Essays 

By Eman Shah. 

The life of a CYP (Child or Young Person) crisis practitioner can look drastically different depending on the day. Christmases, New Years’ Eves, Friday nights and the first Monday after half term break, among the busiest times of the year and each different from the next. If you go into this line of work, I urge you to prepare yourself. The nature of safeguarding comes with more complexity, urgency and responsibility than standard therapeutic practice with adults, as CYP are legally and systematically more vulnerable. The work requires knowledge and proficiency in different approaches, and you will find yourself putting on a systemic practitioners’ hat for the very basics of a risk assessment. Occasionally, you will feel like an investigator, a social worker or a specialized therapist – before reminding yourself you are neither one of those professionals, and you will subsequently draw boundaries. This will be difficult to do as the family looks at you with hopeful eyes, cognizant of the impossible waiting times to see other professionals, you will be tempted to be one stop shop for your service user, but will find a way to kindly, almost lovingly tell them what you cannot offer. You will learn this in quick time. 

In crisis, you will be responsible for being a one-time de-escalation practitioner, for being a front door to specific, specialized and appropriate services. Your responsibility is to:

1. Bring distress levels down,

2. Get the relevant information,

3. Conceptualize a plan (for the family).

A mental health crisis is generally described on paper as a steady increase in symptoms reaching a point that is adversely affecting one’s daily functioning or causing them to be at risk of harming themselves or others (National Alliance on Mental Illness [NAMI], 2023) Statistics for the ongoing downward decline in general CYP mental health is “detailed, considerable and overwhelming” (Doncaster Council, 2022, p 108). Lest we forget, we are still reeling from the aftermath quakes of a debilitating global pandemic that families suffered through, which included nationwide lockdowns, a very real fear of illness and possible bereavements for survivors. The aftermath of COVID is still felt in assessment rooms today– may it be in the form of the precipitating (a specific event or trigger to the onset of the current problem) factors of wellbeing deterioration, physical health difficulties or general change of zeitgeist (à la remote working/education, COVID babies, etc).

On the ground, crisis can look like depressive symptoms that have increased in intensity and frequency, to the point of active self-harming, chronic anxiety and chronic suicidal ideation. Past a prodromal stage, it may lead to attempts to take one’s life, challenging behavior (such as physically hurting others, disruptive behaviors) or addiction to substances. The thread that ties it all together is the inability to regulate one’s emotions, either internally (regulating one’s own thoughts) or externally (regulating responses to others’ thoughts and behaviors).

Occasionally, crisis will come as a long impending consequence of abuse. In this instance, the practitioner has an omnipresent 4th responsibility:

• To swiftly safeguard the CYP.

This is significantly more complicated than safeguarding an adult due to a myriad of reasons. You will meet CYP who are not ready to disclose specifics of events, rendering you helpless in attempting to make referrals that will meet thresholds for social care or specialized support. You may meet CYP that would disclose events that are below threshold for abuse however still worrying – and they would not like you to break confidentiality. There are cases where the family needs social care support however parents do not consent. Or occasionally you may have very real concerns however the CYP has not disclosed anything explicitly worrying. Sometimes parents of CYP will refuse to consent to referrals due to previous bad experiences with local safeguarding systems. You will probably meet a lot of families that have very little if not any faith in the system due to their previous experiences. You will have to offer them an apology and reiterate the same protocol like a helpless telephone customer service representative. A good practitioner will acknowledge their previous experiences, offer reassurance and problem solve in unique ways which may including escalating the case. Each case will be different, and the only way to reach a good decision would be to collate information from all possible avenues and discuss with your clinical team. You may need to outweigh pros and cons, with the ultimate goal of CYP safety – all while making decisions and having uncomfortable conversations. In one of my safeguarding cases, I had to “come out” to the CYP’s parents regarding their sexual orientation due to the very real possibility of sexual exploitation. Of course all other avenues were exhausted until there was no other possibility; however as a practitioner the process may leave you with a feeling of dejection, just as it did for me in this case. You take this feeling home with you.

The practitioner holds responsibility to untangle all possible layers of complexity to understand the reasons for difficulty and identify any key areas of (clinical) risk. The challenge is to untangle just enough to determine whether this is a risk or not, in order to conserve time, not delve in too deeply and further distress the CYP, and to refer to specialists accordingly.

