2
Counselling and Psychotherapy
Published and distributed by:
My Distance Learning College
Tel 0800 622 6157
Publication date
February 2010
Edition Number
06/2010
 UK Open Learning Ltd
All rights reserved.
No part of this publication may be
reproduced, stored in a retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying,
recording or otherwise without the permission of the publisher.
The author believes the contents of this course to be accurate
and correct, and all possible care has been taken in producing
this work, no guarantee can be given.
You should take
professional advice prior to making any decisions.
This
workbook should, however, provide you with good background
information.
3
4
Tutor Information
Joshua Cole MBACP
Joshua Cole is a highly effective Mental Health Professional, specialising in
the counselling and treatment of individuals with complex needs, including
personality, eating and dissociative disorders. He is passionate about helping
those who experience mental health issues, and possesses a unique blend of
entrepreneurial skills and business acumen, combined with exceptional
knowledge of the sector. He is regarded as an inspirational, visionary, leader
amongst peers and a 'safe pair of hands' within the wider profession.
Joshua founded and established the Registered Charity BPDWORLD in 2003,
a service designed and constructed to offer information, advice and support to
those afflicted with Borderline Personality Disorder (BPD). He is trained and
qualified to Post Graduate Diploma level in Mental Health (CBT), and is in the
process of completing a Masters Degree in Mental Health with the University
of the West of England. Alongside this worthy ideal, he is also currently in his
final year of a Social Work Degree, on course to achieve a 2.1.
Having completed a Master Practitioner award from the National Centre for
Eating Disorders, and Certificated in the Treatment and Diagnosis of
Dissociative Disorders, Joshua is an inveterate self-improver. Joshua studied
with
Professors
Anthony
Bateman
(Consultant
Psychiatrist
and
Psychotherapist, and Honorary Senior Lecturer at University College, London
(UCL), and Peter Fonagy (Freud Memorial Professor of Psychoanalysis at
UCL), to become certified in MBT (Mentalisation Based Treatment). This is an
innovative treatment for personality disorder which can be implemented by
nurses and other generic mental health professionals, making it generalisable
to other services in the NHS. He also studied Dialectical Behavioural Therapy
(DBT) with Dr. Fiona Kennedy. DBT combines standard cognitive-behavioural
techniques for emotion regulation and reality-testing, with concepts of distress
tolerance, acceptance, and mindful-awareness largely derived from Buddhist
meditative practice. It is the first therapy that has been experimentally
demonstrated to be effective in the treatment of BPD.
5
Joshua was previously commissioned as an independent consultant in the
role of care coordinator with the social services department of Gloucestershire
County Council. He also provided specialist long term treatment as a
psychosocial development worker for four years to a group of 15 women in a
low secure hospital. The women, who self-harmed regularly, were diagnosed
as having severe borderline personality disorder and considered a risk to
themselves and others.
Joshua
has
organised
conferences on
BPD,
which
have
included
contributions from key speakers and subject matter experts such as Professor
Anthony Bateman.
Contributions to various mainstream media presentations have included the
BBC radio programme "All in the mind", with Dr. Raj Persaud (Consultant
Psychiatrist and Gresham Professor for Public Understanding of Psychiatry),
and a documentary on BPD, which investigated the theories, causes and
treatment of the disorder.
Joshua is committed to promoting change within the mental health profession,
and contributing to the further education of fellow professionals. He has
authored several Open College Network-accredited training courses,
delivering up-to-the-minute knowledge and direction, and providing expert
commentary on key developmental issues and strategies, in the fields of both
counselling and mental health up to HNC-level. He has designed, developed,
and delivered distance learning courses for mental health professionals and
students.
This experience has led to the establishment of his own distance learning
establishment, MyDistance Learning College (http://www.mydistance-learningcollege.com), a UK Limited Company. This venture further expands the muchneeded flexible learning environment for people unable to attend full-time
tertiary education. Joshua has been granted the NCFE Investing in Quality
License, and the College has been awarded NCFE Approved Centre status.
6
In this section:
What is counselling and psychotherapy?
What is a counsellor/psychotherapist?
When is a counsellor not ready to counsel?
Who needs counselling?
Assignment one
7
What is Counselling and Psychotherapy?
The British Association for Counselling and Psychotherapy (BACP) defines
counselling as taking “place when a counsellor sees a client in a private and
confidential setting to explore a difficulty the client is having, distress they may
be experiencing or perhaps their dissatisfaction with life, or loss of a sense of
direction and purpose. It is always at the request of the client as no one can
properly be ‘sent’ for counselling”.
Many people find professional counselling beneficial as it provides them with a
regular time to explore and discuss their thoughts and feelings, as well as
work through any problems they may be experiencing with a person who is
impartial and not a friend or family member. Another important aspect of
counselling is that the issues discussed and explored in sessions by the client
and counsellor will remain confidential.
Although counselling and psychotherapy are similar in the way that they are
both ‘talking’ treatments with someone who is professionally trained to listen,
they also have their differences. Counselling, for example, provides clients
with the opportunity to discuss specific issues and difficulties they may be
experiencing. Psychotherapy, however, is usually used to deal with deeprooted issues, such as traumatic past experiences, which are causing the
client problems in their present life.
Despite the differences in counselling and psychotherapy, the main factor in
ensuring therapy is successful is the counsellor and client’s ability to work
together, rather than the approach used.
8
What is a Counsellor / Psychotherapist?
The law currently allows anyone to be a counsellor or psychotherapist, and
they can charge consultation fees, even if they have not had any form of
professional training. They can come from a wide variety of backgrounds and
may use some form of counselling as part of their everyday interactions with
others.
Nurses, doctors and those in the police, for example, often use
counselling skills as part of their work.
When choosing a counsellor, clients may find it extremely beneficial to
consider the training, accreditation, qualifications and experience of any
counsellor they are planning to see, in order to try and initially establish if they
will be suitable for their needs as a client. In addition to this, counsellors and
psychotherapists who are part of a professional body will have to abide by a
recognised code of ethics (see resource section).
When is a Counsellor not ready to Counsel?
A counsellor is not ready to counsel others when they lack self-confidence
and feel insecure in themselves and their abilities.
Alongside this, any
prejudice they may hold against a client, social distance they feel, or
preconceived notions regarding the issues faced by the client mean that they
are not ready to enter into counselling.
Who needs Counselling?
People need counselling for a variety of issues and at various stages in their
lives. The main focus of counselling is to help clients explore particular issues
or difficulties in their lives, which are causing them problems. It can help them
to discover new strengths and allow them to develop new skills, which they
9
can use to help them cope with any problems which may occur in their lives.
Attending counselling, therefore, is not an admission of weakness or failure; it
can help many people move forward with their lives.
There is a wide range of reasons why a person may attend counselling.
These include:
 Bereavement.
 Abuse and trauma.
 Depression.
 Relationship difficulties.
 Anxiety.
 Parenting difficulties.
 Assertiveness.
 Sexuality issues.
 Addiction recovery.
 Mental health issues.
 Anger management.
 Accidents or illness.
 Improving self-esteem.
Some of these areas will be looked at in more detail further in the course.
Although these questions are self assessed (answers can be found at the
back of the course) it is strongly recommended that you complete them as you
would a marked assignment. Please complete the self assessment questions
before continuing with your assignment. Answers to the self assessment
questions can be found at the back of the course.
10
Self assessment 1
SAQ1) Have a look through the following statements and circle the number
that best describes how you feel about it – be honest. After you have
completed it read through your answers, do you think that your answer would
have an impact on your counselling abilities? Are there any areas in your life
that would mean you would be a good counsellor? Are there any areas in your
life that you feel you need to work on before becoming a counsellor? Keep
your copy of this as you will need to refer to it later.
Strongly Agree
1
5
Strongly Disagree
I am as good as everyone else
1
2
3
4
5
I am aware of my personal limits
1
2
3
4
5
I am comfortable talking to strangers
1
2
3
4
5
I am happy to be me
1
2
3
4
5
I am not afraid to make mistakes
1
2
3
4
5
I can laugh at myself.
1
2
3
4
5
I don’t feel like an overall failure
1
2
3
4
5
I enjoy communicating to others
1
2
3
4
5
I get frustrated with others easily
1
2
3
4
5
I have a good knowledge of different cultures
1
2
3
4
5
I like myself as a person
1
2
3
4
5
I like to take risks
1
2
3
4
5
I often jump to conclusions
1
2
3
4
5
I respect myself
1
2
3
4
5
1
2
3
4
5
Men and women are equals
1
2
3
4
5
Older people are wiser than younger people
1
2
3
4
5
What others say to me has no affect
1
2
3
4
5
I would only socialise or mix with people from the same
ethnic background as me
11
12
Assignment one
1.1 Analyse
the
principal
distinctions between
psychotherapy and
counselling.
1.2 Evaluate the key requirements to be an effective counsellor.
1.3 Evaluate the conditions for which it would be appropriate to see a
counsellor or a psychotherapist.
13
14
In this section:
Cognitive Behaviour Therapy (CBT)
Hypnotherapy
Dialectical Behaviour Therapy (DBT)
Drama and Art Therapy
Psychotherapy and Psychodynamic Psychotherapy
Cognitive Analytic Therapy (CAT)
Person-Centred Therapy
Solution Focused Therapy
Eye Movement Desensitisation and Reprocessing (EMDR)
Gestalt Therapy
Assignment two
15
Cognitive Behaviour Therapy (CBT)
Cognitive Behaviour Therapy (CBT) is built upon the idea that cognition,
emotion and behaviour all interact together.
It is used to treat anxiety
disorders, delusional disorders, depression and eating disorders, as well as a
range of other mental health conditions.
The approaches to CBT are
described by the National Association of Cognitive-Behavioural therapists as
including: “Rational Emotive Behaviour Therapy, Rational Living Therapy,
Cognitive Therapy and Dialectic Behaviour Therapy”.
The aim of CBT is to break the cycle and replace it with a more realistic
approach.
Event
happens
Negative
thinking
Destructive or
negative
behaviour
Negative
feelings
http://www.cbtcounselling.co.uk
The foundations of CBT are based on the fact that our cognition affects both
our emotions and behaviour and therefore works by helping the client to
recognise destructive thinking patterns and replace them with more realistic
ones. As with psychodynamic therapy, cognitive behavioural group therapy
(CBGT) allows clients to interact with others who are experiencing similar
feelings, in order for them to understand that they are not suffering alone –
16
there are others experiencing similar thoughts and feelings as they
themselves are.
It is not uncommon for people experiencing mental health difficulties to
misinterpret situations or the actions of others that can result in the
development of altered patterns of behaviours and negative thoughts and
feelings. CBT can help with such difficulties as it breaks the problem down
into smaller, more manageable, areas.
The table below illustrates the way in which two people can perceive the same
situation in a completely different way.
Situation
A person has just submitted a report to their boss and
now their boss wants to see them.
Thoughts
Oh no! I did a really bad
/
job and I am in trouble with
Cognition
the boss.
Great, the boss liked my
report.
Physical Feelings
/
Psychological
Feeling sick, sweating.
Content, comfortable
Anxious and upset.
Proud and happy.
effects
Emotional Feelings
Walks into their boss’s
Behaviours
office apologising for
report.
Walks into boss’s office
smiling and relaxed.
17
Once a therapeutic relationship has been developed with a CBT therapist,
then specific areas of difficulty are identified. Using the model shown above,
the client and therapist usually explore one or two main areas of difficulty.
CBT tends to be a brief therapy over weeks or several months. The length of
therapy primarily depends on the client’s individual problems and the goals
they want to achieve through therapy. Therefore someone with severe
difficulties would very likely receive therapy over the course of several months
or more. The therapy sessions usually last for between 30 minutes and 1
hour, although the client is almost always asked to perform homework tasks
between sessions.
fortnightly basis.
These therapy sessions are usually held on a weekly or
Although CBT is mainly focused on the present, past
experiences may also be raised in order to understand how these are
affecting the client’s present life.
CBT has produced good results in effectively treating clients by reducing their
symptoms, and has a high level of relapse prevention.
It is therefore
recommended for use with a number of conditions, including clinical
depression and post-traumatic stress disorder (PTSD).
18
Hypnotherapy
Hypnotherapy is often used in the treatment of emotional and psychological
disorders, undesirable feelings, psychological disorders and unwanted habits.
The aim of hypnotherapy is to assist the client in finding more appropriate
ways of thinking, behaving and feeling, as well as allowing them to develop
ways of being more accepting of themselves and others.
In hypnotherapy, the therapist addresses the client’s subconscious mind, and
often requires the client to be in a relaxed state, although this is not an
exclusive requirement. The therapist will enlist the “power of the client’s own
imagination and may utilise a wide range of techniques from story telling,
metaphor or symbolism (judged to be meaningful to the individual client) to the
use of direct suggestions for beneficial change. Analytical techniques may
also be employed in an attempt to uncover problems deemed to lie in a
client’s past (referred to as the “there and then”), or therapy may concentrate
more on a client’s current life and presenting problems (referred to as the
“here and now”). It is generally considered helpful if the client is personally
motivated to change (rather than relying solely on the therapist’s efforts)
although a belief in the possibility of beneficial change may be a sufficient
starting point.”
Often however, a hypnotherapist will incorporate a number of other
therapeutic approaches and counselling skills when working with a client.
19
Dialectical Behaviour Therapy (DBT)
Dialectical Behaviour Therapy (DBT) has been defined as:
“A novel method of therapy specifically designed to meet the needs of patients
with Borderline Personality Disorder and their therapists. It directly addresses
the problem of keeping these patients in therapy and the difficulty of
maintaining therapist motivation and professional well-being. It is based on a
clear and potentially testable theory of BPD and encourages a positive and
validating attitude to these patients in the light of this theory.
The approach incorporates what is valuable from other forms of therapy, and
is based on a clear acknowledgement of the value of a strong relationship
between therapist and patient. Therapy is clearly structured in stages, and at
each stage a clear hierarchy of targets is defined. The method offers a
particularly helpful approach to the management of Para- suicide with a
clearly defined response to such behaviours.
The techniques used in DBT are extensive and varied, addressing essentially
every aspect of therapy, and they are underpinned by a dialectical philosophy
that recommends a balanced, flexible and systemic approach to the work of
therapy. Techniques for achieving change are balanced by techniques of
acceptance, problem solving is surrounded by validation, and confrontation is
balanced by understanding.
The patient is helped to understand her problem behaviours and then deal
with situations more effectively. She is taught the necessary skills to enable
her to do so and is helped to deal with any problems that she may have in
applying them in her natural environment. Generalisation outside therapy is
not assumed but encouraged directly. Advice and support are available
between sessions and the patient is encouraged and helped to take
responsibility for dealing with life's challenges herself. The method is
20
supported by empirical evidence which suggests that it is successful in
reducing self-injury and time spent in psychiatric in-patient treatment”.
1
Dr Marsha Linehan designed this treatment specifically for those that selfharm and have a diagnosis of Borderline Personality Disorder. DBT is
basically a combination of CBT approaches and the use of Zen (Mindfulness).
Patients with BPD present multiple problems, and this can pose problems for
the therapist in deciding what to focus on and when. This problem is directly
addressed in DBT. The course of therapy over time is organised into a
number of stages and structured in terms of hierarchies of targets at each
stage.
The pre-treatment stage focuses on assessment, commitment and
orientation to therapy.
Stage 1
Focuses on suicidal behaviours, therapy interfering behaviours and
behaviours that interfere with the quality of life, together with developing the
necessary skills to resolve these problems.
Stage 2
Deals with post-traumatic stress related problems (PTSD).
Stage 3
Focuses on self-esteem and individual treatment goals.
The targeted behaviours of each stage are brought under control before
moving on to the next phase.
Mental Health Help Net - An Overview of Dialectical Behaviour Therapy in the
Treatment of Borderline Personality Disorder
1
21
DBT consists of a hierarchy of targets in which the main goal of each is to
increase “dialectical thinking”. An example of such a hierarchy would be:
 Decreasing suicidal behaviours.
 Decreasing therapy interfering behaviours.
 Decreasing behaviours that interfere with the quality of life.
 Increasing behavioural skills.
 Decreasing behaviours related to post-traumatic stress.
 Improving self esteem.
 Individual targets negotiated with the patient.
In an individual DBT session, the targets outlined above should be dealt with
in that order. If in between therapy sessions, self-harm or any other incidents
have occurred; these must be dealt with first before the therapist moves on to
anything else.
Dialectical Behaviour therapy is separated into four parts, three of which the
client will experience.
Individual Therapy
In one-to-one therapy with a DBT therapist you will work on your selfdamaging behaviours and work to continually ensure you are following the
skills taught by the DBT course.
Group Work
Group work will help you to work on your social skills but also teach you new
skills from the DBT modules, and ways of implementing these.
22
Telephone support
Should you be feeling suicidal or as if you may be at risk of self-harm, then
you may contact your therapist or a member of the DBT team to discuss these
and work through your thoughts. You will be urged to apply your DBT skills
and techniques. You may only call between times agreed between your
therapist and yourself.
Consult group (for the therapists only)
You could also call it “group supervision”. This group would meet frequently
and is made up of all those who have trained to become DBT therapists. It’s a
place to let off some steam and to make sure you are working effectively and
efficiently, but also keeping to the model of DBT. The group will encourage
you to remain non-judgemental and validating of the person’s thoughts and
feelings.
So now you have a feel for the way the therapy works let’s go into the four
separate modules, working on increasing the quality of life of the sufferer.
Mindfulness
Mindfulness is considered the most important part of Linehan’s DBT skill
module. The mindfulness skills focus on "what" and "how" skills: "what" the
individual needs to do in order to be mindful and "how" to do this. For
example, a typical approach to developing the "what" skill would include an
intent and attempt to observe, describe and participate in open dialogue. The
"how" skill may require non-judgment, one-mindfulness, and collaboratively
determining what is effective.
Interpersonal Effectiveness
Interpersonal effectiveness skills that are used in DBT sessions focus on
assertiveness in saying no, making a request, and coping with problems. The
purpose of the Interpersonal effectiveness skills are to allow the individual to
increase the likelihood of goals being met, while maintaining self-respect and
keeping the relationship.
23
Distress Tolerance
Distress Tolerance is the skill-set for accepting, finding meaning for, and
tolerating distress. This area of DBT focuses on learning to bear the emotional
pain resulting from distressing circumstances and events in the individual's
life. An important focus in Distress Tolerance is the idea of radical
acceptance. Linehan describes radical acceptance as a means by which to
free oneself from suffering, and requires a choice to let go of fighting with
reality. These skills in "letting go" promote acceptance without judgment or
evaluation of the self, others or the situation in general. In theory, focusing on
the acceptance of reality rather than the approval of reality will foster a clearer
understanding of controllable vs. uncontrollable factors and help facilitate
manageability of emotional pain.
Emotional Regulation
Emotional regulation assists individuals with reducing their vulnerability to an
emotional state of mind. This is accomplished by providing methods to identify
and label emotions, finding barriers in changing emotions and applying
distress tolerance skills. The other key component of this skill set is to find
ways to increase positive emotional events through healthy living and
participation in activities that increase self-confidence.
DBT is an effective treatment for borderline patients but does have its
downsides. These include: The course being very difficult and requiring a lot of commitment;
 It excludes those with alcohol or substance misuse and those with
eating disorders, even though these groups account for a high number
of those with a diagnosis of personality disorder.
24
Drama and Art Therapy
Drama and art therapy are becoming increasingly popular forms of therapy
which are used as a treatment method for a wide variety of issues, such as
mental, social and emotional difficulties. Therapists specialising in this area
work in many settings, including child or adult psychiatry, learning disabilities,
forensic medicine and palliative care, as well as the prison service.
As with other forms of therapy, the relationship between the client and
therapist is of the utmost importance. However art therapy, for example, also
differs from other forms of therapy in the way that it is a three-way process
between the client, therapist and artefact / image created in the sessions.
Drama therapy is similar in the way that it provides a method of working and
playing, which uses action methods to facilitate creativity, learning, insight,
growth and imagination.
The overall aim of therapy, therefore, is for the
therapist to help the client communicate and express their feelings in a way,
which they may feel unable to do verbally, or who find other forms of therapy
too stressful.
Therapists need to possess a high level of knowledge and understanding of
art, music or drama, in addition to a secure knowledge of the strong emotions
which may be raised for the client through the therapy programme. Alongside
this, it is vital that therapists have a high level of self-awareness and as a
result, their training will also include personal therapy.
Psychotherapy and Psychodynamic Psychotherapy
Psychotherapy is defined by The Royal College of Psychiatrists as a
treatment, which involves “listening and talking, and understanding the
relationship between the people involved.
Each psychotherapy session
provides the opportunity to find space to tell your story, and be listened to.
The important part of this is establishing a healing relationship with the
therapist or the therapist and other members of a group”. In addition to this,
25
Psychodynamic therapy is defined as being “based on listening and talking. It
involves exploring past conflicts in relation to your current problems in order to
make change possible. It can be used in different formats: for example, group,
individual, couple and family. Therapists come from a range of theoretical
backgrounds, and therefore the exact nature of treatment offered will depend
on whom you work with.2
Psychotherapy focuses on deep-rooted issues that are causing a client
problems in the present life; this may include a traumatic past or issues of
child abuse.
Sessions are usually held on a weekly basis for around 50
minutes, although in group psychotherapy these sessions may last for around
90 minutes, or even longer for specialised groups. Others however, may be
required to attend sessions up to three times per week. Depending on the
needs of the clients, therapy may be short-term, lasting around three months,
or in longer-term cases, a few years.
Many people find psychotherapy beneficial, as it is generally regarded as
effective in reducing problematic symptoms, improving self-esteem and
relationships with others.
Cognitive Analytic Therapy (CAT)
Anthony Ryle developed Cognitive Analytic Therapy for the treatment of
Borderline Personality Disorder in the 1990’s. It looks into what has stopped a
client from making changes in the past in order to help them understand how
they can move forward in their present life.
It is often used to treat
depression, anxiety, personal or relationship problems, and eating disorders.
Through CAT, clients develop self-reflective skills in which they integrate
“unavailable dissociative parts of the self”. Therapists establish “which aspect
of the personality is maintaining dissociation, and which particular contrasting
self-state the client uses to respond. Initial mapping of self-states is carried
2
Royal College of Psychiatrists (2007) ‘Psychotherapy in the NHS’
26
out collaboratively between therapist and client. This is a dialogic, active,
problem-solving process which attempts to change destructive behaviour”3
The overall aim of the therapy is to help clients find new coping strategies
when their ‘habitual coping mechanisms’ make present difficulties harder to
deal with. The coping mechanisms used in past situations are focused upon
how they originated and how they can be adapted and improved.
The
strengths of the client are then used to help bring about change.
This
therefore, allows them to develop coping mechanisms, which can be
successfully used in the future to manage their lives.
CAT usually lasts for an average of 16 sessions and is usually an individual
treatment, although it can be successfully used in group settings. During the
sessions, clients are encouraged to observe the way they think about
themselves, the assumptions they make, and their feelings and behaviour. A
good outcome from this treatment is one in which the client develops the skills
necessary to become their own therapist.
Person-Centred Therapy
Person-centred therapy was developed by American psychologist, Dr Carl
Rogers and is an approach to counselling and psychotherapy in which the
main responsibility for treatment is based on the client rather than the
therapist. Within this form of therapy, the therapist will usually take a nondirective role.
Person-centred therapy has two main goals, which are to increase the client’s
self-esteem and to increase their openness to experience. For this to be
successful, clients need to develop a better understanding of their idealised
and actual selves, as well as a better self-understanding; lower their level of
defensiveness, insecurity and guilt; and to develop more comfortable, positive
3
Castillo, H. “Personality Disorder: Temperament or Trauma?”
27
relationships with others.
In person-centred therapy, clients are also
encouraged to voice their feelings as soon as they occur.
The term ‘self-actualisation’ is an important term used within person-centred
therapy as it refers to the human tendency to reach their full potential, grow
and move forward.
It focuses on human strengths rather than human
deficiencies. When developing person-centred therapy, Rogers found that
self-actualisation can be blocked by the client through unrealistic and negative
attitudes about oneself.
Person-centred therapy is most commonly used by counsellors and
psychotherapists who take an eclectic approach to their work, meaning it is
used with a wide variety of clients with a range of different problems.
Solution Focused Therapy
Solution based therapy was developed at the Brief Family Therapy Centre in
Milwaukee (de Shazer et al, 1986). It usually lasts between 3 and 5 sessions.
It is different from the other types of therapy as it does not look into the past or
causes of a problem, but focuses on how to achieve a desired goal. It asks
what the client wants to achieve rather than what they want to leave behind. It
is based on the fact that there are always exceptions, times you feel less
depressed, less anxious; and it looks into these exceptions to help form a
solution. Focussing and complimenting the client on resources and strengths
the client already has in place, allows them to realise these and build upon
them.
Short-term therapies, such as solution based, can be useful in some
personality disorders outlined in the classifications section, to deal with an
immediate situation or specific problem.
28
Eye Movement Desensitisation and Reprocessing (EMDR)
American Psychologist, Francine Shapiro in 1987, developed Eye Movement
Desensitisation and Reprocessing (EMDR).
It was first developed as a
therapeutic method in helping process and resolve symptoms caused by
trauma’ as it was discovered that eye movements had an effect on both
cognition and emotional processes. EMDR has more recently been used in
the treatment of a wide variety of psychological problems and is regarded as
an effective treatment for PTSD.
In the treatment of PTSD, Eye Movement Desensitisation and Reprocessing
involves the “reliving of prior traumatic experiences during the simultaneous
application of rhythmic bi-lateral stimulation. This is often achieved through
inducing bilateral eye movements. It can also be achieved through the use of
bilateral sounds, specific bilateral music or gentle taps, such as, for example,
through the alternating stimulation of particular acupressure points on the
hands or knees. During the bilateral stimulation, clients are guided to connect
to memories, thoughts, feelings or somatic sensations that relate to their past
traumatic experiences.”
Gestalt Therapy
Fritz and Laura Perls developed Gestalt therapy between 1940 and 1950. It is
defined as an existential and experiential psychotherapy, which focuses on
the client’s experience in the present moment, the therapist-client relationship,
the social and environmental contexts in which these things take place, and
the self-regulating adjustments people make as a result of the overall
situation. The emphasis of the therapy is personal responsibility.
Gestalt therapy is mainly focused on what is actually happening, rather than
content. Clients are encouraged to think about what they thought, felt and did
at the time rather than what they could, should or might have done. Within
therapy, clients learn to become more aware of what they are doing
29
psychologically and how this can be changed, so that they develop selfacceptance and an ability to experience and deal with the present without the
past interfering.
In addition to this, Gestalt therapy can help to enable the client to become
‘free’ from past issues that may be stopping them from fulfilling their full
potential, hindering their growth as a person or diminishing their satisfaction
with life
30
Self assessment 2
SAQ1)
Fill in the table below with 2 different perceptions and possible reactions for
the given situation. Can you think of a time in your life that you have perceived
something but it turned out to be different?
A person has made a big effort in getting ready to
go out, had their hair done and bought a new outfit.
Situation
Their partner makes no comment on it when they
arrive home from work.
Thoughts/cognition
Physical
Feelings
/
Psychological Effects
Emotional Feelings
Behaviours
SAQ2)
Put the following DBT targets in order:

