1. AIFC 440B Provide Counselling for Clients with Common Emotional Disorders

2. Please turn off mobile phones

3. RESOURCES CCFT Volume 4

4. Elements of Competency (Learning outcomes) Read from Handbook

5. PSYCHOPATHOLOGY Abnormal psychology Mental illness WHAT IS NORMAL?  Healthy relationships: - upward towards God - inward towards self - outward towards others

6. CHARACTERISTICS of MENTAL HEALTH - Able to function in a full and balanced manner - Able to adapt to change - An unwavering purpose in life - Able to relate well to others - Able to express and control emotions - Sexual adjustment - Confidence - A right sense of humour - Balanced spiritual growth

7. CAUSES OF PSYCHOPATHOLOGY  Genetic (common in psychoses and some personality disorders) Environmental factors (such as in the family of origin) Precipitating stress Spiritual

8. PSYCHOPATHOLOGY THREE MAIN CATEGORIES  Psychoses - more serious, distortions of reality - delusions, hallucinations, thought disturbances (schizophrenia, etc.) Neuroses – emotional disturbances : anxiety, depression, stress disorders Personality Disorders- serious personality flaws

9. DSM-5  Diagnostic and Statistical Manual of Psychiatric Disorders, American Psychiatric Assn. DSM gives a description of disorders, incidence, causes, diagnostic criteria and differential diagnosis, but nothing on treatment DSM-5 (2013) - 19 years after DSM-IV Many controversial changes especially in relation to depression & bereavement, autism… A real danger of “medicalising normality” ICD-10-CM (WHO) – International Classification of Diseases, 10 th rev. Used more in Europe, etc.

10. CLASSIFICATION (DSM-5)  Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma and Stressor-Related Disorders Dissociative Disorders Somatic Symptom Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders

11. Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control and Conduct Disorders Substance-Related and Addictive disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Mental Disorders Medication-Induced Disorders Other Conditions that may be a Focus of Clinical Attention

12. They motivate They are amoral Two problem areas: - Governed by emotions - Repression of emotions EMOTIONAL AWARENESS (EI) - Recognising and feeling emotions - Expressing them accurately and appropriately - Relating to others emotionally - Dealing with inappropriate emotions THE EMOTIONS 

13. Scriptures Anger is one of the most damaging and fruitless of all human emotions. Everyone is beset with the problem of how to cope with it, live with it and understand it (Albert Ellis) - Emotion of self-preservation (hurt → anger) - Anger with self, others and God - Frustration and blockage of rights and goals - A secondary emotion - Displaced anger – family violence - Repressed anger - Legitimate righteous anger ANGER 

14. COUNSELLING FOR ANGER Find the cause and anger management Anger is a choice (no one makes you angry!) You choose to overreact to the obnoxious behaviour of others, which you could more wisely choose to react in a different manner (Epicletus) - The cause? - AL - Responsible to deal with it: Let not the sun… - Passivity & venting don’t work, assertiveness - Relaxation (‘cool off’), ask Why am I like this? - Cognitive restructuring, anger journal - Confession, forgiveness, group therapy

15. GUILT  Positive/negative aspects to guilt, shame, anxiety TRUE MORAL GUILT - Violation of God’s absolutes - Conscience - the internal monitor - Conviction of sin is specific - Resolved by confession (1 John 1:9) FALSE GUILT - Violation of relatives not absolutes - Vague and produces condemnation - Similar to shame

16. SHAME  HEALTHY SHAME - They knew no shame - Modesty, dignity, privacy UNHEALTHY SHAME - Violation of cultural, family, church standards - Social embarrassment and dishonour - Thinking there is something uniquely wrong with me (Sandra Wilson) - Self judging and rejecting self (self-hatred)

17. CAUSES OF SHAME - Fallen human nature - Hereditary family or cultural shame - Shaming voices from the past - Sexual shame (Gen.2:24) - Sin and guilt (guilty shame) - Criminal behaviour - Addictions - Some illnesses (eg. psychoses) - Poverty - Shame-bound church

18. COUNSELLING FOR SHAME - AL - Facilitate openness – bring it into the light - Deal with the roots (2 Cor.4:2) - Facing shame is facing feelings - Deal with guilt and resentment - Jesus bore the shame - Building Christian identity (Isaiah 61:7) - CBT (false guilt, etc.) - Group therapy

19. DEPRESSION  CLASSIFICATION OF DEPRESSIVE DISORDERS (DSM-5) - Disruptive-Mood Dysregulation Disorder (severe recurrent temper outbursts) - Major Depressive Disorder (depression) - Persistent Depressive Disorder (formerly Dysthymia – mild persistent depression) - Premenstrual Dysphoric Disorder - Mood Disorder due to Another Med. Condition - Substance/Medication-Induced Depressive Disorder

