Clinical Counselling in Medical Settings

Susan Davison, Christopher Rance, Peter Thomas, Susan Davison, Christopher Rance, Peter Thomas

• Publisher: Routledge
• Year: 2013
• Topic: Psychology
• eBook ISBN:
  9781317835158
• Subtopic: Mental Health in Psychology
• Index: Psychology

Clinical Counselling in Medical Settings offers an honest examination of the possibilities and limitations of counselling in a range of medical settings and patient groups. It shows how each setting has unique features that influence the therapeutic process. With numerous clinical examples covering settings such as a rehabilitation centre, a pain relief clinic and a hospice, this book will prove essential reading not only for counsellors and psychotherapists but also to all mental health professionals.

Chapter 1

A review

Emma Coore and Kate Pugh

Introduction

The remarkable growth of counselling in both the NHS and the voluntary sector signals a change in our culture over the past 20 years. General practitioners and their patients value highly the services of their practice counsellor, even when no measurable symptom reduction occurs (Hemmings 1999). Many hospital departments and clinics now employ counsellors to work as part of the multidisciplinary team so as to be able to take a more holistic approach to patient care. In a service where greater efficiency is being squeezed out of all health workers, the counsellor can offer a precious commodity – time. Time to listen; time to attend to questions that ‘I didn’t want to bother the doctor with’; time protected from the demands of emergencies and routines alike; time to assess how much a patient has understood about his or her condition, the treatment and the implications of it for his or her future and family.

Counsellors are being enlisted in increasing numbers to meet a need, perceived by healthcare workers and patients alike, to attend to the psychosocial aspects of modern medicine while the technocrats apply their amazing skills to the patient’s condition. The ensuing chapters in this book will describe how counselling has been integrated into a number of different services, showing how the context and its conditions shape the counsellor’s work and in turn how the counsellor can bring a new dimension to the service.

It has been argued that counselling is an indulgence, fostering dependence in patients whose unpleasant but probably self-limiting mental states should be born with stoicism (Persaud 1993). But this is to misunderstand the complexity of the problems which beset our patients. This chapter aims to set out, in general terms, the case for employing counsellors in medical settings and to outline the nature of the work involved.

There is a large amount of psychological adjustment needed in relation to many serious and non-serious medical conditions. Inevitably the degree to which this is necessary will vary from patient to patient. It is impossible to determine to what extent the problems are directly due to the illness and how much they are related to the patient’s underlying psychological state. Similarly, when counsellors are working with psychiatric services or in general practice, distress may stem from many aspects of a patient’s life, all of which may be worthy of counselling therapy if the patient’s overall welfare is the aim.

There have been a large number of studies to determine the prevalence of psychological disorder amongst medical patients and these suggest that, compared to the general population prevalence of 9 per cent (Goldberg and Huxley 1980), the prevalence in hospital populations is around 30 per cent. For example, eighteen months following hysterectomy, 28 per cent (Gath et al. 1982); adjustment to haemodialysis: 53 per cent depression, 30 per cent anxiety (Kaplan de Nour 1981); psychological morbidity following stoma surgery over 50 per cent (Thomas et al. 1984). A general medical ward can be expected to contain 23 per cent (Maguire et al. 1974) to 29 per cent (Moffic and Paykel 1975) of patients with psychiatric morbidity, generally depression.

Counsellors in healthcare settings are often assisting patients to cope with some of life’s potentially most challenging moments. Life events may have occurred which have been shown to play a significant role in the predisposition towards and onset of depression. Loss in some form or other may have occurred or be imminent. This need not relate just to death but to loss of mobility, independence, fertility or just future hopes, to name but a few (Murray-Parkes, 1976; Daniluk 1997):

It is vital to understand the emotional reactions which grip people in these personal crises can have a crushing power. For some, the anguish of the emotional reaction is harder to bear than the illness itself.

(Nichols 1984)

These reactions are faced by staff on a daily basis whilst working in hospices, renal units, infertility clinics and with any form of chronic illness or where conditions are not amenable to treatment.