Decreasing behaviours related to post-traumatic stress

Decreasing behaviours that interfere with life

Decreasing suicidal behaviours

Decreasing Therapy interfering behaviours

Improving self esteem

Increasing behavioural skills

Individual targets negotiated with the patient
31
SAQ3)
Briefly describe the different types of therapy and who developed them:
Type
Description
Cognitive
Behavioural Therapy
Hypnotherapy
DBT
Drama
and
Art
Therapy
Psychotherapy
Person
Centred
Therapy
Solution
focused
Therapy
32
Assignment two
2.1 Analyse why CBT is recommended by the N.I.C.E frequently as a
treatment for many common mental health problems.
2.2 Evaluate the value of solution focussed therapy as an isolated treatment.
2.3 Evaluate the benefits and limitations of DBT as an effective treatment for
borderline personality disorder.
33
34
In this section:
Addiction
Anxiety
Divorce
Stress
Sexual orientation
Premenstrual syndrome
Accompanying Treatments
Assignment three
35
Addiction
Addiction is defined as: “a dependence on a substance, such as the drug
heroin, or a type of behaviour, such as gambling. The dependence is so
strong that it may seem as if the person is unable to break away from the
dependence.”4 It is estimated that over 2 million people in the UK alone are
affected by addictions which often start when a client begins to take a
substance in order to cope with strong emotional pain, or in order to ‘feel
good’. It is through these ‘escapes’, such as overeating, drinking, gambling
and taking prescribed drugs that addictions occur.
In many cases, people are usually able to break some addictions by
themselves, however, in some cases they will require professional help from a
trained counsellor or psychotherapist.
Therapy for addiction can come in a
number of forms and includes behavioural therapy and integrative therapy.
In behavioural therapy for example, there would be an emphasis on changing
negative behaviour patterns, which can be easily applied in the treatment of a
client with an addiction problem.
In integrative therapy, a number of
psychotherapeutic techniques are combined which provide the therapist with a
flexible way of treating their client.
Anxiety
Anxiety is defined as: “a feeling of apprehension and fear characterised by
physical symptoms such as palpitations, sweating, and feelings of stress.
Anxiety disorders are serious medically. These disorders fill people's lives with
overwhelming anxiety and fear. Unlike the relatively mild, brief anxiety caused
by a stressful event such as a business presentation or a first date, anxiety
disorders are chronic, relentless, and can grow progressively worse if not
treated.”5
4
5
Anxiety can present itself in both the form of physical and
Faqs.org (2007) ‘Addiction’
MedicineNet (2007) ‘Definition of Anxiety’
36
psychological symptoms, such as increased heart-rate, shortness of breath
and stomach pain, as well as irritability, poor concentration and anger.
When treating anxiety, Cognitive Behavioural Therapy tends to be the most
commonly used approach. In this form of therapy, the therapist will explore
with the client the underlying thought processes that result in feelings of
anxiety.
Alongside this, relaxation techniques, which can be used to
overcome these feelings of anxiety, and associated conditions such as panic
attacks, will also be explored.
Divorce
Divorce can be a traumatic experience for all those involved and it can take
time to heal from its effects. There is no set time as to how long this will take,
as every divorce situation will be different and people cope with things in their
own way.
Divorce therapy usually takes the form of Gestalt therapy or person-centred
therapy. In Gestalt therapy, for example, the client is encouraged to address
their feelings of anger, loss and loneliness. Person-centred therapy, on the
other hand, can be used to encourage clients to reflect on their divorce and
use their experiences positively for the future.
In many circumstances, children are also affected by divorce, and they should
therefore also be given the opportunity to voice their feelings to an impartial
professional.
37
Stress
Stress has been defined by Hans Selye, M.D., as a “non-specific response of
the body to a demand”. During a stressful situation, the brain releases stress
hormones which trigger a set of responses, such as an increase in blood
sugar levels, increased heart rate and increase in blood pressure, which in
turn give the body more energy. It is when situations become too difficult
however, that stress can have a negative impact on a client’s life, affecting
both their physical and mental well-being.
Stress management counselling can be useful in helping clients to limit the
negative effect stress is having on their present life, and in addition to this,
prevent any physical or psychological problems associated with this stress.
Therapy can assist clients in recognising the main factor which is causing
them stress, and encourage them to make changes to these situations, so
they no longer have such a negative impact on their lives.
In treating stress, behavioural therapy is the most commonly used treatment
approach, as it allows the client to establish why they react to situations they
way they do, and to find alternative strategies for dealing with stressful
situations.
Person-centred therapy is also often used, as it provides clients
with the opportunity to explore the reasons why certain situations are
triggering their current feelings.
Sexual Orientation
For many people who are confused about their sexual orientation, it can be an
extremely difficult issue to come to terms with. Some are fearful that they will
be rejected by family, friends and colleagues if they ‘come out’. While some
are aware of their sexuality from an early age, others may need more time to
become aware of their feelings and desires, and how to express them.
38
Counselling for issues regarding sexual orientation may take many forms and
come from a variety of counselling models.
If a client is experiencing
problems with their family regarding their sexual orientation for example,
family counselling may be offered, or the client may prefer to see a therapist
on an individual basis. It is common for people who have been abused as a
child to experience difficulties with their sexual orientation.
Premenstrual syndrome (PMS)
The symptoms of premenstrual syndrome (PMS) are estimated to affect
around 85% of women. While for most, these symptoms are manageable,
others who are suffering from the more severe form Premenstrual Dysphoric
Disorder (PMDD) require treatment for a wide range of symptoms, including:
 Difficulty sleeping.
 Lasting anger or irritability.
 Mood swings.
 Crying.
 Panic attacks.
 Feelings of despair, tension or anxiety.
When these symptoms affect life to a great extent, the person may be referred
to a therapist for individual, group or stress management counselling to help
alleviate their symptoms. When therapy is offered for symptoms such as low
self-esteem, cognitive behavioural therapy is the most commonly provided.
Medications such as antidepressants may also be prescribed.
39
Accompanying Treatments
Antidepressants
Although the name ‘antidepressants’ suggests that these medications are
specifically for treating depression, they are also commonly used to treat other
illnesses and symptoms, such as severe anxiety, panic attacks, PTSD (Posttraumatic stress disorder), eating disorders, obsessive compulsive disorders
and chronic pain.
They are not used to treat mild depression. Some
antidepressants also have a sedative effect.
Some common antidepressants: Amitriptyline hydrochloride (Elavil, and also in the compounds Triptafen
and Triptafen-M)
 Amoxapine (Ascendis)
 Citalopram (Cipramil)
 Clomipramine (Anafranil)
 Dosulepin/dothiepin (Prothiaden)
 Doxepin (Sinequan, Xepin)
 Escitalopram (Cipralex)
 Fluoxetine (Oxactin, Prozac)
 Fluvoxamine (Faverin)
 Imipramine (Tofranil)
 Isocarboxazid
 Lofepramine (Gamanil, Lomont)
 Maprotiline hydrochloride (Ludiomil)
 Mianserin hydrochloride
 Mirtazapine (Zispin)
 Moclobemide (Manerix)
 Motival
 Nortriptyline (Allegron; also in the compound Motival)
 Paroxetine (Seroxat)
40
 Phenelzine (Nardil)
 Reboxetine (Edronax)
 Sertraline (Lustral)
 Tranylcypromine
 Trazodone hydrochloride (Molipaxin)
 Trimipramine (Surmontil)
 Triptafen
 Triptafen-M
 Venlafaxine (Efexor and Efexor XL)
Antipsychotics (major tranquilizers)
Antipsychotics are mainly used to treat psychosis and are common treatments
for schizophrenia and bipolar disorder; they can also be used to treat severe
depression and some physical illnesses. As stated in the NICE guidelines for
the management of schizophrenia, antipsychotics are not a cure, but they can
help to control symptoms, to enable the person to engage fully with other
treatments, such as therapy.
Some common antipsychotics: Amisulpiride (Solian)
 Aripiprazole (Abilify)
 Chrlorpromazine (Largactil)
 Clozapine(Clozaril)
 Flupenthixol (Depixol, Flupenthixol, Fluanxol)
 Fluphenazine (Moditen)
 Haloperidol (Serenace, Haldol)
 Loxapine (Loxapac)
 Olanzapine (Zyprexa)
 Pericyazine (Neulactil)
 Perphenazine (Fentazine)
 Pimozide (Orap)
 Prochlorperazine(Stemetil)
 Promazine
41
 Quetiapine(Seroquel)
 Risperidone (Risperdal)
 Sulpiride (Sulpitil, Sulpor)
 Thoridazine (Melleril)
 Trifluoperazine (Stelazine)
 Zotepine (Zoleptil)
 Zuclopenthixol (Clopixol)
Sleeping tablets
Sleeping tablets are useful for their sedative effects and the longer-acting
sleeping tablets can also help with anxiety.
 Clomethiazole (chlormethiazole, Heminevrin)
 flunitrazepam (Rohypnol)
 flurazepam (Dalmane)
 loprazolam (previously available under the trade name Dormonoct)
 lormetazepam
 nitrazepam (trade names Mogadon, Remnos, Somnite)
 temazepam
 Zaleplon (Sonata)
 Zolpidem (Stilnoct)
 Zopiclone (Zimovane)
42
Minor tranquilizers
Minor tranquillizers are used to treat conditions such as anxiety, sleep
problems, epilepsy, and for sedative purposes before surgery.
 Chlordiazepoxide (Librium, Tropium)
 Clorazepate (Tranxene)
 Diazepam (Valium, Tensium, Dialar, Diazemuls, Stesolid, Valclair)
 Alprazolam (Xanax)
 Lorazepam (Ativan)
 Oxazepam
 Flunitrazepam (Rohypnol)
 Flurazepam (Dalmane)
 Nitrazepam (Mogadon, Remnos, Somnite)
 Loprazolam (Dormonoct)
 Lormetazepam
 Oxazepam
 Temazepam
43
Self assessment 3
SAQ1)
Match up the type of medication with the description and example:
Anti depressant
Used to treat anxiety and epilepsy
Useful for their sedative effects
Minor tranquilisers
Not used to treat mild depression
Used to treat psychosis
Antipsychotic
Prozac
Temazepam
Sleeping tablets
Zopiclone
Zyprexa
44
Assignment 3
3.1 Evaluate the benefits and any other impact of at least 5 psychiatric drugs
and the conditions for which they might be most usefully prescribed.
45
46
In this section:
Depression
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Eating disorders
Personality disorders
Borderline personality disorder
Dependant personality disorder
Schizophrenia
Gender identity disorder
Assignment four
47
Depression
The World Health Organization (WHO) defines depression as:
“a common mental disorder that presents with depressed mood, loss of
interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or
appetite, low energy, and poor concentration. These problems can become
chronic or recurrent and lead to substantial impairments in an individual's
ability to take care of his or her everyday responsibilities. At its worst,
depression can lead to suicide, a tragic fatality associated with the loss of
about 850,000 lives every year.”6
Depression consists of extreme feelings of sadness which lasts for a
prolonged period of time, often for more than a few weeks or months. The
term refers to more than just feeling miserable or fed up for a short period of
time; the symptoms can affect a person’s ability to carry out basic daily
activities, as well as their behaviour in social situations.
The National Health Service (NHS) has stated that “about 15% of people will
have a bout of major depression at some point in their lives, and it is the fourth
most common cause of disability worldwide”7. They continue to say, however,
that the true number of people affected by depression is difficult to estimate
due to a large number of people who do not seek help for the condition, or
who are not formally diagnosed.
6
7
World Health Organization (2007) ‘Mental Health’ Depression
NHS Direct (2007) ‘Health Encyclopaedia’ Depression
48
It has been suggested that up to two thirds of people who suffer from
depression do not seek treatment, or receive the right treatment from health
professionals, because:
 Their symptoms are not recognised as depression.
 Depressed people are regarded as weak or lazy.
 Social stigma causes people to avoid the treatment they need.
 The symptoms suffered by the person are so disabling that they are
unable to seek help.
 Individual symptoms are treated instead of the underlying cause.
 Many of the symptoms are misdiagnosed as physical problems.8
According to the National Institute of Mental Health (NIMH), suicide, which is
closely related to depression, is the third leading cause of death in people
aged between 10 and 24 years old. This is often from depression being
undiagnosed and symptoms therefore worsening.
Symptoms
Depression can present itself through a wide range of psychological, physical
and social symptoms. These symptoms can affect a person’s ability to cope
with everyday activities, including their behaviour in social situations. These
symptoms may vary between men, women, children and the elderly, as well
as depending on the type of depression the person is suffering from.
Psychological Symptoms
Typical psychological symptoms of depression include:
 Lack of motivation.
 Continuous low mood or sadness.
 Feeling irritable and intolerant of others.
 Lack of enjoyment in previously enjoyable activities.
 Feeling anxious or worried.
8
Psychology Information Online (2003) ‘Depression’ Information and Treatment
49
 Low self-esteem.
 Feelings of helplessness and hopelessness.
 Difficulty in making decisions.
 Suicidal thoughts or thoughts of harming others.
 Reduced sex drive.
 Feelings of guilt.
 Tearfulness
Physical Symptoms
Typical physical symptoms of depression include:
 Change in appetite and weight loss or weight gain.
 Lack of energy.
 Slowed movement or speech.
 Changes to the menstrual cycle (in women).
 Constipation.
 Lack of interest in sex
 Unexplained aches and pains.
Social Symptoms
Typical social symptoms of depression include:
 Reduced contact with friends.
 Less interest in hobbies and activities.
 Decrease in performance at work.
 Difficulties in home and family life.
 Taking part in fewer social activities.
Who is affected?
Depression affects people of all ages and from all walks of life. It has been
found that women are twice as likely as men to be affected: although men do
still suffer from the condition, they are less likely to admit to feeling depressed.
Instead they tend to describe the physical aspects of depression rather than
the emotional.
50
Depression in women
It is believed that many hormonal factors contribute to the increased
occurrence of depression in women.
Factors such as pregnancy, pre-
menopause, menopause, miscarriage, and menstrual changes are likely to
contribute towards the condition.
The pressures of work and family
responsibilities can also be a contributory factor.
Depression after the birth of a child is also common, due to the physical and
hormonal changes which occur. The extra responsibility of caring for a new
baby on top of existing stresses can lead to depression and therefore requires
active intervention. In this case, emotional support from family and treatment
from a sympathetic physician if necessary, are vital in helping a new mother
recover her physical and mental well-being, and help her to care for her baby.
Depression in men
Although men are less likely to suffer from depression compared to women,
approximately 3 million men are still affected.
Due to the differences in
physical symptoms of depression in men and women, doctors are less likely
to diagnose depression in male patients. Despite the depression rate being
lower, men however are around four times more likely to commit suicide than
women. This figure rises further after the age of 70.
The symptoms of depression in men differ from those in women due to the
way they appear irritable or angry rather than feeling hopeless or helpless.
Despite recognising the symptoms of depression, men are often less likely to
seek treatment due to the stereotypical view that depression is a “women’s
disease”.
Support from family and friends can therefore be an important
factor in assisting men to understand that it is an illness, which needs to be
treated.
51
Depression in children
Mental health professionals have only taken childhood depression seriously in
the last 20 years. As with many conditions, it is not regarded as being the
result of one specific cause; instead a number of factors, such as neglect,
trauma, or the loss of a parent can contribute towards the condition. A family
history of depression may also increase a child’s risk.
It is common for children with depression to suffer from other mental health
conditions such as disruptive behaviour disorder, or bipolar disorder. It is
believed children suffering with depression are also at a higher risk of
substance abuse in adolescence or adulthood.
Depression in the elderly
Depression in elderly people often becomes more common in the decade
following retirement, due to the dramatic changes that occur; the adapting to a
new routine in life, and sometimes moving to a care home can be difficult to
adjust to. As people age, the loss of a partner and friends, as well as a loss of
mobility and other health problems, can also contribute towards the onset of
depression.
It is important that the symptoms of depression in the elderly are recognised
and treated appropriately, as the condition can often lead to a long period of
misery and, in some cases, suicide, from an illness which could be treated
easily.
Causes
Like many mental health conditions, depression does not have one specific
cause; it is the result of a combination of factors which include genetics,
trauma and stress, physical conditions, and other psychological problems.
It is important to note, however, that depression is also the result of physical
changes in the brain.
Imbalances of neurotransmitters are a contributory
factor to the onset of depression, which are often treated through the
52
prescription of antidepressant medication, such as Selective Serotonin
Reuptake Inhibitors (SSRI’s).
Genetic Factors
It is common for some types of depression, such as major depression, to run
in families, which suggests that it may be inherited. Scientists, however, are
not sure what is inherited, but it is believed to be related to hormones, and
changes in the brain structure or functions.
Trauma and Stress Related Factors
Major life events can contribute towards depression, such as the death of a
loved one, or pressures from starting a new job. Past experiences can also
affect the way a person presently feels if they have not had the opportunity at
the time of the experience or event, to find a way of acknowledging and
dealing with how they feel.
Physical Factors
There are many medical conditions which can lead to the onset of depression
due to the physical weaknesses and stress they create.
Such conditions
include cancer, heart conditions and HIV. It is also possible for depression to
make these conditions worse, as it weakens the immune system. In some
cases, the medications prescribed to treat physical conditions can lead to
depression.
Additional Factors
In addition to the possible causes of depression outlined above, there are
many other factors that can lead to its onset. Schizophrenia, eating disorders
and anxiety disorders can also play a big part in its development. Substance
and alcohol abuse is also often a factor in the cause of depression.
53
Major Depressive Episode
Under the DSM-IV, in order for a diagnosis of Major Depressive Episode to be
made, at least five of the following criteria need to have been present during
the same two-week period, and represent a change from the client’s previous
functioning:

A depressed mood which lasts most of the day, nearly every day and is
indicated through either feelings of sadness or emptiness, or from
observations made by others.

Loss of interest or pleasure in activities, most of the day, nearly every
day.

Change in appetite nearly every day, or significant weight loss when
not dieting, or weight gain (body weight changes by more than 5% in a
month).

Insomnia or hypersomnia almost every day.

Psychomotor agitation or retardation almost every day, which is also
observable by others.

Loss of energy or fatigue almost every day.

Feelings of inappropriate guilt or worthlessness almost every day.

Inability to make decisions or concentrate, which is observable by
others, nearly every day.

Recurrent thoughts of death (not just a fear of dying), recurrent suicide
ideation without a suicide attempt or specific plan.
In addition to these criteria, the symptoms:
 Do not meet the criteria for a Mixed Episode.
 Cause significant distress or impairment in social, occupational, or
other areas of functioning which are important.
 Are not due to the use of substances (drugs or medication) or a
medical condition.
 Are not better accounted for by bereavement.
54
Manic Episode
Under the DSM-IV, for a diagnosis of a Manic Episode to be made, the client
has to display a distinct period of persistently and elevated expansive or
irritable mood, which lasts for at least one week. In addition to this, during the
period of mood disturbance, the following symptoms also need to have been
persistent and present to a significant degree:

Grandiosity or inflated self-esteem.

Reduced need for sleep.

More talkative than usual.

Flight of ideas, feelings that thoughts are racing.

Distractibility.

Increase in goal-directed activity or psychomotor agitation.

Excessive involvement in pleasurable activities which have a high
potential for painful consequences.
In addition to these criteria the following must also be taken into consideration:
 The symptoms do not meet the criteria for a Mixed Episode.
 The mood disturbance is severe enough to cause impairment in
occupational functioning or in social activities or relationships.
 Hospitalisation may be needed to prevent harm to self or others, or
there are psychotic symptoms.
 The symptoms are not the result of a substance.
55
Mixed Episode
Under the DSM-IV, for a diagnosis of a Mixed Episode to be made, the
following symptoms need to be present:

The criteria for both a Manic Episode and a Major Depressive Episode
are met (with the exception of duration) nearly every day, during at
least a one-week period.

The mood disturbance is severe enough to impair occupational
functioning in social activities or relationships. Hospitalisation may be
required to prevent harm to self or others, or if psychotic symptoms are
present.

The symptoms have not resulted from the use of a substance.
Hypomanic Episode
Under the DSM-IV, for a diagnosis of Hypomanic Episode to be made, a
distinct period of persistently elevated, expansive, or irritable mood, which is
significantly different from the usual non-depressed state, needs to have been
present for at least 4 days. During this time, at least three of the following
criteria need to be met:

Grandiosity or inflated self-esteem.

Reduced need for sleep.

More talkative than usual.

Flight of ideas or feelings that thoughts are racing.

Distractibility.

Increase in goal-directed activity.

Excessive involvement in pleasurable activities which have a high
potential for painful consequences.
56
Furthermore:
The episode highlights a significant change in functioning that is
uncharacteristic of the client when not symptomatic,
The mood disturbance and change in functioning are observable by others,
It is not severe enough to impact upon social or occupational functioning or to
require hospitalisation and there are no psychotic features. The symptoms are
not the result of a substance.
Major Depressive Disorder
There are two listings for Major Depressive Disorder; Single Episode and
Recurrent. For a diagnosis of Major Depression to be made, the following
criteria need to be met, as stated under the DSM-IV:

Presence of a single (two or more) Major Depressive Episode

The
Major
Depressive
Episode
is
not
better
explained
by
Schizoaffective Disorder and is not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.

There has not been a Manic Episode, a Mixed Episode, or a
Hypomanic Episode in the past.
57
Dysthymic Disorder
According to the DSM-IV, for a diagnosis of Dysthymic Disorder to be made,
the client must present a depressed mood for most of the day, for more days
than not, which is observable by others or subjective account, for at least 2
years. While depressed, at least two of the following criteria should also be
present:

Poor appetite or overeating.

Insomnia or hypersomnia.

Low energy or fatigue.

Low self-esteem.

Difficulty in making decisions or poor concentration.

Feelings of hopelessness.
In addition to this:
 During the two-year period in which the client has suffered the disorder,
they have not been without any of the symptoms previously listed for
more than 2 months at a time.
 During the first two years of the disorder, there has not been a Major
Depressive Episode present.
 There has never been a Manic Episode, a Mixed Episode or a
Hypomanic Episode. Furthermore, the criteria have never been met for
Cyclothymic Disorder.
 The disturbance does not occur exclusively during the course of a
chronic psychotic disorder, i.e. Schizophrenia or Delusional Disorder.
 The symptoms are not the result of a substance
 The symptoms cause significant distress or impairment in social,
occupational, or other important areas of functioning.
58
Bipolar I Disorder
Under the DSM-IV, for a diagnosis of Bipolar I disorder to be made, the
following criteria need to be met:

The criteria, with the exception of duration, are currently met for a
Manic, Hypomanic, Mixed or Major Depressive Episode.

There has been at least one Manic Episode or Mixed Episode in the
past.

The symptoms cause significant distress, and impact negatively upon
social, occupational or other important areas of functioning.

The symptoms described in points 1 and 2, are not better accounted for
by Schizoaffective Disorder. Furthermore, they are not superimposed
on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise Specified.

