Medical and Psychiatric Issues for Counsellors

Brian Daines, Linda Gask, Amanda Howe

• Publisher: SAGE Publications Ltd
• Year: 2007
• Print ISBN: 9781412923996, 9781412923989
• eBook ISBN: 9781446232712
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Praise for the First Edition:

`An interesting overview of medical and psychiatric issues that may arise for counsellors... readable, lucid and free of jargon. The issues addressed include referral and assessment, ongoing counselling and supervision, medical conditions and their treatment, psychiatric conditions and their treatment, and ethical and legal issues... it raises awareness of some important issues to consider when working with clients with medical and psychiatric conditions? - British Journal of Guidance and Counselling

Medical or psychiatric issues frequently arise during counselling and counsellors need to equip themselves with the knowledge and skills to respond appropriately. Medical and Psychiatric Issues for Counsellors, Second Edition is the perfect guide to this challenging area of practice.

It provides a clear introduction to:

" the nature of mental illness,

" the relationship between mental and physical health and

" the role of counselling in relation to both.

Highly practical and right up-to-date, this Second Edition examines how to manage medical or psychiatric issues as they emerge, whether during assessment or at a later stage in the counselling process. Guidance is given on:

" how to recognise serious mental health problems

" the effects of psychiatric drugs

" assessement and referral to other services, and

" legal and ethical issues.

The Second Edition covers changes in the context of counselling practice - particularly in health care settings - such as the use of tools to measure outcomes, evidence-based practice and clinical governance. The common principles of care and working with other professionals are also explored.

This Second Edition is essential reading both for counsellors in health care settings and those practising in more general contexts. It is also suitable for all mental health workers needing a clear, practical introduction to working with clients.

Brian Daines is an independent practitioner, Clinical Tutor in Psychosexual Medicine at University of Sheffield and a college counsellor. Linda Gask is Professor of Primary Care Psychiatry at University of Manchester and Honorary Consultant Psychiatrist in Salford. Amanda Howe is Professor of Primary Care at the Institute of Health, University of East Anglia.

1	A Contextual Framework

 

Introduction

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The first edition of this book, which was written over ten years ago, referred to the controversy, historically going back to Freud, about whether those who are not medically qualified should engage in offering psychological forms of treatment. It is an indication of the rapid period of change since then in the place of psychological therapies in treating a wide range of problems that this issue itself feels now to be a historical one. Despite this, it is still important to recognise the risks associated with counselling practice without having some working knowledge of psychiatric and medical issues and clear channels of referral through to those who can professionally evaluate psychiatric and medical symptoms where this is needed.

Despite the changes, it is still true to say that there are genuine difficulties in practising counselling outside of a medical setting and that counsellors and others still sometimes overstate the role of psychological factors in the generation of physical illness and the extent to which psychological help can be expected to be effective in certain conditions. Hopefully, as those within medicine who see all counselling as at best irrelevant and at worst dangerous have become fewer, so have the counsellors and alternative practitioners who dismiss much of medical work as ill-founded. Counsellors now generally work within a context where medical practitioners recognise the problems attached to the use of medication, especially tranquillisers, in the long-term treatment of psychological disorders. The number of short-term psychological therapies has increased and patients have become more knowledgeable about these and more willing to ask for them.

 

Recent Developments

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The main development in the UK over the past ten years has been a change in context in the NHS within which counselling is provided. There has been a considerable extension of counselling within primary care settings so that most GPs can now refer their patients to this kind of service. Alongside this a lot of measuring and regulatory activities have arisen; regular outcome measures using CORE, NICE guidelines on evidence-based practice, clinical governance, moves towards ‘stepped care’ and clearer requirements in the recording of client notes. The main consequences of all this for counsellors in the NHS have been to place unfamiliar (and often unwelcome) limitations on autonomy in ways of working and an increase in administrative work.

CORE stands for Clinical Outcomes in Routine Evaluation and is a set of questionnaire forms used routinely and widely in NHS settings to evaluate risk and to provide evidence of service quality and effectiveness (CORE System Group, 1998). The NHS has also embraced the concept of clinical governance which aims ‘to assure and improve clinical standards at local level throughout the NHS. This includes action to ensure risks are avoided, adverse events are rapidly detected, openly investigated and lessons learned, good practice is rapidly disseminated and systems are in place to ensure continuous improvements in clinical care’ (Department of Health, 1997). Systems of clinical governance have been developed to address both quality issues in health care and public concerns about poor performance by professionals (Carter, BACP Information Sheet DG9). A key part of this is measuring performance against pre-defined standards. The basic standards for mental health care are set out in the National Service Framework (Department of Health, 2002, 2005) and more specifically in the suite of NICE guidelines published by the National Institute for Health and Clinical Excellence.

