Patrick Kelly MIACP, BA (Hons) Counselling and Psychotherapy

Counselling and Psychotherapy

Kilcolgan

Co. Galway

(087) 783 7892 / (091) 396490

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I have had to disable comments on my Counselling Blog.

Posted on August 17, 2013 at 2:47 PM Comments comments (569)
Dear all,

I have had to remove the ability to comment on my Blog because unfortunately I have found that only 1 in 6 comments so far have been genuine comments. Most were advertising and a small amount of the comments were inappropriate for posting on the site. I was spending a lot of my time reviewing comments. 

You can follow me on twitter @ yllekki or visit my facebook page at 
https://www.facebook.com/pages/Galway-Counselling-and-Psychotherapy/167735623333724

Please accept my apologies for any inconvenience caused.

Patrick Kelly.

How Cognitive Behaviour Therapy can be used to help someone with Depression.

Posted on May 27, 2013 at 2:05 PM Comments comments (476)
How Cognitive Behaviour Therapy can be used to help someone with Depression. 

This essay provides a definition of depression along with the diagnostic characteristics. There is a discussion on the clinical recommendations for Cognitive Behaviour Therapy (CBT) and the efficacy of it. The CBT view of depression is then discussed. This is followed by an insight into the structure of CBT sessions. Finally the essay will look at the major strategies employed by CBT in relation to depression.  

In order to treat a client it is necessary to assess them. To do this it would help if one was familiar with the DSM-IV (American Psychiatric Association 2000). Depression is listed on Axis 1 which contains the mood disorders. The DSM-IV simply defines mood disorders as disorders that have a disturbance in mood as their predominant feature. They are divided into three groups: Depressive Disorders; Bipolar Disorders and Mood Disorders based on etiology. Qualification for each group, and consequent diagnosis, depends on the presence or absence of certain episodes: Major Depressive Episode; Manic Episode; Mixed Episode and Hypomanic Episode. The DSM-IV provides clear definitions and criteria for each of these episodes and subsequent definitions and criteria for the related Mood Disorder diagnoses. CBT was mainly designed to treat non-bipolar and non-psychotic depression i.e. no presence of manic episodes, hypomanic episodes, hallucinations or delusions (Hawthorn, K., Salkovskis, P. M., Kirk, J. & Clark, D. 1989). 

The list and characterisations of the Depressive Disorders, as provided by the DSM-IV, are:
 Major Depression: One or more Major Depressive Episodes (at least 2 weeks of depressed mood or loss of interest accompanied by at least 4 symptoms of depression).
 Dysthymic Disorder: At least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet the criteria for a Major Depressive Episode.
 Depressive Disorder Not Otherwise Specified: Disorders with depressive features that do not meet criteria for other Disorders or depressive symptoms that have inadequate or contrary information.

The National Institute for Clinical Excellence (2004) provide recommendations for dealing with depression. Patients diagnosed with mild depression or a patient who does not want an intervention should be directed to self-help programs based on CBT. For mild and moderate depression, a referral to a psychological therapy focused on depression such as (CBT or Problem Solving Therapy) should be considered for 6-8 sessions. For severe depression, a combination of anti-depressants and CBT should be considered. CBT should be used for recurring depression (NCCM 2004).

In order to judge the efficacy of CBT, NCCM identified 30 acceptable trials to form their opinion. Their conclusions were as follows. It can be established that CBT is as effective as anti-depressant treatment in reducing depressive symptoms across the spectrum of depression severity. Tolerability is higher with CBT than with anti-depressants (Bates, A. cited in Boyne, E. 2003). Adding a course of CBT to anti-depressant treatment (ADT) is more effective than treating with anti-depressants alone (NCCM 2004).  In Ireland the method of counselling preferred by the HSE is CBT (HSE 2006). Anthony Bates (Boyne, E. 2003) also provides studies that say that relapse rates are lower from CBT than from ADT. 

