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Effective Short-Term Counselling within the Primary Care Setting

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This book covers two distinct yet related topics: the primary care setting and the counselling carried out within it, and it can be dipped into or read straight through.Part One, using psychodynamic and systems theory, explores the holding environment of primary care, the interpersonal relationships within the primary care team, and other variables affecting counselling in a medical organisational setting.Part Two takes the counsellor through the 'how' of using psychodynamic and Cognitive-Behavioural Therapy (CBT) approaches within short-term contracts in this setting. Case studies and scenarios are given to illustrate these. The counsellor is guided through assessing the patient's counselling needs either within a psychodynamic or CBT model or to formulate a 'tailor-made' short-term contract, using elements drawn from psychodynamic, CBT, and supportive counselling.

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13 Chapters

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CHAPTER ONE: Setting the scene of primary care counselling against the backdrop of a rapidly-evolving NHS service

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This chapter tracks the progress of counselling provision in primary care against the backdrop of the history of the NHS and the rapid changes which have occurred over the last two decades.

We will begin by looking at how changes in the NHS over the past twenty years have affected and continue to have an impact upon the service as we see it today.

Stability and change in the NHS from the late 1940s

Probably most people would agree that the inception of the NHS in the late 1940s was “the best thing since sliced bread”, especially in the aftermath of the Second World War, a time when the public purse really was tight. We must never forget those years before the NHS, when even basic healthcare was only for those who could afford it.

What has changed? If the reader is over sixty years of age he/she may remember just how it was and recognize that things have changed out of all recognition. The period from the late 1940s until the late 1980s was a time of relative stability in the NHS, and one could argue that, in that time, it was an improving service. That time of stability can now be seen in stark contrast to the rapid changes that have occurred in the past twenty years.

 

CHAPTER TWO: Valuing what you bring to the primary care setting as an experienced or newly graduated counsellor

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Containment of anxiety

The ability to contain anxiety is central to counselling work within the primary care setting. The extent to which a person/counsellor can tolerate and contain anxiety is drawn from circumstances of personal growth and development. This is enhanced in the case of the counsellor by an adequate clinical training. This ability to contain anxiety, your own and that of others, does not mean that you will never feel anxious, as anxiety is a normal response to certain situations and part of the human condition.

The perceived and often accepted role of the GP surgery within the community, and, in particular, that of the doctors employed there, is to provide a safe place and foster the belief that within that place there is a knowledge of, and a capacity to cure or control, emotional problems and mental ill health. This perception often has the effect of containing an individual patient’s anxiety and often, additionally, their family’s anxiety. It may also have the effect of containing the anxiety of surgery staff.

 

CHAPTER THREE: Introduction and induction into the GP surgery

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When first being employed or entering a placement in a GP surgery, the counsellor may need to take proactive steps to elicit the services of the lead GP or the practice manager to carry out a formal introduction to the staff and to the workings of both the building and the organizational running of the practice. Knowing how everything works and knowing who to ask for help and information can go a long way towards helping the counsellor feel confident and informed from the beginning. For instance, in some surgeries, there may be a separate waiting area for counselling, or the counselling room may be in an area quite separate from the general workings of the surgery. In this instance, the counsellor may have very little contact with the receptionists, and consequently they may not know who you are when a patient asks to see you. This is easily remedied with a little effort from the counsellor. You may or may not have access to a computer that is linked to other computers in the surgery, and it may be by computer screen that you will be alerted when your patient arrives.

 

CHAPTER FOUR: Finding your place in the medical organizational “family”

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The primary care setting can be viewed as a “family”, comprising all the family dynamics and systems normally found in an extended family (Reeves, 1998).

This section gives the reader guidance in reflecting upon how their experience of their family of origin can influence how well they begin to find their feet in the surgery. For example, think about whether your family of origin was a patriarchal or a matriarchal family. What was your position in the family, and where were you in the pecking order? Did you feel heard and significant? Was anger expressed actively or passively? In order to make sense of some of your responses and reactions within the primary care setting, it is worth spending time thinking about the above in some depth.

Also remember that the “history” of the organizational setting of the surgery “family” will affect your arrival as a new counsellor. You will be walking on to the stage of a drama that is under way and where all the cast have their roles in place (Dalal, 2001).

 

CHAPTER FIVE: Medical model vs. psychological model

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Communication

The medical model differs from the psychological model in many ways, not the least of these being in the area of communication, where different words can have different meanings in each model. I look at five words that may have different meanings in the two models: symptom, confidentiality, containment, boundary, and treatment. To avoid confusion, it is important that the primary care clinical staff have a grasp of the difference in these meanings.

