Vicarious Trauma Paper Published

The online version of my co-authored paper on vicarious trauma has now appeared in "Counselling and Psychotherapy Research":

Chouliara, Z., Hutchison, C., & Karatzias, T. (2009). Vicarious Traumatisation in Practitioners Who Work With Adult Survivors of Sexual Violence and Child Sexual Abuse: Literature Review and Directions for Future Research. Counselling and Psychotherapy Research, 9(1), 47-56.

Having examined the available research, I'm left with a few questions. I don't think we can be confident about the existence of vicarious trauma in psychological practitioners: we will need further research which clearly defines its terms before we can draw firm conclusions. However it does appear that younger and more inexperienced practitioners are subject to higher levels of distress while working with traumatised clients.

Of particular interest for myself was the finding that some practitioners report positive benefits from working with traumatised clients. This isn't a surprising finding for me, but it's very pleasing to see some evidence that therapists feel they grow and develop through encounters with clients who have faced trauma. I hope to pick up on this theme again in the future.

Final Analysis Complete!

I've just finished the structural analysis for the last interview in my study, which means I'm nearly at the finishing post. Now I have to review the textural and structural descriptions which I've developed from the individual interviews, examining them for consistent and outlying themes, and pull these into one overall description (a tall order). I already know I'm going to focus the dissertation on the idea of the 'conspicuous gay client', as this was a theme which emerged quite strongly in the early stages of the study and which really captured my imagination.
Participants have generally described a desire to provide acceptant and affirmative therapeutic relationships, although this has sometimes been accompanied by an anxiety about potentially 'getting it wrong'. This is likely to be the theme of a second paper.
So, more soon...

The Conspicuous Gay Client, part 3

Early results from my "Ask 500 People" poll suggest that views are divided on the idea that homosexuality is a conspicuous characteristic. Younger people seem more likely to agree with the idea.
http://www.ask500people.com/questions/you-can-tell-if-someone-is-gay-simply-by-looking-at-them-or-hearing-their-voice

The Conspicuous Gay Client (part 2)

“From the dawn of my history I was so disfigured by the characteristics of a certain kind of homosexual person that, when I grew up, I realized that I could not ignore my predicament … I was from birth the object of mild ridicule because of my movements – especially the perpetual flutter of my hands – and my voice ... But these natural outward and visible signs of inward and spiritual disgrace were not enough. People could say that I was ignorant of them or was trying without success to hide them. I wanted it to be known that I was not ashamed and therefore had to display symptoms that could not be thought to be accidental.”

(Crisp, 1968/2007, pp. 5, 34)

So, I've been dawdling with my research project for ages. But I've got my second wind now and am bashing on with the dissertation in order to get it finished as soon as possible.

The participants told me that they could discern the client's sexual orientation prior to any verbal disclosure, and they described some of the bodily marks which they believed indicated a likely homosexual orientation. This has got me thinking...

There's a long history of searching the body for conspicuous signs of homosexuality. The notion that homosexuality is conspicuous can be seen in the second century, but scientific attempts to prove this idea came along much later. Jennifer Terry (1995), for example, has analysed a research project published by George W. Henry in 1941 in which men and women were subjected to intense medical and psychological scrutiny in an attempt to find physical evidence of their homosexuality. The investigation included detailed case histories, family trees, gynaecological examinations for the women, pelvic and skeletal measurements, close observation of hair patterns etc. Unsurprisingly, conclusive evidence was not forthcoming, although the researchers still convinced themselves that lesbian women exhibited signs of 'masculinity' and gay men 'femininity'.

A belief in an essentialist origin for homosexuality appears to underpin this search for physical signs, a search which certainly is not limited to the past: Bailey (2003) and Wilson and Rahman (2005) are modern writers who are vociferous in their essentialism, and there are numerous others. Contemporary essentialists have shifted their gaze towards atypical childhood gender (e.g. effeminate boys), as well as to finger-length, handedness, and even penis size (amongst others). Where the external body doesn't provide sufficient evidence, attempts are made to determine the 'gay brain' or the 'gay gene'. Bailey is particularly strident in his opinion that homosexuality is associated with innate effeminacy - I view which I believe is mistaken.

All these attempts presume that such a thing as a 'gay man' exists, and that this being is somehow distinct from other men. This is an interesting notion, but one which is contested by those who assume a social constructionist position.

I'm in the midst of wading through the literature on these contrasting positions at the moment, and my head is consequently in a bit of a whirl. Some of the essentialist research looks relatively convincing (especially the childhood gender studies, of which there are several), but it is also clear that gay men are a diverse group. Attempts to specify particular indicators of homosexuality have consistently found gay men who DO NOT exhibit the expected signs, which undermines the essentialist arguments.

I've decided to take a straw poll to see what others think: can you tell that a man is gay simply by looking at him or hearing him speak? I'm interested to see what the general opinion will be.

REFERENCES

1) Bailey, J. M. (2003). The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism. Washington, DC: Joseph Henry Press.

2) Crisp, Q. (1968/2007). The Naked Civil Servant. London: Harper Perennial.