Untangling the layers of complexity (add link to pages of statistics)

If you add the possibility of neurodiversity, the flow chart expands and the possible causes of behavior become more complex. For example, CYP with neurodiverse needs are more likely to harm themselves when in distress. (Autistic adults with no learning Disability are 9x more likely to die by suicide than the general population) This makes things much trickier. However over time the first wave of neurodiverse acceptance identified key behaviors that acted as indicators of Autism or ADHD. This was an immense help for practitioners and they developed schemas accordingly. In the second wave however, self-reflective practitioners are finding themselves confused among the midst of misdiagnoses, overlapping symptoms and comorbidity. This acts as a real reminder that we are barely scratching the surface of the spectrum of neurodiversity.

Furthermore, when adding in the complexity of race, gender identities and sexual orientation to an age group where puberty is a biological milestone, with the very real drivers of hormones, social relationships unraveling, unyielding uniform educational structures, familial difficulties and identity formation, it adds layers on layers of pressure. This results in a higher likelihood that the young person will struggle, especially if there are limited tools for them to utilize as support.

Tools

Here tools refer to contextual factors, strategies and protective elements that may support the person to cope. In understanding these tools, we must address the predisposing factors. These can usually be; however are not restricted to, socio-economic status, race, genetics, parental wellbeing levels and their general understanding of mental health. Well-adjusted children would have been acquainted with general wellbeing, understanding, methods of coping (either taught or learnt by observation from carers) and encouraged to be curious in their sense of development.

When we zoom out of the family structure, secondary tools can look like Schools, and the pastoral support or SEN they offer. It may also be the wider family network or close friends’ network. Tertiary tools can look like safe spaces within the community, or the wider social network.

When CYP are unable to access or deprived of most of these tools, this makes it more difficult for them to cope with life circumstances, hence increasing the likelihood of them being affected by mental health crises. As we continue to untangle to the grassroots, we reach the questions that ask what is barring us from providing equal access to these tools?

Trickle down effect

Hospitals, community mental health centers, mental health charities, schools are underfunded. This results in less staff, and even less qualified staff. It also restricts people from acquiring regulated required by regulation.

In the world of mental health, we have the prestigious accredited courses gate-kept. The elusive DClinPsy, that qualifies Clinical Psychologists needs to be funded by the NHS. The experience needed to be accepted consists of particularly roles that are in in plenty vacancy, they are underpaid for the work they do, support worker roles (averaging 11.7 pounds / hour) and assistant psychologists (averaging 26k per year, notoriously so in demand that people often do them for free, with the title of honorary assistant psychologists). Mental health workers, care workers and doctors are all reaching a nation-wide work burn out and protesting for higher pay. They are overworked, often working multiple roles in one single employment, taking extra shifts, underpaid and absorbing the emotional waves of a population that is overtly suffering from medical or psychological ailments.

This feeds back to practitioners requiring mental health support themselves. Samaritans reports a high rise in mental health workers calling their services. On a personal level, it desensitizes practitioners, and they are reprimanded by KPI’s, service user feedback and quality assurance about not being able to give one hundred percent, one hundred percent of the time. The stakes are high as well, one miscalculation in crisis, one important question missed, one thing not assessed or not recorded can lead to major repercussions. “In general, healthcare professionals are more prone to stress and professional burn-out, because they are responsible for human lives and their actions – or lack of action – can have a serious impact on their patients.”

This creates a cocktail of internal and external pressure, set for a burn out, for mental health concerns and eventually, physical health concerns. “Healthcare workers are experiencing high stress and burnout, at rates up to 70%, hindering patient care.”

The very real worry of Coroner’s Court also looms close by. Whispers are heard of how the experience can leave a practitioner dejected. I was once told by a practitioner that it was “the worst thing I ever had to experience, in my 30 year career as a Registered Mental Health Nurse.” In bright lights, its stated that Coroner’s Court is not a process that places any blame, rather attempts to understand the gap that may have been overlooked that resulted in a death. However people’s experiences prove it to be different. It has been said that it simulates the pressures of a trial, with the court looking to place blame decisively. There are claims it is harsher on people of color.

For individuals that once prided themselves in providing structured support to another, they are now afraid they may make a mistake and that will cost someone their life.

Structured support to another

As mentioned earlier, providing structured support can look completely different depending on the day. It may require making sure they have eaten, had a drink and calmed down before we can discuss anything. As supervisor of my work place, in line with the operational practices the aim was to make the space to play a part in the therapeutic de-escalation process. This experience is elevated via audio, visual and tactile stimulation. Calm music in the background, different options for visuals in the sensory room and multiple materials accessible to fidget or play with to support de-escalation. As my director usually said, “the de-escalation has already began”.