Bates (cited in Boyne 2004) traces the roots of CBT theory back to ancient Greece. Epictetus considered that we are upset not by what happens to us but the way we look at things. This idea lends itself to the theories by the two major founders of CBT: Albert Ellis and Aaron Beck. Ellis saw people as having irrational thoughts and beliefs about themselves and their interactions with the world. Beck saw people in terms of living from the perspective of their core beliefs. These beliefs allow them to make assumptions about the world. Sometimes these assumptions become rigid and may not be a true reflection of reality and therefore lead to dysfunctional behaviour. The work of CBT is to tackle these irrational beliefs and assumptions and there is a large focus on dispelling negative automatic thoughts (NATs).
 Fig.1. demonstrates the CBT view of depression (Stephens, E. 2008).
Unlike other forms of treatment CBT is highly structured and aims to be time limited. Before a client is considered for therapy one has to ascertain if they are suitable for the service offered. This takes into account a formal diagnosis, the severity of the depression and how suitable and capable the person is to sustain a therapeutic relationship.

The structure of treatment is as follows: 
CBT starts with the initial interview. As with all forms of therapy it is essential to establish a rapport and use active listening skills to ensure that the client feels understood and listened to.  
 In the initial interview there is an assessment process. This gathers relevant information in regard to the cognitive model (fig.1). From this one can form a hypothesis and share this with the client. One is also on the look out for suicidal intent. A useful tool in assessing a client for depression is the Beck Depression Inventory (BDI) (Stephens 2008). This not only can act as an initial assessment tool but can also help to monitor progress as interventions have been made. One can gauge from it whether or not the therapy is successful. The lower the score on the BDI the less severe the depression is and vice-versa. 
 The next step is to define and focus on goals. A question like “how would you like this situation to be different?” would help in this area. This keeps a focus on the therapy and provides a benchmark. 
 One must next explain the way this form of therapy works, from a practical and a theoretical point of view. One deals with expectations from both parties such as duration of therapy and homework assignments. It is important to explain how negative thinking is a vicious cycle that needs to be broken and also it is important to emphasise that change is possible. 
 A target is agreed upon for immediate intervention. Appropriate homework, monitoring tools and reading are provided. 
 It is also important to get feedback from the client, and this should be ongoing throughout the therapy. 

Subsequent sessions should take a structured form also:
 Firstly an agenda is agreed upon for the session. This focuses the session.
 Clients need to know that they are expected to become more aware and reflective throughout the process. This can be facilitated by a discussion on their progress since the last session. The emphasis in CBT is on self-help; therefore a discussion on homework from the previous session is necessary. Results, awareness and difficulties encountered are discussed.
 The majority of the session is taken up with the day’s major topic/s. This is likely to have come up in the agenda but may come up in the course of the session. It is better to focus on one or two issues and deal with them thoroughly than to deal superficially with a few topics.
 Then one must plan homework that is appropriate arising from the session. One must also deal with and discuss possible barriers to completing the assigned tasks such as NATs. This increases the likelihood of the assignments being completed. 
 The final stage is feedback on how the session went (Hawthorn et. al. 1989).

We have looked at the structure of the sessions for dealing with depression. Now it is necessary to examine the major strategies employed in CBT. These strategies are sequential but may overlap and in some cases some are not necessary. It all depends on the characteristics of the individual client. 

The first strategy is a cognitive approach (Hawthorn et. al. 1989). This provides the building blocks for a client to learn how to avoid dwelling on negative thoughts which can lead to distress. The client learns how to distract themselves. There are various techniques which the client learns. Theses are: focusing on an object; developing sensory awareness of their surroundings; performing various mental exercises; focusing on pleasant memories or fantasies and engaging in absorbing activities which occupy the body and mind. Another technique is counting thoughts allowing the client to number their NATs and put them aside. 

The behavioural strategies are designed to facilitate the client to monitor and schedule mood elevating activities. Clients with depression tend to engage in thought processes that avoid or devalue engaging in such pleasurable activities.  Monitoring activities helps the client to test how what they are thinking about doing activities with the reality of actually doing them. This is done by recording activities and associated moods and thoughts on an hourly basis. Scheduling encourages the client to plan activities on an hour by hour basis, based on their records. The technique of graded task assignment is then used to break down tasks to a manageable level and overcome any difficulties (Hawthorn et. al. 1989). 