Counselling as information and education

Other general aspects of medical settings that influence the work of counsellors include the trend towards giving patients more and more information about what is happening to them and the choices available to them. Health professionals are not always as skilled at imparting this information as would be ideal. Counsellors have been employed to provide information, with the focus being on effective communication with the patient, helping them to reach decisions about investigations and treatment options. In this way they can act as advocates for the patients to guide them through the illness and help them voice their needs and concerns. This is particularly common in fields where the most critical decisions are being made, for example, prior to termination of pregnancy, in genetic disease testing or transplant surgery. This sort of help for patients has been shown to increase their knowledge and reduce their anxiety about procedures such as angioplasty for cardiac disease (Tooth et al. 1997) and in epilepsy treatment (Jain et al. 1993). The same applies to the relatives of patients, especially of child patients, who often have a lot of questions about treatments but little opportunity to express their fears. Caring for carers in all fields of healthcare is a neglected but important part of the task (Ward and Cavenagh 1997).

A similar sort of work is being undertaken in the area of patient education. Here again effective communication with patients, including appreciating their view point, is essential in enabling them to adjust psychologically to their illness and to feel motivated and able to participate fully in their treatment. Examples include the counselling role of nurse practitioners in diabetes and post-myocardial infarct care where patient co-operation is essential for a good outcome (David et al. 1997; Martin et al. 1997). One method described to do this is ‘dialogue medicine’ (Hellstrom et al. 1998). This whole field is a very specialist area into which counselling has expanded and, though it is obviously different from more generic forms of counselling, it represents a significant aspect of counselling in medical settings.

The contexts of counselling

There are many different settings in which counselling is taking place that are a part of wider healthcare services. Each of these has unique features that also influence the counselling process. Rehabilitation services work on adaptation to injury or disability and so counselling in that setting is focused on adaptation to change, self-empowerment and regaining control (Cain 1995; Oliver 1995). Hospices, on the other hand, are concerned with symptom control at the end of life and so counselling there is involved with decisions about when to stop life-sustaining treatment. These choices are dependent on the patients’ and their relatives’ understanding and acceptance of the illness and its potential outcomes (Stanley 1995). Spiritual issues are bound to play a part in counselling in both of these settings, perhaps more than would be expected in other areas of counselling (McCarthy 1995a, 1995b).

Staff counselling, in contrast, has other pressures which affect the process. The client’s needs are affected by the culture of the employing authority, including the pressures put on staff (Goss and Mearns 1997) and fears about job security (Cummins et al. 1995; Smith 1997).

Even the nature of the clients themselves can be affected in some fields. In centres for genetic disease many of the patients are asymptomatic but are waiting for test results that will affect any children they may have. Often relatives who are not directly involved may be having tests and may also need counselling (Du et al. 1998). The populations eligible for testing will also vary, depending on knowledge about genetic linkages with disease (Lalloo et al. 1998). Therefore there is the potential to create new ‘patient’ populations and with it psychological need as people discover that they may develop conditions of which they would not otherwise have become aware for some years (Wahlin et al. 1997).

Lastly, one huge variable of counselling within medical settings is exactly who should be performing the counselling and where. At present there is great variation, particularly in the former. Health professionals have traditionally carried out the role, though increasingly specialist nurses or nurse practitioners are being employed to extend this work (Hulskers and Neiderer-Frei 1997). However, the need for counselling in healthcare has grown out of a recognition that there is a neglect of the psychological needs of medical patients and that there are powerful forces which limit the ability of health professionals to meet those needs.

On the one hand, there are time constraints on most professionals due to the continuous demand for more patients to be seen and more procedures completed. This does not always allow for the depth of enquiry into any one patient’s psychological state as might be desired. Also health professionals may lack the skills to deal with certain situations where more specialised knowledge and experience is needed, for example in HIV counselling (Worm et al. 1998) and addiction (Arborelius et al. 1995; O’Connor et al. 1997).

