Time Limited Therapy in Primary Care

A Person-Centred Dialogue

Richard Bryant-Jefferies

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315345444
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

"Many counsellors who work in primary care find it difficult to explain to colleagues in the primary care team what they actually do with clients behind the closed door of their room. In this book the author brings to life in a gripping way what really does go on when a counsellor sees a patient in the primary healthcare setting. It's good to read for once a book that describes so realistically and movingly the minute-by-minute account of what actually happens, not a book describing clever therapists getting it right all the time. The book should be required reading for newly appointed non-clinical managers of counselling services and for primary healthcare staff about to start working with a counsellor as a member of their team."
— Graham Curtis Jenkins in his Foreword

SESSION 1

Mandy had never been to counselling before. Her doctor had suggested she speak to the surgery counsellor. She had come to the surgery the previous week feeling generally run down, finding it hard to motivate herself and just feeling incredibly fragile. She didn’t understand why she felt like this. She had always been active and worked hard. OK, she had a demanding job as a marketing executive, but she liked it; it made her feel alive. But recently it had all seemed such a struggle. It all came to a head for her when she burst into tears one evening returning home on the train, and couldn’t stop the tears. She had cried driving home from the car park and for the rest of the evening. The next day she had seen her GP and talked to her. She had felt better for that chat. Doctor Hill had not prescribed anything, said she was reluctant to start a chemical intervention when probably she needed a rest and some time to talk things through with the counsellor.

So Mandy sat in the waiting room. She was aware that she was feeling anxious. She knew that this wasn’t like her. She had always felt confident, but now everything seemed an effort. She just felt so self-conscious sitting there. A couple of minutes to go. As well as feeling anxious she was aware that there was a tinge of relief. She also felt quite tense, her shoulders were stiff and she just felt, well, generally tight. Felt odd, somehow. She didn’t know what to expect. She had heard things said about counselling, that it was all about making you cry about your past. This had made her wonder if she really wanted this, but the doctor had been quite persuasive, saying that the surgery counsellor was a pleasant man called Martin, that many patients had benefited from counselling sessions with him. She had felt that Dr Hill had been genuine about this, and she trusted her. She had helped her with a few minor problems over recent years. Mandy heard her name being called and turned to where the voice was coming from.

‘Hi, I’m Martin. And you are Mandy?’ Martin noticed the slightly anxious look on the face of the woman who had turned towards him.

‘Yes, thank you,’ Mandy replied.

‘Come on through. The counselling room is just along the corridor.’

Mandy followed Martin along the corridor. He stepped back and let her enter the room first. It seemed pleasant enough, pale lemon/white walls, two comfortable-looking chairs, a small table, a couple of prints on the walls. It felt quite a contrast to all the other rooms that she had been in at the surgery.

Rooms used for counselling in GP surgeries and healthcare settings generally vary a great deal. Sometimes it is a GP’s room or a nurse’s room. These are never ideal as the deécor and the whole feel of the room is generally highly ‘medicalised’, conjuring up an expectation within the client of being given a specific ‘treatment’ by an ‘expert’. This is not the nature of counselling, particularly person-centred counselling, which by its very nature is relational and which seeks to encourage a greater balance of power between client and therapist. Should the person being seen be thought of as ‘a patient’, ‘a client’ or as ‘a person who happens to have a problem to resolve’? Language can so easily shape attitudes. The need to ‘de-medicalise’ the counselling environment can be so important.

When collecting a client from a waiting area in a surgery, the client has a right to feel that the reason she is there is confidential. Introducing yourself with ‘Hello, my name is Martin and I am the counsellor’ is inappropriate when other people are in the waiting area.

‘So, Dr Hill has referred you and she has given me some background to what has happened. I understand things have kind of got on top of you and she felt that having some time to talk things through and explore what has happened and is happening for you would be helpful.’

Martin has deliberately kept it non-specific as he wants to leave it for Mandy to feel free to pick up on what is most imporant for her. His approach is ‘non-directive’, trusting that the client knows what they need to focus on. He also wants to be transparent, to ensure that his client is aware of what he already knows about her. In an approach that values the counsellor’s congruence, there is a need to try and ensure that secrets are not being held. Martin is keen to encourage openness.

‘Yes,’ Mandy replied, ‘but I’m not sure where to begin.’

‘Not sure where to begin, sounds like there are a lot of different places you feel you could start from?’

‘That’s right.’

‘OK. Can I check whether you have had counselling before?’ Martin asked.

‘No.’

‘Would it help if I said something about it?’ Martin sensed that Mandy was uneasy but he did not voice this. He knew that too much empathy of this kind early in a session can make clients feel unnecessarily uncomfortable and vulnerable.