They are then guided to a soft-lit room, where they are given some information on who the practitioner is, what they do and what support they will be offering. This is crucial to CYP, especially children. They are often overlooked when “adults are talking” and might feel they have not been given enough information on what is going on. They follow their parents lead and meet new people and answer questions, all the while not really knowing what the issue is, why it needs to be addressed and how it is going to be addressed.

Then the gentle probing begins. Sometimes CYP jump in headfirst into their life story, and it is then the practitioner’s job to selectively? listen, extract important information, ask the right questions at the right time. They may interject, comment, react and allow them a level of catharsis and connection.

Other times CYP responses are a jumble of ‘I don’t know’s’ and shrugs. Here practitioner responsibility lies in building rapport, ensuring they feel safe and comfortable and trusting the process that reminds us that when young people feel safe, they will be able to reach out for support.

And it is this faith and trust in safety that is the heart and epicenter of therapeutic intervention. That safety is simultaneously a birthright and our most complex challenge to provide to everyone in our community and care.

By Eman Shah.

This essay was written by the complete list of moving parts in me: an able bodied, fairly educated, working class, Muslim Pakistani immigrant in the U.K, a cisgender, heterosexual woman in her mid-twenties (alright, late twenties) working in healthcare. With some parts blessed and others handicapped, some filled with awareness and others with blind spots, they create their own unique combination of ‘cards dealt on the table’, ready to be made use of or to be weighed down by. 

In this paper, I aim to use these parts to recognize, peer into and dissect the issues stemmed from power, privilege, culture and how these affect “therapy relationships” (Proctor, 2017, p. vii). This will be in light of the need for diversity in our beloved profession. As ever, I attempt to do this with reflexivity and brevity. 

Definitions in Context

Power: an inherent imbalance of influence, with one party having more over the other. Proctor (2017) discusses how it arises from societal structures at play, placing the therapist in a position of authority. Spinelli (2007) similarly discusses the asymmetry of power due to therapists’ ‘expert role’. This is also in context of therapists’ influence over what is considered ‘normal’ (Foucault, 1980, as cited in Proctor, 2017). Foucault (1980) defines power as a verb, as opposed to a noun, establishing that at its very core, power is something that is “exercised over” and exists “in action” (Foucault, 1980, p.89).

Privilege: refers to the benefits gained, or disadvantages avoided by having implicit or explicit power. This is usually in the context of social, cultural and economic status through race, gender, sexuality and how they intersect and interlock (Crenshaw, 2017).

Culture: the norms and way of being of a particular group or society. This can often be used as a playground for power and privilege to be “exercised” (Foucault, 1980, p.89). In therapy relationships, this can be done by therapists who attempt to enter the client’s world from solely their own worldview possibly denying the client’s reality, and risking the quality of therapeutic practice (Sue et al., 2022).

Therapy relationship: Relationships based in therapy with a therapist and client(s). This paper aims to keep this term distinct from ‘therapeutic relationships’, following Proctor’s (2017) definition which highlights the detriment in assuming all therapy relationships are therapeutic. (p. vii)

Therapeutic relationship: This paper defines this as a professional relationship that is based on trust, collaboration and exploration between the therapist and client(s), leading to meaningful changes in worldview for (but not limited to) the client(s). This definition is most similar to the one given by Yalom (2002) where he underscores co-creation and its dynamic nature. 

Service users/clients/patients: Individuals accessing therapeutic services. Although these terms are used interchangeably, it is done so with gratitude and respect for these individuals that lead rich, multifaceted lives and the trust they put in practitioners to learn from them (Shah, 2025).

Everyman and Everywoman Stories

“There is no such thing as a single issue struggle because we do not live single issue lives” (Lorde, 1984, p. 138). 