The mood symptoms described in points 1 and 2 are not the result of a
substance or general medical condition.
Bipolar II Disorder
For a diagnosis of Bipolar II Disorder to be made, the following criteria need to
be met as stated under the DSM-IV:
 Presence or history of one of more Major Depressive Episodes.
 Presence or history of at least one Hypomanic Episode.
 There has not been a Manic Episode or a Mixed Episode in the past.
 The mood symptoms highlighted in points 1 and 2 are not better
accounted for by Schizoaffective Disorder and are not superimposed
on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise Specified.
 The symptoms described cause significant distress, or impact
negatively upon social, occupational or other important functioning.
59
Cyclothymic Disorder
As stated under the DSM-IV, in order for a diagnosis of Cyclothymic Disorder
to be made, the following criteria need to be met:
 For at least two years, the presence of a number of periods with
hypomanic
symptoms
and
numerous
periods
with
depressive
symptoms that do not meet the criteria for a Major Depressive Episode.
 The symptoms described in point 1 are present during the two year
period in which the client will not be without them for more than two
months at a time.
 During the first two years of the disturbance, there has not been a
Major Depressive Episode, Manic Episode or Mixed Episode present.
 The symptoms described in point 1 are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia,
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
 The symptoms are not the result of a substance or general medical
condition.
 The symptoms cause significant distress or impairment in social,
occupational or other important areas of functioning.
60
Eating Disorders
Eating disorders or severe disturbances in eating behaviour are a prevalent
problem among women today (American Psychiatric Association; APA, 2000).
It is estimated that five to ten percent of all women have some form of an
eating disorder (National Eating Disorder Association, 2003). However, this
number rises to even greater proportions in young women. It is estimated that
19–30% of college females can be diagnosed with an eating disorder and
between 1% and 5% of adolescent females meet the criteria for the diagnosis
of an eating disorder (Fisher, Golden, Katzman, & Kreipe, 1995; Radar
Programs, n.d.)9
What are Eating Disorders?
Eating disorders are defined as a distorted pattern of thinking about food and
size / weight. There are very few people who can claim they eat a healthy
balanced diet on a daily basis.
The pressures of work and social
commitments often result in people picking up a snack while they are ‘on the
go’. It is therefore hard in modern day society to define ‘normal’ eating. For
the majority of people however, food does not preoccupy their lives. Cultural
ideas of perfection, which are heavily influenced through the media, can result
in people feeling the need to be thinner, and an increase in their risk of
developing an eating disorder. Biological and genetic factors are also thought
to further affect a person’s risk of developing certain types of eating disorders.
It is unlikely that an eating disorder will result from a single cause. It is more
likely to be a combination of many factors, events, feelings or pressures that
lead to the sufferer feeling unable to cope, resulting in this maladaptive coping
mechanism. Examples of such factors include low self-esteem, problematic
family relationships, trouble with friends, the death of someone special,
difficulties at work, college or university, lack of confidence, and sexual or
9
Watson, Rebecca and Vaughn, Lisa M. , 'Limiting the Effects of the Media on Body Image:
Does the Length of a Media Literacy Intervention Make a Difference?', Eating Disorders, 14:5,
385 - 400
61
emotional abuse.
They use food as a way of externally expressing their
internal emotional pain - as a coping mechanism for this pain which they
cannot express in any other way. People with eating disorders tend to focus
on what they look like, rather than who they are as a person.
Often people with eating disorders say that the eating disorder is the only way
they feel they can stay in control of their life, but as time goes on it becomes
evident that the eating disorder itself is controlling them.
It is common
amongst those with eating disorders to experience feelings of despair and
shame. They may also identify with feelings of failure or lack of control, due to
an inability to overcome these feelings about food alone.
It has been estimated that 1.2 million people in the UK alone suffer with eating
disorders10. This includes those who have been diagnosed with a disorder, as
well as those who have not sought treatment and remain undiagnosed.
Contrary to popular belief, eating disorders do not only affect women. Despite
the figures being significantly lower, men can also suffer with anorexia,
bulimia and compulsive or binge eating.
An eating disorder is an illness that permeates all aspects of the sufferer’s life.
It is a serious health condition that can be both physically and emotionally
destructive. People with eating disorders need to seek professional help as
soon as possible, as early diagnosis and intervention may enhance recovery.
Eating disorders can become chronic, debilitating, and even life-threatening
conditions.
Common symptoms of eating disorders include:
 Obsession with weight.
 Obsession with the content of calories and fat in food.
 Dramatic change in weight within a short period of time.
 Hiding food.
10
Beat – Beating Eating Disorders: Some Statistics
62
 Feelings of anxiousness, loneliness or depression.
 Obsession with food and body image.
 Loss of sexual desire.
 Low self esteem or confidence.
 Fear of eating around others.
 Mood swings.
 Feeling tired.
 Insomnia or poor sleeping habits.
 Unusual food rituals or eating secretly.
Symptoms
Anorexia
Symptoms of anorexia include:
 Weight loss of at least 15-25% of original body weight.
 Extreme fear of becoming fat.
 Ritualised eating habits.
 Self-induced vomiting, laxative abuse or abuse of slimming tablets,
intense and strict exercise regimes.
 Hoarding or hiding food.
 Obsession with food preparation, recipe books and other people’s
eating habits.
 Denial of the severity of the illness and refusal to participate in therapy /
rehabilitation.
 Hypothermia (drop in body temperature).
 Lanugo (neonatal-like body and facial hair).
 Menorrhea (menstruation stops).
63
Bulimia Nervosa
Symptoms of bulimia include:
 Intense exercise regimen.
 Blistering on the knuckles from forced vomiting.
 Frequent pain in the stomach.
 Frequently feeling tired and weak.
 Dramatic increase in food intake without a change in weight.
 Isolation from family and friends.
 Frequently going to the bathroom immediately after a meal.
 Dehydration.
 Frail hair or nails.
 Dry skin.
 Menstrual cycle ending.
 Depression.
64
Binge Eating Disorder
Symptoms of binge eating disorder include:
 Eating large quantities of food frequently.
 Low self-esteem / low confidence.
 Frequent changes in weight.
 Feeling out of control.
 Eating even when full.
 Eating for comfort when sad, bored or lonely.
 Feeling anxious or depressed.
 Obsessed with food and body.
 Eating quickly.
 Unable to stop binging even when aware of the emotional distress it will
cause.
 Feeling guilty after a binge.
 Secretly eating.
 Binging twice a week, or more over a period of months.
65
Complications
There are a large number of side effects and complications associated with
eating disorders. It is therefore important that people with any form of eating
disorder seek professional help as soon as possible, as this may help to
improve the success of treatment and avoid long-term physical and
psychological damage.
Side effects and complications associated with anorexia include:
 Feeling weak, tired and dehydrated.
 Menstrual period ending (in women).
 Loss of hair.
 Sensitive to bruising.
 Dry, fragile bones and nails.
 Heart problems or a low heart rate.
 Anaemia
 Infertility.
 Insomnia.
 Poor blood circulation.
 Death.
Side effects and complications associated with bulimia:
 Dry, fragile bones, hair and nails.
 Menstrual cycle disrupted (in women).
 Discolouration of teeth.
 Problems with teeth and gums.
 Dehydration.
 Feeling tired and weak.
 Stomach pain.
 Inflammation or tear of the oesophagus due to forced vomiting.
 Broken blood vessels in the eyes.
 Heart problems or irregular heartbeats.
 Problems during pregnancy.
66
 Chronic irregular bowel movements.
 Kidney problems, even kidney failure.
 Death.
Side effects and complications associated with binge eating disorder include:
 Obsession with appearance.
 Feelings of anxiety or depression.
 Low self esteem and confidence.
 High blood pressure.
 High cholesterol.
 Lack of energy.
 Feeling tired and weak.
 Mild breathing difficulties.
 Heart disease.
 Gall bladder disease.
 Some types of cancer.
 Liver problems.
 Kidney problems.
 Type II diabetes.
Who is affected?
It has been stated that eating disorders are a widespread problem which has
greatly increased over the last 30 – 40 years. Such disorders are responsible
for a greater loss of life each year than any other psychological illness.
In the UK alone there are 1.2 million people affected by an eating disorder,
with the majority of those affected aged between 14 and 25 years old. This
figure, however, does not include those who have not received a diagnosis of
an eating disorder. Further statistics have stated that if the number of people
affected included those responsible for caring for someone with an eating
disorder, this figure would almost triple.
67
The UK charity Mind, for example, has found that “as many as one woman in
20 will have eating habits which give cause for concern” and The Royal
College of Psychiatrists have backed this further by stating that “girls and
women are 10 times more likely than boys and men to suffer from anorexia or
bulimia”.
Overall, as found by the Independent on Sunday “at least one
percent of women are affected by eating disorders”11.
It is important to realise however, that despite the number being significantly
lower, men also suffer with eating disorders and are believed to make up to 10
percent of those diagnosed with an eating disorder.
Causes
It is difficult to specify a single cause for the development of an eating
disorder; instead it is believed to be a combination of biological, genetic,
psychological and social factors.
Psychological
There are a number of psychological factors which can contribute towards the
development of eating disorders.
Those with such disorders tend to be
‘perfectionists’, expecting the very best of themselves, with failure resulting in
feelings of shame. They believe that things are either all good, or all bad,
without any middle ground. Therefore, they regard being fat as bad, and
being thin as good.
They are generally unhappy with their figure and
therefore develop eating disorders as a method of managing their weight
without dieting.
Eating disorders can also develop due to traumatic events or major life
changes. An example of this may be physical or sexual abuse.
11
Disordered Eating: Eating Disorders Statistics (UK)
68
Biological
Biological issues can also contribute to the development of eating disorders.
It has been suggested that people are more likely to develop eating disorders
if there is a family history of it. Further research has suggested that the levels
of serotonin, in particular the 5HT2A receptor, in the brain can also contribute
to the development of eating disorders, as those with high levels of this
chemical are less likely to crave food.
Social
The media often present being thin as the only way in which people can
appear to be ‘normal’. Many magazines depicting celebrities as role models
can also contribute towards the development of eating disorders, due to the
pressure it places on individuals. These ‘role models’ do nothing to promote
healthy eating.
Further social pressures also come from a person’s occupation. Jockeys and
dancers, for example, are encouraged to keep their body weight low as this
can enhance their performance. The added pressure from family and friends
regarding appearance can also contribute towards the development of an
eating disorder.
Psychological Treatment of an eating disorder
When working with a client who presents with an eating disorder, it is vital that
you insist on them receiving a medical from their GP. This is important due to
a number of reasons, one of which is that if they have a BMI (Body Mass
Index) of 17 or below, you cannot work with them due to the effects the low
weight has on the brain. Also there may be serious health consequences to
someone who has engaged in the behaviour of someone who has an eating
disorder, and they may either need to be admitted to a general ward for their
physical symptoms or to a psychiatric unit.
69
When working with eating disorders its important that you do this in
conjunction with a nutritionist and a medical doctor. This is important so that
you may focus on why someone may have an eating disorder and what
maintains it, whilst the other professionals involved work on issues of weight
and increasing that if necessary, in cases of anorexia nervosa.
Treatment should be tailored to the individual, and will vary according to both
the severity of the disorder and the patient's individual problems, needs, and
strengths.
Nutritional counselling
The initial aim of treatment is to re-establish a healthy attitude towards food
and a consistent pattern of eating, with three meals a day at regular times.
It is a necessary stage of treatment and should incorporate education about
nutritional needs and planning for, and monitoring, rational choices of the
individual patient.
Nutritional counselling and advice can help your client to identify their fears
about food and the physical consequences of not eating well. Education about
the nutritional value of food can be beneficial, particularly if they have lost
track of what 'normal eating' is.
Asking your client to keep a diary of eating habits to discuss with a GP, and
learning about healthy eating and sensible weight control, may be helpful.
There are a number of treatment approaches used for those with eating
disorders, in which a combination may be offered. Before treatment begins,
the first stage for those of a very low weight is to put weight on, which could
be done as an in-patient at hospital or in a specialist facility.
Due to the psychological causes and effects of some eating disorders, talking
therapy can play an important role in treatment. Such treatments may include
counselling, Cognitive Behaviour Therapy (CBT), psychotherapy, group
70
therapy, and family therapy. The implementation of family therapy can be vital
in the treatment of eating disorders, as they can also impact heavily upon
family life and those caring for someone with an eating disorder. Further
therapies, such as drama and art therapy and relaxation, may also be used in
treating eating disorders.
Where necessary, medications may also be prescribed as a treatment option,
such as Ondansetron (commonly used to treat nausea and vomiting) for
bulimia, or antidepressant and anti-anxiety drugs.
In extreme circumstances, where the person suffering with an eating disorder
is at a dangerously low weight and physical condition, compulsory admission
under the Mental Health act may be enforced. In some cases this is the only
treatment option left available, due to the effects starvation can have. In these
circumstances, it can be difficult for people to think rationally and they may not
make appropriate decisions regarding their treatment.
Hospitalisation,
therefore, is used to prevent death / suicide and to observe any other medical
complications which may have resulted from the eating disorder.
Group Therapy
Group therapy is often used as a treatment approach for eating disorders, as
it provides people to share their experiences with others in similar situations.
Although this treatment is not always successful with those with anorexia, due
to their tendency to be more withdrawn or anxious than those with bulimia,
many have still benefited from group therapy.
Group therapy usually involves educating those with eating disorders on
important areas which they may not have received information about
elsewhere. Typical examples include details regarding nutrition, the effects of
laxative abuse and techniques in assertiveness. There are many positive
aspects to group therapy, which include the sufferers’ ability to educate each
other from their own experiences and to identify and solve problems. This
allows sufferers to realise that they are not alone, and that there are others
who understand how they feel, due to their own similar experiences.
71
Eating disorder groups are either segregated or heterogeneous (mixed). A
segregated group for example, will only include people with the same eating
disorder. This is so that members in the group will benefit from the similarities
they share, due to some complaints from mixed groups who have stated that
they feel unable to relate to each other.
Heterogeneous groups however, can be successful.
There are many
similarities between those suffering with anorexia and those with bulimia.
Some sufferers have benefited from the stories those with an eating disorder
different to their own have shared. Such stories can help them to realise that
they do not want to experience similar situations to those described by other
sufferers.
Family Therapy
Families play a major role in attitudes towards eating disorders, and it is
therefore important that the family receive treatment as well as the sufferer
(parents, siblings, partner, spouse). This type of therapy can be used for both
younger and older clients, although it is often more commonly used for
teenagers.
Family therapy provides families with the opportunity to develop ways to cope
with any issues which may have occurred, as well as coping with the eating
disorder itself. The success of this treatment however, is dependent on the
willingness of the family to fully participate in the therapy and to change their
behaviours.
If a person suffering with an eating disorder is hospitalised, family therapy will
not usually begin until they have started to gain weight. Therapy, however,
should not begin after the sufferer has been discharged, but should still carry
on after they have left hospital.
72
A person with an eating disorder can be helped much more easily if the
problem is identified and treated early. However, for treatment to be
successful, he or she must be ready to get better. Admitting that they have a
problem is the first, yet hardest, step for sufferers of an eating disorder. If they
take that step, they can find the support and treatment they need to stop the
disorder taking over their lives.
What are Personality Disorders?
Definition: "Personality disorder, also called character disorder, mental
disorder that is marked by deeply ingrained and lasting patterns of inflexible,
maladaptive, or antisocial behaviour. A personality disorder is an accentuation
of one or more personality traits to the point that the trait significantly impairs
an individual's social or occupational functioning. Personality disorders are
not, strictly speaking, illnesses, since they need not involve the disruption of
emotional, intellectual, or perceptual functioning. In many cases, persons with
a personality disorder do not seek psychiatric treatment for such unless they
are pressured to by relatives or by a court" — Encyclopaedia Britannica.
Personality disorders have further been defined as: “pervasive chronic
psychological disorders, which can greatly affect a person's life. Having a
personality disorder can negatively affect one's work, one's family, and one's
social life. Personality disorders exist on a continuum, so they can be mild to
more severe in terms of how pervasive and to what extent a person exhibits
the features of a particular personality disorder. While most people can live
reasonably normal lives with mild personality disorders (or more simply,
personality traits), during times of increased stress or external pressures
(work, family, a new relationship, etc.), the symptoms of the personality
disorder will gain strength and begin to seriously interfere with their emotional
and psychological functioning.
Those with a personality disorder possess several distinct psychological
features, including disturbances in self-image; ability to have successful
interpersonal relationships; appropriateness of range of emotion; ways of
73
perceiving themselves, others, and the world; and difficulty possessing proper
impulse control. These disturbances come together to create a pervasive
pattern of behaviour and inner experience that is quite different from the
norms of the individual's culture and that often tend to be expressed in
behaviours that appear more dramatic than what society considers usual.
Therefore, those with a personality disorder often experience conflicts with
other people and vice-versa. There are ten different types of personality
disorder that exist, which all have various emphases.”12
In the years prior to 1750, people held very simplistic attitudes towards those
with mental health problems – they were seen as ‘mad’ or thought to be
possessed by devils. They were generally poorly treated and received very
little (if any) medical treatment. Instead, they were often confined to their
homes, or to an institution.
There has always been a divide regarding the underlying causes of mental
illness. On one side, biological factors are seen to be the main cause, on the
other side however, social problems or personal stresses are seen as the
main contributory factor. Throughout the 1800’s, the biological viewpoint was
considered the most accurate.
During the 19th century, the first attempts at classifying mental illnesses were
made.
These began in 1800, when William Cullen introduced the term
“neurosis” and were further developed by Philippe Pinel, who divided mental
illnesses into four categories:
 Mania
 Melancholia
 Dementia
 Idiocy
Life Watch – Personality Disorders
http://www.lifewatch-eap.com/poc/center_index.php?id=8
12
74
Pinel went on to describe patients who “lacked impulse control, often raged
when frustrated, and were prone to outbursts of violence” through the term
‘insanity without delusions’, as he noted that such patients “were not subject
to delusions”.
In 1835 the term “moral insanity” (later to become known as ‘personality
disorder’) was coined by J.C. Pritchard, who stated that moral insanity was “a
morbid perversion of the natural feelings, affections, inclinations, temper
habits, moral dispositions, and natural impulses…without any insane delusion
or hallucination”.
By the beginning of the 20th century, there was an increased awareness of
personality disorders when Kraepelin identified six types of personality
disorders:
 Excitable
 Unstable
 Eccentric
 Liar
 Swindler
 Quarrelsome
The introduction of the DSM in 1952, and its subsequent revisions, provide
up-to-date definitions of personality disorders.
The DSM-IV defines a personality disorder as “a lasting pattern of behaviour
and inner experience that markedly deviates from norms of the patient’s
culture”. Under the DSM-IV, ten personality disorders are specified, which are
divided into three clusters, which are shown on the following page.
75
Cluster A – odd or eccentric

Paranoid (pervasive mistrust).

Schizoid (socially detached).

Schizotypal (socially isolated, distorted perception).
Cluster B – dramatic, emotional, erratic.

Antisocial (discounts others, no empathy).

Borderline (unstable, impulsive).

Histrionic (dramatic attention seeking).

Narcissistic (needs admiration).
Cluster C – anxious or fearful.

Avoidant (socially inhibited, inadequate).

Dependent (submissive, separation fear).

Obsessive-Compulsive (order, perfection).
There are many different personality disorders as described above, but in
counselling and psychiatric services we mainly see those with a diagnosis of
borderline or dependent personality disorder. For this reason treatment
options for these two disorders will be provided.
76
Borderline Personality Disorder
Adolph Stern coined the term ‘borderline’ in 1938. This name was used to
describe patients who were on a ‘borderline’ between neurosis and psychosis.
However, the symptoms of BPD are not so simplistic as to be defined in terms
of neurotic and psychotic. The diagnosis of BPD is based upon signs of
emotional instability, feelings of depression and emptiness, and identity and
behavioural issues rather than signs of neurosis and psychosis. However, the
name Borderline has remained even though the definition has changed.
Throughout Europe, the same disorder has been given the more appropriate
and less misleading title of ‘Emotionally Unstable Personality Disorder.’
One of the core signs and symptoms in BPD is the proneness to impulsive
behaviour. This impulsiveness can manifest itself in negative ways. For
example, self-harm is common among individuals with BPD and in many
instances, this is an impulsive act. Sufferers of BPD can also be prone to
angry outbursts and possibly criminal offences (mainly in male sufferers) as a
result of impulsive urges. Other characteristics of this condition include reality
distortion, tendency to see things in ‘black and white’ terms, excessive
behaviour such as gambling or sexual promiscuity, and proneness to
depression.
BPD is not usually diagnosed before adolescence, as the personality is said
not to be fully developed. It has been suggested that BPD symptoms can
sometimes improve as time goes on, or even disappear all together. This is
not always the case, however, as BPD can continue to affect sufferers well
into later life.
77
A method, which can be used to remember some of the diagnostic criteria for
BPD, is ‘Praise’:
P-
Paranoid ideas.
R-
Relationship instability.
A-
Angry outbursts, affective instability, abandonment fears.
I-
Impulsive behaviour, identity disturbance.
S-
Suicidal behaviour.
E-
Emptiness.
In order for a client to be diagnosed with Borderline Personality Disorder, at
least five of the following criteria need to be met:

Frantic efforts to avoid real or imagined abandonment. Note: Do not
include suicidal or self-mutilating behaviour covered in Criterion 5.

A pattern of
unstable and intense interpersonal relationships
characterised by alternating between extremes of idealisation and
devaluation.

Identity disturbance: markedly and persistently unstable self-image of
sense of self.

Impulsivity in at least two areas that are potentially self-damaging (e.g.
spending, sex, substance abuse, reckless driving, binge eating). Note:
Do not include suicidal or self-mutilating behaviour covered in Criterion 5.

Recurrent suicidal behaviours, gestures, or threats, or self-mutilating
behaviour.

Affective instability due to a marked reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hours and
only rarely more than a few days).

Chronic feelings of emptiness.

Inappropriate, intense anger or difficulty controlling anger (e.g. frequent
displays of temper, constant anger, recurrent physical fights).

Transient, stress-related paranoid ideation or severe dissociative
symptoms.
78
Treatment Options
Psychotherapy is the main treatment option in helping clients with borderline
personality disorder. Although medications may help to relieve some of the
symptoms related to this disorder, they cannot assist clients in learning new
coping mechanisms or emotion regulation. In psychotherapy, assessment
should be regularly conducted with regard to the risk of suicide. If the client’s
feelings of suicide are severe, hospitalisation and the prescribing of
medication should be considered.
Dialectical behaviour therapy (DBT), designed by Marsha Linehan is regarded
as the most effective treatment for clients with borderline personality disorder,
as it was created specifically to treat those with the disorder. The aim of DBT
is to teach the client to take control of their emotions and their lives. It is
frequently used through a group therapy setting, although it may not be an
ideal treatment for those clients who struggle to learn new concepts.
Borderline personality disorder is regarded as difficult to treat, with therapy
usually lasting for at least a year. During treatment it is important, as with the
treatment of other personality disorders, that a structured and therapeutic
setting is established from the onset.
Clients with borderline personality
disorder are often discriminated against by mental health care professionals
and regarded as “trouble-makers”. It is important that therapists take into
consideration the fact that the client’s behaviour, whilst sometimes regarded
as inappropriate, is a result of their disorder. The main aim of therapy should
be to provide a highly structured environment in which the client’s ability to live
more independently is improved.
Hospitalisation
Hospitalisation is frequent for those who suffer from borderline personality
disorder, due to the way they often present themselves to the mental health
services suffering from severe depression or due to self-harm. In times of
crisis however, clients should be encouraged to seek support from other
sources where possible, such as their therapist, or support help lines.
79
Medications
The prescription of some antidepressants may prove beneficial at some points
within the client’s treatment, for example, when the client is experiencing
suicidal feelings. However, when medication is prescribed for this reason, it
should only be used in the short-term, as these feelings are often related to
specific situations which may come and go quickly in the client’s life.
Dependent Personality Disorder
Clients with Dependent Personality Disorder feel the need to be taken care of.
They are fearful of separation or abandonment, which can lead to clingy
behaviour. This behaviour in turn can lead to others taking advantage of
them.
As people with Dependent Personality Disorder require constant
reassurance, they may find it difficult to make decisions and to complete tasks
or projects on their own. They have a tendency to belittle themselves and to
agree with people, even when they know the person is wrong.
A method, which can be used to remember some of the diagnostic criteria for
Dependent Personality Disorder, is ‘Reliance’:
R-
Reassurance required for decisions.
E-
Expressing disagreement is difficult.
L-
Life responsibilities (needs to have these assumed by others).
I-
Initiating projects difficult.
A-
Alone (feels helpless and discomfort when alone).
N-
Nurturance.
C-
Companionship sought urgently when close relationships end.
E-
Exaggerated fears of being left to care for self.
80
In order for Dependent Personality Disorder to be diagnosed, the client must
meet at least five of the following criteria:

Requires excessive reassurance from others in order to make
decisions.

Needs others to assume responsibility for major areas of life.

Finds it difficult to express disagreement for fearing loss of approval or
support.

Finds it difficult to carry out projects on own.

Will go to excessive lengths to gain nurture and support, even by
volunteering for unpleasant tasks.

When alone feels discomfort or helplessness.

Urgently seeks another relationship after a close one is lost.

Is preoccupied to an unrealistic extent with fears of being abandoned
and left to take care of themselves.
Treatment Options
Psychotherapy is again the most commonly used treatment choice for those
with dependent personality disorder. Clients usually present themselves for
treatment when stress or other particular problems in their lives have become
too difficult for them to manage. Like most other personality disorders, it may
initially appear that the client has a clear Axis I diagnosis, with the dependent
personality disorder only becoming apparent after a number of therapy
sessions.
It has been found that the most effective psychotherapeutic approach is one in
which the main focus is on finding solutions to specific life problems. Longterm therapy, while being beneficial for some personality disorders, may be
counterproductive in the case of dependent personality disorder as it only
reinforces the dependency on the therapist. Although there will always be a
form of dependency in treating someone with dependent personality disorder,
the shorter the treatment in this case, the better. The termination of therapy in
81
the case of treating dependent personality disorder will be of extreme
importance and will be an overall test as to how effective treatment has been.
The examination of the client’s faulty cognitions and related emotions is an
important aspect of therapy.
Assertiveness training and additional
behavioural approaches have all been found to be beneficial in the treatment
of those with dependent personality disorder. Group therapy may provide
further benefits, although it is also important to ensure that the client does not
use the group to form other dependent relationships. Initially, the therapist
should avoid challenging dependent relationships which the client has with
other people and which could be considered unhealthy.
When treating those with dependent personality disorder, it is extremely
important to consider the termination of therapy. While the decision to end
therapy should be a joint decision between the client and therapist, people
with the disorder are often unaware of how much therapy is enough. When
this is the case, the therapist may have to guide the client towards ending
therapy. It is common for the client to re-experience feelings of insecurity and
a lack of self-confidence they initially experienced when beginning therapy.
The therapist must deal with these feelings appropriately, but should not allow
them to prolong the current therapy treatment programme. The main target is
to jointly agree a time and way in which to end therapy, and the client should
be encouraged to use the skills they will have developed through therapy
sessions to manage their feelings of anxiousness.
Medications
Again, as with the majority of personality disorders, medication should only be
prescribed to treat specific problems, such as an additional Axis I diagnosis.
Therapists should also refrain from over prescribing medication to someone
with dependent personality disorder, due to the way in which they present a
number of physical complaints or anxiety.
82
In the case of anxiety, this is frequently related to a particular situation, and
medication, therefore, may have a negative impact upon psychotherapeutic
treatments.
Schizophrenia
Schizophrenia and Schizophrenic disorders have been defined by the World
Health Organisation as being:
“Characterised in general by fundamental and characteristic distortions of
thinking and perception, and affects that are inappropriate or blunted. Clear
consciousness and intellectual capacity are usually maintained, although
certain cognitive deficits may evolve in the course of time.
The most
important psychopathological phenomena include thought echo; thought
insertion or withdrawal; thought broadcasting; delusional perception and
delusions of control; influence or passivity; hallucinatory voices commenting
or discussing the patient in the third person; thought disorders and negative
symptoms”.
Schizophrenia is a severe and debilitating disease that can be found
worldwide. People who suffer from this disorder are usually very frightened
and confused by the symptoms they experience.
There are many misconceptions about schizophrenia, and people who suffer
from it are often stigmatised due to people’s lack of education and
understanding about the disorder. Even if a person no longer suffers from
Schizophrenia, they often find it hard to get on with their life due to the stigma
and judgements people make about them.
83
Symptoms
The symptoms of schizophrenia can vary from person to person, although the
main ones are generally indicated through:

Paranoia.

Social isolation.

Unusual emotional reactions.

Unusual sensitivity.

Hostility.

Hyperactivity or inactivity.

Deterioration in personal hygiene.