20. Up to 40% of adults will suffer from significant depression in their lifetime

23. MAJOR DEPRESSIVE DISORDER  (5 or more of the following for 2+ weeks) - Depressed mood most of the day (sadness) - Diminished interest in daily activities - Significant weight loss - Insomnia/hypersomnia nearly every day - Fatigue nearly every day - Feelings of worthlessness and guilt most days - Diminished ability to think and decide - Recurrent thoughts of death and suicide (Does not include normal bereavement)

24. MAJOR DEPRESSIVE DISORDER Major Depressive Episode for 2+ weeks <25% women, <12% men Teenage and adult suicide high Ten times more common than in WW2 CAUSES Excessive reaction to loss, guilt, anger (frozen anger, anger turned inward), rejection, postnatal, perfectionism.. Chemical imbalances – a myth! CYCLES - Xmas, Winter, Decades Depression Exercise (see Volume 4)

25. GENERAL MANAGEMENT  Accurate assessment (possibly medical help) MAJOR DEPRESSIVE DISORDER Mainly counselling Medication - antidepressants more severe cases (Research at U Hull - antidepressants no better than placebo - chemical imbalances a myth)

26. COUNSELLING FOR DEPRESSION - Serious depression – refer to GP (medication ?) - Deal with guilt, anger, resentment, self-pity - CBT - Depression journal - Identity and self-acceptance - Assertiveness training - Exercise and diet - Remove clutter - Good music - Good lighting and colour - Encourage outside focus – gradual activation

27. Happiness is a choice

28. Exercise also plays a major role in depression management

29. Dietary adjustment plays a major role in depression management

30. SUICIDE PREVENTION  Clients with major depression may be suicidal Careful assessment is therefore necessary If a person suggests they are suicidal they must be taken seriously It may be necessary to ask a direct question such as “have you contemplated suicide?” The safety of the client is critical and the therapist must do all they can to prevent suicide Warning signs (See Volume 7) Myths about suicide (See Volume 7) How to help persons contemplating suicide Where you can go for help (See Volume 7)

31. ANXIETY  Healthy and unhealthy anxiety Irrational fear leading to avoidance behaviours 10%+ suffer anxiety that affects functioning CAUSES OF ANXIETY Childhood trauma Learned from parents (especially mother) Past and recent trauma Fear (of failure, terrorism, disasters, cancer, death, etc.)

32. CLASSIFICATION OF ANXIETY DISORDERS (DSM-5)  - Separation Anxiety Disorder - Selective Mutism (failure to speak) - Specific Phobia - Social Anxiety Disorder (Social Phobia) - Panic Disorder - Agoraphobia (fear of open/closed spaces, etc.) - Generalized Anxiety Disorder (GAD) - Substance/Medication-Induced Anxiety Disorder - Anxiety due to Another Medical Condition

33. Anxiety disorders are common and commence early

34. SEPARATION ANXIETY DISORDER Excessive fear concerning separation from those attached Children <4%, adults <2% SELECTIVE MUTISM Consistent failure to speak in social situations when expected to < 1% pop.) SPECIFIC PHOBIA Fear of object or situation causing avoidance and affecting normal function (see list of phobias in Volume 4) (<9%)

35. SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) Anxiety to certain social situations producing avoidance (people, public speaking, public eating places, public toilets, etc.) (<8%) PANIC DISORDER Sudden intense apprehension, fear, terror (shortness of breath, palpitations, chest pain, choking, smothering, fear of going crazy and losing control) (<12% pop. – twice as high in females) Half will also have agoraphobia

36. AGORAPHOBIA Anxiety about, or avoidance of, places from which escape may be difficult or in which help may not be available (outside the home alone, crowds, in buses, trains, cars, etc.) (<2%) GENERALISED ANXIETY DISORDER Persistent excessive anxiety/worry for 6+ mths. - causing restlessness, fatigue, muscle tension, sleep disorders (<4%) Exercise - Anxiety Assessment

37. ANXIETY - GENERAL MANAGEMENT - Cannot be completely eliminated – part of life - Accurate assessment COUNSELLING Counselling the best approach to management MEDICATION - Not useful for most anxiety disorders - Tranquillizers used in past - Antidepressants can help in some cases

38. COUNSELLING FOR ANXIETY  (Depends on type and degree) - Do not worry, Fear not, trust in the Lord, etc.) - Confess unbelief - Deal with root causes - resentment, guilt, etc. - Anxiety journal - CBT (predictions and evaluations) - Build identity - Assertiveness training - Relaxation exercises - Graded exposure (systematic desensitization) - Voluntary ventilation/hyperventilation control - Good diet