Past is Prologue  

Try as we might to separate ourselves from the rope that ties us to our woeful history, it is still tightly wound around our profession today. Since its inception psychotherapy has made extensive efforts to analyse and treat the ‘powerless’, consequently expertly positioning itself as the ‘powerful’. The inescapable psychodynamic theory (Freud, 1900) stitched itself into our foundation, hailing unconscious conflicts as the driving cause for behaviour, whereby assuming service users were completely unaware of the ‘underlying’ difficulties that led them to seeking professional help. This had originated from work with hysteria patients, which was a common mental diagnosis at the time, particularly for women, and was usually treated by acute methods, such as sedating, restraining or lobotomizing patients (Foucault, 1965). Symptoms of hysteria can now be understood as trauma or repressed emotions (Berrios, 1996). Later, cognitive behavioural therapy (CBT) was famously influenced by Seligman (1975)’s work on learnt helplessness, which theorized that individuals who had low perceived control over their circumstances were prone to depression. These models of thinking and treatment stripped patients of their own personal agency (Charland, 2020).

At the time, the profession knew of little else outside a medical model, as the founding fathers (Sigmund Freud, Alfred Adler, Carl Jung) were psychiatrists. This created an inherent dynamic of skewed power and authority between one who ‘needs to be fixed’ and the other who is the ‘fixer’. Later critique likened psychiatry to the Inquisition due to the ability of this dynamic to act as a vessel for the state. This was done by use of coercive control, seizing patient will and further employing mental health sanctions (Cooper, 1967, as cited in Proctor, 2017) leading to cultural iatrogenisis (Illich, 1976).  Even now, the Mental Health Act (1983) allows certain practitioners to section individuals against their will, raising extensive issues of systemic racism, discrimination and neglect (The Guardian, 2018). Additionally, multiple reports over the years have uncovered systemic abuse against vulnerable sectioned patients in institutions (The Independent, 2022; Norfolk Safeguarding Adults Board, 2021)

A Double Edged Sword

Proctor (2017) discusses how these patients are usually oppressed groups in societal structures. For example women, non-white races, poor communities, disabled individuals, queer communities, and gender non-conformists. She argues that higher prevalence of oppressed groups in institutions mirror the amount of power held by the institutions. Having worked extensively with the unemployed population in London, I could see how this manifested. My service users were primarily oppressed by the socio-economic system. This was further compounded by lack of access to healthcare and education. The government had made this program mandatory as part of their scheme to get people back into employment, and this led to service users feeling frustrated at being forced to seek support from my team. Taylor (2017) describes these programs as coercive and highlights the punitive nature of these employment strategies in the U.K, stripping individuals of their autonomy. This dynamic would be in direct conflict with the British Association for Counselling and Psychotherapists’ (BACP) Ethical Guidelines (2018) which lists client autonomy as a principle, and yet I met many BACP practitioners practicing in this context.

A by-product of my role here was that I could influence service user health and housing benefits, which could in turn affect their life in significant ways. I was an educated practitioner; this was my Ace of Spades, a high card, and I was aware of the power it gave me in this role. As a postgraduate, this distribution of power and responsibility was not a surprise to me, as it was made understood in my clinical focused training. What did surprise me was a sense of specific responsibility I felt for the South Asian community; to those who perhaps did not speak English as well as I did, and consequently were left out of important conversations that affected their livelihood. This was due to the unique position of privilege I was in, to bridge the gap with my fluency in several languages and ability to understand cultural and colloquial terms. Johal (2017) found that multilingual practitioners shared this sense of responsibility and usually attempt to operationalize a culturally competent practice. 

The weight of this duty was made clear to me when I began a therapy relationship with a Punjabi speaking Afghan woman who had absolutely no clue why she was in the program and why she was meant to see me. Silently cursing my younger self for being embarrassed of my parents speaking Punjabi (this language is primarily spoken in villages and considered uneducated), and for not having learnt the language diligently (I could understand the language but struggled getting my point across), I contemplated calling the translator service. From experience, I knew the challenges of using telephone translators, (Robertson, 2014) an issue immigrant groups regularly face. So I took a deep breath and watched the words as they poured out of me with accuracy, lighting up the room in bright shimmery gold, (Shah, 2024) enriching the therapeutic relationship. With a grateful heart, I later learnt that "… (speaking the client’s language) serves as a leveller of power and a way of mirroring and showing empathy.” (Costa, 2019, p.19)

In the same job role however, I felt powerless as an immigrant woman; a lower card, meant to stay hidden or to be bluffed on. Honest reports of service user engagement and progress became tricky once I received my first threat of violence from an economically desperate older male service user. I became alerted of my visibility in the community I worked and lived in, vigilant on my routes home. Silverstein (1991) details in her case study how “The occurrence then of (sexual) harassment, reverses the power relations back to those of the traditional culture and the female therapist becomes again the object of the male patient's hostile action” (p. 5).