Inability to concentrate.
The symptoms of schizophrenia are divided into three sections:
 “Positive” symptoms – the presence of symptoms which are not
normally noted in the general population.
 “Negative” symptoms – the absence of what is generally noted in the
general population.
 “Cognitive” symptoms – problems with attention, certain types of
memory
and
executive
functions,
which
allow
planning
and
organisation.
Positive Symptoms

Delusions - Ideas the person has about him or herself or surroundings,
which are false.

Disrupted thoughts and behaviour - Difficulty maintaining train of
thought or concentrating, unpredictable or erratic behaviour.

Hallucinations - Sensations which are heard, seen, smelt or felt that a
person experiences but others do not.

Grossly disorganised behaviour - Behaviours which appear bizarre and
lack purpose, inability to suppress impulsive behaviours and emotions,
inability to perform goal-directed tasks, unpredictable agitation.
84
Negative Symptoms

Catatonic behaviour - Apparent unawareness of the environment, lack
of self-care, bizarre postures, decreased motion or excessive
and
aimless motions.

Flattened or blunted affect - Reduction of, or lack of emotional
expression.

Alogia - Difficulties with speech, lessening of fluency, inability to hold
conversation.

Avolition - Difficulty in creating goal-directed behaviour, social
withdrawal, lack of interest or enthusiasm for activities which were
previously enjoyable.
Cognitive Symptoms

Inability to sustain attention

Difficulties with “working memory”.

Poor executive functioning.
Causes
Schizophrenia is not believed to be caused by a single factor; it is regarded as
being due to a combination of issues, such as brain abnormalities, genetic
factors and developmental factors.
Brain Abnormalities
There are differences in the brain chemistry of people with schizophrenia
which are regarded as being a possible cause of the condition. These are
imbalances of:
 Specific amino acids.
 Certain proteins.
 Specific neurotransmitters.
85
Additional factors regarding the brain are related to the brain structure. The
loss of brain tissue, for example, and abnormal activity in the parts of the brain
which are responsible for emotion, reasoning and memory can lead to the
onset of schizophrenia. Furthermore, MRI scans have indicated that there are
some differences between the brain structures of those with schizophrenia
compared to non-schizophrenics.
The circuitry of the brain, such as
disruptions in the communication between the left and right hemispheres, is
also believed to be a contributory factor.
Genetic Factors
It has been stated that schizophrenia more commonly occurs in people who
have a family history of the condition. However, 60% of people do not have
such a history, making it more likely therefore, to be the result of other factors.
Developmental Factors
There are a number of developmental factors, which are believed to contribute
towards schizophrenia, which include:
 Exposure to a virus during infancy,
 Prenatal exposure to a viral infection,
 Early parental loss / separation,
 Low oxygen level due to prolonged labour, premature birth or low birth
weight.
Additional Factors
Further factors which may lead to the onset of schizophrenia include
environmental stresses, hormonal changes which have an effect on the
chemistry in the brain, and side effects from some drugs.
Treatment
The most common type of treatment for schizophrenia is medication. The type
of medication usually prescribed for schizophrenia is antipsychotic medicine.
This is at present the most effective way of treating the symptoms of
86
schizophrenia. However, these drugs are not a cure for the illness, only a way
to relieve its symptoms.
The majority of schizophrenic patients benefit from taking antipsychotic
medication, but a few do not find they ease their symptoms.
In these
instances, people may often feel that it is best to discontinue the treatment
because they are not helping, but cause unpleasant side effects. Individual
patients have individual needs, so doctors have to estimate
the correct
dosage for each patient, based on their assessment of them. Some patients
do not appear to need antipsychotics at all.
Antipsychotic drugs can cause side effects in patients. When first taking the
medication, some of the most common side effects are muscular tremors or
spasms, dry mouth, blurred vision, drowsiness or restlessness. These
symptoms can usually be treated quite easily by altering the dosage, using
other medications to treat them or changing to a different type of
antipsychotic, as there are several available. Some types suit some patients
more than others.
In addition to these side affects, long-term use of antipsychotics can lead to
more serous effects. In particular, antipsychotic drug use can lead to the
development of the disorder Tardive Dyskinesia. This disorder causes
involuntary movements in the body, usually affecting the mouth, lips and
tongue and less frequently the body and limbs. ITD is much more common in
people who have been prescribed the older types of antipsychotics, usually for
a long period, although it can occasionally happen as a result of short-term
use.
Whilst antipsychotics are very effective at removing the positive symptoms of
schizophrenia, they do not help patients who have difficulty with enthusiasm,
motivation,
social
interaction
and
emotional
expression.
Sometimes
psychosocial interventions can be beneficial to help people improve their
social skills and return to living a fuller life.
87
Gender Identity Disorder
Gender Identity Disorder is characterised by two factors, both of which must
be present in order for a diagnosis to be made:
The client must display evidence of a strong and persistent cross-gender
identification, which is the desire to be, or the insistence that they are, of the
opposite sex. Alongside this they must display persistent discomfort about
their sex or a sense of inappropriateness in their current gender role.
There must be evidence of clinically significant distress or impairment in the
client’s functioning in social, occupational or other important areas.
A good support system and counselling are regarded as the best treatment in
helping clients with this disorder. Where counselling is provided, children are
usually given individual and family counselling, and individuals or couples
therapy for adults.
88
Self assessment 4
SAQ1)
List 5 symptoms of depression for each heading.
Psychological symptoms
1.
2.
3.
4.
5.
Physical symptoms
1.
2.
3.
4.
5.
Social symptoms
1.
2.
3.
4.
5.
89
SAQ2)
Using the mnemonics list the diagnostic criteria for the following:
Borderline personality Disorder:
PRAISE-
Dependant personality disorder:
RELIANCE-
90
SAQ3)
Match the symptoms with the description. What mental health condition are
these the symptoms for?
Problems with attention, certain types of
“ positive” symptoms
memory and executive functions, which allow
planning and organisation.
“Negative” symptoms
“Cognitive” symptoms
The presence of symptoms which are not
normally noted in the general population.
The absence of what is generally noted in the
general population.
The mental health condition is:
_____________________________________________
Name three of each type of symptom common to this condition
Positive symptoms
1.
2.
3.
Negative symptoms
1.
2.
3.
Cognitive symptoms
1.
2.
3.
91
92
Assignment 4
4.1 Describe the principal symptoms of depression.
4.2 Analyse why depression is more common in women than men.
4.3 Describe the principal aspects of a hypomanic episode.
4.4 Describe the requirements for treating a client that has anorexia.
4.5 Describe the principal features of personality disorders.
4.6 Analyse the conditions associated with a ‘split personality’
93
94
In this section:
Individual Counselling
Group Therapy
Couples Therapy
Family Therapy
Online Counselling
Telephone Counselling
SMS Text Counselling
Video Counselling
Stages of listening
Types of validation
Common Problems in Counselling and Psychotherapy
Assignment 5
95
96
Individual Counselling
Individual counselling is a one-to-one therapy in which the client and therapist
will discuss the problems facing the client and work together towards a
solution.
Some people find individual counselling extremely beneficial, as it provides
them with the opportunity to discuss the problems and issues they are facing,
whether past or present, in a confidential environment where the client does
not need to feel that they will be judged by others. It also allows them to
discuss these issues at their own pace and discuss them as and when they
feel ready to do so.
The various models and types of therapy are usually available as individual
sessions. Most last for around 50 minutes to an hour and are held as weekly
sessions.
97
Group Therapy
Group therapy has been defined as therapy which is “conducted with at least
three or four non-related individuals who are similar in some area, such as
gender, age, mental illness, or presenting problem”13.
During group therapy sessions, members of the group are encouraged to
decide what they will talk about in that particular session. Within this, the
clients listen to what each member of the group says and then give feedback,
expressing their own feelings about what someone has said or done. All
members of the group are encouraged to interact, and many clients find group
therapy beneficial, as they are made more aware that they are not the only
ones who feel the way they do, and that there are others who understand. In
group therapy sessions, clients can share with each other how they got
through a particularly difficult time, which can help the other members of the
group to learn new coping strategies for when they need them. If self-harm is
being discussed, for example, clients can share with other members of the
group a time when they wanted to self-harm, but found an alternative coping
strategy which avoided them carrying out this destructive behaviour.
Group therapy sessions usually last for approximately 45 minutes on a weekly
basis; however, depending on the nature of the therapy, this may be
increased to 2 or 3 times a week. As with all other forms of therapy, all
sessions are confidential and what is discussed within each session will not
be discussed outside of this time.
13
AllPsych Online (2003) Psychology Dictionary
98
Couples Therapy
The aim of couples therapy is to promote better communication or to work
towards resolving specific issues facing a couple. Although it is often referred
to a ‘marriage counselling’, the clients do not need to be married in order to
see a therapist of this nature.
Couples often attend therapy after one partner expresses a wish to see a
therapist in order to deal with the problems they are facing as a couple. In
some cases, the other partner is reluctant to attend, as they fear that the
therapist will automatically take the other partner’s side. This should never be
the case and a good therapist should not take sides, but allow both partners
to express their feelings without being judged or feeling ‘picked’ on.
During sessions, the therapist will allocate an equal amount of time for both
clients to talk about their feelings. Any arguments which occur between the
couple should be dealt with appropriately, as the aim of the sessions is to
promote better communication between them. If however, the therapist feels
that one of the clients would benefit from extra counselling for mental health
issues, they will be referred to another additional therapist to deal with these.
There is a broad range of approaches to couples therapy which includes
behavioural therapy and cognitive behavioural therapy. Sessions are often
held for around 50 minutes on a weekly or fortnightly basis.
99
Family Therapy
Family therapy has been defined as “Treatment involving family members,
which seeks to change the unhealthy familial patterns and interactions”14.
Often the aim of family therapy is to help members of a family understand a
client’s problem or disorder. With eating disorders, for example, families are
encouraged to take part in family therapy so that they can learn more about
the eating disorder, as well as express their emotions about how the disorder
has affected their lives and the way in which it makes them feel.
Family therapy is not restricted to eating disorders, it can also be beneficial for
a wide range of issues including:
 Substance abuse.
 Grief / trauma / loss.
 Abuse.
 Martial problems.
 Work-related stress.
The aim of therapy is to help families as a whole to develop meaningful
changes in relationships, both within and beyond the family, and to work
towards resolving individual problematic issues. The therapist will work with
members of the family to help them find new ways of communicating with
each other, and to develop the skills they need in order to bring about a
positive change to their current situation.
14
AllPsych Online (2003) Psychology Dictionary
100
Online Counselling
Online counselling is becoming increasingly popular as sessions are not faceto-face, but instead consist of email correspondence between client and
therapist.
There are many reasons why a person may choose online
counselling, which include:
 Not wanting to see a counsellor face-to-face.
 Living too far away from a counsellor who specialises in the client’s
particular needs.
 Client has too little time during the day in order to go and see a
counsellor for face-to-face sessions.
Some people do not like the idea of seeing a counsellor face-to-face, and
therefore online counselling can be useful as they do not have to worry about
trying to interpret a therapist’s body language, tone of voice or facial
expression. Furthermore, online counselling allows clients to express their
feelings within a confiding relationship, but at a “safe distance”. However, a
problem that may arise from online counselling, is that, due to the distance
between the client and therapist, clients may be more likely to discuss things
they would not normally do in a face-to-face session.
While this can be
beneficial to some, it is also possible that doing such can take a client out of
their ‘comfort zone’, and that further sessions may be affected by the client
feeling that they have previously said too much.
The benefits to online counselling are that the client has the opportunity to
reflect on their feelings after writing them down, before they have received a
response from the therapist. Further benefits to this form of counselling are
that the client will have a copy of all the “sessions”, so that over a period of
time they are able to see the progression they have made since they initially
started.
101
Telephone Counselling
Telephone counselling is similar to face-to-face counselling, although
sessions are held over the phone which means that the client does not have
to travel to see a therapist. Just like face-to-face counselling, all sessions are
confidential and focus on bringing about change to problematic situations
within the client’s life. The sessions are a way for the client to express their
thoughts and feelings in a safe therapeutic relationship, and develop new
ways of dealing with difficult situations within their life.
Telephone counselling is particularly beneficial for those who have very busy
lifestyles and do not have the time to travel to see a therapist every week, or
for those who are housebound. Sessions can take place either during the day
or in the evenings, once the client and therapist have found a time which is
suitable for them both.
Sessions are very similar to other forms of therapy in the way that they last for
approximately 45 minutes and can be held on a weekly basis, although this
could be more or less frequently depending on the needs of the client.
102
SMS Text Counselling
SMS text counselling is another form of “new wave” counselling which is
becoming increasingly popular. This form of counselling involves sessions
taking place in the form of text messages sent by mobile phone.
Like online counselling, SMS text counselling allows clients who do not like
the idea of attending face-to-face sessions to receive the help and support
they need. Furthermore, another advantage to SMS text counselling is that
‘sessions’ can take place while the client is on the move, or at any other time
that is best for the needs of the client. This is particularly beneficial for those
who have very busy lifestyles, or who live a long distance away from a
therapist who meets their specific needs, as this form of therapy allows them
to correspond with their therapist at a time that suits them (during lunch
breaks etc.).
In some cases, clients do not have their therapist’s personal number. Instead,
any SMS texts they send to their therapist are sent to a number from which
the message is routed to the therapist. This is in order to protect the therapists
themselves, to stop the possibility of clients harassing the team, as well as
enforcing a boundary to the client. In other cases however, clients do have
their therapist’s personal number on which they can be contacted.
103
Video Counselling
Another form of online counselling is video counselling, in which the client and
therapist correspond through the use of webcams.
This form of therapy
comes closest to face-to-face counselling, as the client and counsellor can
both see and hear each other during sessions.
This form of counselling is beneficial for those who again, do not live close to
a counsellor whom they feel is suitable for their needs, since through video
counselling, the client does not need to live in the same town, or even country,
as the therapist. Video counselling has further benefits for those who do not
possess good keyboard skills, but would still like to use some form of online
counselling.
Another advantage is that the counsellor can pick up cues
through their client’s facial expressions as to how they feel and the emotions
attached to the issues they discuss during therapy sessions.
Before beginning video counselling, it is important that the client ensures they
have the necessary equipment to enable them to take part in the sessions.
The client should check that such equipment, such as the webcam and
microphone, are working correctly before the session begins so that they are
not paying for sessions which they later realise they cannot participate in as
they expected.
104
Stages of Listening
As a therapist good listening skills are a vital part of your job. Listening, which
is an active process, has three steps:
Hearing
Simply hearing what has been said
Understanding
Taking what you have heard and understanding it in your own way
Judging
After hearing and understanding what has been said, you need to think
whether you believe what you have been told
To be a good listener as a therapist you should:
 Ensure you are completely focused on what your client is saying, giving
them your full attention.
 Allow your client to finish speaking before you begin to talk; you should
not interrupt them.
 Listen for the main points of what your client is saying.
 If you are unsure about anything your client has said, ask questions for
clarification.
 Give your client feedback on what they have said, to show you have
understood – verbally, facial expression etc.
105
Types of Validation
Validation is an important part of therapy and consists of:
 Mindful listening.
 Reflecting and acknowledging.
 Clarifying and summarising.
 Putting problem behaviour in a larger context.
 Normalising.
Mindful listening
The first part of validation, mindful listening, requires the therapist to give their
total, undivided attention to what the client is saying. Within this, they should
make the client aware that they are listening by not appearing distracted by
other things in the room, and giving a series of verbal and non-verbal cues
(i.e. facial expression) that show the client that they are listening and
interested in what they have to say.
Reflecting and acknowledging.
In the second part of validation, reflecting and acknowledging, the therapist
should acknowledge what the client has said and demonstrate they have
listened by reflecting on what this means. In this, the therapist should not
repeat what the client has said word for word, but instead convey the essence
of what the client has discussed.
Clarifying and summarising.
In clarifying and summarising, the therapist may ask the client questions for
clarification on any areas they did not understand fully. In summarising what
has been said, the client can correct the therapist on anything which they
have misunderstood.
106
Putting problem behaviour in a larger context
By putting problem behaviour into a larger context, the therapist does not
ignore the client’s problematic behaviour but avoids more negative behaviour
following. If a client for example describes a time in which he / she had an
argument with their partner and said something nasty, they may feel that they
themselves are entirely to blame for what happened. If however, the client’s
partner also said something nasty, this could be validated by saying, “Yes you
said something nasty, but your partner also did the same.
Rather than
storming out of the house you stayed and calmed yourself down”.
Normalising
Normalising requires the therapist to explain to the client that their feelings
and reactions can be perfectly legitimate. If the client has said that he / she
was upset because they had arranged a family outing and no one came, the
therapist could say, “I understand you are upset that no one came, anyone
would feel the same in that situation”.
Common Problems in Counselling and Psychotherapy
Supervision
The British Association for Counselling and Psychotherapy (BACP) defines
supervision as “a formal arrangement for counsellors to discuss their work
regularly with someone who is experienced in counselling and supervision.
The task is to work together to ensure and develop the efficacy of the
counsellor / client relationship. The agenda will be the counselling work and
feeling about that work, together with the supervisor’s reactions, comments
and confrontations. Thus supervision is a process to maintain adequate
standards of counselling and a method of consultancy to widen the horizons
of an experienced practitioner.”15
15
BACP (2007) Information Sheets: What is Supervision?
107
Supervision can take place as a one-to-one session, group session or peer
group session, and takes place for at least 90 minutes every month. It is an
important part of a therapist’s practice and ensures that they themselves stay
safe and can discuss any issues that therapy sessions have brought up for
them as individuals, as well as professionally.
Like actual counselling
sessions, the issues discussed during supervision remain confidential. More
information and guidelines regarding supervision can be found on the BACP
website:
http://www.bacp.co.uk/members/info_sheets/S2.html
108
Clients with Communication Problems
For clients with communication difficulties, many counselling services are
unsuitable as they are very often not able to cater for their individual needs.
The NHS Improvement Network however, is working to reduce the boundaries
which face those with communication problems, to make counselling and
psychotherapy services more accessible.
For those therapists who have clients with communication difficulties, it is
worthwhile testing different forms of counselling to find a way for the client to
best communicate their issues and feelings.
Sign language for example,
while allowing clients to explain how they feel, is often problematic, as it
cannot express emotion in the same way that a person’s voice can. In this
case, alternatives such as art therapy may be beneficial in allowing clients to
express their emotions.
For other clients, such as those with autism, it is vital that therapists learn as
much about the condition as possible, so that they are aware of any changes
they may need to make to their therapeutic approach. Clients with autism for
example, take what is said on a very literal level. They may find it difficult to
understand some types of humour, and may not like certain colours or
objects.
Observing your limits
As a counsellor, it is important that you are aware of your limits and know
when you should refer your client to another therapist who may be able to
help them better.
If, for example, you had a client with a diagnosis of
personality disorder, an area in which you may have very little understanding
or training, it may be more beneficial for your client and your own well-being
for you to refer them to another professional who specialises in this area.
109
Ready for counselling?
Before commencing your practice as a counsellor or therapist, it is vital that
you ensure you are ready to take on such a responsibility, for both the wellbeing of your clients and your own.
To be an effective counsellor you should ensure that you:
 Listen actively to what your client says.
 Do not judge your client or anyone else.
 Give your clients your undivided attention and do not let your own
personal issues interfere with their treatment.
 Are understanding.
 Show respect for your client and others at all times
 Are honest and trustworthy.
 Know your limits as a counsellor.
 Take responsibility for what you say or do.
 Are patient and compassionate.
 Practise ethically as set out by your governing body.
Power and Control Issues
Power and control issues can often be a concern for therapists, when they are
seeing clients who completely take over the therapy session, or who are
aggressive in their speech. This can leave therapists unsure as to how they
can deal with the client, due to transference and counter-transference issues.
Further issues regarding power and control can come in the form of the
physical appearance of the client. For example clients who are extremely tall
and well built may be daunting for a therapist who is the complete opposite.
Clients such as these, who can also be prone to aggressiveness, can scare
therapists and make it difficult to work with them.
Transference
Transference has been defined as “The main characteristic (of transference)
is the experience of feelings to a person which do not befit that person and
110
which actually apply to another. Essentially, a person in the present is reacted
to as though he were a person in the past. Transference is a repetition, a new
edition of an old object relationship.... The person reacting with transference
feelings is in the main unaware of the distortion”16.
An example of
transference could be that a person during childhood may have had a bad
experience with someone who had a beard. In adult life, the person may not
trust, or be fearful around, others who have beards, even if they are in no way
connected to their past experiences.
Another form of transference is Abusive Multiple Transference in which
abusers transfer the negative feelings they have against their own abusers
onto their victims, but also transfer the power and dominance of their abusers
onto themselves.
During therapy sessions, it is important that one of the main aims of the
sessions is to resolve the transference, so that the client can identify and
understand the unconscious feelings and expectations they may have towards
others, and manage these effectively. In the example used above, it would be
important for the therapist to work on resolving the transference so that the
client no longer brings their past experience of someone with a beard into
their present-life perception of people with beards.
Counter-Transference
Counter-transference occurs when the therapist begins to transfer their own
unconscious feelings onto their client. Dealing with counter-transference can
be one of the biggest challenges facing a therapist. While it is not necessarily
possible to completely avoid counter-transference occurring, it is important
that it does not harm the therapeutic relationship as much as possible.
Projection and Projection Identification
As a therapist, it is important to be aware of projection and projection
identification issues.
16
Projection identification is the term given to the
http://www.tir.org/metapsy/jom/101_transfer.html
111
psychological process in which a person projects an emotion, belief or thought
onto another person.
A person, for example, may project their anger onto
someone else, with the unconscious intention that this other person will react
to what they have said or done. If this person were to react to the anger, they
will have characterised themselves by the projected thoughts or beliefs
originally expressed.
As a therapist you should take care not to project your own thoughts,
emotions or beliefs onto your clients, as this can be harmful to their work
within therapy sessions
Issues of Dependency
The setting of boundaries are vital early on in therapy to ensure that clients do
not become dependent on the therapist. Although initial dependency on the
therapist is to be expected at first, during sessions clients should be
encouraged to work through their issues with the ultimate goal of them being
able to decrease their dependency on the therapist, and increase their ability
to function as an individual.
Dependency issues are often one of the most difficult problems facing a
therapist, as it can become extremely difficult to work with clients who become
dependent, as they start to want more than just a therapeutic relationship. In
some cases, for example where a client has had a difficult childhood, they
may begin to depend on their therapist and want them to take on a parental
role in which the therapist “takes care of them”; something they may not have
had during childhood.
Aggression
As a therapist, it is likely that you will come across clients who can be
aggressive during sessions. It is important to remember that despite a need
to be understanding of a client’s anger, you should not tolerate aggressive
behaviour in any form. In one case for example:
112
“Lottie, a marriage counsellor, received a call one evening from an irate
husband. He yelled at her, cursed her, and blamed her for the state of his
marriage.
She listened to his verbal barrage for a long time, not saying
anything and getting angrier by the minute. The next day, the man came in
for his regular session and barely mentioned the phone call. When Lottie told
him that his behaviour the previous evening was rude and inappropriate and
that she expected an apology, he replied, “But you’re a therapist. Your job is
to listen and be understanding.’”17
A therapeutic relationship is built upon respect and trust, and it is important
not only that you respect your client, but they return that same respect and
trust to you. Aggressive behaviour should not be tolerated, and if you feel that
your client is being aggressive in sessions, this should be addressed
immediately, as well as working together to resolve the underlying issues
causing this aggression
Safety Issues
When working with clients it is important that, as a therapist, you take into
consideration any safety issues which may occur.
Some of the steps
necessary to take may seem simple, but help to ensure that you remain safe
during your sessions. These may include:
 Hold sessions in an office where other colleagues are close by so they
are available should they be needed,
 Constantly risk-assess clients and ensure procedures are in place
should any problems arise during sessions,
 Ensure tea / coffee machines or any sharp objects are not within the
therapy room,
17
Weiss, L. (2004) Therapist’s Guide to Self Care
113
 Have a phone (either landline or mobile) in the room so that emergency
services etc. can be contacted if necessary (ensure these are set to
silent so they do not interrupt therapy sessions).
Therapist’s Personal Issues Interfering
During therapy sessions, the therapist should take great care not to let their
personal issues interfere with their client’s treatment, and as such, not divulge
personal information to their clients.
If a client is aware of a therapist’s
personal issues, they may begin to alter their behaviour in a way in which they
analyse the therapist. Other examples may include the therapist’s views on
certain subjects. If a client for example, was planning to have an abortion,
and the therapist had personal views against the termination of pregnancy,
the client’s awareness of this, may result in them making a decision that they
will later feel was wrong for them, and therefore cause further problems at a
later stage.
Managing out of session contact with clients
When working with clients it is important to set boundaries in regard to out of
session contact. This is due to the way clients may think that they can contact
you regularly outside of sessions, whenever they have a problem. Therefore,
it should be agreed that clients contact you only if they are in crisis (i.e. at
imminent risk of harming themselves or others) or to inform you that they may
not be able to attend a therapy session. Setting boundaries in this way works
towards stopping the client from becoming overly dependent on you and
thinking that you will always be able to “solve” their problems.
114
Self assessment 5
SAQ1)
Circle the type of counselling would be most beneficial in the following
situations:
‘The client with mobility problems causing them to be virtually housebound,
suffering from depression who lives in a rural area with very limited public
transport access.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
‘A client with interpersonal difficulties, low self-esteem, and trust issues.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
‘A client who suffered abuse and neglect as a young child is finding it hard to
cope with daily life. She has recently given up her job due to depression.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
‘A young client suffering from an eating disorder, the parents and older
siblings don't understand about the disorder.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
115
‘A couple who are continually arguing with each other. the lines of
communication between them have broken down.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
SAQ2)
Think about different styles, issues and forms of counselling discussed so far.
Write below the areas which you feel you would most like to do and which you
would least like to do. Why do you think you would be good at the ones you
would most like to do?
Most like
Most dislike
116
SAQ3)
To be a good listener as a therapist, you should:





