But some therapists worry that helping a client explore all aspects of their feelings about their gender or sexuality could be misconstrued as ‘conversion therapy’. This fear is explored by Paul Mollitt in our ‘Big issue’ article on therapists’ attitudes to working with trans clients. But they also take pains to stress that treatment method is important: ‘It remains a matter of judgment and methodology on how much each contributes, but there is virtual unanimity that both the relationship and the method (in so far as we can separate them) “work”. Looking at either treatment interventions or therapy relationships alone is incomplete. We encourage practitioners and researchers to look at multiple determinants of outcome, [and] particularly client contributions.’ Timeliness of support is also important, and here too, the Bereavement During COVID study showed that people faced difficulties and long waiting times to get help, exacerbating their isolation and potentially impeding their ability to process their loss. What helps is revisiting and talking about the death, the loss, again and again – whether that is with a therapist, a volunteer supporter, or with peers. Given the scale of probable need – unsurprising, given the massively increased exposure to bereavement stressors – how do services meet it, and in a timely way? John Wilson is Director of the Bereavement Service at York St John University Counselling and Mental Health Clinic (CMHC), and an honorary research fellow of the university. He set up a Facebook group for people bereaved by COVID in the very early weeks of the pandemic. It was, he and colleagues decided, the best way to reach people who would be needing help now and, moreover, because it was online and so global, would be a resource that would be available 24 hours a day every day; given time-zone differences, someone somewhere would be there for people to talk to at any time of day or night. Bearing witness to dementia and holding an embodied awareness in dementia relationships is a political call – we are summoned both personally and professionally. In this last reflection on the film, Jonathan Wyatt, Director of Counselling and Psychotherapy at the School of Health in Social Science, University of Edinburgh, speaks of this kinaesthetic and affective call:

Another highlight of this issue for me is our ‘Experience’ piece, in which Max Marnau, a BACP senior accredited counsellor, shares the dilemma of whether to ‘come out’ to clients about her late diagnosis of autism. She also questions why therapy for autists still focuses on helping them conform to a neurotypical world. Is there a significant message here for the counselling profession? There is, says Cooper, an understandable wariness among person-centred counsellors about questioning Rogers’ six conditions and the fundamental client-led ethos of the person-centred approach. But, he argues, the research tells us this may not be what some clients want or find useful, and ethical practice demands that we listen to what clients say they want. ‘It is often assumed as a fixed position that it is the relationship that heals, but that’s not what the evidence always shows. It’s great if a therapist wants to be non-directive and work from a wholly relational stance, and there is evidence that it can really help some clients, but those practitioners need to be clear that it may not suit all clients, just as CBT doesn’t suit all clients.

A sense of loss and disorientation is not uncommon in psychotic experiences generally and is a common feature of the advanced stages of dementia. This sense of loss exists in a tangled web of self–other relationships. 16 What happens when, inside the therapy room, we bear witness to a life’s unravelling? A body’s unraveling (snap – lost)? Loss of tangles and plaques – the ruthless biological process that biomedical science is labouring to impede. Norcross and Lambert have also helpfully summarised what it is about the therapy relationship that is ‘demonstrably effective’: the therapist-client alliance, collaboration, goal consensus, therapist empathy, positive regard and affirmation, and the recording of client progress data. 4 The supreme compendium of data on the effectiveness of relational factors in the talking therapies is Psychotherapy Relationships That Work, 3 which is based on the findings of the Third Interdivisional APA (American Psychological Association) Task Force on Evidence-based Relationships and Responsiveness. Now in its third edition, it is in two volumes: Evidence-based Therapist Contributions, edited by John Norcross and Michael Lambert, and Evidence-based Therapist Responsiveness, edited by John Norcross and Bruce Wampold. The book brings together findings from 18 vast meta-analyses of data on what makes talking therapies effective.