39. PRINCIPLES OF NUTRITION  - Two thirds plant, one third non-plant - Low fat - reduced meat and lean meat - Low fat milk and milk products - Low refined sugar - Low salt - Low fast, refined and packaged foods - Low or no alcohol - Low butter/margarine - High fish - High water (10-12 glasses per day) - High vegetables (especially dark green) - High fruit and unsweetened fruit juices - High fibre/fruit breakfast

40. OBSESSIVE COMPULSIVE DISORDER (OCD)  CLASSIFICATION OF OC DISORDERS Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair-Pulling Disorder) Excoriation (Skin Picking) Disorder Substance/Medication-Induced OCD OCD Due to Another Medical Condition

41. OBSESSIVE-COMPULSIVE DISORDER  Obsessions (producing anxiety) and/or Compulsions (neutralizing anxiety) for 1+hr/day (<2%) - Negative predictions - Perfectionism common COUNSELLING - Thought-stopping, modification, substitution - Medication (antidepressants in some cases) OCD Exercise (see Volume 4)

42. Revision In view of counselling a fellow student AIFC GENERAL COUNSELLING MODEL

43. Theoretical Framework Based on the three-fold definition of Christian counselling and the Eight Core Conditions

44. THE EIGHT CORE CONDITIONS ATTENDING - non-verbals, being with, tuning in RESPECT - the client and their views EMPATHY - most important Accurately perceiving the feelings and content of what the client is saying and reflecting it back GENUINENESS - most challenging SELF-DISCLOSURE - most used and abused CONCRETENESS - general to specific CHALLENGING - most difficult Discrepancies, choosing life, moving to action IMMEDIACY – challenging the counselling relationship when things are not going right

45. Attending Respect Insight Spirit Empathy Experiential SoulGenuineness Self-Disclosure Power of God Concreteness Cognitive Beh. Body Challenging Immediacy Medication AIFC GENERAL COUNSELLING MODEL Theoretical Framework

46. Clinical Application PREPARATION STAGE - Spiritual preparation - Initial history, contract agreement ENGAGEMENT AND ASSESSMENT STAGE - AL, clarifying client’s expectations - Concreteness - Tentative diagnosis, counselling plan - Informed consent RESOLUTION (TREATMENT) STAGE - Facilitating change (goal setting, etc.) - The past, resentment, guilt, identity, etc. TERMINATION STAGE

47. AIFC GENERAL COUNSELLING MODEL Practical Clinical Application Preparation Engagement/Ass’ment Resolution Termination Attending Genuineness Respect Self-disclosure Spiritual Empathy Concreteness Facilit. Challenging preparation change Immediacy Initialhistory Body Insight Soul Insight Experiential Spirit Experiential CBT Experiential Medication

48. Procedure Chart SESSION COUNSELLING 1-3Initial information and agreement form Client engagement & initial assessment: - AL, self-exploration - Clarifying client’s goals - Concreteness Tentative diagnosis / Counselling plan Informed consent 2+AL, Hurt (Trauma) List 3+AL, Resentment List 4AL, Guilt List 5AL, Identity/Self-acceptance 6+AL, Other issues? (CBT, etc.) 7+Every 6 weeks for maintenance Termination

49. IMPORTANT REMINDER Reliance on techniques (the Model) too much can lead to mechanical counselling The counselor - client (therapeutic) relationship is the most important thing and should be firmly established first, then techniques can be carefully employed

50. COUNSELLING A FELLOW STUDENT WHAT YOU WILL NEED TO START Small lockable filing cabinet (for secure and confidential storage of client records) A4 writing pad for taking notes of each session (half to one page of legible notes) Stapler – staple records in chronological order A4 manila folders for each client’s records A-Z dividers

51. GENERAL GUIDELINES (MAIN POINTS) (Read ‘General Guidelines’, Volume 3, p.88-89) Be professional in your manner and appearance Observe spiritual preparation Initial information/agreement form completed Follow the model closely Keep sessions to 50-60 minutes Do a proper assessment, tentative diagnosis, counselling plan and informed consent Keep to the material in Volumes 1-4 Don’t hesitate to refer if out of your depth Achieve something tangible at each session Take appropriate notes and securely file

52. STRUCTURING A ONE HOUR SESSION Initial information completed, agreement signed Introduction Friendliness, What would you like to share? Client engagement, therapeutic relationship Body Gathering information, skilfully guide the session, concreteness, tent. diag, ther.plan, IC Closure Finish on time, summary, feedback, homework Send client away with a sense of hope

53. EXAMPLE - SCENARIO Scenario of a client named Mary suffering from depression with Suggested Terminology in using the General Counselling Model Carefully read and follow the procedure and terminology (see Volume 3, p.90-95)

54. TERMINATION As counselling will be terminated before completion (unless you continue with the same client in Year 2) an appropriate Termination Stage is essential so the client will not feel abandoned Referral may be necessary

55. Form groups of 5-6 so each in turn can share insights or concerns from the revision of this unit