Presenting Issues Considerations for Counselling and Psychotherapy An Introduction to Counselling and Psychotherapy: From Theory to Practice

Anxiety and Panic Attacks Support can including specific techniques to help manage anxiety and panic, but also space to explore underlying issues Strategies can include: Relaxation techniques (e.g., relaxation CD, or meditation) Guided imagery (e.g., talking the client through an imagined place they associate with calmness) Use of self-help books and online resources Breathing exercises (e.g., encouraging calm, steady breathing) Physical exercise Avoiding stimulants (e.g., caffeine, alcohol) Ensuring good sleep routines Positive ‘self-talk’ (e.g., I am going to be okay) Meditation techniques, such as mindfulness Medication (if agreed between client and GP as a short-term strategy).

Depression Important the client understands the nature of therapy being offered and how it might help Undertaking a careful assessment Where depression is suspected but not yet diagnosed, exploring with the client possible benefit of a GP referral Taking an holistic approach: social and physical factors are as important as psychological ones in a move to health Timing sessions when the client is best able to make use of them (e.g., early morning sessions might not work) Understanding the impact on the client of any existing prescribed medication Ensuring regular reviews Helping the client to understand the nature of their fluctuating mood (to help build resilience to ‘down’ times) Paying careful attention to the risk of suicide or self-harm.

Post-Traumatic Stress Disorder (PTSD) Specific approaches have been identified as particularly useful for PTSD: CBT Exposure therapy Cognitive therapy Anxiety management (see previous slide) Eye movement desensitisation and reprocessing (EMDR) Hypnotherapy Medication Always work within own competence and make careful use of supervision Ensure the client has sufficient support in place (e.g., self- support and social support), prior to beginning therapy.

Eating Disorders Assessment might include: Current and past physical health treatment Cognitive abilities Any present physical disabilities Family and interpersonal relationships Social circumstances and support Occupational and social functioning Therapy should also consider: Client’s understanding of therapy and willingness to engage Agreement to liaison with other professionals, where appropriate A recent health check by GP Clearly defined agreements of confidentiality should physical or mental health deteriorate An agreement about the focus of therapy (which might not necessarily always include food).

Loss and Bereavement Important to acknowledge how hard it is for people to talk about dying and death Importance of listening and providing a forum for the client to talk Important to ‘normalise’ the grief process (e.g., not pathological), and to help the client locate their own experience within that context Where appropriate, gently challenge any internalised ‘scripts’ (e.g., I should be over it by now) Psycho-educational intervention can be helpful (providing information) Keep in mind the potential for other mental health distress Be aware of current research and thinking (e.g., continuing bonds).

Suicide and Self-Injury (SI) Be aware of personally held views about suicide/SI and how they can influence your approach Working with risk can provoke anxiety in practitioners. Anxiety is not a ‘bad’ thing if self-support is in place, but is problematic when it prevents us from engaging with our clients Be aware of context of working situation and any policies or procedures in place for working with clients at risk Be aware of the contract of confidentiality and how limitations to confidentiality would be managed in practice Be aware of local agencies and mental health support options in the event of crisis – know of these before you need to Understand relevant social policy and be aware of research Know the legal and ethical parameters in which you work Reflect on how risk is recorded in case notes Always be prepared to ask the ‘suicide question’.

Sexual Problems Consider referring to a specialist service, if appropriate Always remember there may be a physiological cause for problems and a GP referral is advised prior to therapy Be comfortable in talking about sex and sexual problems Ensure there is careful discussion in supervision about any work to be undertaken Asking about sex in assessment can help flag problems early Make use of self-help and online resources for the client to work on between sessions Help explore the link between the client’s perceptions of their sexual self and their sexual relationships (including their relationship with themselves).

Psychosis Psychosis requires careful and specialist assessment If in doubt, agree with the client a referral for such an assessment Consult carefully with your supervisor Psychosis can be treated with a number of interventions, including: Medication Education Family support Hospitalisation Rehabilitation programmes Self-help groups Nutrition, rest and exercise Talking therapies The provision of talking therapies needs to be in the context of a well-planned and supported network of care.

Borderline Personality Disorder (BPD) Help the client to explore what a diagnosis of BPD means for them During assessment, explore the factors that led to a diagnosis, when it was made, and by whom As with all therapy, offer clearly articulated boundaries, empathy, respect and honesty Work within agreed boundaries and do not allow these to be undermined Make careful use of supervision Be clear with the client what they hope for from therapy and what their goals might be Be aware of current research, and also some of the writing that critically reflects on the nature of BPD as a diagnosis.