In comparing and contrasting two different contexts where counselling skills are used, I am going to use the examples of:
an LGBTQ+ organisation that offers counselling alongside other services
caring for the elderly
I have experience of both receiving counselling from an LGBTQ+ organisation and caring for the elderly. I had a number of therapy sessions through Yorkshire MESMAC, renowned as one of the oldest and largest sexual health organisations in the UK but also offering services including counselling to LGBTQ+ communities, diverse ethnic groups, people misusing drugs, and sex workers. From 2016-2019, I was a full-time unpaid carer for my elderly parents, both of whom developed forms of dementia, one also suffering from delirium. Obviously, these two scenarios are very different – with the former I was a client, the latter I was the caregiver – but I am able, looking back, to see how each situation involved someone taking responsibility, exercising care, and presenting with empathy.
The LGBTQ+ counselling organisation
MESMAC provided an environment that would be familiar to anyone attending counselling with any organisation: the client is referred or makes an appointment directly, attends a building, enters a room set up to facilitate the nurturing of a therapeutic alliance, is invited to go through a helping contract and reach agreement on the terms of it, is provided with an hour of therapy for each subsequent session while being assured of confidentiality.
I attended therapy sessions at one of their offices. There were no obvious signs outside the building that an LGBTQ+ organisation was situated therein but once inside I immediately found myself in a welcoming and professional environment with posters on walls that clearly told me this was a safe space for people in my community.
As a client I felt safe in this professional environment sat opposite a member of my own community. This sense of safety and shared belonging assisted in the development of the therapeutic alliance and was necessary to encourage my opening up to the counsellor. There were many things said by me at the time that I believe only another gay man who lived through the same points in history could fully understand.
I have no doubt others could have had empathy and been able to recognise the psychological and emotional impacts of being surrounded by aggressively anti-gay messaging in society and the media, before anyone thinks I might suggest otherwise. I do not. I just think, as a client at that time, I was confident the man sat opposite me could ‘get’ where I was ‘coming from’ without needing lessons in social and political history or what it truly feels like to have lived the life of someone outside the parameters of conforming to the prevalent hetero-orthodoxy of the 1980s and 1990s.
An LGBTQ+ client attending an LGBTQ+ counselling agency having been assured they will be seen by someone who is the ‘same’ in one fundamental regard means, in a sense, disclosure has taken place before the therapist and client have the opportunity to even meet. I found this helpful as a client.
My counsellor was qualified and experienced, reassuring me that he was competent and knew what he was doing. Our sessions were every two weeks, which gave me time to reflect upon each one before attending again, while the fact that getting to and from the office involved travel allowed me space before and after to psych myself up and wind down. Inevitably, I often felt emotionally raw with old memories at the front of my mind when I reached the end of the session, needing to process and reflect. I always, however, felt safe in the presence of my therapist and secure in the knowledge that I was fully accepted and largely understood. The counselling I received was person-centred, with few questions from my therapist other than when seeking clarity.
This clearly demarcated client/therapist scenario taking place in a professional context away from my everyday life was a markedly different experience to that in which you have an at-home carer with vulnerable person(s). And yet, there are similarities as well.
The at-home carer’s use of counselling skills
You are largely left to your own devices when you are caring for a family member in your own home. Many people caring for vulnerable relatives at home report feeling abandoned and forgotten by the authorities. This was largely my own experience. Social workers would drop by occasionally for fleeting visits but the feeling of being on my own was omnipresent.
My father suffered from vascular dementia for almost a decade before his death, which was an unusually long time as it normally imposes on sufferers for around five years on average. Apart from practical day-to-day challenges, he did not present much in the way of emotional and logistical difficulties. He was not aggressive or prone to mood swings. He was mostly gentle, forgetful, understanding and cooperative when it came to things needing to be done for his benefit, like bathing, getting dressed and mealtimes.