Additionally, I was in a KPI (Key Performance Indicators) driven environment, based on ROMS (Routine Outcome Measures). Engagement from service users reflected my performance, and rattled my job security with profound effects on my immigrant status. In this way, I believe, due to the pressure of making sure service users were engaged, what suffered the most was the therapeutic relationship, rather than one party i.e. therapist or service user. Franco (2015) discusses how these performance standards affect therapists poorly, locking them in the quality versus quantity predicament and Hatchett and Coaston (2018) highlight the negative effect of such measures on therapist’s job security and hence, their practice. 

Even then, the irony of the situation was apparent to me, I was scrambling to create meaningful therapy relationships with service users who were on benefits (ones I am not entitled to) as they watched me with rightful resentment, sitting in a high rise twinkling corner office in my (charity shop) office clothes. I had heard anti-immigration opinions, racist remarks, Islamaphobic statements and misogynist views in my therapy room, carefully prefaced with “this is nothing against you, but…”, and I had done so with the professional responsibility to lock away my private world where I could allow myself to interpret and respond. But later, on the walk home, as I unravelled, I would begin to unpick how it was not about me, but unfortunately, inadvertently, it was against me. 

While Proctor’s (2017) work discussed the need for cultural competency and awareness of power dynamics when working with diverse populations, it can occasionally feel unilateral and one dimensional. In my experiences detailed above, I found that the layers of power and privilege were entangled around therapist and client with varying degrees. Sue et al., (2022) discusses how these complexities of intersecting identities should be taken into account when understanding power and Falardeau (2002) further highlights the fluid dynamic nature of power in the therapy relationship that can be influenced by both therapist and client. 

To be an Organ and a Blade

“If a way to the better there be, it exacts a full look at the worst…” (Hardy, 1895-96, p. 447)

In all my therapeutic work experiences, I attempted to redirect power toward multidisciplinary meetings and tested my limits with my managers for service user benefit. I continued to maintain my empathy and unconditional positive regard (Rogers, 1951) and ensured consent and client-autonomy where I could. Despite this, the dynamic of ‘fixer’ and ‘one to be fixed’ was steadfast. Admittedly, I revelled in this analytic dynamic. And if I may say, I was good at it. I had consistently met all engagement and positive feedback targets, and enjoyed being someone who others looked to for answers, someone who asked thought provoking questions, structured sessions for solution focused work and ‘fostered insight’, like the founding fathers of psychotherapy I had read about as a young girl. It had made me feel knowledgeable, needed and appreciated. 

Upon reflection, I realize that I take this role on in my personal relationships as well. My friends have usually looked toward me for answers on a range of matters, from moving house, engagement ring designs to buying ‘the right bed’. I suspect (alright, I am sure) this has roots in my familial relationships, where I was the ‘baby of the family’, someone who never had to take the brunt of decision-making and consequently was not taken very seriously. 

This now-realized motivation (among others) for being a therapist is hardly ideal in the Person Centred universe, due to its dangers widely theorized (Proctor, 2017). Additionally, research now shows that structured and client-led approaches are almost equally effective for client progress as structured approaches like CBT (Barkham et al., 2021). With this confession, I worry if Carl Rogers would have me shunned from the community, if Scott Reeves could revoke my ‘fitness to practice’, and heart-rendingly, I am forced to inquire, if my beneficence “concealed something sinister,” (Triet, 2023). 

Exculpatory Evidence

In my very own self-incriminating trial, for my metaphorical defence, I would begin with the classic Altruism debate, in relation to psychological egoism (Mysterud, 1998) which deliberates whether any actions of benefiting others are solely for the other, or if every ‘giving’ action is rotten with intrinsic selfish roots. 

Soon after, I would argue that most mental health roles in the U.K require therapists to be directional as they mostly prioritize and use CBT or Dialectical Behavioural Therapy (DBT) based interventions, (NHS Digital, 2023; Cambridge University Press, 2023) which are considered structured and directive (Beck et al., 1979) and hence, the therapist holds more ‘power’. The nature of my roles included interventions that were usually time specific and CBT or DBT based, in the unemployment sector and in crisis. This resulted in a naturally directional approach. De Geest & Meganck, (2019) finds a similar correlation in their literature review, where therapists were found to modify their approaches to be directive to meet demands in limited time.