In the medical model, a symptom is usually a feature that indicates a condition or disease. This may be pain, rashes, etc. Palpitations and sweaty hands could be caused by a condition of disease or by anxiety. Even when no organic origin can be found, these symptoms are often treated as though they are organic in origin and are medicated. The prescribing of medication, even when the GP suspects that the symptoms may be psychological in origin, is often the doctor’s first line of treatment.

This is often done even when there is a counsellor on the primary care team, as doctors and patients alike see symptoms something to be got rid of.

 

CHAPTER SIX: The primary care counsellor’s support systems

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Your effectiveness as a counsellor in any setting can depend considerably upon how well you feel supported. I divide this section into two: external support and internal support. External support is just as it says, relationships, structures, and systems which are in place for the counsellor, with the internal support being the counsellor’s inner world and its projections. I cannot stress strongly enough the counsellor’s need of personal support systems. The counsellor is a human being, and, as such, is prey to becoming emotionally vulnerable at any time.

External support

Professional support comprises collegial and peer relationships, CPD (continuing professional development), and membership of accrediting and professional bodies. In the primary care setting, staff alliances and knowledge of the unique culture of the medical organizational setting are very important. Last, but not least, your accrued body of knowledge and experience in your subject will support you.

Never forget that when working in primary care, you are subject to the same group pressures as everyone else working in that setting. You may become just as competitive, resistant, and reluctant to expose your failures, weakness, incompetence, and insecurity as the other members of staff, but you are likely to be more self-aware and have understanding of the unconscious processes at work. This self-awareness and understanding is part of your support system.

 

CHAPTER SEVEN: Whose needs are being met?

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This chapter is about recognizing whose needs are being met by a referral to counselling. This assessment of need may begin before the clinical assessment of the patient.

The GP’s needs

As I have mentioned earlier, a patient’s symptoms, emotions, or behaviour can arouse distress and/or unease in a GP, other referring member of staff, or a patient’s family members. Sometimes, it is difficult to divine whose distress is actually being displayed. By this, I do not mean that the patient is not distressed, but he/she may be containing and/or acting out a family or marital problem; in other words, they become the person identified as the patient. Sometimes, this is obvious to the GP treating the patient, and some useful work can be done, in consultation with the counsellor, to try to identify the best course of action and/or therapy for the whole family or couple, in addition to helping the “identified patient”. The identified patient may be unconsciously containing and displaying strong emotions and conflicts for other members of his/her family. I use the word “contain” here referring to the term and meaning contributed by Bion (1962a,b, 1970), that of “container– contained”. I elaborate on this concept later in the text.

 

CHAPTER EIGHT: Time and how we use it: assessing what is appropriate for the patient

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By whichever model of counselling the reader is guided, this seems a good place to talk about the importance of time. Most counsellors agree that the concept of time is important and that we, as humans, are not just as we seem in the moment, but that our lives are influenced by our past experiences as well as our ideas about our present and future. Whatever we wish to call this phenomenon, our behaviours are not only ruled by our conscious thoughts and feelings. We, as therapists, have a duty of care to embrace this concept fully for our patients. As Mann says, “One way of understanding the failure to give time central significance in short forms of psychotherapy lies in the will to deny the horror of time by the therapists themselves” (Mann, 1973, p. 10).

Mann believes that any time-limited therapy must recognize that child time and adult time are in the counselling arena, that is, children experience time differently from adults. This fact can give rise to powerful conflicting reactions, responses, and expectations, as the inner child of the person wants and expects as much time as he/she needs, whereas time in the adult world is often rationed and limited. For example, if we are making a meal that requires several ingredients and we discover that one crucial ingredient is nowhere to be found, we may swear or kick the cat. Most people would agree that this behaviour falls within the bounds of normal. But, for some people in certain situations, their reactions may be excessive and harmful either to themselves or someone else.

 

CHAPTER NINE: Assessment

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The counsellor working in primary care should think of him/herself as an apprentice with each new referral, where he/she is learning from the patient in order to facilitate them in their journey.

As stressed earlier in the text, a thorough assessment is often key to the successful outcome of counselling in primary care. This assessment may begin before the person enters the consulting room, as the counsellor may glean useful information from the GP’s referral letter.