3) Henry, G. W. (1948). Sex Variants: A Study of Homosexual Patterns (Vol. 2). New York: Paul B. Hoeber, Inc.

4) Terry, J. (1990). Lesbians under the Medical Gaze: Scientists Search for Remarkable Differences. The Journal of Sex Research, 27(3), 317-339.

5) Terry, J. (1995). Anxious Slippages Between 'Us' and 'Them': A Brief History of the Scientific Search for Homosexual Bodies. In J. Terry & J. Urla (Eds.), Deviant Bodies (pp. 129-169). Bloomington, IN: Indiana University Press.

6) Terry, J. (1999). An American Obsession: Science, Medicine, and Homosexuality in Modern Society. Chicago, IL: University of Chicago Press.

7) Wilson, G., & Rahman, Q. (2005). Born Gay: The Psychobiology of Sex Orientation. London: Peter Owen.

The Conspicuous Gay Client - Interim Findings

I'm now approaching the final stages of my phenomenological study examining heterosexual counsellors' and psychotherapists' experiences of working with gay male clients.
I didn't set out to examine prejudice or discrimination, as I felt this was the central issue around which too many of the previous studies had revolved. Instead, I wanted to 'go back to the things themselves' - to apply Husserl's metaphorical cudgels to the experience of working therapeutically with sexual minority clients. The findings have, in some regards, been surprising...

A key theme which has emerged at this interim stage is the idea that the client's homosexuality is (or should be) conspicuous to the therapist - that gay clients will give off cues and clues which identify them as gay men. These markers can be overt (e.g. dress, posture, behavioural similarities to cultural stereotypes of gay men) or more subtle (e.g. male clients' interaction with female therapists as sexually non-threatening for the therapist). The presence of these markers leads the therapist to anticipate a homosexual identity. Their absence in clients who subsequently disclose homosexual feelings or declare a gay identity leads to shock or surprise on the part of the therapists, who 'didn't see it coming'!

The study also outlines the complex and varied responses of therapists to a client's gay sexual orientation. A number of therapists told me of their pleasure at working with gay men - describing these clients as often easier to work with therapeutically than heterosexual male clients, who were sometimes characterised as gruff, emotionally inarticulate and reticent to discuss sexually intimate matters. It would appear that 'traditional' masculinity underpins some encounters with male clients, who can be assessed by the degree to which they fulfill or diverge from 'masculine' behaviours.

There is more work to do before themes are clarified and an overall outline can be written, but results will be posted on my website once available. I will also be presenting interim findings at the ScotCon event on the 22nd May 2008.

BACP Online Directory

After considerable humming and hawing, I decided to put my details onto the BACP Directory of Counsellors, Psychotherapists and Supervisors, and my details are now uploaded and can be seen by searching here. Searching for a therapist or supervisor in Edinburgh will bring up my profile, including a link to my website.
My research on heterosexual therapists' experiences of working with gay male clients is progressing - one more interview to conduct now. I'll put some interim findings up as soon as possible.

Therapeutic Authenticity and Rudeness

Since the early days of my training I've found myself feeling slightly ambivalent about the concept of 'congruence' in the person-centred approach. It's perhaps the most complex of the 'core conditions' to get our heads around, and it's undoubtedly the most abused!

While it's to be expected that trainee therapists will experiment and will make some mistakes, as I did, in the struggle to find their personal style within a therapeutic approach, sadly I have seen experienced as well as trainee person-centred therapists use 'congruence' to justify or explain inappropriate and counter-therapeutic behaviour. Consequently I think it's worthwhile re-examining 'congruence', as it seems to be open to very wide interpretation.

Congruence is related to 'authenticity'- to the therapist being real in the therapeutic relationship, and to there being a congruence (or matching) between the internal feelings of the therapist and their awareness of their experience. This is contrasted with incongruence, where some of our feelings or experiences may be out-of-awareness or disowned. We've probably all experienced an incongruent person who aggressively, with a sweaty red face, says, "No, I am NOT ANGRY!!!" The personal development required of therapists during and following training can be thought of as a method to increase our congruence - our ability to be empathically and acceptantly in tune with our own feelings and experiences without denying or distorting them. In this sense congruence could be described as 'owning' our own feelings, rather than behaving like the Mr. or Ms. Angry mentioned above.

There has been an ongoing controversy within the person-centred approach about whether being congruent means that we communicate or behave in a 'congruent' fashion towards clients, supervisees and colleagues, or whether it is predominately about the internal state of the therapist (increased awareness and ownership of thoughts, feelings and experiences) rather than our external behaviour. This is where the ground starts to get a bit sticky for me...

Experience has taught me that there can be narcissistic and selfish motivations underlying verbal and behavioural expressions of 'congruence'. It can be an unfortunate 'acting out' of the therapist's personal frustrations, difficulties or limitations, rather than an attempt to forge or maintain an authentic therapeutic relationship. So how should we go about differentiating between therapeutic and counter-therapeutic congruence?

