13 Chapters
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CHAPTER ELEVEN: The contract

Garrett, Valerie Karnac Books ePub

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.

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

Garrett, Valerie Karnac Books ePub

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.

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CHAPTER SEVEN: Whose needs are being met?

Garrett, Valerie Karnac Books ePub

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.

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

Garrett, Valerie Karnac Books ePub

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.

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CHAPTER NINE: Assessment

Garrett, Valerie Karnac Books ePub

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;

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