The cognitive behavioural strategy teaches the client to recognise, question and test their NATs. The client learns the cognitions that lead to such thoughts such as: overgeneralization; selective abstraction; dichotomous reasoning or jumping to conclusions without sufficient evidence. These thoughts are recorded and then challenged and explored for alternatives. The client is then encouraged to run behavioural experiments to test the validity of their negative assumptions (Hawthorn et. al. 1989). 

The next stage is to create preventative strategies to cope with and avoid the onset of depression in the future (Hawthorn et. al. 1989). In order to achieve this one needs to delve deeper than the surface negative automatic thoughts. The client needs to learn to identify and challenge the dysfunctional assumptions which underlie them. Clients are prepared for set-backs in the future and they can use their set-backs while in therapy to learn to deal with future set-backs positively. When the therapy is at an end the client is encouraged to explore likely events in the future which could instigate depression. This deepens awareness and prepares them to deal with such events. 

CBT is a much more structured and directive approach than other forms of Psychotherapy. It is also generally more accepted by the scientific and medical community than the other forms. It is a very important tool for dealing with depression. However it does purport to deal with cognition and behaviour in order to affect emotions, which runs counter to most other psychotherapies. There is a large emphasis on the positive whereas other therapies allow for the negative feelings and consider them just as healthy as the positive ones. There seems to be no room to work on the origin of depression and there is no major provision for holding the client and letting them own their own feelings. 



References:
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders-IV-TR. Arlington VA: American Psychiatric Association.

Boyne, E. (2003). Psychotherapy in Ireland. Dublin: The Columba Press.

Hawthorn, K., Salkovskis, P. M., Kirk, J. & Clark, D. (1989). Cognitive behaviour therapy for psychiatric problems. Oxford: Oxford University Press.

Health Services Executive (2006). Guidance document for the provision of counselling in a primary care setting. Dublin: Health Services Executive.

National Collaborating Centre for Mental Health(2004). Management of depression in Primary and secondary care. National clinical practice guideline number 23. U.K.:  National Institute for Clinical Excellence. Retrieved 20/03/08 from http://www.nice.org.uk/nicemedia/pdf/cg023fullguideline.pdf

Stephens, E. (2008). Cognitive behavioural therapy for depression. Cognitive Behavioural Therapy Ireland. Retrieved 21/03/08 from http://www.cognitive.ie/_mgxroot/page_10766.html

How important an influence is the family of origin, in the life of the individual and the difficulties which the client presents in therapy?

Posted on April 15, 2013 at 8:25 AM Comments comments (71)
Patrick Kelly BA (Hons.) Counselling & Psychotherapy
Oranmore Counselling Centre
Oranmore
Co. Galway

This essay is mostly based on “Families and how to survive them” by Robin Skynner and John Cleese. The book is in the form of a dialogue between Skynner and Cleese. It outlines a substantial amount of psychodynamic theory on the origin of personality and psychopathology. It also covers the developmental stages of the child, what is required at each stage and what can happen if the needs are not fulfilled. It also covers sexual identity and sexual dysfunction. Both of which are a function of one’s parents attitudes and expression around sex, intimacy and love.

The book posits that personality and psychopathology are a result of the interaction between the individual with the family of origin and in particular the mother. However, in some instances, Skynner does allow for genetic hereditary. He also takes into account environmental factors but mainly from the viewpoint of correcting something that was missing from primary care situation. For example one may find a caring teacher or mentor who supplies the boundaries or modelling needed that was not provided by the mother or father.  

As mentioned already the mother is taken to be the primary care giver. She is therefore primarily responsible for the physical and emotional well being of the child. However it takes two people to make a baby so how does a family start? First one must choose a partner. How is this achieved? 