On the other hand, there is a need for health professionals to remain impersonal and to maintain a degree of emotional detachment in order to be able to carry out their duties. The illness itself demands psychological adjustment by the patient but the healthcare setting is rarely able to facilitate this process as health carers themselves are inevitably defended to some extent against the psychological impact of the illness on their patients. These defences are required to bear the burden of clinical responsibilities without becoming overwhelmed with anxiety, but the cost is the neglect of psychological care, unless this is planned for in the provision of counselling (Nichols 1984).

Isobel Menzies Lyth (1959, 1988), in her study of nurses’ behaviour and relationships in a large teaching hospital, showed how the development of relationships with patients was blocked by giving nurses a few tasks to perform on many patients, with a ritualisation of care and with denial of feelings in the staff and depersonalisation of the patients in their care.

The capacity of health carers to remain emotionally attuned to their patients is enormously variable, but the nature of the need for medical and surgical intervention often requires the organisation to operate in such a way that feelings are denied, and the use of the defences of splitting and projection dominate (Jaques 1955). Counsellors in medical settings may, therefore, allow the health carers to continue to do their tasks that require this ‘process of detachment’ (Leif and Fox 1963) while providing the listening and response required by the patient.

Doctors and nurses do provide counselling in the form of giving information to patients and facilitating their decisions about ongoing medical care, but this can differ from the role of the counsellor, who will provide a skilled response to the distress of their patients that may at times seem to have little to do with the complaint that is brought to the doctor.

Cawley (1977) defined three levels of psychotherapy. Doctors and nurses provide level one therapy, which is the empathic and facilitating response in a caring professional relationship. Trained counsellors provide level two therapy, which draws on training in a variety of specific models of psychotherapy, for example, problem solving, cognitive/behavioural and psychodynamic. Counsellors have an important role in assessing the needs of patients who could benefit from level three therapy. This third level comprises specialist psychotherapy services delivered by psychotherapists in mental health centres, for example, an NHS psychotherapy outpatient department.

The location for counselling

Counselling relating to healthcare work is largely taking place within the hospitals and clinics which provide specialist services. However, where more general emotional problems are being encountered, alternative environments could be better. Counsellors frequently operate private practices, which are able to accept self-referrals and offer help in a context entirely separate from the healthcare setting. The advantage of this can be clearly seen in the situation of staff counselling, where employment issues may be more openly discussed outside the employer’s premises (Tehrani 1994). This may also be the case where a patient feels there have been problems in his or her relationship with healthcare professionals. However, the disadvantages of this separation of functions probably outweigh the benefits.

There are several advantages to counselling occurring in the healthcare environment. First, it facilitates communication between all the professionals involved with a patient. This is essential for good medical practice, particularly in sensitive areas such as HIV care (Gibb et al. 1997). It avoids any misunderstandings or potential for manipulation in the doctor–nurse–counsellor–patient interactions (Jones et al. 1994). Collaborative relationships here have enabled professionals to give a consistent message to patients, encouraging them to play an active role in their disease management (Hyland et al. 1995; Papadopoulos and Bor 1995). Such relationships also bring a closer awareness of other professionals’ working practices and have allowed closer links to develop between services, for example in psychiatry. This makes it easier for counselling clients to be seen by a psychiatrist when necessary (Owen 1991) and more acceptable for psychiatric patients to receive counselling for certain aspects of their illness (Buchkremer et al. 1997), a treatment favoured in public opinion surveys (Jorm et al. 1997). It also allows for skills transfer between professionals and an improvement in the quality of referrals for counselling. There is currently a real lack of skills transfer between psychiatry and general practice (Aoun 1997). Counsellors are well placed to help GPs in this area. Counsellors empl...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of figures and appendices
• Notes on the contributors
• Notes on the editors
• Introduction
• 1. A review
• 2. Genetic counselling
• 3. A psychodynamic counselling service for pregnant women
• 4. Nurse-led counselling in a renal unit
• 5. The development of a counselling service in a rehabilitation centre
• 6. Professional development through supervision and staff groups
• 7. Staff counselling in a hospital setting
• 8. Counselling in a pain relief clinic
• 9. Counselling in the hospice movement
• Index