When you next have a conversation with a friend, colleague or family
member, think about these five skills and try to use them in the conversation.
117
Assignment 5
5.1 Explain for whom group therapy is appropriate.
5.2 Evaluate the issues around counselling on-line.
5.3 Analyse the types of validation, their importance and the contexts in which
each is used.
5.4 Analyse the issues around managing out of session contact with clients.
5.5 Analyse the implications of working within an ethical and legal framework.
5.6 Evaluate the importance and implications of routine evaluation of the
counsellor’s own practice.
5.7 Evaluate the importance of maintaining sound administrative systems.
118
119
In this section:
Suicide
Self harm
Eating distress
Relationship breakdown
Assignment six
120
Suicide
Why do people commit suicide?
To bring about change: suicide is a way for a client to change how they feel or
what is happening in their present life.
To make a choice: when a client feels that they do not have choices or that
important choices are being taken away from them, suicide may seem to be
the only choice left to them.
To exert control: an act of suicide is meant to stop the person’s behaviour, to
control events or to effect change in others.
As a way to punish oneself: suicidal behaviour is a means of relieving guilt or
punishing oneself for his / her actions.
As a way to punish others: the act of suicide may be intended to inflict harm or
punishment on others.
Talking to a client who is suicidal
When talking to a client who is suicidal, it is important as a therapist to
remember:
 Not to act shocked, as this will put distance between you and your
client.
 Not to be sworn to secrecy – seek support from your supervisor or
other colleagues if necessary, including any agencies who deal in crisis
intervention and suicide prevention.
 Offer your client hope that there are alternatives to suicide, but do not
offer them glib reassurance.
 Ensure you take action which removes a means of suicide, such as
stockpiled medications / drugs and poisons.
 If necessary seek help.
121
 Be direct with your client and speak openly and matter-of-factly about
suicide.
 Be willing to listen to your client, ensuring that you allow them to
express their feelings and that you are accepting of these.
 Do not debate with your client the ‘rights’ and ‘wrongs’ of suicide, or
lecture them on the value of life.
 Show interest in and support for your client, become available to them
and be actively involved in helping them through their crisis.
 Do not dare your client to commit suicide.
 Use active listening skills and constructive questions.
 Be resourceful.
 Be practical.
 Get support / help for yourself as a therapist.
 Avoid being judgemental or shocked, minimising your client’s fears,
patronising them or using guilt, or agreeing confidentiality.
Suicide Management Plan
As a therapist you should:
 Avoid labelling your client’s suicidal feelings as the result of behaviour
or being manipulative.
 Ask the client questions about their future plans.
 Assess / judge the hopelessness of your client.
 Keep documentation of your decisions and rationale.
 Identify where your client is on the continuum of suicidality (low – high
risk).
 Establish the client’s present situation.
 Determine the client’s accompanying psychopathology.
 Ask yourself how realistic your client’s plans of suicide are.
 Identify deterrents and protection.
122
Questions to ask your client about suicide ideation:
 Have you thought about harming yourself?
 What have you thought about it?
 When did you start thinking this way?
 Do you want to die?
 Have you told anyone you feel this way?
 Have you made a suicide plan?
 Have you made any preparations to commit suicide?
 Do you have the means to commit suicide (firearms etc.)?
 What has stopped you from committing suicide so far?
 What gives you hope?
Factors which contribute to an increased risk of suicide
 Alcohol and drugs.
 Anniversaries.
 Giving away possessions.
 Separation and divorce.
 Psychiatric history.
 Chronic illness.
 Feeling rejected
 Impulsivity.
 Anxiety.
 Improvement in severe depression.
 Loss of standing / reputation.
 Inability to meet obligations.
 Explosive episodes.
 Depression.
 Recent change in behaviour.
 Isolation.
 A deep sense of loss.
 Unusual behaviour.
123
 Relative who has committed suicide.
 Loss of friend / relationship support.
 Efforts for help have been unsuccessful.
Known critical suicidal feelings
Client:
 wishes they did not exist
 thinking they would like to sleep and not wake up
 dwelling on death
 believing they would be better off dead
 thinking about killing themselves
 making plans to kill themselves
 showing recent suicidal / harming behaviour
 the pervasiveness and incidence of the above
Self Harm
The mental health charity ‘Mind’ defines self-harm as “a way of expressing
very deep distress. Often, people don't know why they self-harm. It's a means
of communicating what can't be put into words or even into thoughts, and has
been described as an inner scream. Afterwards, people feel better able to
cope with life again, for a while.
Self-harm is a broad term. People may injure or poison themselves by
scratching, cutting or burning their skin, by hitting themselves against objects,
taking a drug overdose, or swallowing or putting other things inside
themselves. It may also take less obvious forms, including taking stupid risks,
staying in an abusive relationship, developing an eating problem, such as
anorexia or bulimia, being addicted to alcohol or drugs, or simply not looking
after their own emotional or physical needs”.18
18
Mind (2007) ‘Understanding Self Harm’
124
Why do People Self-Harm?
Self-harm affects roughly 1% of the population. A person self-harms for many
reasons, but the underlying cause is usually to deal with painful emotions,
such as anger, loneliness, unhappiness, shame or guilt. These emotions may
be related to abuse issues, such as flashbacks or self-hatred, resulting in a
wish to punish themselves.
Many individuals that self injure find it difficult to talk openly about their
feelings, so harming themselves is a way of relieving their emotions and
temporarily obtaining a sense of calm. For many people that self mutilate, it is
much easier for them to deal with physical pain than with emotional pain.
Other people injure themselves because they feel numb and pain is one way
in which they can prove they are able to feel something, or that they are
actually alive.
Self-harm can be seen as a way to prevent suicide or to help cope with
suicidal or intense unmanageable feelings. In this way it can be viewed as a
survival mechanism, because the person feels that they have no other way of
coping. Where self-injurious behaviour is used to prevent suicide it is
important to recognize that this has taken a great deal of effort for the person
not to go to more extreme measures. It is also vital to understand that the
severity of the injury is not indicative of the degree of emotional pain that the
person is experiencing or their risk of suicidal behaviour.
Methods of preventing self-harm
There are many ways to help prevent a client from self-harming, some of
which will work better than others, as it will always depend on the individual
concerned. While for some clients keeping busy can help, for others doing
something relaxing or pampering is more beneficial. When working with a
client who is prone to self-harm, it is important that they are aware of the
following techniques which may help them to prevent or reduce the episodes
of self-harm.
125
Clients could try:
 Keeping a diary.
 Phoning a friend to talk.
 Focusing on breathing and the movement of the abdomen and chest.
 Sucking lemons slices.
 Holding ice cubes or rubbing them on their skin.
 Listening to soft music.
 Watching a favourite comedy film.
 Calling a helpline.
 Eating comfort food.
 Listening to upbeat music and dance.
 Learning breathing exercises to aid relaxation.
 Treating self to a luxurious bath.
 Tearing up old newspapers.
 Putting on loud music and screaming.
 Playing a physical game like squash or tennis.
 If a client is angry or upset with a particular person, they could write
them a letter and then tear it up or burn it.
 Cleaning the house or car.
 Eating a hot curry or other spicy food.
 Going for a walk or run.
 Going to the gym.
 Hitting a punch bag.
 Punching pillows.
 Writing about happy times in their life.
 Using a red marker pen and drawing on the area they want to cut.
126
What can friends and family do?
It can be very difficult for friends and family to understand self-injurious
behaviour. However, it is important that they are encouraged not to make
negative remarks towards your client and that they accept that self-harm is
how your client copes with difficult feelings. Furthermore, if your client feels
that their friends and family are shocked, fearful or rejecting of their self-harm,
they will be unlikely to ask them for support again in the future, if they believe
it will cause their loved ones distress. However, if a client’s friends and family
are accepting of the self-injurious behaviour and understand that it is a coping
mechanism, they can become a valuable source of support by giving your
client the opportunity to talk about their feelings without fear of being judged.
In some cases, it is important that you as a therapist, as well as friends and
family, realise that your client may not want help with their self harm. When
this is the case, it is vital that their privacy is respected. When a client does
seek help for self harm, however, it is important that all those concerned in
giving support to the client are clear on exactly what support the client wants
from them. In some cases, just having someone around who the client can
talk to can be extremely beneficial to them and help to reduce self-harm. This
is for two reasons: firstly, because there is someone available to talk should
they need to, and secondly because self-harm most frequently occurs when a
client is alone.
When working with a client who self harms, you should not try to prevent the
self-harm from occurring by trying to lay down rules. You should remember
that no-one wants to hurt themselves, but this is the only way the client feels
able to deal with the painful emotions they are experiencing. In some cases, if
a client is forced to stop their self-harming behaviour and they do not have an
alternative coping mechanism to fall back on, they may feel that the only
option left to them is to take their own life.
127
What to do if your client has self-harmed
If your client has self-harmed and requires medical assistance, you should do
one of the following:
If your client’s injuries are life threatening or require urgent medical attention,
999 should be contacted for an ambulance, or they should attend the nearest
Accident and Emergency department immediately.
If you are unsure of the severity of your client’s self harm then:
Contact NHS Direct who will assess whether or not your client will require
medical attention or if they can self-care at home.
Unless urgent medical attention is required for your client, a local G.P. surgery
or nurse could be contacted for an emergency appointment and necessary
first aid
If your client will only require home care, their local pharmacy will be able to
advise them on the appropriate first aid.
128
Breaking the pattern of self injury
The feeling and emotions that cause your client’s self harm do not just
disappear, nor do they suddenly develop new healthy coping mechanisms
from nowhere. Recovering from self-harm will mean that your client will be
able to discuss it openly with you, so that you can work through the underlying
issues for this behaviour together. The first step towards breaking the pattern
of self-injury, however, is ensuring that you have a stable, trusting relationship
with your client. Self harm for some clients is the only coping mechanism they
have and should be recognised as such.
Eating Distress
Clients with eating disorders need to seek support as soon as possible, before
the condition becomes life-threatening. If a client is admitted into hospital for
eating related disorders, counselling may be offered and the client given a fair
amount of choice regarding food. If the condition is severe however, some
hospitals may use ECT, drugs or force-feeding techniques. This is particularly
the case if a client is admitted to hospital under the Mental Health Act.
It is important for therapists to remember that clients with eating disorders
often use food as a way of taking some control of their lives. This in turn
however, often results in a loss of control as the disorder takes over their life.
The client should be encouraged to talk about the underlying issues which are
causing their eating distress (such as low self-esteem, lack of confidence). To
ensure this however, the client needs to feel that the therapeutic relationship
is safe and confidential.
If you are concerned that your client requires urgent medical attention, they
should be encouraged in the first instance to go to their nearest hospital
immediately, or the emergency services should be contacted, in order for
them to receive urgent treatment.
129
Relationship Breakdown
The breakdown of a relationship is an extremely difficult time for anyone, and
therapists should encourage their clients to talk about their feelings regarding
this openly. If the breakdown has come as a shock to the client, they may feel
extremely hurt and betrayed.
It is common for those going through a
relationship breakdown to feel that they no longer have a reason for living.
The therapist should therefore encourage their client to take the space and
time they need to grieve from their loss.
The client may feel frightened of being alone, which in some cases can cause
them to rush into another relationship which may not be ideal and could cause
further problems later. In other cases, a client may lose their confidence and
it may take them some time to rebuild this confidence and self-esteem. As a
therapist, it is important that clients are aware that this process can take time
and that their thoughts and feelings will be listened to and acknowledged in
sessions
If a client is believed to be at high risk of suicide following a relationship
breakdown, the guidelines set out earlier in this course should be followed to
prevent this or any other damaging behaviours.
130
Self assessment 6
SAQ1)
Why do people commit suicide? Which of the following statements are true
and which are false?
To bring about change: suicide is a way for clients to
change how they feel or what is happening in their
True
False
True
False
True
False
True
False
True
False
present life.
To make a choice: when a client feels they do not have
choices or that important choices are being taken
away from them, suicide may seem to be the only
choice left to them.
To exert control: an act of suicide is meant to stop the
person's behaviour, to control events or affect change
in others.
As a way to punish oneself: suicidal behaviour is a
means of relieving guilt or punishing oneself for his/her
actions.
As a way to punish others: the act of suicide may be
intended to inflict harm or punishment on others.
SAQ2)
Imagine you have a client who is suicidal; Write down some questions you
could ask your client to enable you to carry out a risk assessment and think
about some of the possible answers you may be given. How do you think you
will react to these answers?
131
Assignment 6
6.1 Analyse why people may consider taking their own life.
6.2 Evaluate the factors which might increase a clients risk of suicide.
6.3 Discuss the possible processes to be followed if a client informed you they
were suicidal.
6.4 Evaluate the available techniques and tools available when helping
someone stop self harming.
132
133
In this section:
Staying safe
Abuse and the Law
Reporting Abuse as a Counsellor / Therapist
Why do people abuse?
Assignment 7
134
Abuse has been defined as “a general term for the misuse of a person or
thing, causing harm to the person or thing, to the abuser, or to someone else.
Abuse can be something as simple as damaging a piece of equipment
through using it the wrong way, or as serious as severe maltreatment of a
person. Abuse may be direct and overt, or may be disguised and covert.”
Source: Wikipedia
Abuse can take many forms, and can occur across all cultures and social
backgrounds. There are four main types of child abuse; physical, sexual,
psychological and physical and emotional neglect. All forms of abuse are
detrimental to the well-being of a child and can have a serious impact upon
their development. Physical abuse for example, can result in psychological
damage, which can affect the child into adulthood.
Despite some people believing that sex with children should be encouraged,
all forms of abuse are illegal. A child is incapable emotionally, intellectually,
and does not possess the physical maturity to protect themselves from adults
and, as such, is protected by law.
There are many problems facing adult survivors of abuse; one of the biggest
of these problems is denial. In many cases a child often deals with the abuse
by dissociating themselves from the situation, which results in them being in
denial throughout the future. Others may turn to drug and alcohol abuse as a
way of releasing the tension they feel, and at the same time diverting attention
away from the abuse they experienced as a child.
Those who have suffered child abuse may imagine themselves as young
adults when they think back to what happened to them. They sometimes find
it hard to realise that they were only a child and that what happened to them
was the fault of the adult abuser, not their own.
135
Staying Safe
For those in abusive situations, it is important that they are aware of how they
can keep themselves safe and develop an escape plan should the need arise.
Possible ideas include:
 Keeping a mobile phone to hand at all times.
 Keeping a record of any abusive situations that occur.
 Keeping letters, messages or anything which may contain frightening or
abusive messages so that they can be used as evidence against the
abuser if necessary. If they are in electronic format (such as emails or
text messages) ensuring that the original message is kept, as well as
ensuring a hardcopy is printed.
 Keeping a diary soon after an event occurs, which includes as much
detail as possible.
 Keeping a tape recording of telephone conversations, if possible.
 Confiding in a friend, colleague or other member of the family.
 Keeping photographic evidence of any injuries.
 Planning possible responses to crisis situations.
 Keeping any important and emergency telephone numbers to hand (i.e.
National Domestic Violence Helpline).
 Ensuring children understand that they need to call 999 in an
emergency and provide the operator with their name, address and
telephone number, so they know how to react in an emergency
situation.
 Finding a safe place to go in an emergency, avoiding mutual friends or
family where possible.
 Confiding in any trusted neighbours, and telling them what is
happening and asking them to phone the police if they can hear a
violent attack.
 Keeping an emergency bag packed as well as one for any children –
ensuring it is kept hidden so that it is ready should the need to leave
quickly arise.
136
 Being aware of where the nearest phone is if it is not possible to use a
mobile.
 Keeping a small amount of money to hand at all times so that there is
enough for bus fares or a pay phone.
 If an attack seems imminent, trying to avoid areas of the house where it
is possible to be easily trapped or where there are objects which could
be used as weapons.
Abuse and the Law
Domestic violence is dealt with under both criminal and civil law. In civil law,
the main aim is the protection of the victim of domestic violence, as well as
any application made for an injunction against an abusive partner. Alongside
this, family proceedings such as child contact will also take part in a County
Court.
In criminal law, the main aim is punishing the offender.
This process is
initiated by both the police and the Crown Prosecution Service. Such cases
are heard in either a Magistrates’ Court or the Crown Court, although this is
dependent on the severity of the charge.
There are now a number of laws protecting people from domestic violence
and sexual assault. These include the Sexual Offences Act 2003 and the
Domestic Violence, Crime and Victims Bill 2003.
137
Sexual Offences Act 2003
The Sexual Offences Act is “an Act to make new provision about sexual
offences, their prevention and the protection of children from harm from other
sexual acts, and for connected purposes”19. The Act is divided into three
parts.
The first covers the “non-consensual offences of rape, assault by
penetration, sexual assault and causing a person to engage in sexual activity
without consent”20. This Act also covers sex offences against children, who
are defined under the Protection of Children Act 1978 as anyone under the
age of 18 years old. Further provisions are made for anyone over the age of
16 where the defendant is the victim’s partner.
The first part of the Act
continues by covering offences which relate to child pornography, trafficking
and prostitution, as well as the administration of a substance with the intent to
commit a sexual offence.
The second part of the Act “contains measures for protecting the public from
sexual harm”21.
Amendments have been made to the Sex Offenders Act
1997, as well as a range of orders which have been specifically designed to
protect children from sexual harm. The Act also includes travel orders in
which convicted sex offenders are prevented from travelling abroad when they
are at risk of abusing other children.
The third part of the Act “contains general provisions relating to the Act,
including minor and consequential amendments and commencement
provisions”22.
Domestic Violence, Crime and Victims Bill 2003
The Domestic Violence, Crime and Victims Bill 2003 is divided into three
parts. Within the first section clauses 1 to 3 are amendments to the Family
Law Act 1996. Under these sections a “breach of a non-molestation order will
become a criminal offence”23.
This will also include same-sex cohabiting
Office of Public Sector Information – Sexual Offences Act 2003
Office of Public Sector Information – Sexual Offences Act 2003 Explanatory Notes: Summary
21
Office of Public Sector Information – Sexual Offences Act 2003 Explanatory Notes: Summary
22
Office of Public Sector Information – Sexual Offences Act 2003 Explanatory Notes: Summary
23
Parliament UK – House of Lords – Domestic Violence, Crime and Victims Bill – Explanatory Notes
19
20
138
couples and those who are in intimate personal relationships for a significant
period of time, but have never lived together or been married.
Within clauses 4 and 5 of the Bill, a new offence has been included of causing
or allowing the death of a child or vulnerable adult. “The offence will apply
where a child or vulnerable person dies as a result of unlawful conduct; a
member of the household caused the death; the death occurred in anticipated
circumstances; and the defendant was or should have been aware that the
victim was at risk but either caused the death or did not take all reasonable
steps to prevent the death”. Under these clauses, subject to age restrictions
and mental capacity, all members of the household will be liable for this
offence. Under this offence, the maximum penalty is imprisonment for up to
14 years.
Within clause 6, arrangements are set out “for the establishment and conduct
of domestic homicide reviews”24.
Within Part 2 of the Bill, criminal procedure is set out, in which common
assault is an arrestable offence and the availability of restraining orders
specified under the Protection from Harassment Act 1997, are extended.
Part 3 of the Domestic Violence, Crime and Victims Bill “makes provision
about victims and witnesses of crime”. Within this section, the Secretary of
State is permitted to pay grants to “bodies which assist victims and witnesses,
giving a statutory basis for existing financial arrangements”.
Rights of Victims
All victims of abuse have the right to receive information about the progress of
their case, and any explanation they need should be provided. They have the
right to receive compensation and to be protected in any way necessary. It
should be the responsibility of the state to decide what should happen to an
24
Parliament UK – House of Lords – Domestic Violence, Crime and Victims Bill – Explanatory Notes
139
offender, and the victim should be entitled to receive support and respect for
any decisions they make.
Injunctions
Victims of domestic violence can gain some protection from their abusers by
applying for a protection order or civil injunction. Under the Family Law Act
1996 there are two types of injunctions available: a non-molestation order, or
an occupation order.
A non-molestation order is defined as an order which is aimed at preventing
an abusive partner threatening or using violence against their partner or any
children. Under this order they are also unable to intimidate, harass or pester
their partner.
Under an occupation order, it is regulated who is allowed to live in the family
home, as well as restricting an abuser entering the house or area surrounding
it.
It is a criminal offence to breach a non-molestation order and should a victim
of domestic violence wish to, they can take their abuser back to a civil court
for breaking the order. If a victim of domestic violence has an injunction with a
power of arrest attached to it, this can also be attached to an occupation
order. Victims should be aware however, that while in some cases a court
order can provide a certain level of protection, it may also be counterproductive.
Applying for an Injunction
In order for a person to apply for an injunction, the following conditions apply
to the two parties:
 They are, or have been, married to each other.
 They are, or have been, in a civil partnership.
 They are relatives.
140
 They are living, or have lived, in the same household.
 They have formally agreed to marry each other, even if this agreement
has now ended.
 They have a child together.
 If they are not living together, they have been in an “intimate
relationship of significant duration”.
The Domestic Violence Crime and Victims Act, 2004 amends the Family Law
Act so that couples who do not live together, or do not have children together,
can apply for non-molestation orders, as well as same-sex couples being able
to apply for occupation orders.
If under the terms given above, a person is not eligible to apply for an order
under the Family Law Act, or they are being threatened and harassed
constantly after a relationship has ended, they can apply for a civil injunction
under the Protection from Harassment Act 1997. A restraining order can also
be used to provide the same protection as an injunction under civil law, and
may be more effective in the long run, as it carries stronger penalties for
breaking its terms.
An injunction is usually set for a specific period of time but can, if necessary,
be renewed. There is not a time limit on the period of time in which a nonmolestation order can be extended, whereas an occupation order can only be
extended beyond 12 months if they have the right to stay in the home legally.
If the victim of abuse needs an injunction application to be made immediately,
due to them being in immediate danger, an application can be made to the
court on the same day without the need for the abuser to be present. In this
situation, the court will consider whether or not the victim is at risk of
significant harm, and whether or not they will be deterred or prevented from
applying if they are made to wait. If the court decide to grant a ‘without notice’
order, the victim will be required to attend a full court hearing once the person
accused of abuse has been served with this notice.
141
Evidence Required
In order for proceedings to take place, the victim will need to make a sworn
statement to the court in which precise details about the emotional and
physical abuse the person has suffered will be given. This will also need to
include dates and times in which the incidents occurred, if possible, and the
effects this had on the victim themselves, as well as their children. Police
reports and medical records may also be given as evidence if necessary.
Before the court will make a decision on an injunction, they will consider a
range of factors such as the health and well-being of both parties, housing
and financial arrangements and general needs.
If an injunction is regarded as unsuitable, the court may instead ask the
abuser to make an undertaking, stating that they will not harass or threaten
the victim further. In breaking this however, there are no powers of arrest, so
while doing so would be contempt of court, it is generally much harder to
enforce.
Breaking a Court Order
If a court order is broken, it should be treated as a criminal offence, as stated
under the Domestic Violence, Crime and Victims Act 2004. When the abuser
is arrested they will then be required to attend a Magistrates’ Court, as this will
strengthen the power of any court orders made. If a non-molestation order
has been made after 1st July 2007, or if there is a power of arrest attached to
the order, the police are required to arrest the abuser and bring him back to
court within 24 hours.
Role of the Authorities
In 1948 it was specified under the Children Act that it was the responsibility of
a local authority to take a child into care if they were being abused or
neglected by their primary caregivers. These powers were developed further
in 1952, when the authorities gained the additional power to investigate cases
of neglect, and again in 1963 to take preventative action against this neglect,
in order to protect the child.
142
These measures were taken after it was believed that there was a link
between children who were being abused or neglected and young offenders.
In 1969, the Children and Young Persons Act removed the distinction
between those who had been neglected or abused and young offenders. The
Children Act 1989 broke this, however, by removing the power to admit a child
into care after committing an offence.
This 1989 Act defines the grounds in which a child can be admitted into care
by the authorities. It states that any admission has to be in the best interests
of the child’s welfare, which takes into account their needs and wishes, as well
as family background. It further states that the child must be at significant
risk, or suffering significant harm, in which their health and development is
impaired.
Although the Children Act 1989 defines the circumstances in which a child can
be taken into care, it also limits these circumstances in comparison to
previous legislation.
Under such legislation as the Children Act 1989, the role of social services is
to ensure the welfare of all people. This applies not only to children, but to
families, the elderly, those with mental health problems etc.
Reporting Abuse as a Counsellor / Therapist
If as a counsellor or therapist you are concerned that your client is being
abused, it is important that you seek the appropriate guidance from your
governing body and report it to the police immediately. If your client is a child,
the Department of Health states that therapists must “…refer any concerns
about child abuse or neglect to social services or the police”. While
acknowledging a potential duty of confidence towards the child, this may be
over-ridden “(w)here there is a clear risk of significant harm to a child, or
143
serious harm to adults, the public interest test will almost certainly be
satisfied”25.
Although reporting abuse can be regarded as a break of client-therapist
confidentiality, it is a necessary break.
More information regarding the
reporting of abuse and the confidentiality guidelines surrounding this can be
found in the BACP Information Sheet in the ‘Resources’ section.
The Inner Child
An important part of recovering from childhood abuse is the healing of the
‘inner child’. This is something everyone has inside of them, and for those
that have been abused in their childhood, this ‘inner child’ can feel frightened
and hurt.
‘Inner child’ therapy is growing in popularity, as it tends to be less evasive
than many other forms of therapy and allows the survivor of childhood abuse
to focus on understanding their own behaviours, rather than talking in detail
about what actually happened to them. It allows people to focus on feeling
safer within themselves, and helps to try and reduce any nightmares or
flashbacks they may be experiencing about the past abuse.
Inner child therapy aims to help survivors understand any dissociative
tendencies they may have, as it is common for children to dissociate in order
to cope with traumatic events. It is believed that by helping survivors become
‘friends’ with their inner child, they can help to reduce their likelihood of selfharming or other destructive behaviours.
Relationships after Abuse
Many people have done the tough work of recovery from sexual abuse,
whether with help in therapy or on one's own. It challenges us to the core, but
it also frees us, and gives life and possibility where we once felt that we might
never get through it.
25
BACP (2007) E6 Information Sheet
144
For some, getting into a relationship, or continuing with one we've been in,
after abuse recovery, is a fairly smooth process. For others, the challenge
holds a range of feelings, such as the longing to be loved, mixed with
uncertainty, anxiety, fear, even panic. It often comes with a deep sense of
undeserving, or the belief, "I am unlovable." Some people will go through a
long period of celibacy, even after sexual abuse counselling. Others might try
dating, but find themselves repeating patterns that occurred in abusive
relationships, with their new partners. Sometimes abuse survivors find it very
difficult to be intimate, either sexually or emotionally, or both. Or they might
tend to feel more like a sex object, and not be recognized for who they are as
a person.
"Healthy Relationships are not only a source of fulfilment, they are where the
final healing takes place."
But we can love and be loved, trust and be trusted, again. I have a number of
clients who have sexual abuse history, and do the work of recovery, only to
discover that they feel handicapped when the time comes to be in a healthy
relationship. Yet healthy relationships are not only a source of fulfilment, they
are where the final healing of sexual abuse issues takes place. I have seen
many women and men overcome their fears, and build healthy and loving
relationships.
While everyone is different, there are a few common themes that surface for
those with a history of abuse. For instance, it's unlikely that one who suffered
abuse was taught much about boundaries. Yet good boundaries are inherent
in any healthy relationship. This comes up in a variety of ways. For example,
many couples have learned to be very careful not to say hurtful things to their
partner during a fight; they've learned not to be flirtatious with others if they
are in an exclusive relationship. These may seem like small concerns, but
they actively maintain safety and respect, both for each other and for the
integrity of the relationship.
145
People without abuse history typically recognize when another person (man or
woman) is "coming onto" them inappropriately, and they have no trouble
telling the "intruder," so to speak, to back off. With abuse history, especially if
the abuse was chronic, we don't even recognize inappropriate behaviour,
because such behaviour was "normalized" during one's childhood. ("I thought
that was normal!") The abuse survivor then is less likely to take steps to
protect themselves, and is left with an array of feelings, including frustration,
disappointment, confusion ("How come this keeps happening for me?"),
anger, and resignation ("All men / women are like this, they just want me for
sex.") How different it becomes when the survivor learns to recognize
inappropriate behaviour for what it is, use appropriate boundaries, move on,
and then be able to open to what we do want, a person who is respectful,
loving, honest, and so on.
"As children, when our parents directly contradict our inner voice, our intuitive
knowing, we'll trust them and discount our own truth. As adults, we have to
learn to trust our intuition all over again."
Another unfortunate, but repairable, side-effect of sexual abuse is that we
have often lost trust in our intuition. If our intuition told us that something that
happened wasn't right, but all the adults in our family said, "I don't see any
problem here," or "You're lying! Shame on you!" we get confused. As children
we need to trust our parents for our basic survival. When our parents say and
do things that directly contradict our inner voice, our intuitive knowing, we'll
trust mom or dad, and discount ourselves. For children, it's safer this way. But
as adults, it takes retraining to trust our intuition again. This is a gradual
process, but it can be done. Once we trust our inner knowing more fully, we
become confident, more empowered, and more able to receive what is
beneficial to us.
Love, trust, intimacy, and ease are not only possible; they are our birthright.
We mustn't allow someone else's violation of us to impede our right to love
and be loved. Thankfully, we don't have to.
146
Source:
http://www.articlemotron.com/Article/After-Abuse--The-Challenging-
Work-of-Forging-Healthy-Relationships/69641
Why do people abuse?
The reasons why people abuse have multiple answers and can vary from
person to person. Some people abuse others as they have learned it from
their own childhood from witnessing a parent being abused by another, or
from being abused themselves. Others begin to abuse due to stress, social
isolation, lack of appropriate resources available to them, inappropriate
expectations of others around them, or poor parenting skills.
For those who have witnessed abuse from a young age, they may find having
an “abuser” and “victim” role to be a normal relationship dynamic. They are
familiar with, and understand ,the terror associated with being a helpless
victim, from their own experiences. In some cases, rather than being the
helpless victim in later life, they themselves take on the role of the abuser.
This does not, however, mean that everyone who has been abused will later
go on to abuse other people.
Trauma Work
Stigmatisation
Often enough, a person that has suffered from abuse will feel that others have
certain ideas and pre-conceptions about someone who has suffered abuse. It
may be that your client feels as if others will think they are dirty, or that it was
their own entire fault. Often these thoughts and ideas about what others are
thinking may actually be your client reinforcing the ideas and views they have
about themselves. It is important that the first stage of trauma work would be
working on combating this common problem. CBT can be extremely useful in
this process at changing the negative and unhelpful thoughts a client may
have about themselves.
147
Betrayal
A client who has been abused may have experienced this from a friend,
neighbour, teacher, or parent. In some cases this may be a complete stranger
who is unknown to our clients as children, but ask yourself, as a child don’t we
all think that adults are there to protect us? When thinking about this, does it
come as any surprise that our clients will often feel completely betrayed? For
clients who have experienced this level of betrayal it isn’t any wonder that
working with a client who has been abused as a child may be very difficult in
building a safe therapeutic relationship.
Powerlessness
So young, so helpless, so easily misguided and even easier to fall at the
hands of an abuser who is often a care giver. As an adult your client may
have felt that they should have done something, told someone, or they may
have tried but were disbelieved. As an adult, your client will have completely
different ideas about the abuse as their once under-developed minds are now
fully developed risk assessors. It’s important that your client works on the guilt
and shame they feel about the abuse that they presently see as their own
fault.
Traumatic sexualisation
For clients who were sexually abused as children, they may have present
issues as an adult with sexual relationships. They may be able to have sex
with strangers but unable to make love in a relationship; they may be
promiscuous, they may be taking risks; they may not engage in sexual
activities at all, which can cause issues in relationships; they may only enjoy
rough sex or have strange sexual fantasies relating to the abuse, which again
can lead to guilt and shame as they may become fixated in the notion that the
abuse is again their fault as they must have wanted it. These are all issues
which need to be worked on in therapy so the client is able to enjoy a better
and healthier quality of life.
After working through the stages above, your client may feel as if they have
lost a huge part of what they considered their identity. It is important that you
148
work through these issues with your client to enable them to formulate a
clearer picture of who they are. Another issue to consider is, now they have
laid their past to rest, what is it they want from life, what are all the things that
their past has taken from them? What would they like now?
Maybe your client would be interested at this stage in meeting other survivors
of child abuse? Maybe they would like to engage in a support group?
149
Self assessment 7
SAQ1)
Think of 3 different steps that you as a practicing therapist could take to
maintain both yours and your client’s safety while in a session.