Skynner (1983) proposes the concept of screens. Every family has them. The function of the screen is to screen off any emotion or feeling that the family is uncomfortable with. So in their everyday dealings with each other one or more emotions are put behind a screen. Therefore the offspring in a particular family are not exposed and have no experience of dealing with the particular screened off emotion. It is a familial taboo. Sigmund Freud believed that the two things we have no conscious choice over are our career choice and life partner. Individuals unconsciously seek out others with the same screened off emotions. We choose partners who have the same screens. Since the family backgrounds are the same, the children of a couple will have the same emotions screened off as both of the parent’s family of origin. 

For example: Ciara comes from a family who are uncomfortable with anger. In this family expressions of anger are considered inappropriate and are therefore screened off. Ciara marries Eugene. Eugene comes from a similar family. As an infant their daughter Aoife feels her parent’s discomfort with anger and associates it with rejection. She hides her anger from her parents and eventually from herself. As a teenager she has developed a propensity to self harm. She has learned to screen off her anger and internalise her angry feelings.  She also has low self esteem as she has a feeling of falseness about herself due to her concealment of anger from her parents.

The reason why the mother is so important in the person’s life, is that she is the first care giver, provider of food, love and warmth. In general the father has less contact with the baby for the first few months. The parents take up different roles. The mother tends to be more nurturing and the father tends to set and impose boundaries. 

The mother needs to emotionally connect with the child. There are varying levels of psychopathology that can arise if this does not happen. At one extreme Autistic Spectrum Disorder can occur. Psychoanalytic theory purports that people with this disorder tend to see people as objects and cannot emotionally connect. They also have no facility for imagination and communication tends to be impaired and awkward. In the seventies and eighties mother’s of ASD children were referred to as “refrigerator mums”, implying that they were emotionally cold to the child. This theory has come in for staunch opposition and criticism over the years.

When a child is born it has no sense of self. It cannot see itself as a separate entity to its environment or the people around it. In the first few months of life it learns that it is separate. This is done by the mother reinforcing the concept of separateness by teaching the child boundaries. If the mother is always there on demand, then the child cannot learn that it is a separate being. The child needs to be let down. If it is hungry for instance it needs to experience the hunger and instant gratification is not always helpful. If the mother has not allowed the child to experience itself as separate by putting boundaries in place and therefore the boundaries are “fuzzy”, problems arise which effect development and can lead to psychopathology. 

Winnicott (2006) distinguished between different types of mothers. He referred to the good enough mother as the healthiest for the child. The good mother smothers the child and provides an on demand service. The child will struggle with its own separateness and identity. The bad mother neglects or abuses the child leading to emotional instability. The good enough mother does not strive for perfection and provides a safe base from which the child can explore its world.

The child enters rage when hungry. Since it considers itself omnipotent it cannot understand why it is not being fed immediately. It enters a state of bliss when feeding. These are two extreme emotional states. It can perceive a good mother who feeds it and a bad mother who does not, even though they are the same person. If the child has not got clear boundaries it could end up projecting its uncomfortable emotions onto something outside itself while keeping the good emotions for itself. This can lead to a paranoid personality type. It is noteworthy that we all have some sense of paranoia, anytime we break things into good and bad we are reliving this childhood experience.

This paranoid behaviour can also be used to project the unhappy or negative emotions onto one sibling in the family. This person gets blamed for everything and becomes the family scapegoat (Satir, V. 1983) . This can affect self esteem and behaviour. Conversely there can be a “golden child”. This is someone who in endowed with all the good qualities. This can lead to a false sense of self and Narcissistic Personality Disorder. 

As the baby develops a sense of itself as separate it leaves this stage of development and starts to obtain object permanence (Santrock, J. W. 2001). If it cannot see itself as separate, then as it develops, it starts to see people as objects or in parts: neck; breasts; lips etc. This can lead to schizophrenia and/or addictive behaviours. This again is due to the lack of emotional connection from the mother and an inability for the parent to define boundaries. This is due to the parent’s own childhood experience. Some people with unhappy childhoods cannot connect with the child, because to go there is too painful. In some cases the mother uses the child to sooth themselves. The mother can go to the baby’s level but cannot get back to the adult self. For a child all the emotions, sensations and mental processes are very confusing and if there is no one available to sooth them, and indeed they have to deal with someone else’s confusion, they get overwhelmed and can end up disassociated and emotionally disconnected.