My mother, on the other hand, suffered from dementia for only the last four years of her life. What type of dementia Mum had was never ascertained, either vascular like my father or Lewy Body, the latter hard to diagnose and only confirmed through a post-mortem if carried out. It was complicated by intermittent episodes of extreme delirium.
Mum’s expressions of delirium could involve fantastical stories that were sometimes nightmarish in content with her expressing agitation, frustration, hostility, and anger. Before she moved in with me after my father’s death, I would routinely be woken in the night by phone calls from the police and emergency services responding to my mother having called them to report imagined burglaries, assaults upon myself and thefts of her imagined lottery winnings by almost every other member of the family. Every week my mother would claim to have won millions of pounds, only for my sisters and brothers, nephews and nieces, to have raided her bank account and taken all the money. She even claimed, on more than one occasion, that my eldest sister had dug up my father’s coffin to steal the treasure he was buried with.
Many of these stories subsequent to my mother’s passing can be told with a wry smile at the sheer absurdity of them, marvelling in the abstract at the strangeness manifested by a brain in crisis. At the time, however, they presented huge emotional and physical challenges around the clock, seven days a week. They made the job of being her carer exceptionally demanding.
I was unaware throughout the time I cared for my mother at home that I was using counselling skills by instinct whenever we had conversations. But I was. I would often, for example, use reflection and paraphrasing in response to the things she said; I would respond to statements aiming to encourage calm consideration on her part.
An example of the conversations we had is below:
MUM: “[Names my eldest sister] came round last night and poured paint all over your car. Did you get it off?”
(This was an imagined event, of course. Mum and my eldest sister were estranged after a falling out. They had not seen each other for a decade.)
ME: “It must have been someone else’s car, Mum. Mine is okay. That must have been upsetting, though. How did it make you feel?”
MUM: “Well, I was angry.”
ME: “Okay. What calms you down when you get angry like that?”
MUM: “I made myself a cup of tea and phoned you.”
(She hadn’t phoned me.)
ME: “Did we talk? I don’t remember.”
(We had not and I knew this.)
MUM: “Well, we did.”
ME: “Okay. What did we talk about?”
MUM: “What she did! You told me you’d come over but you’ve waited until today.”
ME: “I probably went back to sleep. So, you say that [my sister] poured paint over a car you thought was mine and that upset you. You made a cup of tea and called me. We had a conversation. Is that right?”
MUM: “Yes, that’s right. What are you going to do about it?”
ME: “What would you like me to do about it?”
MUM: “Call the police and get her arrested!”
ME: “Okay, I can do that. Will that make you feel better?”
MUM: “It will!”
ME: “You’ve asked me to call the police and I will do that for you. Are you okay with that?”
(I wasn’t about to call the police but these ‘necessary lies’ are sometimes essential to calming a person with delirium.)
MUM: “Yes. That’s what I want. Can I have a biscuit?”
(The conversation would be diverted and the story would not be brought up ever again. Mum was happy as a consequence of how I handled it.)
In a situation like this, caring for a vulnerable elderly person, it is evident that counselling skills are secondary to the physical acts of care. Nevertheless, the skills are there: being able to actively listen, reflect, and paraphrase while not judging.
As is the case when working as a counsellor, being a carer requires a great deal of empathy. Counselling skills – whether innate and instinctive or learned in a structured way by having done courses – are useful in helping people with dementia and delirium to process their feelings and reduce their emotional burden. They help carers to identify what the vulnerable people in their care are feeling, wanting and needing. In the above example, I looked behind the fictional story my mother told and recognised she was feeling insecure. She wanted reassurance that I took her seriously and would do as she asked. As soon as her sense of having authority was restored, all the anxiety dissipated and she switched to more benign conversation.
There are fewer boundaries involved in the relationship between a carer and a vulnerable person needing care, than there are in a standard therapeutic alliance. When the person you are caring for is a loved one such as a parent, the carer can find themselves uncomfortable and distressed at times. Outside of a care home where professionalism and qualifications determine emotional distance from the tasks that need to be performed, doing those things for someone who raised you and whom you love is challenging in a unique way, requiring of you that you develop some degree of distancing without training.