SAQ2)
Only certain types of abuse are detrimental to the wellbeing of a child
Domestic violence is dealt with under both criminal and
civil law
There are three parts to the sexual offences act 2003
There are three types of injunction available for victims
of domestic violence under Family Law Act 1996
The breaking of a non-molestation order should be
treated as a criminal offence
Councillors should not report disclosed abuse under
any circumstances
True
False
True
False
True
False
True
False
True
False
True
False
150
151
Assignment 7
7.1 Abuse and trauma could be seen as a cause for most mental health
conditions. True or false? Explain your answer.
7.2 Your client discloses they are currently being abused and are
considered vulnerable. What would you do?
7.3 Your client discloses they physically abused their child. What would
you do?
7.4 Why could intimate relations be difficult for a client who has been
sexually abused?
7.5 People who have been abused are more likely to abuse. True or false?
Discuss and explain your answer.
152
153
In this section:
Therapist’s toolbox
Therapeutic tools and interventions
Assignment eight
154
Therapist’s toolbox
As a therapist, you will always hear about the toolbox, which is basically what
it says on the tin: a tool box of skills and tools to use with your clients. In this
section you will find some skills and tools which you may like to use with your
clients.
Therapeutic tools and interventions
The ‘and and’ approach
This is a great tool when working with someone who may have an eating
disorder or someone who self-harms. The idea behind it is for your client to do
something positive to take care of themself just before or just after a period of
self-harm or purging. In doing this with your client you will be helping them to
break an often addictive cycle.
Example: a client could have just self-harmed by cutting. Directly after this
incident, using this approach they would take a nice, hot, and relaxing bath or
indulge in some of their favourite chocolates.
Halting protocol
The idea behind this is each and every time your client wants to engage in a
self-mutilating or damaging behaviour you would ask them to stop and think
for a period of time. This could start at a time such as five seconds (remember
to always keep things achievable to increase confidence) and then rise each
and every time as a client feels more able and confident.
Example: your client suffers with Bulimia Nervosa and as she is about to
purge she would stop for five seconds and think of anything other than the act
of purging. Should they do this time and time again you will find that after a
period of 30 seconds or more it will be very unlikely that your client will still
have the urge to purge.
155
Pro and con list
To continue using the example of eating disorders, and specifically Bulimia
nervosa, it can be useful to look into the specifics of what someone considers
the pros and cons of continuing to engage in the behaviour of someone with
this condition.
Example:
Keeping eating disorder
Letting go
Pro:
Pro:
Way to manage emotions
Able to be normal
Way of being thin
Healthier
.....
.....
.....
.....
Keeping eating disorder
Letting go
Con:
Con:
It hurts
I’ll get fat
Rules my life
Who would I be?
.....
.....
.....
.....
Writing letters

Write a letter to the illness as a third person.

Write a letter to your therapist five years after treatment, but still having
the illness. How do you feel?

Write a letter to your therapist five years after treatment, without the
illness. How do you feel?

Write a letter thanking the illness for everything it gives you.

Write an angry letter to your illness asking for explanations of what
opportunities it has taken from you and why.

Write a letter to a friend who has just been diagnosed with the same
condition as yourself. What advice would you give them? What would
156
you say? You can also do this with a friend that may have recently selfharmed. Often clients will find they are great advice givers but find it
difficult to apply the same advice to themselves.
Feeling safe
Ask your client to think of a place where they felt completely safe. Ask them to
go there in their mind and explain exactly what they take from this place and
why exactly it feels safe to them. Really get them to explain their
surroundings. When they have completed this exercise with you, ask them if
they would feel comfortable going to this place at times of distress.
Transactional object
Ask a client if they have any object that they can relate to feeling safe. This
may be an object such as a pebble from the therapy room they attend with
you or it could be a comfort blanket they had when they were a child. Ask
them to keep this on them and concentrate on the safeness and memories
this item brings them when feeling down or distressed.
Breathing exercises
Ask your client to take a deep breath in and then out. This should be done
slowly and take a period of five seconds. Your client should do this ten times;
after completing this, they should feel much calmer. They can do this with
their eyes open or shut, and you as the therapist can do this with them if it
helps the client.
Mindfulness
One of the exercises your client can try is to close their eyes and relax in a
chair. Ask them to picture a stream of water with leaves. On each of these
leaves, ask them to place each of their thoughts or troubles. After they have
been able to do this, ask them to notice the leaves passing them by. Ask them
to notice how it feels and to just breathe in and out slowly and calmly. Should
anything else distract them, like feelings throughout the body or external noise
from outside, ask them to acknowledge the noise or feeling and then let it go
157
and re- concentrate on the task in hand. This is a good tool for clients who
may be mildly distressed and with practice can really be useful.
Another mindfulness task is for a client to again close their eyes and be asked
to notice the different feelings in their body. Start with the toes maybe, then
their feet and moving their way up through the whole body. Again, whilst doing
this, they acknowledge any noise or feeling and then let it / them go, and reconcentrate on the task in hand.
Reduction and ultimately replacement
It is often possible for you to help a client to reduce a self-damaging
behaviour, such as self–harm, and replace it with something else that may still
be harmful, but not as much.
As an example, you could ask a client who cuts quite deeply to try pulling an
elastic band on their wrist and letting go. Another example to use with clients
in distress is instead of the usual and more self-damaging behaviours you
could ask them to try filling a bowl full of very cold water and if possible top
this up with a few ice cubes; then suggest your client immerses their head into
the bowl. In doing this your client should find it restarts the emotional centre
of the brain.
Third person (Client) approach
When asking clients questions, sometimes it can be difficult to get a straight
answer. There are many reasons for this; one of these could be that you have
asked a difficult question. This is when it could be useful to use this technique
of asking your question in a different manner to the way you may usually.
Example: “Often with clients experiencing similar problems to yourself, it’s
common for them to feel such and such; would you consider yourself to have
the same issue?”
158
Validation
Validation is the communication to the client that his or her responses make
sense and are understandable within his / her current life context and
situation.
‘Look out for the nugget of gold in the bucket of sand.’
Different types of validation can be used.
Level 1 – Listening and observing
Trying to understand the client and their context.
Level 2 – Accurate reflection
Reflecting the client’s own feelings, thoughts, assumptions and behaviours
from a non-judgemental stance,
Level 3 – Mind reading
Communicating to the client that you understand their unspoken feelings by
‘reading their behaviour’ and working out what they may feel.
Level 4 – Effects of the past
Communicating to the client that their behaviour is valid in terms of past
experience, but not in the present.
Level 5 – Current context
Validates client’s behaviours in terms of its validity in the present – i.e. it is
justifiable or normative or effective.
Level 6 – Radical genuineness
Validates capacity for future validity through cheerleading, having confidence
in the person’s ability to solve their problems, and believing in their capacity
for change.
Need to be able to validate all aspects of the individual – i.e. their actions,
159
thoughts, physiological responses and emotions.
Can validate in an explicit and overt way, or implicitly by what we as therapists
do.
Use of Metaphors
The use of metaphors in therapy sessions can be extremely useful, and it
would be beneficial for you to have a list of examples that you could use in
sessions with your clients.
Example:
“You can take a horse to water but you cannot make it drink.”
Splitting
Your client may never have acquired the basic trust in a loving caretaker – or
having learned to trust they have been betrayed. Their world is split in good
and evil. They can put people on a pedestal one day and topple them the next
when they fail to meet their expectations.
Clients are also likely to split their own perception of self – they strive for
perfection and feel they have achieved it, only to condemn themselves at the
slightest flaw.
When clients are good they may feel entitled to special treatment and live
outside the rules for others.
When bad they may feel entitled to nothing and feel responsible for all that is
evil and expect punishment. If it doesn’t come to your client, they may invite it
from others or inflict it upon themselves. This paradox may be very confusing
to family and friends, who may experience your client as arrogant, demanding
and entitled, and the next minute as contrite, self negating and even suicidal.
Splitting prevents clients from developing an enduring image of self and
others, and is partly behind their elusive sense of identity.
160
Projective identification
Sometimes the other people in your client’s world fit into the rules they have
scripted for them. Clients may even feel the projected emotion. This is a key
defence mechanism.
People can be enlisted as allies and others can be identified as the enemy.
So people’s behaviour can be manipulated. In a wish to retaliate against
someone, the feelings are projected onto others which are then acted out and
arguments occur – they are really the client’s feeling which she has been
unable to express herself and therefore projects them onto others and
watches dissent and arguments from the sidelines, secretly savouring them.
Projective identification also means that other people believe the image that is
cast upon them – classic projective identification – care team arguing amongst
themselves – not singing from the same hymn sheet - that is why this concept
is so important.
Life Goals and Target Behaviours
LIFE GOALS: Family, job, house, car, relationship, ability to say no.
TARGET BEHAVIOURS

Life-threatening behaviours: Suicide, self harm, alcohol misuse, drug
misuse.

Therapy-interfering behaviours (client): Lateness, missing days,
crisis, being dishonest.

Therapy-interfering
behaviours
(therapist):
Being
defensive,
holidays, other commitments.

Quality of life-interfering behaviours: Unstable housing or finances.
So on.
161
Stabilisation
Although some therapists / counsellors do not have a stabilisation process
before the commencement of therapy, it will be argued in this course that it is
vitally important.
Imagine if your life was so chaotic, with changing jobs frequently, relationships
breakdowns, no fixed address, or your residence in a state of disrepair. Also
you would often wake with no sense of how you’re going to feel. How would
this feel for you? As it’s often exactly the situation our clients find themselves
in.
If this were life for you, would you feel able to commit to therapy? Attend each
week for an hour out of your day? What if you had no money as your benefits
were all messed up, or you didn’t understand how to apply for them?
The reasons above are exactly why you, as the therapist, must help your
clients firstly with issues of stability.
So what does this mean?
It means that you would be proactive in helping your client to:

Secure and maintain housing, benefits.

Work on a support network for outside sessions. As you will know therapy
can bring up many feelings / emotions which may not always be positive.
Also one of the highest factors for the completion of suicide is a lack of
social support.

Budgeting.

Repair of any on-going housing issues.

Secure contact between clients and children, if they have a court order for
contact or visiting rights given by the main caregiver.

Complete a crisis plan of exactly what a client will do should a crisis occur.

Help your client to develop a list of coping mechanisms.

Work on issues of boundaries, and not just your own, but try to establish
162
the boundaries of your client.
This list is by no means exhaustive and can be added to with your own ideas
and those of your clients.
It is hoped that you have truly seen the importance of stabilisation in the
reading of this material and that you now see that this process will maximise
the chances of your client being able to fully commit to therapy.
Setting homework
There is much evidence to suggest that setting homework can be useful to
your client in implementing the skills taught in therapy; not only this, but it is
also a great way to learn further skills.
Nice guidelines recommend self help for many kinds of mental health
conditions, including depression. Therapies such as Cognitive Behavioural
Therapy and Dialectical Behavioural Therapy routinely ask clients to complete
homework between therapy sessions.
It is important when setting homework that you remember to keep tasks
achievable to help clients feel a sense of achievement, and to build on their
self-confidence.
Ensure that you always follow up on home work tasks set. This is important
for a number of reasons, including the need to make sure your clients are
keeping compliant with therapy, and also to show your interest.
Although it is important that your clients complete set homework tasks, it’s
equally important they are not felt to have let you down, as this will affect the
therapeutic relationship you have worked hard with your client to build. It could
be of use to use the failure to complete homework as a topic for one of your
sessions, so that the reasons for non-compliance can be discovered and
worked upon. It may be that your client just needs reminding of the
163
importance of these tasks.
For therapists contracting their work with clients, you could refer the client to
the contract you made with them, which they would have signed and agreed
to. This could be used as a basis of discussion.
Keeping a Diary
As a therapist, you should keep a record of your sessions with each client.
This not only helps you week to week in jogging your memory over certain
issues your client may have discussed, which is particularly useful if you have
a large number of clients, but can also be useful if you are required to recall a
particular session in detail due to an accusation being made against you.
Keeping a diary of sessions can also be useful for supervision, which is
usually only held once a month.
This allows you easily to recall specific
details which may have brought up issues for you, so that you can recall the
context in which such feelings were brought up and how you may have
reacted to them.
Boundaries in Therapy
Boundaries are an important part of therapy and should be agreed upon at the
beginning of therapy commencing. The purpose of boundaries is to prevent
unethical behaviour between the client and therapist; their main aim is to
ensure that any potential issues which may affect a client’s potential of having
an appropriate therapeutic relationship are removed. Such boundaries must
be clear and adhered to.
Boundaries agreed upon by the client and therapist may include:

No consumption of alcohol or non-prescribed drugs before or during
therapy sessions.

Agreement on contact outside of therapy sessions should this be needed
(i.e. during crisis).
164

No violence of any kind during sessions.

Length of therapy.
Boundaries are also important in ensuring that the client does not become
dependent on the therapist, and to encourage them to develop the skills
necessary to become independent.
Grounding
For clients who suffer with hallucinations or flashbacks, grounding is an
important technique to help them reduce the effect these have. Grounding
works by bringing clients back into the present, and making them aware of
themselves and surroundings in the here and now.
Example
A 30 year old woman who was abused as a child is suffering from frequent
flashbacks of her abuse.
To deal with an issue such as this, it may be beneficial for her to keep a card
to hand which can help her deal with her flashbacks. The card may look like
this:
My name is Katie.
I am 30 years old.
My husband is called Peter.
I have 2 children. Their names are Katrina and
Lucy.
I live at 30 Green Road, London.
The card can be used to help bring the client back into the present by
reminding them that they are no longer a child who is being abused for
example, but an adult who has a new life, away from the abuse.
165
Self Help
Self help can play an important role in therapy, by allowing clients to develop
their own skills in helping them through difficult situations. CBT, for example,
puts a large emphasis on clients using a range of self help materials.
Self help materials come in many forms and may include:

Books,

Websites / forums

Self help groups

Audio tapes
Self help materials can also be beneficial by reducing the client’s dependency
on the therapist.
Rather than seeing the counsellor / psychotherapist as the
only solution to their problems, clients can develop new skills independently
that can help them to help themselves.
Endings
Endings are both important for your client and also for you as the therapist /
counsellor. From the moment you start, you could consider your work to be
heading for the ending, as with life there is always a start and an end.
Endings can be especially difficult for your client, as often they would have
come to you after years of bad experiences with people, whether this is
through the mental health system or through families and friends.
In discussion of endings it is assumed that you have completed quite some
work together. From the moment your client starts with you as a therapist /
counsellor it is important that they know of any restriction your company or
you, individually, impose on the work you do with each other. Often therapists
/ counsellors work with clients for a period of 12 months.
Your work with your client should be reviewed regularly and this is something
166
your client should be aware of. At around six months prior to an ending,
should you be working for a year, you should start mentioning the ending of
therapy more frequently.
It is important that you discuss the feelings and thoughts of your client around
the issue of endings, the different achievements of your client through the
therapy process, and discuss future plans and relapse prevention.
Relapse is something that should always be expected and not be seen as a
negative process, as working through a relapse can make your client stronger
for future instances of distress.
167
Self assessment 8
SAQ1)
Explain the 6 types of validation:
Accurate reflection
Current context
Effects of the past
Listening and
observing
Mind reading
Radical genuineness
SAQ2
Give a brief explanation of what each of the following is, give an example of it.
Description
Example
Slitting
Stabilisation
168
SAQ3)
Asking your client to keep a diary can be a very useful tool to help them
monitor their feelings and emotions in-between sessions. This can be of
particular use for clients that live in the moment and may forget how they were
feeling a few days ago. Have a go at keeping your own diary for a couple of
weeks, note down any events that happened, how you felt, how you dealt with
them.
169
Assignment 8
8.1
Discuss and explain how you could use the halting protocol.
8.2
List ten metaphors for use with clients.
8.3
What is the stabilisation process and why is it useful?
8.4
Why are boundaries essential?
8.5
What is grounding
170
171
Unit nine
Being a Therapist
In this section:
Outline for the process of therapy with a dissociative or personality disorder
Confidentiality
Benefits and issues of registration and accreditation
Professional liability insurance
Setting up your own practice
Setting up your own practice
Assignment nine
172
Outline for the process of therapy with a dissociative or
personality disorder.
Assessment
 Issues of confidentiality
 Payment
 Holidays, breaks, missed sessions.
 Home Work
 Contacts
 Tests
Commitment
 Psycho education.
 What your commitments are.
 Explaining process of therapy.
 Setting goals.
 Therapist / client interfering behaviours.
 Quality of life interfering behaviours (Drugs, risky sex, legal issues).
 Fears, concerns, and worries.
 Pros and cons of therapy.
 Prior commitments – therapist / client.
Stabilisation
 Housing.
 Finance.
 Family issues / friends.
 Support structure.
 Coping mechanisms.
 Crisis planning.
 Keeping yourself safe.
 Boundaries.
173
DBT Skills
 Mindfulness.
 Interpersonal effectiveness.
 Distress tolerance.
 Emotional regulation.
Trauma work
 Stigmatisation.
 Betrayal.
 Powerlessness.
 Traumatic sexualisation.
Reconnection
 Building a new future.
 Identity - who are you now?
 Support groups and relationships.
Endings
 Future plans.
 Achievements.
 Summary.
 Feelings around endings.
174
Confidentiality
As a counsellor or therapist you have a duty to keep everything your client
tells you in complete confidence. This is, of course, excluding a couple of
exceptions which you are expected to report as a matter of duty; these
exceptions we will come on to shortly.
In the assessment and commitment sessions you would explain to your client
the restrictions of confidentiality and re-assure them where possible that
mostly everything that you are told is in complete confidence.
Remember when you have supervision you will commonly speak about your
clients, although this is not to say you will be identifying them personally.
It is important that you explain exactly the obligations you have, as a therapist
/ counsellor, to pass on information to third parties.
You must disclose concerns relating to:
 Child abuse (Children’s Act).
 A client becoming a risk to themselves and others (Suicide Act).
 A client partaking in terrorist activities including money laundering
(terrorism law).
Whilst it is your duty to disclose under the terms set out above, there is no
harm in asking for your client’s consent prior to disclosing to a third party’
whilst explaining that this is something you must do. Remember at all times
that you also have a duty to your client and the therapeutic relationship you
have built with them.
Many counsellors / therapists feel confused when it comes to disclosing child
abuse; this is mainly due to the concern of whether we disclose all incidents of
abuse past and present. When talking about this subject it’s important you
175
understand the context. If we are talking of an adult client that was abused as
a child, you may wish to ask yourself is this client still being abused by the
perpetrator, and are they considered vulnerable? Alternatively, does this
person have access to other children? If the answer is yes to either of these
questions, then you must disclose. You, of course, have the option to seek
advice and direction from your supervisor at any time.
Benefits and issues of registration and accreditation
By registering and gaining accreditation with a professional counselling or
psychotherapy body, therapists initially put themselves in good stead of
proving to potential clients the knowledge and skills they possess. Before
seeking therapy, clients are encouraged to research therapists in their area
and take into consideration the specialist knowledge and skills of a therapist
they consider going to see, to determine whether they will be suitable for their
needs.
There are a large number of professional bodies with which counsellors and
psychotherapists can register, the main of which are:
 The British Association for Counselling and Psychotherapists (BACP).
 UK Council for Psychotherapy (UKCP).
 British Association for Behavioural and Cognitive Psychotherapies
(BABCP).
 Counselling Society.
These organisations often provide newsletters throughout the year with
information regarding current issues in counselling and psychotherapy, as well
as providing details of future training events available to members. A further
benefit of registering with a professional body is your inclusion on their
therapist database, which allows potential clients to search for therapists in
their area. Being listed on this public database is optional, but it may be
176
particularly beneficial for new therapists in initially gaining clients and
developing a reputation.
Professional liability insurance
Like all other professions, those working as counsellors and psychotherapists
are at risk of clients making accusations against them. Such allegations can
be extremely damaging to a therapist’s career (even if the allegations are
found to be false), and as such, professional bodies recommend that their
members protect themselves by carrying professional liability insurance
Towergate Professional Risks is one example of an insurance company which
specialises in legal cover for counsellors and psychotherapists.
Their
insurance policies provide cover “which combines public liability, professional
indemnity, product liability, and libel and slander”26.
26
Towergate Professional Risks (2007) Liability Insurance for Counsellors, Psychotherapists &
Hypnotherapists
177
Setting up your own practice
Setting up a private practice requires a large amount of planning and careful
consideration of a number of factors. These include;
 The ethical framework you will follow.
 Professional liability insurance.
 Safety issues.
 Finding a suitable therapy room.
 Cost.
 Bank accounts.
 Constructing a website.
 Creating leaflets / marketing material.
 Business partners / solo venture.
 Registering as a business / charity etc.
 Creating a business plan.
All these need to be carefully considered before a decision to set up a private
company is made.
It is important to set realistic targets and not rush to
achieve too much too soon.
Continuing professional development
Continuing professional development is an important aspect of a therapist’s
accreditation with a professional body.
The BACP, for example, requires
members to complete a set number of CPD hours in order to maintain their
accreditation status. These professional bodies provide details of suitable
training events which members can attend.
The guidelines for CPD are individual to each professional body and use
different systems / points. It is therefore important to check the guidelines of
the professional body you join to ensure you complete the necessary hours of
training.
178
Working Ethically
When joining a professional body, as a therapist you agree to work and abide
by their set code of ethics. These are guidelines set out to ensure that as a
therapist you work to set standards, and cover all aspects of your work. Each
body has its own framework, which may have some variations, but are very
similar overall. The ‘Resources’ section contains an example of a code of
ethics which is used by the British Association of Art Therapists. The code of
ethics for each professional body can be found on their individual websites or
by contacting them directly.
179
Self assessment 9
SAQ1)
Think of at least one situation in last year you felt you didn’t handle so well,
(this can be in any area of your life i.e. with family, friends, at work or socially.)
Using the skills you have learnt in the course how could you have handled
things differently? How do you think this could have altered the outcome?
SAQ2)
Have a look through the following statements and circle the number that best
describes how you feel about it, do not look at the one you completed at the
beginning of this course. After you have completed it compare it to the one
you filled in at the start, are there any differences?
I am as good as everyone else
1
2
3
4
5
I am aware of my personal limits
1
2
3
4
5
I am comfortable talking to strangers
1
2
3
4
5
I am happy to be me
1
2
3
4
5
I am not afraid to make mistakes
1
2
3
4
5
I can laugh at myself.
1
2
3
4
5
I don’t feel like an overall failure
1
2
3
4
5
I enjoy communicating to others
1
2
3
4
5
I get frustrated with others easily
1
2
3
4
5
I have a good knowledge of different cultures
1
2
3
4
5
I like myself as a person
1
2
3
4
5
I like to take risks
1
2
3
4
5
I often jump to conclusions
1
2
3
4
5
I respect myself
1
2
3
4
5
1
2
3
4
5
Men and women are equals
1
2
3
4
5
Older people are wiser than younger people
1
2
3
4
5
What others say to me has no affect
1
2
3
4
5
I would only socialise or mix with people from the same
ethnic background as me
180
Final Assignment (Assignment nine)
9.1 In no less than 500 words:
Describe and explain the process for treating someone with depression.
Please include:
 An assessment of the client.
 A contract.
 Which model you would use and why.
 When you would review your work.
 How you would know therapy worked.
181
The terminology in the mental health system
Accreditation:
An endorsement of an individual practitioner’s level of training or experience.
Anorexia Nervosa:
Anorexia nervosa is an eating disorder characterised by unusual eating
habits, such as avoiding food and means, picking out a few foods and eating
them in small amounts, weighing food, and counting the calories in foods.
Antidepressants:
Antidepressant medicine is used to treat depression. For example, Fluxotine
Paroxetine.
Antipsychotic:
Antipsychotic medicines are used to treat schizophrenia, mania and bipolar
disorder. For example, chlorpromazine.
Anxiety:
Anxiety is an unpleasant feeling when you are worried, uneasy or distressed
about something that may or may not be about to happen.
Anxiolytic:
Anxiolytic medicines are used to treat anxiety. For example, benzodiazepines,
busperone.
Behaviour Therapy:
As the name implies, behavioural therapy focuses on behaviour-changing
unwanted behaviours through rewards, reinforcements and desensitization.
Benzodiazepines:
Benzodiazepines are a group of medicines used to help sleep, reduce anxiety
and as a muscle relaxant. For example, temazepam.
Beta Blocker:
Beta blockers are drugs that lower blood pressure and slow the heart rate, by
reducing the amount of oxygen that the blood needs.
Binge Eating Disorder:
Binge eating is an eating disorder characterized by frequent episodes of
compulsive overeating, but unlike bulimia, the eating is not followed by
purging.
182
Bipolar Disorder:
Extreme mood swings punctuated by periods of generally even-keeled
behaviour characterize this disorder.
BPD:
Symptoms of borderline personality disorder, a serious mental illness, include
pervasive instability in moods, interpersonal relationships, self-image, and
behaviour. The instability can affect family and work life, long-term planning,
and the individual's sense of self-identity.
Bulimia Nervosa:
Bulimia nervosa is an eating disorder characterized by excessive eating.
People who have bulimia will eat an excessive amount of food in a single
episode, and almost immediately make themselves vomit or use laxatives or
diuretics (water pills) to get rid of the food in their bodies.
Clinical Psychologist:
A clinical psychologist is a professional with a doctoral degree in psychology
who specializes in therapy.
Cognitive Therapy:
Cognitive therapy aims to identify and correct distorted thinking patterns that
can lead to feelings and behaviours that may be troublesome, self-defeating,
or even self-destructive. The goal is to replace such thinking with a more
balanced view that, in turn, leads to more fulfilling and productive behaviour.
CBT:
A combination of cognitive and behavioural therapies, this approach helps
people change negative thought patterns, beliefs and behaviours so they can
manage symptoms and enjoy more productive, less stressful, lives.
Counselling:
Counselling is guided discussion with an independent trained person, to help
you find your own answers to a problem or issue.
Delusions:
Delusions are bizarre thoughts that have no basis in reality.
Dependence :
Dependence is a compulsion to continue taking a drug in order to feel good or
to avoid feeling bad.
183
Depression:
Depression is when you have feelings of extreme sadness, despair or
inadequacy that last for a long time.
DSM-IV:
An official manual of mental health problems developed by the American
Psychiatric Association. Psychiatrists, psychologists, social workers, and other
health and mental health care providers use this reference book to understand
and diagnose mental health problems.
Emergency Services:
A group of services that is available 24 hours a day, 7 days a week, to help
during a mental health emergency.
Genetic Disorder:
A genetic disorder is a disorder caused by a fault in the genes. It is usually
hereditary (runs in the family).
Hallucination:
Hallucinations are sensory experiences in which a person sees, hears or feels
something or someone that isn't really there.
Individual Therapy:
Therapy tailored for a patient / client that is administered one-on-one.
Mental: Mental refers to the processes in the mind.
Mental Health:
How a person thinks, feels, and acts when faced with life's situations. Mental
health is how people look at themselves, their lives, and the other people in
their lives; evaluate their challenges and problems; and explore choices. This
includes handling stress, relating to other people, and making decisions.
Mental Health Problems:
Mental health problems are real. They affect one's thoughts, body, feelings,
and behaviour. Mental health problems are not just a passing phase. They
can be severe, seriously interfere with a person's life, and even cause a
person to become disabled.
Mental Illness:
This term is usually used to refer to severe mental health problems in adults.
184
OCD:
Obsessive Compulsive Disorder (OCD) is a chronic, relapsing illness. People
who have it suffer from recurrent and unwanted thoughts or rituals.
The
obsessions and the need to perform rituals can take over a person’s life if left
untreated. They feel they cannot control these thoughts or rituals.
Phobia:
Phobias are irrational fears that lead people to altogether avoid specific things
or situations that trigger intense anxiety.
Prognosis:
A prognosis is a prediction of the possible outcome of a disease or condition.
Psychiatrist:
Psychiatrists are doctors who treat mental and emotional health conditions,
using talking and listening methods.
Psychiatry:
Psychiatry is health care that deals with the study, diagnosis and treatment of
mental and emotional health disorders.
Psychotherapy:
Psychotherapy is the treatment of mental and emotional health conditions,
using talking and listening.
Schizophrenia:
Schizophrenia is a mental disorder characterized by "positive" and "negative"
symptoms. Psychotic, or positive, symptoms include delusions, hallucinations
and disordered thinking (apparent from a person's fragmented, disconnected
and sometimes nonsensical speech). Negative symptoms include social
withdrawal, extreme apathy, diminished motivation, and blunted emotional
expression.
SAD:
Seasonal affective disorder (SAD) is a form of depression that appears related
to fluctuations in the exposure to natural light.
SSRI: SSRI (Selective serotonin re-uptake inhibitor) is a medicine used to
treat depression.
Stimulants:
Stimulants are substances that can change your mood, or produce a sense of
alertness and energy. For example, caffeine.
185
Useful Tools
Chain Analysis of Problem Behaviour (part 1)
Name:
Date of problem behaviour:
What exactly is the problem behaviour? (Be specific.)
What was the trigger or prompting event in the environment that started the
chain?
When did I know I was going to do it?
What links form a chain between the problem behaviour and the prompting
event? (Start with the prompting event. Include the thoughts, feelings,
behaviours, sensations and events.) It might be helpful to imagine you are the
director of a play, instructing an actor to play your part (the more details the
better).
Prompting event:
Problem behaviour:
186
Chain Analysis Of Problem Behaviour (part 2)
What were the consequences of my problem behaviour for:
Me:
Others:
Do I need to make repairs, and if so, what?
What other links could have been in the chain that were more skilful, and
might not have led to the problem behaviour? What could I have done
differently?
Alternative better outcome:
How can I reduce my vulnerability in the future?
Is there anything else I would like to share?
187
Start up pack
BPDWORLD ASSESSMENT SHEET
Personal details:
First Name:
Surname:
Address:
Postcode:
Sex:
Telephone:
M/F
DOB:
Mobile:
Next of kin / emergency contact:
First
Name:
Surname:
Address:
Postcode:
Relationship:
Telephone:
Mobile:
188
Presenting problem(s) Please circle all that apply.
A
B
C
D
E
Communication
Young
Financial
Mental
Domestic
difficulties
children
problems
illness
violence –
physical,
Past relationships
In-Laws
Work problems Alcohol
abuse
separation/divorce Adolescent
Housing
children
problems
relationships
Sexual problems
financial.
illness
Step family
Difficulty forming
emotional
or
Physical
An affair
verbal,
Unemployment
Physical
/
Single
sensory
parenting
disability
Bereavement
Drug
abuse
Cross-
Current
Cultural
sexual
difficulties
abuse
Past
sexual
abuse
189
People involved in your care: (i.e. GP, Consultant, mental health team.
Please use additional sheet if needed.)
Name:
Position:
Address:
Postcode:
Telephone:
Name:
Position:
Address:
Postcode:
Telephone:
Other information:
Diagnosis:
Medications:
Other Issues:
190
How does your illness affect you?
Ethnic origin: (please circle one which best describes how you see yourself.)
White
British
Irish
Other white
Mixed
White/Black
Caribbean
White/Black
African
White/Asian
Other
Asian/Asian
Black/Black
British
British
Indian
Caribbean
Chinese
Pakistani
African
Other
Bangladeshi
mixed Other
background
Other
Other
Black
background
Asian
background
If other please state:
_________________________________________________________
191
History:
Client’s definition of difficulties:
192
Your current ways of coping in a crisis:
193
Depression Questionnaire
The following is a set of sixteen questions which may help to identify some of
the symptoms of depression.
However, this does not provide an actual
diagnosis.
Tick the options which best describe you over the last seven days.
Falling asleep:

I am always asleep within 30 minutes.

It takes 30 minutes to fall asleep less than half the time.

It takes 30 minutes to fall asleep more than half the time.

It takes more than an hour to fall asleep more than half the time.
Sleep during the night:

I never wake up at night.

I sleep lightly and wake up briefly during the night.

I wake up at least once a night but am able to go back to sleep easily.

I wake up more than once during the night for at least 20 minutes, more
than half the time.
Waking up too early:

Most of the time I do not wake up more than 30 minutes before I need
to get up.

More than half the time I wake up more than 30 minutes before I need
to get up.

I nearly always wake up more than an hour before I need to get up, but
I am able to go back to sleep eventually.

I wake up at least an hour before I need to and cannot go back to
sleep.
Sleeping too much:

I do not sleep for more than 7 – 8 hours and do not nap during the day.

I do not sleep for more than 10 hours, including naps during the day.
194

I do not sleep for longer than 12 hours, including naps during the day.

I sleep for longer than 12 hours, including naps during the day.
Feeling sad:

I do not feel sad.

I feel sad less than half the time.

I feel sad more than half the time.

I feel sad nearly all the time.
Decreased appetite:

No change in usual appetite.

I eat somewhat less than usual.

I eat far less than usual and only with personal effort.

I rarely eat within a 24-hour period and only with extreme personal
effort, or when others persuade me to eat.
Increased appetite:

No change in usual appetite.

I feel a need to eat more frequently than usual.

I regularly eat more frequently, or greater amounts than usual.

I feel driven to overeat at mealtimes and in between meals.
Decreased weight (within the last two weeks):

No change in weight.

I have lost a small amount of weight.

I have lost 2 pounds or more.

I have lost 5 pounds or more
Increased weight (within the last two weeks):

No change in weight.

I have gained a small amount of weight.

I have gained 2 pounds or more.

I have gained 5 pounds or more.
195
Concentration / decision making:

No change in ability to concentrate or make decisions.

I sometimes feel indecisive or find it difficult to concentrate.

I struggle to concentrate and make decisions most of the time.

I cannot concentrate enough to read and cannot make minor decisions.
View of myself:

I see myself as equally worthwhile and deserving as other people.

I am more self-blaming than usual.

I largely believe I cause problems for others.

I think almost constantly about major and minor defects in myself.
Thoughts of death or suicide:

I do not think of death or suicide.

I feel that life is empty or wonder if it is worth living.

I think of suicide or death several times a week for several minutes.

I think of suicide or death several times a day in some detail, or I have
made specific plans for suicide or have actually tried to take my life.
General interest:

There is no change in my usual interest in other people or activities.

I am less interested than usual in other people or activities.

I only have interest in one or two activities that I enjoy.

I have no interest in any of the activities I usually enjoy.
Energy level:

No change in energy levels

I get tired quicker than usual.

I have to make a big effort to start or finish usual daily activities.

I cannot carry out most of my usual daily activities due to a lack of
energy.
196
Feeling slowed down:

I think, speak and move at my usual speed.

My thinking is slower than usual or my voice sounds flat or dull.

It takes several seconds to be able to respond to a question and I think
my thinking has slowed down.

I am often unable to respond to most questions without extreme effort.
Feeling restless:

I do not feel restless.

I am often fidgety, or need to shift my sitting position.

I have impulses to move around and I am often restless.