In addition to the time constraints and popularity of the structured approaches discussed above, a dilemma for practitioners when navigating power is one of credibility. Due to the Second World War, there had been an increase in need for psychological professionals and to help psychiatrists in the workforce, psychologists were trained and recruited to provide psychological testing. In the U.K, as the NHS was formed it was assumed that psychologists would be solely assessors and researchers, and would endeavour to help manage perceptions of psychiatry (Hall, 2015). This distinction between the two roles is imperative in understanding the current climate of power in mental health profession hierarchies. 

Despite years of jarring critique, psychiatrists earn considerably more than other professionals in psychology related fields (NHS Careers, n.d.). With recent research finding that due to their medical training and ability to prescribe medication, they are considered more “authoritarian” whereas psychologists are considered more approachable but that they dealt with less severe issues (Patel et al., 2017). This is further compounded by how the NHS mental health workforce primarily constitutes of mental health nurses (Evan et al., 2012). This highlights the deep-rooted dilemma mental health professionals still face, of recognizing the constraints and potential dangers of a monolithic, directional and medicalized model while simultaneously adhering to the system to legitimize their roles in professional and public perception. 

Further down the credibility continuum, sit counsellors, as reflected in salary disparity and employability, with psychologists and CBT therapists being paid more than counsellors on average (NHS Careers, n.d.) The NHS Benchmarking Network (2023) reported estimates of the psychological professions workforce, with clinical psychologists constituting as the largest workforce at 23%, CBT therapists at 20% and counsellors at 10%. 

These hierarchies in the profession are crucial to understand our established power structures, and Proctor (2017) discusses these comprehensively, highlighting the inferiority counsellors feel in multidisciplinary meetings, as evidence based short term approaches (such as CBT) are easier to evaluate, hence are researched more and favoured. She compliments this with a particularly astute analysis of IAPT services (Increasing Access to Psychological Therapies) now called Talking Therapies. 

Lastly, studies find that immigrants face barriers in establishing credibility in regard to credentials, employment barriers, visa-related challenges that affect their ability to practice (Al Achkar 2023; Migration Observatory, 2024). As a Pakistani immigrant, it is possible my search for credibility, my death grip grasp on my Ace of Spades, affects my therapeutic approach. 

Now, in the matter of my potential sinisterness, I enter into evidence: my hope that “perhaps continuing to ask the questions in ways that permit novel ‘mirrors’ to reflect and reveal uncomfortable truths will prove to be the best we can do” (Spinelli, 2001, p. 124).

Person Centred Therapy and I 

Around the same time as the Second World War, oceans away, as a psychologist in the United States was emerging, the idea of powerlessness as a result of social, cognitive or emotional barriers was introduced (Rogers, 1951). In contrast to psychoanaylsis’ idea of unconscious conflicts, he argued that humans had an innate drive to self-actualize, redirecting power towards individuals seeking help. As I began training in this philosophy, I found myself letting go of some of the responsibility I held of ‘knowing’ what to say. In triads, I found it incredibly freeing to not have the ‘answers’ and be able to be in the here and now. Geller (2010) discusses how this mindfulness fosters therapeutic alliances, and the importance of the present moment is emphasized in Person Centred work (Rogers 1961; Mearns, 1997).

Consequently, in my experience, the Rogerian non directive attitude has aided and abetted the unwanted power dynamics that can occasionally arise in therapy. For example, leading the session with a structure can often feel uncomfortable, dismissive or disrespectful. You find yourself rushing things along, or interrupting the flow often. Being allowed and in turn, allowing myself to have the session be client-led has alleviated the risk of possible micro ruptures in the therapeutic relationship that can arise when structuring a session, that would often need mending in directional approaches. Moon & Rice, (2012) discuss how the person centred approach allows space for power dynamics to be minimized. 

On the other hand, the experience of being a client in triads, and in personal Person Centred therapy has felt simplex. I have enjoyed having a space to discuss my failures and triumphs, I have especially enjoyed having a safe space to cry in front of another, however I am unsure if it has caused me to introspect on the changes I may need to make. This might be due to the “lace-curtain nature of triads”, or my very new relationship with my personal therapist, which might affect the degree of psychological contact made (Mearns, 1997, p.19). 