Severe neglect and abuse, in childhood, can also lead to psychopathology. The results are usually low self esteem and depression, eating disorders self harm, or harming others. This is due to the feeling of powerlessness, as a helpless child, or even identification with the aggressor.

The healthiest children, emotionally, are those that are cared for when they need caring. However all children suffer distress, discomfort and sadness. Some mothers, due to their own denial of a need for themselves to be nurtured, can not access the feeling of “healthy sadness”, so when the child is sad they react inappropriately.  They might become emotionally withdrawn. So the child is left helpless and left in the state of distress. Conversely they may rush in to stop the child’s pain every time, because this sad emotion is so unbearable for them.  If this happens the child will not be able to experience sadness themselves and continually require comforting without the full experience. This leads to avoidant behaviour. The feelings are cut off. One is left in “sadness limbo”. The full emotion is not experienced so one cannot come out the other side. This is depression.  Every time the sadness is avoided the feelings keep piling up behind their screen leading to further and deeper depression. This stage happens after the child has learned he is separate but the closer to the earlier paranoia stage the client is the more severe the depression. Manic depression is a form of severe depression. In a manic state the client can regress back into a paranoid or schizophrenic state.  

So far we have discussed the role of the mother but what part does the father play? The father needs to reclaim the mother from the child and needs to be the one who sets and enforces the rules. If this is not done the child will grow up with authority issues and have an inability to be authoritative and assertive, it may also lead to lack of confidence and role confusion among the children. 
If the child ends up taking sides with one of the parents against the other because the parents are in conflict, they can end up as a problem child. This is the child’s attempt at uniting the parents by putting themselves as the focus of the problem. This pattern is a hard one to break and can result in a underachievement or antisocial behaviour. Alternatively they can become ill in order to bring the parents together. This can result in somatoform disorder in adulthood. 

The relationship of the child with the parents also leads to gender identification and sexual identity. Firstly the child needs the parents to have a loving healthy sexual relationship. This is the model for them when they are seeking a partner. From the attitudes and expressions of the parents the child learns to form relationships and explore sexual relationships. Therefore the parent’s relationship has an impact on the individual’s future ability to form loving, caring and healthy sexual relationships. 

The mother is the primary love object. In order for a girl to have a heterosexual identity she needs to be able to stay identified with the mother but then the father becomes the love object. For boys they need to cross over and identify with the father’s masculine standpoint while keeping the mother as a love object. If this does not occur or they only make it a fraction along the way of the transitions then the child will become homosexual or may not be comfortable with their sexual identity. In former years this was seen as the model to “cure sexual deviance”. In these times it is rare for someone looking for a treatment to cure homosexuality. However this insight may give a therapist a glimpse of the family structure. This is also an aspect of psychoanalytic theory that has come in for some severe criticism.  

I struggle with accepting some of this theory, especially in relation to autism and homosexuality. Perhaps this has to do with my own denial about the influence that my family of origin had to do with my development. It becomes so much clearer when I see the impact of the family on others. My own screening must be at work here. Once I see it from the perspective that there is no blame being attributed it sits better with me.

Working from a psychodynamic framework, it seems that most presenting issues have their roots in childhood and the family of origin. The most notable exception to this being PTSD. However one must note that one’s predisposition to acquiring PTSD may also have its roots in family experience and indeed the disorder may be caused by the family of origin. There is continual debate as to causes of certain disorders and sexual identification issues. I do not believe the nature vs. nurture debate will ever be thoroughly resolved. 

Psychodynamic theory and the knowledge of the issues arising from the family of origin gives us a insight and a way of working with complex issues presented in the consultation room. One needs to also bear in mind the actual time in the person’s life that the problem began. Generally the earlier the problem started the harder it is to work with. I think it is always necessary to keep in mind that we are not playing a blame game here. These processes and family interactions happen at an unconscious level. Only by becoming aware of them can we do anything to change them.