Burton (1998) suggests a set of inclusion criteria for brief therapy. Her first suggestion is that the patient must also be suitable for long-term counselling or psychotherapy:

•  can respond to an interpretive approach;

•  is able to work in the transference;

•  has sufficient ego strength—no risk of ego diffusion or disintegration;

•  no history of gross acting out, such as repeated suicide attempts or life-endangering behaviour;

•  not currently heavily dependent on drugs or alcohol;

•  no active psychosis or part psychotic episodes;

 

CHAPTER TEN: Use of psychotropic drugs, their probable impact upon counselling, and their side effects

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This chapter is taken from the BACP information sheet P8, 2005, written by Rachel Freeth, which she produced to provide an introduction to psychopharmacology for counsellors, psychotherapists, supervisors, and trainers (Freeth, 2005). I have included additional information supplied by the Depression Alliance.

Drugs are often prescribed with the same broad aim as counselling and psychotherapy, that is, to improve psychological functioning. The primary care counsellor will come across patients who are taking drugs, and this may be a concern to counsellors who are new to working in a healthcare context. It is useful, therefore, to have some knowledge about psychotropic drugs, including why they might be prescribed and their potential benefits and harm, and possible side effects that may affect the emotions or normal everyday functioning.

What is psychopharmacology?

This is the name given to the scientific study of the chemical receptors to which psychoactive substances bind, of the levels of these substances that are achieved in the brain, and of their effect on psychological functioning.

 

CHAPTER ELEVEN: The contract

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Within the primary care setting, the largest percentage of referrals for counselling present as depression and/or anxiety. If the GP writes a referral letter, he/she will normally state the symptoms that the patient has presented in consultation. As the counsellor becomes more experienced and begins to be able to read between the lines of doctors’ referral letters, he/she may be able to glean what is underlying those symptoms. GPs develop styles of referring that can give many encoded clues.

Some symptoms of depression and anxiety are normal reactions for any person when something is experienced as “at odds”, out of balance, or confusing, either physically or emotionally, in their life. At this point, due to our dependence upon the NHS in our society, it is quite usual to consult with our GP as our first port of call when we feel unwell in a way that is not normal or manageable for us. Also, most GPs who employ a counsellor within the primary care setting will tend to refer anyone who requests counselling to that counsellor rather than to an outside agency or private practitioner. When a trainee is on his/her clinical placement, his/her mentor or a more experienced counsellor within the setting may have screened the patients that they are allocated to counsel. It is important that this screening takes place in order that a trainee works within their competency. Unfortunately, not all mentors offer this service.

 

CHAPTER TWELVE: Approaches to different categories of patient and presenting problem

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Due to the nature of the setting, the counsellor in primary care will see patients who fall into many different categories; similarly, with the nature of the problems presented.

All the issues that are covered in Chapter Four may be presented by any one of the categories of patient examined below. The counsellor will need to adapt their approach to each.

In primary care, the counsellor is working at the “coalface”, where the client base will be different from those seen in private or agency counselling and is often more challenging. Counselling in this setting is free at the point of need, and, therefore, money is not an issue. For most patients referred to the surgery counsellor, this will be their first experience of counselling, and because paying for counselling will not have entered their heads, only a relatively small proportion of surgery patients find the motivation to move on to longer-term private counselling, even when they agree with the counsellor that it would be the best course for them.

 

CHAPTER THIRTEEN: Waiting lists, endings, and referring on

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As in all counselling, endings are very important, but in short-term counselling the ending is present all the time as part of the work and needs to be kept continually in sight in the counsellor–patient partnership.

When, how and where to refer a patient on

As with the above, referring on is a very important area that needs to be borne in mind by the counsellor throughout the work. For appropriate and successful referring on, the primary care counsellor must research what facilities there are in their working area and what might be appropriate for different types of client. Henderson (2007) points out that it is important that counsellors have a good grasp of which patients they are competent to see within the constraints of their service, and who they need to refer elsewhere. There are other types of help or support available for people who have emotional problems. Many voluntary organizations run support groups and self-help networks where a person can meet people who have similar experiences. It is helpful both to the counsellor and patient if he/she researches which of the above is available in their local area. There will be counselling agencies that offer a graded fee structure, some of whom will be able to offer counselling to people on state benefits. Many patients who need longer-term counselling or other types of support only need the counsellor to “walk beside them” while they do the research for themselves. In affluent parts of the country, many patients will be able to afford private counselling or psychotherapy, and it is useful if the primary care counsellor points them in the right direction by offering the details of several options. If a person has private health insurance, this widens the field of possible help.

 

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