Similarly, while there is a clear separation between the therapist and client, things are considerably more fuzzy when conversations take place between a son and his mother. I was long accustomed to how conversational exchanges would go between myself and my mum over the course of my lifetime. However, when she developed delirium I found there were times when the conversation would, through what my mother said, transgress established familial norms. For example, my mother took to candidly referencing sex and using coarse language. I had to adapt. My mother had never before said rude things but now she did. The familiar was still present but the unfamiliar, when it manifested, could be shocking and upsetting, at first. It stopped being so.
Unlike in professional counselling – which involves the meeting of two strangers agreeing to enter into a working relationship that has clear rules and boundaries – conflicting roles and responsibilities are always present when you are caring for an elderly parent with dementia and delirium. You cannot refuse to engage with a vulnerable person who lacks capacity and is being offensive or aggressive in a given moment in the same way that you can terminate a therapeutic alliance when a client becomes threatening.
There was never any period of time when I could ‘just’ be the carer. I was always the son as well. My mother was never a patient or resident. She was always my mother. I was carer-son, a hybrid I had never been before and never will be again now that both my parents are dead.
I was unaware of boundaries as a topic throughout my time as an at-home carer. I simply did whatever needed to be done to assist with love and respect. A professional carer working in a care home is undoubtedly helped in maintaining boundaries by the need to travel to and from work, in much the same way as a counsellor. For me, my workplace was my home. The living room in which I would make sure my mother was comfortable every morning, sat in front of the television with her breakfast on a table next to her, was the same living room in which I slumped onto the sofa after settling my mother down for the night in her bedroom.
Learned counselling skills are essentially about acquiring an understanding of how people work in terms of their feelings and thoughts; how those can be affected by experience. For example, we learn about how early childhood experiences shape us. To a significant extent, lifelong loving relationships provide us with deeper understanding of those we love than we have when it comes to strangers. This deeper understanding is what I am really talking about when I refer to innate or instinctive counselling skills. We are there for those we love when they divorce, if they lose a baby, when they have an accident, and so on.
In those situations, most of us express empathy and listen. We counsel. A counsellor has gained through an educational process a knowing awareness of these skills and when to use them, but their ability is greatly enhanced when they come to the profession with a lot of life experience behind them. It is often this life experience that leads them to consider counselling as a career in the first place. This was certainly the case after my mother died, when I decided I wanted to continue using my empathy and care to help others.
The aim of the counsellor is to encourage the client’s journey towards greater self-awareness, confidence, self-belief, wholeness and healing. A successful therapeutic alliance will result in a lessening of anxiety and a reduction in the power of triggers to effect upset and disruption. Beyond the physical responsibilities of the carer, they too seek to encourage and promote well-being, reduce anxiety, and help the vulnerable through listening, engaging in conversation, promoting social activities and the recall of happy memories, by steering them away from triggering memories and fantasy scenarios. As with the therapist/client alliance, the carer/cared-for relationship involves engagement in the form of attentive listening, reflection, paraphrasing and gentle questioning to increase understanding and alleviate distress.
An interesting question I found to reflect upon was whether I would have better served my mother and my own self if I had undertaken a course in counselling skills at some point prior to her and my father needing my help. I do not think so. I did the best anyone could have done. To rephrase that, nobody could have done better. What I do know is that my decision to study counselling resulted from my experience of using my care and empathy to look after my parents. I knew that counselling would be very different to caregiving but in one sense was the same, being fundamentally about helping people.
There are a multitude of ways in which we can seek to make the world a better place by supporting others and alleviating their distress. Caring, be it professional or at home, is one. Counselling is another. The focus of this essay has been on those two but a question you, as the reader, might want to ponder is: what other professions or personal situations make use of what we group together and call counselling skills?
Thank you for reading.