‘Yes, it would. I’ve heard different things but, well, some of it makes me feel apprehensive.’

‘OK. Well counselling is an opportunity for you to talk through difficulties and for me to listen to you and help you to become more openly aware of yourself and to maybe make choices to help you feel more satisfied with your life. It’s not that I am going to have answers, I actually believe that we all have more resources within ourselves than we often give ourselves credit for. I hope to help you feel able to talk about whatever you feel you want to air.’

‘OK. That feels strange hearing you say that you are not going to have answers. I was hoping you’d tell me what was wrong and what to do.’

‘It would be nice to be given answers, yes?’

Mandy nodded slowly. ‘I just want to make sense of what is happening to me. I really am not sure where to start though.’

‘OK, you want to make sense of things and I really hope that we can achieve that.’ Martin was aware he hadn’t clarified confidentiality. ‘I do need to say that what is said here is confidential, and what I mean by that is that I would normally write a brief letter to the GP saying that we have had a first session, and what we plan to address and over how many sessions. I also update a card in the notes that confirms attendance at sessions and the focus of the session.’

‘The GP said that there was a maximum of six sessions. How long is a session?’ Mandy replied.

‘Yes, it is a maximum of six sessions, and I generally see people for 50 minutes,’ Martin responded, sensing that the number of sessions was an issue for Mandy. ‘Does that leave you with any specific thoughts or feelings?’ Martin always tried to offer the opportunity for clients to respond with thoughts or feelings. Counselling, in his view, was about engaging with the whole person and not simply directing them constantly into their feelings, or indeed only towards their thoughts as in more cognitive-behavioural approaches.

‘Just seemed strange that there’s a limit put on treatment before it has even started. But I guess there must be quite a demand.’

Martin could feel himself smiling. Nice one, he thought.

It is an important issue that counselling is often time limited, although not always to six sessions. Few other areas of NHS treatment are rationed in quite this way, and it is an area that needs resolving urgently. It sometimes seems that the ‘quick-ix’ culture has made its way into this important area of working. Some people do only require six sessions or fewer to work through an issue or diiculty, but others need longer. Martin knew that some surgeries ofered counselling to an average of six sessions, which created greater flexibility. Unfortunately, this was not the service agreement that Martin had to adhere to, and he knew he resented it.

‘It is strange, but it is what we have. At least we know the timescale we are working towards, and there are options for referral on should it become recognised by us both that longer-term work would be helpful.’ Martin did not feel it appropriate to get into a philosophical discussion on the relative merits of six-session working. He hadn’t actually finished highlighting confidentiality and what it meant, but it had seemed important to pick up on Mandy mentioning the six sessions.

‘OK, we discuss that later if we need to?’ Mandy asked.

‘Yes. I need to say a little more about confidentiality. This is confidential. The letter to the GP does not go into detail over the content of the session. However, there are criteria for breaking confidentiality, for instance if you disclose anything that is indicative of intent to self-harm, including suicidal ideation and intent, intent to harm others or information concerning acts of terrorism. Also if you disclose anything that indicates harm to children, I then have a statutory obligation to breach confidentiality. Normally it will become obvious and we will talk about it should it arise.’

‘That sounds heavy stuff. You have to tell everyone that?’

‘It’s good practice to do so. I think it is about being open and real. Confidentiality has its limits and I think it is important to be clear about this at the start.’ Martin had initially felt uneasy at having to introduce this, particularly when clients often came through the door wanting to talk, or ready to release pent-up emotion in the first breath. But he knew he had to do this. He continued. ‘And I need to say that counselling can be upsetting, it can release painful feelings or leave the person connecting with memories that are uncomfortable. It is not necessarily pain-free, although it doesn’t have to be this way. It is important for you to feel clear about this as, in a very real sense, you have a right to know what you are consenting to.’

Providing clients with an information sheet about what to expect from counselling also helps ensure informed consent. This could be given by the counsellor, or by the referring GP.

Mandy nodded and thought about it. She didn’t like the idea of connecting with painful memories, but then she thought that really her problems were about work and painful memories weren’t really a factor. She was much more interested in sorting herself out and getting herself back to work again.

‘OK. I consent, and I can see why you need to say all these things.’ Mandy was feeling somewhat frustrated with all of this though, she had come along wanting to get on with talking about her problems, not to have to sit and listen to all of this.

