot expect it to work.
- Donna Leon. Earthy Remains, Heinemann 2017, page 286