Important new areas of counselling have also emerged, for example bibliotherapy and e-therapy. Bibliotherapy is the use of books to treat mild mental health problems. These may be specifically on mental health or, for example, novels with appropriate themes. An example of bibliotherapy is the service provided by East Ayrshire Libraries in partnership with the NHS. An appointment is made with the bibliotherapist to meet for a discussion and the recommendation of appropriate books, usually with one or two follow-up sessions. E-therapy takes the form of e-mail correspondence with a counsellor or psychotherapist. It may be suitable for those who are reticent about face-to-face contact with a counsellor and those who do not live near a practice, or have restricted mobility. The usual assessments of medical and psychiatric issues made in counselling are clearly more difficult in some of these new modalities.

Changes have also taken place in non-statutory sectors. The pressure on voluntary sector organisations to follow the statutory sector in evaluation of outcomes, clinical governance and audit has both raised standards and also put considerable pressure on the staff and trustees of organisations who often have to develop these with no additional funding or resources. The growth of provision of counselling within the voluntary sector for those with particular medical conditions also has made medical support and liaison even more relevant. The independent sector has up to now been less subject to requirements in areas such as clinical governance but there are indications that this may change in the near future.

 

The Approach of this Book

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There are many ways of covering the subject matter dealt with by this book and our particular approach is best outlined at the outset. One of the assumptions we have chosen to work within is the validity of psychiatry in the treatment of certain disorders which may come the counsellor’s way. There are conditions which present mainly with psychological symptoms where counselling does not have a major contribution to make and, within this, a smaller group where it may be harmful. Clients may need medication and hospitalisation and in some cases, where the person’s life or the life of others is at risk, these may need to be compulsory.

In relation to physical illness we accept that in most instances the causes are mainly physical or environmental and that the role of counselling is a peripheral one, both in prevention and treatment, except in relation to a limited number of conditions or for certain people. However, counselling can have an important role to play in a number of areas, such as assisting in helping a person to come to terms with what has happened to them and, in some cases, help in pain control. There can also be benefits in the reduction of stress, which can sometimes make relapse less likely and ongoing treatment more effective. The rationale for what follows is that the concerns of counselling and medicine, especially psychiatry, are closely related and that the counsellor needs to have a grounding of knowledge in these areas. This will not make the counsellor an expert, or equipped to make either diagnoses or recommendations about treatment. The intention is more to alert the counsellor to situations where advice or referral should be sought. It is important that we are all aware of our limits to competence, as required in most counsellors’ codes of ethics and practice, and that we know what to do when we are faced with such situations.

 

Theoretical Perspective and Working Context

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The counsellor’s approach to any issue is very much influenced by the theoretical perspective within which she works. In the course of a short book it is not possible to deal with the issues from all the major theoretical perspectives, so a broad integrative approach is taken with some occasional reference to specific theories. This book may also reflect in parts a closer relationship between the activity of the counsellor and the client’s GP than many counsellors practise. In the relationship between the client’s counsellor and her GP our view is that contact and co-operation are at least desirable and often essential for the well-being of clients and we hope, without being over-prescriptive, to promote a re-think of ways of operating where this is appropriate.

Counsellors in primary care now also work alongside graduate workers in mental health. These are people who have completed a degree in psychology or other relevant discipline who have undergone a year-long training programme to equip them with the necessary skills to work with patients with brief cognitive-behaviourally informed techniques in such areas as guided self-help for depression and anxiety management. This book is primarily directed to those who operate within a clear counselling framework, but we hope that others, such as graduate workers, who use counselling as part of their work will also find it of value. However, it is important to recognise that particular problems attach to combining counselling with some other activities, such as advocacy, and it is beyond the scope of this book to explore these extensively. Some of the boundary issues that arise, however, form part of the discussion of ethics in Chapter 7. Much confusion surrounds the similarities and differences between counselling and psychotherapy. These terms are used synonymously by some and in a clearly different way by others, although with no consistency in the differences. One of the clearest differences between counselling and psychotherapy in our view is that counselling is a skills-orientated and problem-solving activity whereas psychotherapy is based more in theory and addresses issues wider than those that led to the referral, but practitioners from both fields encounter the kinds of issues raised in this book.