Reading the chapter on Stoicism in Alex Howard's fascinating "Philosophy for Counselling and Psychotherapy" today, I came across a section that resonated strongly with my own thoughts about counter-therapeutic congruence:

"The Stoic's emotional and moral attraction to reason is in stark contrast with the contemporary romanticism within the 'human potential' movement, which tends to see reason as cold, unnatural and alien to nature. Reason, for many of the personal growth aficionados who emerged from the 1960's, was likely to cut you off from your authentic self, your natural emotions, your intuitive knowledge of your inner and outer worlds. The Stoic view, on the contrary, was that we were beset with mundane, short-term desires. These could corrupt our perceptions and judgement. Will power was needed to see beyond our baser instincts and to develop self-discipline. Maturity of perception and self-control were in our best longer-term interests. They were also best for the society to which we belonged as active citizens. Everyone, according to Stoic philosophy, could therefore live the 'good life' since its achievement consisted in our finding not so much the 'inner child', as in contemporary parlance, but in developing, cultivating and committing to the 'inner adult'." (Howard, 2000; pp63-64).

Hear, Hear!!! I have seen congruence used as an undisciplined 'acting out', a thoughtless and selfish expression of whatever is in the mind of the therapist at that time, with this being viewed as an authentic cri de couer. "I was only speaking my mind", the naive therapist protests when anyone challenges their use of 'congruence'! Personal authenticity on the part of the therapist is viewed as a virtue in and of itself, with no reference to aims, intention or consequences. Based on Romantic notions of self and growth, this egotistical approach to congruent behaviour reminds me of the psychobabble spouted by those who suggest that we are solely responsible for our own feelings. Within this skewed view of behaviour I cannot state that you are making me angry, but am instead encouraged to take personal responsibility for the ways I am 'angering myself' as a response to your behaviour! If you insult me I cannot therefore claim you have hurt me, only that I have chosen to take your insult personally! The idea that someone can say or do anything they like without having any responsibility for the emotions this may produce in the other is palpable nonsense, and plays very well into the hands of those who could use 'congruence' in an irresponsible and unethical manner.

Trainers, therapists and supervisors do their respective clients a disservice if they fail to encourage a thoughtful self-discipline and maturity around their use of congruence. While some trainers support therapists to make this differentiation, others have assumed a laissez-faire approach which has meant practitioners have completed their training valuing personal authenticity above their responsibility to the other. Many of the problems I have discussed relate to poor training or poor self-development and maturity in the therapist. Being 'congruent' is not the same as spontaneously acting on our feelings or (very commonly) our frustrations. Stoicism, with its emphasis on mature reflection and self-discipline rather than immature, egotistical 'authenticity', can provide a useful counterbalance here. My own supervisor was enormously helpful to me when she helped me differentiate between 'reacting' (i.e. having a knee-jerk response to something provocative) and 'responding' (i.e. processing and attempting to understand my feelings, thoughts and experiences in the context of the therapeutic relationship). For example, if I am feeling exasperated at the helplessness I experience with a particular client, it may be 'congruent' to react by expressing my frustration and impatience, but that does not mean that it is therapeutic or even ethical to do so. If I can instead recognise my frustration and consider what this might be telling me about my experience of this client and/or their situation then I am in a better position to respond in a way which will help forge a therapeutic relationship rather than break it. My therapeutic response might then be to recognise the level of helplessness this client experiences in their world, and instead of impatiently or aggressively confronting them with my feelings (which assumes that can do anything with these other than feel guilty and responsible), I can instead put my perspective back to them in a genuine, empathic and acceptant manner: "I'm aware of how truly helpless you feel, like you can't move in any direction. How does it sound when I say that?" Or I may become aware that I experience the client as rejecting of me, or not wanting to 'take' anything from me, so that all my offerings are seen as insignificant or inadequate. Then I can raise this in a questioning, curious way with the client in order to explore it. There is a discipline involved here; doing some internal processing of my experience before deciding on a therapeutic course of action, rather than a hasty 'acting out' on the basis of my frustration or difficulty.

Mearns and Thorne (1999) recognise the danger of 'splurging congruence', which they believe results from therapists having restrained difficult emotions for some time before finally blurting them out with force and abandon. I would add that, in my view, splurging congruence may also be immediate rather than long-term; where the therapist has paid insufficient attention to the potential damage which their 'congruent' expression may do.

However, my preference for a disciplined congruence and authenticity does not mean that I want to show a 'blank screen' to clients, which is often really an evasion of responsibility for our impact on the other, nor does it mean I would encourage therapists to avoid sharing difficult or challenging perspectives with their clients. What I am suggesting is that congruence and authenticity have to be disciplined rather than impetuous; in the service of the client rather than the egotistical outpourings of the therapist; aimed toward fulfilling the client's therapeutic needs rather than the therapist's. It is about finding our personal style of therapy; being authentically ourselves while also being in the service of the Other. Being genuine for the sake of the Other, not for its own sake.


REFERENCES
Howard, A (2000). Philosophy for Counselling and Psychotherapy: Pythagoras to Postmodernism. Basingstoke, Macmillan Press.
Mearns, D. and B. Thorne (1999). Person-Centred Counselling in Action (2nd ed.). London, Sage.