Her aim with this book is to encourage people to recognise that they are resilient, they are able to come through such losses, by drawing on their own and others’ strengths and support. ‘The counselling profession is very much needed for people who have depression and are suicidal and so on. But for the rest of us, what we need is psychoeducation,’ Boss says. ‘I believe it’s information that will help people to cope with the natural stress that comes out of an unnatural situation. There are long waiting lists for professionals and we need to know that not the entire population needs to go into a therapy room. There aren’t enough therapists to do one-to-one therapy and nor can many people afford it, so you need to give out psychoeducational material so they can help themselves and each other.’ However, she is not an advocate of passively sitting and waiting for the client to take the lead. ‘For the lay person, therapy can be an uncomfortable experience, particularly for people who are working class, because of the mystique around it. So it’s good to establish with them what would be a good outcome from therapy for them. But what we end up working on very often isn’t the issue that brings them through the door. Often it’s very much more flavourful – attachment issues, how they were loved or unloved, self-fulfilling prophecies, humiliation – how all of these feed into their personal lives. I articulate to clients that in unknowingness I have seen magnificence unfold that neither I nor the client could have predicted. I see what naturally emerges, which takes me into a space of spontaneity, listening as their lives are unfolded to me and reacting to what they bring.’ Neimeyer R, Lee SA. Circumstances of the death and associated risk factors for severity and impairment of COVID-19 grief. Death Studies 2022; 46(1): 34–42. As a CBT practitioner, he uses exposure to challenge the avoidance: ‘What is striking in research is that a strong predictor of complex grief is the fear people have of the intensity of their pain – they endorse statements saying the pain would be unbearable, too intense. Such catastrophic misinterpretations or phobia-like predictions are strong predictors of complex or prolonged grief. CBT is about targeting that avoidance and gradually confronting the loss, the irreversibility, the pain, the implications, but very gently, at the pace of the client, which is central to the approach. CBT asks the client to test these fears. We don’t aim to take away the pain; we try to turn the unhealthy grief into healthy grief that people can live with. So the grief doesn’t necessarily decrease but people learn how to build their activities around it and are less preoccupied with their loss.’ I think young people are often not well supported in terms of their autonomous thinking. School is often really prescriptive and that doesn’t help young people to think for themselves. I approach working with young people with the attitude that they are the expert on themselves and I have some potentially helpful ideas and information that I might share with them with their permission. It is a subtle difference; I am offering information, not giving advice.’She says coaching is frequently misunderstood as highly directive and technique based. ‘Yes, coaches often have a toolbag of frameworks to use, but we also need to have the discipline to be focused on the person in the room and give them space to think – not reach for this or that tool and think this will fix them. That’s not our job. The tools are a way of helping them to explore things further for themselves. And you are always listening for their strengths and for the resources within them as well as the pain and suffering.’ Another gay woman told me she started a relationship with a trans woman and that the therapist ‘was so fascinated by my partner’s genitals and experiences I had to stop the session, and remind her I was the client, not my partner’. For me and, I am guessing, for thousands of other practitioners, reading Yalom’s books provided a beacon of hope during the early years of training, promising that, at some point, all this hard work would pay off in the creation of human connections like no other. It seems that, at the age of (almost) 90, Yalom is still creating those connections. Don’t miss our extraordinary ‘Big interview’ this issue.

Our cover theme, the ‘Big issue’ report ‘Riding the waves’, assesses the impact of the predicted post-COVID mental health tsunami and confirms what many of us know from our own practice – that it’s the most vulnerable in our society who have been most impacted. In this article, we ask what needs to happen now to minimise the effects. I am aware that Therapy Today’s readers work in a wide range of settings and with a variety of modalities, but if we are BACP registered or accredited, one thing we all have in common is monthly supervision. Given that this is mandatory and a regular expense, it makes sense to get the most out of it, so this month we launch a new column to answer a common supervision question each issue. The first looks at the benefits of pre- and post-supervision reflection. Says Emily Harrop, one of the lead researchers, ‘People described the distress and guilt caused by being unable to say goodbye and provide comfort to their dying relative; parents also described the added confusion and upset caused to their children by being separated from grandparents before the death. Having unanswered questions, regrets and doubts made it harder to process and reconcile their feelings surrounding the death, and these difficulties were reflected in the numbers of participants – some 60% – reporting high or fairly high needs for help dealing with their feelings about the way their loved one died.’ My mum was suffering from dementia. She was diagnosed in 2017 and we had to move her into residential care in December 2019. Then COVID came and I couldn’t visit daily, as I’d been doing. Then I got a call saying they’d got COVID in the home, and I knew it was a matter of when not if Mum got it. They called me on Friday 10 April to say she’d got a cough and they’d called 111 and been advised to treat it as COVID.We operate GDPR-compliant contracts with any third party involved with the journals, including designers and printers, which cover how data is handled and how long it is retained. Department of Health. 2010 to 2015 Government policy: dementia. London: www.gov.uk/government/publications/2010-to-2015-government-policy-dementia He has found worryingly high levels of PGD among the COVID bereaved. Using the Pandemic Grief Scale, which he developed and validated with his colleague Sherman Lee, he found that more than two-thirds of a sample of some 850 people in the US who were bereaved by COVID were experiencing what he calls ‘the shadow pandemic of dysfunctional grief’ and would benefit from specialist interventions to help them make meaning of their loss, both of the death itself and the surrounding circumstances, including the mourning and funeral rituals. The key mechanism in people’s recovery is the exchange of stories. People can’t make sense of the death – because they weren’t there, they had to rely on reports from healthcare staff, they’ve been denied the eulogies and conversations after the funeral – it’s delayed grief and, as the research has found, people aren’t recovering. But we have been monitoring participants in our Zoom groups that we’ve also been running, using an Assimilation of Grief Experiences Scale that we developed to measure how well participants are beginning to accommodate their loss into their lives, and it’s clear that, even when the rest of their lives are still difficult, and they may be struggling with their anxiety and depression as shown on the PHQ and GAD scales, their relationship with the deceased and making sense of the death steadily improve. We are seeing changes and adaptation in the people in our groups.’