It might also be compounded with the difficult process of finding a competent Person Centred therapist where I currently live. In my pursuit to Person Centred supervisor, I have been disappointed. My realistic options for a supervisor were between a South Asian British woman who I thought would be culturally competent, however was extremely rude, and a white British male who has a history of informal complaints by young women. The former experience could possibly be explained by how the difference in class positions between British South Asians and immigrant South Asians can affect power dynamics (Sharma, 2021). The latter experience made me guarded as violations of boundaries are more likely to be crossed in opposite gender in therapy (Hook & Deveroux, 2018) Although there isn’t any specific research in relation to Person Centred therapists in my area, Elliott, Watson, and Greenberg (2013) discuss how therapists might engage in malpractice if they are unable to meet the core conditions of Person Centred Therapy (PCT). 

Although I understand the risk of parenting counselling trainees and the need to establish an “Adult-Adult” relationship in training (Mearns, 1997, p. 33) I found myself wondering if the lack of explicit training in skills contributes to malpractice in counsellors. Understanding Mearns (1997) skills curriculum was helpful for my person-centred practice, which provides a partial list of skills indicators, which I found imperative in my understanding of the client led theories. 

Nonetheless, I have been fortunate to have had culturally sensitive triads, fostering camaraderie and ally-ship amidst positions of privilege. Personally, I seek spaces like these as explaining the context of my specific culture can often be taxing. 

Previously, as client, I had experienced the heavy and vulnerable environment therapy can create, where attunement is key. Small reactions or behaviours by the therapist can lead to intense feelings of distress. An unusual experience I had when I was in my undergraduate degree, with an older male person centred counsellor shaped my understanding of the fragility of therapy. I had opted for private therapy alongside my undergraduate degree, to better understand the therapy room from all angles. A few rapport-building sessions in, I had gathered some courage to admit a secret fleeting suicidal thought. This was met with an unusual silence, a steely cold lack of acknowledgement. I reflect now proudly on how I responded, describing in detail how the silence was affecting me and how he appeared statuesque. But to no avail, my therapist did not speak for what felt like hours. I departed the therapy room soon after, and my departure from personal therapy followed. Even then, I understood how he might have been triggered and was unable to respond, however the lack of attempt to repair had fragmented the relationship deeply. This was the first time the importance of non-verbal communication in therapy (Westland, 2015) and its link to power dynamics (Ndoumbé Fall LMHC, 2023) was highlighted for me. 

Land of the Powerless (بے اختیار لوگوں کی سرزمین)

It is not lost on me, that in the same timeline in history, soon after the Second World War, my ancestors in South Asia were enduring the largest mass migration in history (Talbot & Singh, 2009), in order for a two state nation solution and decolonization from the ‘powerful’ British rule. During this traumatic time of displacement, resources were low and the ‘mentally ill’ were kept away in what they would call ‘mad houses’ often keeping individuals with challenging behaviours in chains (Gadit, 2007). These practices by which power is exercised are not uncommon across Asia (i.e., the Eastern Mediterranean, European, South East Asian and Western Pacific). Meshvara (2002) explains:

The reason for this lop-sided development of health care for the mentally ill can be traced to the development of mental health care in many of the poorer parts of Asia that came under colonial rule. The state of the art in mental health care, in the early 1800s and up to the late 1950s, was the mental asylum, usually situated far from the cities and towns, out of sight and often out of the minds of health care systems (p. 118).

The enduring legacy of this historical event had catastrophic implications for decades to come, with studies suggesting intergenerational trauma being passed down to survivors’ children and grandchildren (Kaur & Jaggi, 2023) which affects the collective South Asian diaspora (Qureshi et al., 2023). My first glimpse of these effects was through observing the only grandparent I had met, my Nani Ma (grandmother), who was typically a hard to reach, august matriarchal woman. But come night-time she would be reduced to a fearful delicate bird, a slave to her own shadow. Asking her grandchildren to check the locks repeatedly, only to check them twice herself before bed. A few years later I watched my aunt develop bipolar disorder and I began to understand mental illness in secret, as secret. I listened in on conversations related to her mania, depression and care plans, and the ever impending threat of ‘being taken away to the mad house’. Studies now show that the mere anticipation of tangible repercussions can have implications on patient autonomy (Halpern, 2023).

