Presenting Issues

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

2. 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).

3. 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.

4. 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.

5. 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).

6. 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).

7. 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’.

8. 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).

9. 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.

10. 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.