Often clients do attend with this expectation, and this can create a tension. There is a strong argument to say that the GP should clarify the consent to counselling, allowing the counselling to begin from first contact, to ensure that the therapeutic relationship is being established from the start. But not all GPs are clear about counselling, and anyway, it would then be different to any other kind of referral for treatment. It is important for counsellors to develop their own style of conveying what needs to be said regarding confidentiality and clarity of what is being offered, so that informed consent is gained from the client.

Some counsellors will ask clients to sign a confidentiality agreement and a declaration of consent to counselling. Both can be helpful to clarify what has been agreed. However, it could be argued that both are being introduced from outside the client’s frame of reference and that the client is being directed to sign them. This could therefore be regarded as contrary to the principles of person-centred counselling in which the client is encouraged, from the start, to make his or her own direction within the therapeutic relationship.

‘I just want to find out why I feel so, I don’t know, uptight about everything and have no energy to get on with things. I feel utterly deflated and bursting at the same time.’

‘Yeah, deflated and bursting at the same time.’ Martin kept to a simple straight reflection, as these words were spoken by Mandy with a lot of feeling. He said them slowly and deliberately.

‘It’s not like me. I like to live my life, get on with things. My job keeps me busy, and I really like it, but, oh, I don’t know. . . .’ Mandy tailed off into silence and looked down.

Martin allowed the silence to run for a while. He could sense that this was a silence in which Mandy was connecting with her thoughts and feelings, and he wanted to respect this and allow her time before responding. He wanted to show his empathy for what she had been saying but now the priority felt it should be in holding the silence. After about 30 seconds he spoke quietly.

‘You’re not feeling like you. You like your busy job, but. . . .’ Again he allowed the silence that followed to be present.

‘I do like my job and I feel good when I am moving around, getting sales, motivating my team, producing reports, I like the buzz. At least, I thought I did.’

‘You thought that you did.’

‘Yes, well I do.’ Mandy took a deep breath. Yes, she did like her job, but she just felt that somehow she had had enough. All the rushing around, deadlines, targets, traffic jams. She looked up and met Martin’s eyes.

‘That sounded quite hesitant,’ he responded, choosing to empathise with the way Mandy had spoken her words more than the words themselves.

‘Yeah. It’s just too much effort.’ She could feel the tightness in her shoulders and she wanted to relax. It felt strangely good to feel that someone was listening to her. She hadn’t really experienced that. It felt quite comfortable, although inside herself she could feel a dull ache somewhere inside her chest. She consciously made an effort to try and drop her shoulders and relax a little. She found it hard. ‘Oh, I don’t know.’ She took another deep breath. Her eyes were beginning to brim with tears. She swallowed but said nothing. Her breathing returned to its normal rhythm. What is happening to me? she thought. I’m not going to start blubbing. She tried to compose herself. She felt strangely alone with her feelings, her anxieties, her sense of feeling overwhelmed by the demands of work, of not having time for herself, of not having space, of not knowing what to do, of feeling helpless, of feeling out of control. The thoughts, the feelings rushed in on her. She couldn’t hold them back.

Martin felt a surge of compassion for Mandy. She looked so sad in that moment and somehow very small. He felt the presence of that deep sadness within himself. He wanted to do more than just hold the eye contact, so he tightened his mouth and nodded his head up and down, ever so slightly, and took a deep breath himself. He had learned with experience that taking a deep breath was actually a powerful therapeutic intervention for the client, often allowing them to do the same, which frequently led to emotional release of some kind.

Martin’s warmth is genuine, he is empathically in touch with his client and he is experiencing feelings within himself that are connected to this relational state. It is a powerful moment and he is right to voice what he senses as being present. The core conditions are all powerfully present and this will have a therapeutic impact on Mandy.

‘I am sensing a lot of sadness, Mandy’. He used her name, it helped personalise the therapeutic and relational connection he was seeking to make with her.

‘Yes.’ Tears began to roll down Mandy’s cheeks. Martin passed her a tissue, which she took gratefully and dabbed to her face. ‘Yes.’ Mandy could feel her body crumble. It was like all the energy that had been holding her so tight suddenly vanished. She felt weak and wobbly.

Martin said nothing, he trusted that Mandy needed to be experiencing whatever was happening for her. He believed strongly that offering a facilitative climate through empathy, congruence and unconditional positive regard would allow people to begin to risk being more open to themselves and allow that openness to find expression. He sensed that the tears were probably about more than the job, but he didn’t want to push he...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Forewords
• Preface
• About the author
• Acknowledgements
• Introduction
• Session 1
• Session 2
• Supervision 1
• Session 3
• Session 4
• Supervision 2
• Session 5
• Session 6
• Supervision 3
• Session 7
• Reflection
• Conclusion
• References
• Further reading
• Further information
• Index