This short multi-layered film speaks, sings and dances the lived experience of dementia. If, as witnesses, we become baffled in trying to solve the puzzle of the, at times, peculiar and other-worldly narrative (and imagery) of I Can’t Find Myself, it is because we are not looking, feeling or listening hard enough. Because dementia is peculiar, other-worldly and alienating. Most importantly, the film highlights that dementia is unavoidably an embodied, relational and affective experience. One of the key problems for LGBT people, especially those living outside big cities, is the difficulty of being able to easily connect with people with the same experience. Sometimes when they do, because that community is made up of many traumatised people, often drinking and partying, it can sometimes not be the most welcoming place. The need for authentic connection is vitally important. For some of the men who have attended A Change of Scene, a monthly discussion group for gay and bi men facilitated by Simon Marks, it’s their first experience of sitting with a group of other gay men and discussing their lives, even though they have been out for 20 or 30 years. Marks also runs group therapy for his clients, which he believes can particularly help gay and bi men connect. He believes one upside of the pandemic may be that more support has become available online. ‘A Change of Scene, as well as many 12-step LGBT meetings, are now being held on Zoom,’ he says, ‘which means people from across the country can access them who might not have been able to before. I hope this continues when the pandemic is over.’ However, not every therapist has had a negative experience. BACP registered therapist Katie Rose, who has set up a Facebook group for UK therapists working for BetterHelp to share tips, says you can make it work for you: ‘Yes, clients can message you at any time of day, but you don’t need to respond at any time of day. I respond during my normal working hours. The system does pester you if you don’t respond within 24 hours but you’re not expected to respond immediately or at the weekends,’ she says. ‘Plus, you do get paid for messaging so for me, there is an incentive to respond.’ I am also delighted to bring you a heartfelt account of finding meaning after loss, written by David Kessler, the US grief specialist who worked with Elisabeth Kübler-Ross on her famous books about grief. He describes how no amount of knowledge prepared him for the impact of the sudden death of his 21-year-old son. But through his experience of surviving more pain than he ever thought imaginable, he offers valuable insights both for practitioners and for anyone personally dealing with loss.Harrop E, Selman LE. Bereavement during the COVID-19 pandemic in the UK: What do we know so far? Bereavement, 2022; 1: https://doi.org/10.54210/bj.2022.18 Taking outcome measures can help validate a client’s sense of distress – that they really do need help, which for some is important if they are to engage with therapy. Continuing to do so then provides a measure of progress, or an alert that progress has stopped. But McInnes’ own main reason for doing it originally was curiosity, he says. ‘I wanted to know how I compared with the overall effect rate. What’s my effect size? I’d be disappointed if therapists had no curiosity to know what difference they are making.’ Collaborative meaning making is, of course, an intersubjective process: one of mutual recognition where we can shift between being in relationship as well as observing relationships around us. In the dementia relationship, as with any traumatic experiences, the capacity to observe breaks down. Therefore, as therapists and carers, the intersubjective question we may find ourselves asking is, ‘How can I remember for the person living with dementia?’