 

Summary

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The next chapter looks at the basic common principles of care and of working with other professionals. We consider what is meant by mental illness, models of mental illness and the relationship between mental and physical health. Concepts of team-working in health care settings, the shortcomings of service delivery in the NHS and the problems that counsellors may face when working in medical settings are all introduced. Chapters 3 and 4 look at the way in which challenges to the counsellor’s knowledge and skills may arise at various points in the counselling process and aim to help the counsellor think through situations and, where necessary, make decisions and take action. Chapter 3 examines both problems that arise at the point of referral and those that may happen during the process of assessment. It is important that the counsellor is able to have discussions with professional referrers (and with clients who self-refer) about the appropriateness of the referral that include taking account of relevant medical and psychiatric information. In assessment it is often important to be able to elicit and evaluate the client’s past and present medical and psychiatric history before making any decision about ongoing counselling. Chapter 4 considers how to manage the situation where medical or psychiatric conditions emerge during the course of counselling, either because they occur part way through counselling, or because they have been hidden. There are also issues to address when illness or psychological disturbance occurs in the counsellor’s own life.

Chapter 5 looks at medical conditions and their treatment in relation to counselling. Using the distinction between signs of illness that the counsellor can recognise, and the symptoms that clients may talk about, we then go on to discuss particular physical health problems which the counsellor can learn to recognise, and what sort of response to these the counsellor should make. Additionally, both the impact of medical conditions and treatments on counselling and the potential positive and negative effects of counselling are considered. Chapter 6 addresses psychiatric conditions and their treatment in relation to counselling. This is approached from the viewpoint of assessing the problems that the client presents, rather than from a starting point of diagnosis. Important aspects covered are helping the counsellor to recognise serious mental health problems and to understand the effects of drugs prescribed for psychiatric conditions.

The final substantive chapter deals with the ethical and legal issues that can arise around medical and psychiatric issues in the work of counsellors. An important part of this is trying to establish what the boundaries are to the counsellor’s duty of care to clients in relation to their psychological and physical health. The ways in which this may vary according to the setting in which the client is seen are considered and relevant sections of the BACP Code of Ethics and Practice for Counsellors are identified and discussed. Ethical issues are becoming increasingly relevant as counselling seeks to further establish itself as a profession and clients become more aware of the standards they can expect from professionals and how to complain if they are not met.

Within the book is some duplication, overlap between chapters and direction to other chapters to facilitate its use as a reference book rather than just one that is read from cover to cover. For the same reason, we have also included in the glossary terms which are defined in the book, but not in every chapter where they are found. Whilst we have tried to give sound advice based on current understandings in the various disciplines that impinge on counselling in this context, we cannot be responsible for the way in which this information and guidance is used by practitioners. Throughout we stress the importance of counsellors having multiple sources of support and advice, particularly from medical and psychiatric sources, and especially in dealing with difficult situations.

2	Common Principles of Care and Working with Others

In this chapter we will explore the concepts that underpin clinical practice, and introduce certain ideas and themes to which we will return in later chapters.

What is Meant by ‘Mental Illness’?

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The differences between mental health and illness, and what is considered normal and abnormal in psychological terms, are perhaps not so easily determined in mental health care as in physical medicine. However, there are some principles that can be usefully applied. Generally, in medicine, the concept of a ‘syndrome’ is applied to a collection of symptoms that can be recognised as commonly occurring together in an identifiable pattern. When it is possible to further define an underlying biophysical process that can be demonstrated to cause this syndrome the term ‘disease’ is used. For most syndromes in physical medicine the term ‘disease’ can be applied. This is not so in psychiatry except in neuropsychiatric disorders, such as dementia, in which physical changes can clearly been seen in the structure of the brain. However, there is increasing evidence that biophysical processes in the brain play a part in the development of other disorders such as schizophrenia and severe depression.

So when does a psychiatrist use the term mental illness? This is generally when a clear syndrome can be identified and there has been a definite change from how the person used to be (which is important in differentiating illness from ‘personality disorder’ which is not viewed as ‘illness’) and there is a deterioration in the person’s ability to function effectively. Dependence on alcohol or drugs is similarly not viewed as being mental illnes...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Figure and tables
• Notes on authors
• Acknowledgements
• Chapter 1 A Contextual Framework
• Chapter 2 Common Principles of Care and Working with Others
• Chapter 3 Issues at the Beginning of Counselling
• Chapter 4 Issues in Established Counselling and in Supervision
• Chapter 5 Taking Account of Medical Conditions and Their Treatment
• Chapter 6 Taking Account of Psychiatric Conditions and Their Treatment
• Chapter 7 Safety and Safeguards
• Chapter 8 Conclusion
• Appendix 1 Suggested Reading
• Appendix 2 Glossary
• Appendix 3 Useful Organisations and Internet Addresses
• References
• Index