Treatment of support had also long taken form of ‘healing’ via religious or spiritual methods (Deva, 1999) and as I began my undergraduate degree these forms of treatment proved to be more challenging than ever for my scientism rooted beliefs. On an internship in the outskirts of my bustling city of Lahore, under the leadership of a psychiatrist, we were meant to deliver and administer medication to one of the ‘mad facilities’ governed by spiritual ‘Pir Sahbs’. As I placed capsules in plastic cups to give to chained patient-prisoners, I questioned petulantly how we could let this happen, and walk away. The look on the physician’s face was one of pity, for me and for the patient-prisoners. Looking back it might have been my last act as what could have been considered an ingénue – as I learnt an important lesson in understanding the unyielding and inextricable influence of political power over mental health systems, which results in a faith or belief in the population affected. He explained that these long standing systems, no matter how painful, have begun to provide stability, a source of faith, belief and meaning with association to divinity. This has led to obstinacy, because the alternate reality of years of persecution is too painful to bear. These powerful institutions are widely considered a major barrier to evidence based care in these areas (Peteet, 2019).

When All is Said and Done

Having long been programmed to be ‘eclectic’ by my mentor in undergrad, I have sought to learn a diverse range of skills. While working with different populations, and a lot of trial and error, I learned to adapt according to the client walking into my therapy room. I learned to shape-shift into different versions of myself, some stern and serious, others endearing and relatable. In my experience this has depended on age, gender and political opinions of clients and the person they think I am. These versions of myself are revealed depending on context, like Rogers (1959) Configurations of Self. For example, with older white British men and women, I found myself needing to become a more endearing version of myself to counter the distrust they might have in me. In other cases, particularly with middle aged men I have found I have needed to be sterner, especially when making boundaries (these are of course, not always the case). 

I struggled to find research to validate the former experience, as most research regarding cultural competency acquired a lens that focused on racial and ethnic minority clients, (Huey & Polo, 2008) and the voices of racial or ethnic minority therapists on the matter seems to be few and far between. In regard to the latter gender dynamic, research focused on sexual dynamics (Lukac-Greenwoord et al., 2021) seemed prevalent in a female therapist-male client dyad. It has also been theorized that it is important for women to avoid following a traditional gender dynamic for men in the therapy room where women may be at risk of falling into a nurturing role and ‘sheltering’ their male clients from vulnerability (Carson, 1981).

The pearl formed from years of therapeutic processing was the lesson to use certain skills when they were needed, and shelving them when not needed. For example, using a directional approach when necessary, such as in crisis and competently and neatly, placing it at the door during Person-Centred counselling. This was further complicated for me when I went for my first session as a trainee Person Centred counsellor. I had specifically joined a LGBTQ+ charity, in hopes of gaining more information and education in an area where I am privileged as a heterosexual, cisgender woman, and may have many blind spots. I was asked by my client to “ask more questions to prompt them,” this was followed by a sexual abuse incident disclosure. As I sat there, I remember finding it ironic that the skills I had prepared for were rendering me disconnected from the client and further caused them anxiety, such as allowing silences and allowing the client to find their own direction, and a part of me sprung to action. I asked questions, I prompted them where necessary, and I ‘held’ the space, letting them explore when they felt able to. I left that therapy room feeling more integrated as the therapist I was, and the therapist I’d like to be. I aim to spend my career in this pursuit of balance. 

The process of writing and structuring this essay highlighted to me the intertwining nature of power, more than ever. It reminded me that the work of relational ethics will continue to be fluid, just as the power dynamics it attempts to minimize. At this time in my career, I have not been able to gather the wisdom and expertise to be able to provide a clear, concise plan of action that might lead the way for a better therapeutic tomorrow, however, my recommendation to all practitioners, governing bodies and training institutions would be to “exact a full look at the Worst" (Hardy, 1895-96, p. 447). This may be done by giving minorities (gender, ethnic, race, sexuality, etc) platforms, extended periods of time to assimilate their grievances, reflections and anger in the community. In contrast to Barnett’s (2008) positive ethics, and in the spirit of Buber-ian approaches (Farber, 1967), the profession must be seen as the ‘I’ with ‘Thou’ referring to clients, therapists and trainers alike, with transparency. We have done incredible work on how the profession affects clients; however we must take a look at how psychotherapy affects all individuals in the profession, and hopefully, maybe, this in turn will help us hold clients firmly. 

Yalom (1989) reminds us: 

Though these (tales of psychotherapy) are abound with the words patient and therapist, do not be misled by such terms: these are everyman and everywoman stories. Patienthood is ubiquitous; the assumption of the label is largely arbitrary and often dependant more on cultural, educational and economic factors than on the severity of pathology… We therapists cannot simply cluck with sympathy and exhort patients to struggle resolutely with their problems. We cannot say to them you and your problems. Instead we must speak of us and our problems” (p. 14).