At times I am unable to sit still and need to pace around.
197
Simple Complexities
Counselling sessions
We are both making a commitment of time and energy to each other in
deciding to work together. It is important for you to know what agreements we
are making and what to expect.
Frequency of sessions
Sessions will last for 50 minutes and will normally be at the same time and on
the same day each week. The whole session belongs to you, whether you
choose to attend or not. If you come 5 minutes from the end of ‘our time’, I will
be there. I will not offer your time to anyone else, even if you are away on
holiday. It’s important that when you attend a counselling session you are
free from any influence of drugs or alcohol.
Fees
My fees are £35 per session and will be reviewed in September each year. I
will give you a month’s notice if I decide to raise them. When you buy
counselling you are giving yourself something of value, therefore all sessions
are paid for whether you attend or not.
Letters and Telephone
There may be occasions when you feel the need to talk to me between
sessions, either by telephone or letter. You may not get a response
immediately, so you may feel very rejected. Try to work through your difficulty
first, and then talk about it at our next session. There are times when I
understand that working through it alone may not feel possible. Should this be
the case, then you may contact me by telephone and we can speak about
your emotional crisis / distress for a short time. I know that when you make
such a call it will be at a time of crisis and I trust that you will make the call at
a time that respects my need for free time.
198
Letters are a useful way of containing feelings and thoughts until the next
session. If you post the letter to me it is unlikely I will reply and normally I will
explore the contents of the letter during our next session together.
Holidays
I do not work on Bank Holidays. I will give you notice of my holidays as soon
as possible. I do not charge fees for missed sessions whilst I am on holiday.
Cancellation
There will be occasions when I shall not be able to give you your sessions
either because of illness, family commitments, or because I am attending the
occasional training session or meeting. I will give you as much notice as
possible and, if I can, offer you an alternative time. If you cannot come at any
of the times I suggest, I will not charge you for the session that week.
Confidentiality and Notes
The content of sessions is confidential to you and to me. I will need to discuss
our work with my supervisor who has the same rules and confidentiality as
me. It is important that you also respect the confidentiality of our sessions.
Although friends may be interested and well meaning, their comments are
bound to affect our relationship.
If you turn to a doctor because of emotional difficulties, it is important that s/he
‘knows about our work together, and that I know you have consulted her / him.
I will not communicate with your doctor without your permission and
knowledge of what is to be discussed.
I do make brief notes after a session. These are securely stored and there is
no way that you can be identified from the notes.
Occasionally, with your consent, sessions may be taped for supervision
purposes and then the tape would be destroyed.
199
Endings
There may be times in the counselling when you feel very distressed and
believe that counselling is not helping you. It is wise to come and talk about
these difficulties and not to suddenly end counselling. The reason for this is
that many of us have already experienced difficult and sudden losses. If this
happens in counselling as well, these losses have no chance to be
understood and resolved.
Your personal circumstances may change so that the agreed time and day of
your sessions are no longer convenient to you. If this happens I will do my
best to accommodate you, but if I cannot, we may have to finish working
together, even if the work is incomplete. In this event we would look at
alternative arrangements.
Should any physical damage occur to either myself or my property I reserve
the right to end counselling.
Normally you will know when you are ready to end counselling, and together
we will work out an ending which suits you.
Client’s signature:
Date:
Counsellor’s signature:
Date:
200
Code of Ethics And Principles Of Professional Practice
For Art Therapists
Introduction
Art therapy is a way of using art for therapeutic purposes. It involves the use
of visual and tactile media as a means of self-expression. Art therapists and
art psychotherapists aim to enable clients both to discover an outlet for often
complex and confusing emotions that cannot always be expressed verbally,
and to foster within themselves self-awareness and growth. Practitioners have
evolved distinct ways of working according to their specialism. They work in a
clinical context where aspects of health, ill health, difficulties and impairments
are a great part of what the client brings to the art therapy sessions. In this
context, and as registered health professionals, art therapists and art
psychotherapists are expected to exercise clinical judgement as a means of
practising safely and effectively.
The British Association of Art Therapists (‘the Association’) has issued this
Code of Ethics and the supporting Principles of Professional Practice and
Guidelines with the aim of providing members of the Association (‘Members’)
with the fundamental principles, standards and guidelines for good practice.
This is to support them in their work, as well as to inform and protect members
of the public using their services.
Art therapy is a regulated profession and, in the United Kingdom, only those
persons who are appropriately qualified and registered by the Health
Professions Council (‘HPC’), may legally describe themselves art therapists or
art psychotherapists. Membership of the Association is only open to registered
art therapists and art psychotherapists.
Throughout their professional life Members must:
 maintain their registration by the HPC; and
 adhere to this Code of Ethics and the Principles of Professional
Practice and Guidelines.
201
For Members:
 undertake supervision in accordance with supervision guidelines; and
 undertake continuing professional development (‘CPD’) as required by
both the Association and the HPC.
1. Membership
1.1 Only those who are registered by the HPC in the Arts Therapy Part of the
Register and entitled to use the title “registered art therapist” or “registered art
psychotherapist” are eligible for full membership of the Association.
1.2 Members must:
(i) abide by this Code of Ethics;
(ii) be informed by the Principles of Professional Practice and Guidelines for
Members;
(iii) undertake clinical supervision in accordance with the supervision
guidelines; and
(iv) undertake continuing professional development (CPD) as required by the
Association and the HPC.
1.3 Membership of the Association may be terminated in respect of any
Member who:
(i) contravenes this Code of Ethics;
(ii) is convicted of a crime which has a bearing on their fitness to practise;
(iii) has their registration suspended or revoked by the HPC, or are similarly
disciplined by another health care regulatory body; or
(iv) is expelled from, or disciplined by, another professional organisation.
2. General principles
2.1 Members should seek to establish the highest ethical standards and
should regard the therapeutic interests of the clients as paramount.
2.2 Members should strive to practise lawfully, safely, effectively, accountably
and fairly.
202
2.3 Members should only treat and advise on cases in which they are
competent, as determined by their education, training and experience. This
principle is summarised in the proposition that a Member has a ‘scope of
practice’ at any particular point in their career.
2.4 Members should be culturally competent. Cultural competence is a set of
congruent behaviours, attitudes and policies that enable Members to work
effectively in cross-cultural situations.
2.5 Members should acknowledge and incorporate into their professional
work:
(i) the importance of culture, and variations within cultures;
(ii) the assessment of cross-cultural relations;
(iii) cultural differences in visual symbols and imagery;
(iv) vigilance towards the dynamics that result from cultural differences; and
(v) the expansion of cultural knowledge and the adaptation of services to meet
differing cultural needs.
2.6 Members should establish their clients’ accountable agent and encourage
clients, or their carers, to identify and to seek the advice of a qualified doctor
or psychiatrist for their medical welfare.
2.7 Members should assist clients in understanding their options in making
their own decisions, and will respect the choices they make.
3. Professional competence and integrity
3.1 Members must maintain high standards of professional competence and
integrity.
3.2 Members must keep informed and up to date with developments in their
field, through educational activities, clinical experience and CPD. The learning
schemes that Members undertake as part of their CPD must have the
objective of maintaining and developing their professional competence.
3.3 Members must:
(i) keep themselves informed about current thinking and clinical developments
which are related to their practice;
(ii) make use of any financial or other support provided by their employer to
develop their professional skills through attending in-service training
programmes, lectures, conferences or workshops. Ideally, they should also
203
keep in contact with fellow professionals through regional groups of the
Association.
3.4 Members must, so far as practicable, inform themselves of any other
treatment being undertaken by their client, and make appropriate clinical
decisions according to the context and the client’s needs.
3.5 Members must exercise care when making public their professional
recommendations and opinions through testimony or other public statements,
and recognise their potential to influence and alter the lives of others.
3.6 Members must not distort or misuse their clinical and research findings.
4. Supervision
Members must monitor their own professional competence through clinical
supervision in accordance with the Association’s supervision guidelines, and
clinical supervisors should apply to be accredited by the Association.
5. Accepting clients
Members should, where appropriate, seek a written referral for a client from
the appropriate agent. Clients who self-refer should be asked to provide a
written request for art therapy after the initial contact. Members must retain
the right not to accept certain clients following their assessment.
6. Assessment
6.1 Members must develop and use assessment methods which help them
understand and serve the needs of their clients. Such assessment methods
should only be used within the context of a defined professional relationship.
6.2 Members should use only those assessment methods in which they have
competence through appropriate training and supervised experience.
7. Informed consent
7.1 Members should obtain informed consent for treatment, which must be
recorded in their clinical notes. If a client has difficulty understanding the
language or procedures used, Members should arrange for appropriate
support to be provided to the client, such as the assistance of a qualified
interpreter or signer.
204
7.2 Members must consider any factors which may influence the outcome of
therapeutic practice, including assessment and the reporting of its results,
such as culture, race, gender, sexual orientation, age, religion, education, and
disability.
8. Accountability and consistency of care.
8.1 Members should be clear about their accountability in relation to the
treatment of clients, and must take reasonable steps to be aware of the
current law, and changes to the law, which may affect their practice.
8.2 Members must provide as much consistency of care as possible for their
clients, be assertive in their efforts to maintain contact with them during the
course of therapy, and make every effort to prepare the client for the ending of
the therapy. Where circumstances mean that therapy has to end prematurely,
Members must make reasonable efforts to help the client find alternative
sources of help, within the limitations of the context of the clinical settings.
9. Clinical Judgement
9.1 Members must take appropriate steps to ensure that their judgement is
not impaired, that they do not exploit clients, and that that they act in the
client’s best interest. Members should not practise while under the influence of
alcohol or drugs, or if their physical or mental state might affect their ability to
practise.
9.2 Members must seek appropriate professional help for any personal
problems or conflicts that may impair or affect their work performance or
clinical judgement.
10. Confidentiality
10.1 Members must respect and protect confidential information obtained from
clients in conversation or through artistic expression.
10.2 Information, conversations, transactions and art expressions between a
Member and client must remain confidential within the treatment team.
However, disclosure may be authorised by the client, required by law, or
made by the Member in appropriate circumstances, for example, where the
safety of the client, the therapist, those caring for the client, or the public
205
would be threatened by non-disclosure. In such cases disclosure must be
made in the manner which best protects the client's interests.
10.3 The circumstances in which Members must seek to protect a client’s
confidentiality include:
(i) within the framework of the multi-disciplinary team;
(ii) within the employer’s terms and conditions;
(iii) within the bounds of multi-agency good practice for child protection and
the care of vulnerable adults;
(iv) within private practice; and
(v) within the client-therapist relationship.
11. Clients who are minors
11.1 Members must, so far as possible, seek to preserve the confidentiality of
minor clients and refrain from disclosing information to the parent, guardian or
carer of a minor client which might adversely affect the treatment of the minor
client, or place them at further risk.
11.2 Members must take appropriate action if they believe that a young
person is in danger, wherever possible adopting the established multi-agency
approach to child protection.
12. Dual Relationships
12.1 Members should always maintain the therapist-client relationship on a
professional basis. A Member should not engage in a dual relationship with
clients. A dual relationship occurs when a Member and client engage in a
separate and / or distinct relationship from that of therapy. Some examples of
dual relationship are:
(i) engaging in a close personal relationship with a client;
(ii) engaging in sexual intimacy with a client;
(iii) borrowing money from a client;
(iv) employing a client; and
(v) engaging in a business venture with a client.
12.2 Members must ensure that any relationship they have with the client after
therapy terminates is not exploitative.
206
12.3 Members who are supervisors, training instructors or personal tutors of a
student or a supervisee, should not engage in a dual relationship with that
student or supervisee, either concurrent with, or for at least two years
following, termination of the professional relationship.
12.4 At the start of a therapeutic relationship, a Member must agree a clear
contract with the client or with the client’s parent, legal guardian, or carer, as
appropriate. The contract should state the expected start date of therapy; the
approximate length of therapy; the agreed frequency of the sessions; and the
boundaries of the therapeutic relationship (e.g. any limits to confidentiality).
13. Practice Environment
13.1 Members must treat clients in an environment which protects privacy and
confidentiality, and provides a safe and functional place in which to offer art
therapy services, including:
(i) proper heating and ventilation;
(ii) adequate lighting;
(iii) access to a water supply;
(iv) furniture which conforms to relevant health and safety standards;
(v) knowledge of hazards or toxicity of art materials and the effort needed to
safeguard the health of clients; and
(vi) storage space for clients’ artwork.
14. Records
14.1 Members must record the client’s attendance for therapy. Material
produced during the art therapy session should be named, dated, and safely
stored throughout the therapeutic relationship. In general, the client’s art
expressions should be kept within the therapeutic relationship, and the
disposal of such artwork should be negotiated with the client.
Ultimately the ownership of the artwork remains with the client, as does the
manner of its disposal. If storage space is at a premium, photographic or
digitally or video-recorded images may be used an alternative record of the
client’s art expression.
207
14.2 Members must ensure that they follow the policy guidelines laid down by
their employer with regard to the retention of written or computer generated
client treatment records.
15. Reproduction and Exhibition of Clients' Artwork
15.1 Members should use their own judgement as to the need to obtain
permission before publishing a client’s artwork. In general a distinction can be
made between publication or exhibition to a public audience, and to a limited
audience or forum comprised of fellow health professionals.
15.2 Members who wish to use verbal dialogue, pictorial or written products
from art therapy sessions for the purposes of research, education, publication
or exhibition should:
(i) wherever possible, seek the written consent of the client or the client’s legal
guardian or carer; and
(ii) clearly inform the client, legal guardian or carer about how the material will
be used.
15.3 Members must, wherever possible, obtain written consent from the client,
legal guardian or carer, before a client or client’s art work is photographed,
recorded digitally, video-taped, audio-recorded, or otherwise duplicated for the
purpose of public display and exhibition.
15.4 Members who wish to use verbal dialogue, or pictorial or written excerpts
from art therapy sessions may do so without the specific permission of the
client, providing:
(i) the excerpts are only used for supervision, training, education, or for the
purpose of disseminating evidence from art therapy practice;
(ii) the excerpts are used with limited audiences of health professionals who
adhere to rules of confidentiality comparable to those which apply to
Members; and
(iii) an indication is given in the treatment agreement or contract that excerpts
from sessions may be used in these ways.
15.5 Members should never seek to profit financially from the sale of art
expressions produced in the therapeutic relationship.
208
16. Responsibilities to students and supervisees
16.1 Members who act as teachers, supervisors and researchers must
present accurate information and maintain high standards of scholarship in
their continuing education.
16.2 Members in a supervisory relationship with students or other Members
must not also engage in a formal therapeutic relationship with them.
16.3 Members who act as supervisors are responsible for maintaining the
quality of their supervision skills and must obtain consultation or supervision
for their work as supervisors whenever appropriate.
17. Research governance
17.1 As stipulated by the employing institution, (e.g. University and / or NHS
Trust) research is an aspect, a part of Clinical Governance and as such, the
same ethical principles, protocols and processes will apply to all research art
therapists.
17.2 Research art therapists must respect the dignity and protect the welfare
of participants in research.
17.3 Research art therapists must abide by the laws, regulations, ethics and
professional standards governing the conduct of research and publication.
17.4 Information obtained by a student / clinician about a research participant
during the course of an investigation must be confidential, and any identifying
information will be made anonymous. (See Client Consent forms for Student
Researchers.)
18. Responsibility to the Profession
18.1 Members must respect the rights and responsibilities of professional
colleagues.
18.2 Members should seek to assist and be involved in developing or
changing laws and regulations relating to the field of art therapy where to do
so is in the public interest.
19. Financial Arrangements
19.1 Facts should be presented truthfully to clients, third party payers, and
supervisees regarding services rendered and the charges.
209
19.2 Members should ensure that they are paid for their contribution to
training programmes for colleagues or students, and for supervising trainees
on clinical placement.
19.3 Members in private practice must make financial arrangements with
clients, their agents, and supervisees that are clear, easily understood, and
conform to accepted professional practices.
19.4 Members must not offer or accept payment for referrals.
19.5 Members in private practice must disclose their fees at the
commencement of service and give reasonable notice of any changes in fees.
20. Advertising
20.1 Members must engage in appropriate informational activities which
enable the public to make informed choices in relation to professional
services.
20.2 Members must accurately represent their professional competence,
education, training and experience.
20.3 Members must ensure that all advertisements and publications, whether
in directories, business cards, newspapers or conveyed on radio or television
or by electronic media, are formulated accurately to convey their services to
the public, so that clients can make an informed decision about therapy.
20.4 Members must not use any description which is likely to mislead the
public about their identity or status, and must not hold themselves out as
being partners or associates of an organisation if they are not.
20.5 Members must not use any professional identification (such as a
business card, office sign, letterhead, internet website or telephone or
directory listing) if it includes a statement or claim that is false, fraudulent,
misleading or deceptive. A statement is false, fraudulent, misleading or
deceptive if it:
(i) fails to state any material fact necessary to keep the statement from being
misleading;
(ii) is intended to, or is likely to, create an unjustified expectation; or
(iii) contains a material misrepresentation of fact.
210
20.6 Members must correct, whenever possible, false, misleading or
inaccurate information and representations made by others concerning the
Member’s qualifications and services.
20.7 Members must ensure that the qualifications of persons in their
employment are represented in a manner that is not false, misleading or
deceptive.
20.8 Members must only represent themselves as specialising within a
specific area of art therapy if they have undertaken further education, training,
or experience which would enable them to practise in that speciality area.
20.9 Members who practise privately may advertise their services. However,
advertising should be limited to a statement of name, address, qualifications
and type of therapy offered, and such statements should be descriptive and
not evaluative.
20.10 Members must adhere to professional, rather than commercial,
standards in advertising their services. They must notify related professions
and referring agencies of their practice, and should promote and facilitate
public awareness and understanding of the profession with dignity and
discretion.
21. Private practice
21.1 Members who wish to work in private practice must:
(i) have completed three years full time post-qualifying clinical work, or 3,000
hours of face to face clinical work, before doing so; and
(ii) submit an application for private practice (PP) status to the Association’s
Membership Group.
21.2 Members in private practice must confine their practice within the limits of
their training.
Members must neither claim nor imply professional
qualifications beyond those they hold, and are responsible for avoiding and
correcting any misrepresentation of those qualifications.
21.3 Members in private practice should ensure that they obtain the client’s
permission to contact the client’s General Practitioner, who is responsible for
the client’s medical welfare, and partner, carer or next of kin, should it be
necessary to do so.
211
21.4 Members in private practice should ensure they have made living will
arrangements to inform clients, in the case of the therapist’s incapacity or
death.
21.5 Members in private practice who intend to hold information about clients
on their home computer must register with the relevant Data Protection
Authority.
21.6 Members in private practice must have adequate professional indemnity
insurance.
22. Referral and acceptance in private practice
22.1 Members in private practice must, on accepting a client, explain to the
client their:
(i) fee;
(ii) method of payment;
(iii) session times;
(iv) notification of holidays;
(v) notice of cancellation;
(vi) boundaries;
(vii) information relating to the limits of confidentiality; and
(viii) duty as a therapist to report infringements against minors or violent risk to
others.23. Treatment and planning in private practice
23.1 Members who work in private practice must make art therapy plans that:
(i) seek to attain and maintain the client’s optimum level of functioning and
quality of life;
(ii) delineate the type, frequency, and duration of art therapy;
(iii) set goals that, wherever possible, are formulated with the client’s
understanding and permission, and reflect the client's current needs and
strengths; and
(iv) allow for review, modification and revision.
24. Termination of services
24.1 Members, on terminating a therapeutic relationship, must write a
discharge / transfer summary that includes a record of the client's response to
treatment and any recommendations for future treatment.
212
24.2 Members should, wherever possible, terminate art therapy services in
agreement with the client and in a planned manner, and must do so when
therapy is no longer helpful or appropriate. When it is not possible to discuss
the termination of therapy with the client, others close to the client, such as a
parent, carer, guardian or case manager, should ideally be involved.
25. Caseload
Members will increasingly face challenges in the workplace as conditions
change, but, so far as possible, should specify their own caseload, in
accordance with their preferred method of working and with the best interests
of their clients being the paramount consideration. Members should seek to
negotiate adequate time for preparation, record keeping, administration,
clinical and managerial supervision, meetings and case conferences.
Source: http://www.baat.org/codeofethics.pdf
213
Volunteer application form
This is an application for a voluntary position with
BPDWORLD in conjunction with My Distance Learning
college.
This completed form, together with a covering letter, resume and 2 passport
sized photos, should be returned to: Volunteer Applications, UK Open
Learning,
BPDWORLD,
22
Revenue
Chambers,
St
Peters
Street,
Huddersfield, HD1 1DU.
Position
Telephone
Student
applied for:
Support Work
Number:
Personal details
Title:
D.O.B.
Surname:
Forenames:
Home Address:
Postcode:
214
Email Address:
Home
Telephone
Number:
Daytime
telephone
number:
Mobile:
Academic / professional education
Schools
Dates from – to:
School
Address:
Name
&
Exams
passed
(e.g.
GCSE, A Levels):
(Please show grades.)
215
College / Uni
Exams
Dates from – to:
passed
College / University
degree):
Name & Address:
(Please
show
(e.g.
grades/
classification.)
Present / previous employment
Please give details of all previous employment, in date order, with the most
recent shown first.
Dates from – to:
Employer Name &
Address:
Job
description
duties:
title/ Reason
of leaving
for
&
final
salary:
216
Professional
Membership:
Registration Number:
BPDWORLD is an equal opportunities employer
We recruit, select and promote people solely on merit, ability to do the job and
potential to contribute to the success of BPDWORLD. Our policy is to promote
equal opportunity in employment, free from discrimination on the grounds of
colour, race, ethnic or national origin, sexuality, religion or disability.
Interest in supporting people with ill mental health
Please explain why you are interested in this area:
217
Other information in support of your application.
Please include any relevant experience:
References
Please supply the name and addresses of two referees.
Name and address:
Telephone number:
Connection:
Criminal record
Please supply details of any criminal record.
218
Declaration
Please sign below to indicate that the contents of this application form are true
to the best of your knowledge.
Signed:
Date:
Office use only
references
Outcome
Start date
219
Your work with BPDWORLD
BPDWORLD understand this is a voluntary post, but we still feel that there do need
to be rules and regulations, as, after all, we are dealing with vulnerable people.
These rules and regulations are below and will be added to, so it’s your responsibility
to read them and also adhere to them.
All volunteers are subject to a 3 months trial period.
Hours of work
Please can you try and keep to the hours of work you agreed to when you first
applied. If this will not be possible, and we understand you may have personal
circumstances that prevent this, please let the Joshua Cole know as soon as
possible. You also may be required to attend staff meetings, whether this is to be on
the Internet, through the staff area of BPDWORLD chat, or a personal staff meeting.
It is in your best interests to attend these meetings. If for any reason you are not
available for any of the arranged meetings, then please let Joshua Cole know as
soon as possible. You will be informed of staff meetings usually with a minimum
notice of 15 days.
Volunteer details
Please make sure all details are up to date: this is your responsibility, and is to be
done in writing.
Your work
Please note all work you do for BPDWORLD remains the property of Joshua Cole,
should you be dismissed or leave the team, and it may be edited, added to or
deleted at anytime for any reason.
220
Appraisal
Once a year, unless otherwise stated, we will discuss your performance with you,
and any problems you may be having. A copy of the findings will be given to you.
Place of work
Unless other wise stated all the work you do for BPDWORLD will be carried out from
your home.
Holiday
If you are going to be going away for a holiday, or you would like a break, please let
Joshua Cole know as soon as possible so we are able to cover your position.
Sickness
If you are sick in any way, then could you please let Joshua Cole know as soon as
possible? Could you also inform us what is wrong, and how long you are expecting
to be away. This is so we don’t have to keep asking when you will be back, and so
we can offer any support you may need from us. If you remain inactive for a period of
three months without explanation, we will revoke your position. If a senior member of
staff feels you are not well enough to carry out your duties, you will be asked to take
a break. You may appeal against this decision to the next ranking member of the
team.
Notice if you wish to leave
Out of courtesy to our users and us, could you please provide Joshua Cole with 30
days notice should you wish to leave the organisation. This is for stability reasons
more than anything, and we also need to find a suitable replacement for your
position.
Confidentiality
You will not, either during the continuance of your work with BPDWORLD, or
afterwards (unless authorised to do so in writing by Joshua Cole or by a court of
competent jurisdiction), either use for your own benefit, or the benefit of any other
221
persons, or disclose, any confidential information relating to BPDWORLD or the
staff.
Contact with service users
Staff must not have contact with any service users outside of BPDWORLD without
the prior permission from Joshua Cole. No instant messaging information should be
given out to service users.
Complaints against another staff member
Please inform your line superior if you have any problem with another member of
staff, and they will do their best to resolve this.
Feedback
As part of your role, we will regularly ask for feedback from your service users. They
will be aware of your student status.
Discipline procedures
At every stage during your time with BPDWORLD you will be advised of any
complaint against you, and you will be given the opportunity to state your case
before any decision is made. No one will be dismissed for the first breach of
discipline, except in cases of gross misconduct. You do have the right to appeal
against any decision made concerning any disciplinary penalty imposed. Please do
this in writing to the Chairman within 14 days. The Chairman’s decision is final.
The first step is a verbal warning given to any staff member. (Lasts for 3 months.)
Secondly a written warning will be given. (Lasts for 6 months.)
Next is a final written warning. This is basically a last chance, and after this there is
nothing but the termination of your time with BPDWORLD. (Lasts for 1 year.)
As mentioned above, for more serious cases of misconduct we may not start at the
beginning of this process.
222
Examples of gross misconduct include:
 Breach of your confidentiality agreement.
 Giving any form of suicide advice to a user.
 Saying anything to a user that may endanger their safety.
 Disorderly or indecent conduct.
 Threats of violence.
 Theft, fraud or any other criminal offence.
 Flagrant disregard of BPDWORLD’s documented procedures and regulations.
 Failing to carry out a reasonable request made by your managers on more
than one occasion.
This list is not exhaustive.
I have read and understood the above statement. As a staff member of BPDWorld, I
agree to abide by these terms, and will seek to make BPDWorld a safe environment
for individuals with BPD and other co-existing mental disorders. In addition, as a
staff member of BPDWORLD, I agree to maintain contacts’ information confidential.
Signed:
Date:
223
Volunteer information record
Position:
Name:
Address:
D.O.B.
Postcode:
Time at address:
Telephone Number:
Mobile:
Medical details
Doctor’s (GP) details.
Name:
Address:
Postcode:
Telephone Number:
Mental health team’s details
Doctor’s (GP) details
Name:
Address:
Postcode:
Telephone Number:
Diagnoses:
Medications prescribed:
Current employment/education:
224
In the event of an emergency please notify
Name:
Address:
Postcode:
Relationship to yourself:
Telephone Number:
Mobile:
225
References
CBT Counselling (2007)
http://www.cbtcounselling.co.uk
[10/2007]
Faqs.org (2007)
http://www.faqs.org/health/Sick-V1/Addiction.html
[10/2007]
Mind (2007) ‘Understanding Self-Harm’
http://www.mind.org.uk/Information/Booklets/Understanding/Understanding+selfharm.htm#What_is_self_harm_
[09/2007]
The British Association of Art Therapists (2007) ‘Code of Ethics and Principles of
Professional Practice for Art Therapists’
http://www.baat.org/codeofethics.pdf
[10/2007]
Priory (2007) ‘An Overview of Dialectical Behaviour Therapy in the Treatment of
Borderline Personality Disorder’
http://www.priory.com/dbt.htm
[10/2007]
‘Professional Practice for Art Therapists’
http://www.baat.org/codeofethics.pdf
[10/2007]
The Royal College of Psychiatrists (2007) ‘Psychotherapy in the NHS’
http://www.rcpsych.ac.uk/mentalhealthinformation/faqs/psychotherapyfaq.aspx#Q1
[10/2007]
226
227
Self assessment 1 answers
SAQ1) There are no right or wrong answers to this question. It is designed to get you
to think about yourself and your beliefs. If it has brought up anything for you that you
think could be worked on to make you a better counsellor you can take the
opportunity to work on this as you are doing this course. This could be through self
help books, having some counselling for yourself or reading or talking to different
people about their lives and cultures..
228
229
Self assessment 2 answers
SAQ1)
There are many possibilities for an answer for this question, this is one possible
answer.
Situation
A person has made a big effort in getting ready to
go out, had their hair done and bought a new outfit.
Their partner makes no comment on it when they
arrive home from work.
Thoughts/cognition
They hate the way I
They have had a hard
look, I am ugly!
day at work
Physical
Feelings/Psychological Tight chest, tearful
Calm and relaxed
Effects
Emotional Feelings
Angry, upset, self
conscious
Happy with how they
look, looking forward to
going out.
Snappy with partner,
Behaviours
shouts at them or
Talks to partner calmly
ignores them
SAQ2)
The DBT target should be in the following order, the idea behind this is to work on
behaviours that will interfere with the ongoing DBT first, if the therapy interfering
behaviours are not dealt with they are likely to cause problems in dealing with the
other behaviours further down in the list and so forth.

Decreasing suicidal behaviours

Decreasing Therapy interfering behaviours

Decreasing behaviours that interfere with life

Increasing behavioural skills
230

Decreasing behaviours related to post-traumatic stress

Improving self esteem

Individual targets negotiated with the patient
SAQ3)
Briefly describe the different types of therapy:
Type
Description
Belief that cognition, emotion and behaviour all interact
Cognitive
together. Works to break the cycle of an event causing
Behavioural Therapy
negative thinking leading to negative feelings which
(CBT)
results in destructive or negative behaviour which
leads back to negative thinking.
The client’s subconscious mind is addressed by the
Hypnotherapy
therapist. The client needs to be in a relaxed state for
this to happen, and motivated to change.
Four part structured form of therapy that combines
CBT
DBT
approaches
with
mindfulness.
Specifically
designed to help those who self harm and have
Borderline personality disorder diagnosis. Consists of
group and individual work.
Enabling the client to express themselves and their
Drama and Art
emotions through art or drama in a way that they may
Therapy
not be able to do through other forms of ‘talking’
therapy.
Focuses on deep rooted issues that are causing
Psychotherapy
problems in the clients present life, can be held as
individual or group sessions. Can last from a few
weeks to years, depending on the clients needs.
231
The main
goals are
to
increase openness to
Person Centred
experience and self esteem of the client. Main
Therapy
responsibility lies with the client rather than the
therapist.
Short term therapy that lasts between 3 and 5 sessions
Solution focused
to deal with an immediate situation. Looks towards
Therapy
goals for the future using coping methods the client
may already have rather than past issues.
232
233
Self assessment 3 answers
SAQ1)
Match up the type of medication with the description and example:
Anti depressant
Minor tranquilisers
Antipsychotic
Sleeping tablets
Not used to treat mild depression
Prozac
Used to treat anxiety and epilepsy
Temazepam
Used to treat psychosis
Zyprexa
Useful for their sedative effects
Zopiclone
234
235
Self assessment 4 answers
SAQ1)
You should have 5 of the following:
Psychological symptoms

Lack of motivation

Continuous low mood or sadness

Feeling irritable and intolerant of others

Lack of enjoyment in previously enjoyable activities

Feeling anxious or worried

Low self-esteem

Feelings of helplessness and hopelessness

Difficulty in making decisions

Suicidal thoughts or thoughts of harming others

Reduced sex drive

Feelings of guilt

Tearfulness
Physical symptoms

Change in appetite and weight loss or weight gain

Lack of energy

Slowed movement or speech

Changes to the menstrual cycle (in women)

Constipation

Lack of interest in sex

Unexplained aches and pains
236
Social symptoms

Reduced contact with friends

Less interest in hobbies and activities

Decrease in performance at work

Difficulties in home and family life

Taking part in fewer social activities
SAQ2)
Using the mnemonics list the diagnostic criteria for the following:
Borderline personality Disorder
P - Paranoid ideas
R - Relationship instability
A - Angry outbursts, affective instability, abandonment fears
I - Impulsive behaviour, identity disturbance
S - Suicidal behaviour
E - Emptiness
Dependant personality disorder
R - Reassurance required for decisions
E - Expressing disagreement is difficult
L - Life responsibilities (needs to have these assumed by others)
I - Initiating projects difficult
A - Alone (feels helpless and discomfort when alone)
N - Nurturance
C - Companionship sought urgently when close relationships end
E - Exaggerated fears of being left to care for self
237
SAQ3)
Match the symptoms with the description. What mental health condition are these
the symptoms for?
“ positive” symptoms
“Negative” symptoms
The presence of symptoms which are not
normally noted in the general population.
The absence of what is generally noted in the
general population.
Problems with attention, certain types of
“Cognitive” symptoms
memory and executive functions, which allow
planning and organisation.
The mental health condition is:
____________Schizophrenia_______________________
You should have 3 of the 4 positive symptoms and all of the symptoms listed for
negative and cognitive.
Positive symptoms
Negative symptoms
Cognitive symptoms

Delusions.

Disrupted thoughts and behaviour

Hallucinations

Grossly disorganised behaviour

Catatonic behaviour

Alogia

Avolition

Inability to sustain attention

Difficulties with “working memory”

Poor executive functioning
238
239
Self assessment 5 answers
SAQ1)
‘The client with mobility problems causing them to be virtually housebound, suffering
from depression who lives in a rural area with very limited public transport access.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
‘A client with interpersonal difficulties, low self-esteem, and trust issues.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
‘A client who suffered abuse and neglect as a young child is finding it hard to cope
with daily life. She has recently given up her job due to depression.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
‘A young client suffering from an eating disorder, the parents and older siblings don't
understand about the disorder.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
240
‘A couple who are continually arguing with each other. the lines of communication
between them have broken down.’
Individual counselling - Group therapy - Couples therapy
Family therapy - Telephone counselling
SAQ2) this question is about personal choice.
SAQ3)
To be a good listener as a therapist, you should:

Ensure you are completely focused on what your client is saying, giving them
your full attention.

Allow your client to finish speaking before you begin to talk; you should not
interrupt them.

Listen for the main points of what your client is saying.

If you are unsure about anything your client has said, ask questions for
clarification.

Give your client feedback on what they have said, to show you have
understood – verbally, facial expression etc.
When you next have a conversation with a friend, colleague or family member, think
about these five skills and try to use them in the conversation.
241
Self assessment 6 answers
SAQ1)
Why do people commit suicide? Which of the following statements are true and
which are false?
To bring about change: suicide is a way for clients to
change how they feel or what is happening in their
present life.
True
To make a choice: when a client feels they do not have
choices or that important choices are being taken
away from them, suicide may seem to be the only
True
choice left to them.
To loose control: an act of suicide is meant to stop the
person's behaviour, to loose control over events.
False
As a way to punish oneself: suicidal behaviour is a
means of relieving guilt or punishing oneself for his/her
actions.
True
As a way to punish others: the act of suicide may be
intended to inflict harm or punishment on others.
True
242
SAQ2)
Imagine you have a client who is suicidal; Write down some questions you could ask
your client to enable you to carry out a risk assessment and think about some of the
possible answers you may be given. How do you think you will react to these
answers?
Possible questions you could ask are:

Have you thought about harming yourself?

What have you thought about it?

When did you start thinking this way?

Do you want to die?

Have you told anyone you feel this way?

Have you made a suicide plan?

Have you made any preparations to commit suicide?

Do you have the means to commit suicide (firearms etc.)?

What has stopped you from committing suicide so far?

What gives you hope?
SAQ3)
3 steps to maintain safety could be:

Sit closest to the door, so you are able to leave the room quickly without
having to get past the client should you need to.

Do not leave or keep any personal or valuable possessions in the room with
your client; don’t keep hold of any personal or valuable possessions for your
client.

Ask about any medical conditions that your client may have, and ask what to
do in case of an emergency. I.e. people who have angina often have tablets
or a spray that they can take if they suffer an attack.
243
Self assessment 7 answers
SAQ1)
Only certain types of abuse are detrimental to the well-
False
being of a child
Domestic violence is dealt with under both criminal and
civil law
There are three parts to the sexual offences act 2003
True
True
There are three types of injunction available for victims
False
of domestic violence under Family Law Act 1996
The breaking of a non-molestation order should be
treated as a criminal offence
Councillors should not report disclosed abuse under
any circumstances
True
False
244
245
Self assessment 8 answers
SAQ1)
Explain the 6 types of validation:
Reflecting the client’s own feelings, thoughts,
Accurate reflection
assumptions
and
behaviours
from
a
non-
judgemental stance
Validates client’s behaviours in terms of its validity
Current context
in the present – i.e. it is justifiable or normative or
effective
Communicating to the client that their behaviour is
Effects of the past
valid in terms of past experience, but not in the
present.
Trying to understand the client and their context.
Listening and
observing
Communicating to the client that you understand
Mind reading
their unspoken feelings by ‘reading their behaviour’
and working out what they may feel.
Validates capacity for future
Radical genuineness
validity through
cheerleading, having confidence in the person’s
ability to solve their problems, and believing in their
capacity for change
246
SAQ2)
Give a brief explanation of what each of the following is, give an example of it.
Description
Example
Client’s world split into A
friend,
who
they
‘good’ and ‘evil’ due to regularly go out with,
never
learning
trust
or
basic looked up to, can do
having
it nothing wrong, doesn’t
betrayed.
Slitting
Can
show for an arranged
also
perception
split meeting. The friend then
of
self, becomes
the
worst
striving for perfection, friend in the world, in the
condemning themselves client’s eyes.
for the slightest thing
wrong.
A process of ensuring A client is unable to
your client’s life is in a work
due
to
mental
suitable stage to ensure health
issues,
therapy is going to be looked
into
has
claiming
most beneficial and the benefits but finds the
client is less likely to forms
too
daunting.
disengage from therapy They live several miles
Stabilisation
due
to
a
chaotic life.
hectic
or away from where the
therapy is held. The
likelihood of this client
stopping
higher
therapy
as
they
is
are
unlikely to be able to
afford
attend.
the
fares
Working
to
on
helping them to fill in the
247
forms
will
provide
a
better chance for the
client to be able to
afford to attend.
SAQ3)
This is a self awareness question; there are no right or wrong answers.
248
249
Self assessment 9 answers
SAQ1)
Could you have?

Listened or spoken to the person in a different way?

Not jumped to a conclusion about the situation, got all the facts?

Not let your beliefs interfere with the situation?

Was projection identification occurring between any of the parties involved?

Something else.
SAQ2)
Again there are no right or wrong answers to this question. Hopefully if the first time
you filled this in highlighted issues that you felt needed working on you have
improved on these while completing this course.
250