Patrick Kelly BA (Hons.) Counselling & Psychotherapy
Oranmore Counselling Centre
Oranmore
Co. Galway
April 2013

References:

Santrock, J. W. (9th Ed.). (2001). Child development. (pp 206-211). New York: McGraw-Hill.

Satir, V. (3rd Rev Exp edition). (1983). Conjoint family therapy. Palo Alto: Science and Behavioral Book.

Winnicott D. W. (2006) The family and individual development. Trowbridge: The Cromwell Press.

Bibliography:

Skynner, R. & Cleese, J. (1983). Families and how to survive them. London: Vermilion.

Stress and Relaxation

Posted on April 6, 2013 at 6:20 PM Comments comments (61)

In this essay I will be discussing the effects that the Autonomic Nervous System has on various organs in the body. 

First of all let us examine briefly the background to the flight or fight response. We have inherited a set of biochemical systems to deal with stressful and potentially dangerous situations from our ancestors. Chemicals are released to enhance our muscle capacity to respond to a dangerous situation by either fighting or running away. This response was a saviour to our ancestors but because of our developed social mores this ‘emergency response’ is not as useful today. In brief when we perceive a problem, imaginary or real, the cerebral cortex sends an alarm to the hypothalamus, which subsequently stimulates the sympathetic nervous system to alter certain functions in our bodies. If the fight or flight response continues to go unchecked during periods of stress this can lead to negative long term effects as your body will produce corticoids, which can lead to inhibited functioning of the digestive system, reproduction, growth, tissue repair and the responses of the immune and inflammatory systems. Research into this area is producing evidence that the prevalence of some of our modern diseases can be as a result of chronic stress. The body has a natural “off switch” to stop the alarm messages being sent once the perceived danger has past. The fight or flight response becomes extinct and everything returns to normal via the parasympathetic nervous system (Davis, M., Robbins Eshelman. & McKay, M. 2000).

Now let us look in more detail at the effects of the Sympathetic stimulation on the Autonomic Nervous system. As we have outlined above in a perceived potentially dangerous situation the Sympathetic System changes the normal functioning of some of our organs. It also increases blood sugar and blood flow to the large muscle groups and organs necessary to deal with a flight or fight situation such as the heart, lungs, quadriceps, and biceps. All these put the body into high gear so once we perceive an impending stressful situation the stress response occurs within a split second. 

These are the individual organ responses to the Sympathetic stimulation:

Iris: Our pupils dilate to improve focus.tear ducts: Production of tears is halted so we can see clearly. 
Sweat glands: Stimulated to secrete excess waste products. Therefore we begin to sweat.
Arteries: Arteries to the periphery contract increasing blood flow to the large skeletal muscles, heart and lungs. This results in us going pale and a cold feeling in the extremities.  
Skin: External skin hair straightens to trap air to keep the body warm, which leads to more effective large muscles for running or fighting. We have often heard the expression ‘My hair stood on end’ used when people express fright or shock. 
Heart: Heart is stimulated to increase blood flow. This can result in palpitations and you feel your heart racing. This can be measured by your increased pulse rate. Continued exposure to stress can lead to heart problems. Lungs: We unconsciously breathe very quickly taking shallow and fast breaths, this can give one the feeling of breathlessness. This allows us to take in more oxygen to supply the large muscles that aid in fight or flight. Prolonged exposure to stress can lead to breathlessness and exacerbation of respiratory conditions such as asthma. 
Digestive System: The digestive system is shut down to conserve energy and to divert blood to the large muscle groups. The outward expression of this is a dry mouth feeling. Long term effects include indigestion, fluctuating weight, IBS and ulcers.
Adrenal glands: Stimulates the secretion of stress hormones (corticoids) such as adrenalin noradrenalin.
Bladder: The muscles in the bladder tighten to inhibit you from urinating. .
Anus: The muscles around the anus tighten to inhibit bowel movements. Long term effects of stress may include diarrhoea and constipation.
Sex organs: Blood flow to the sex organs is decreased and secretions of all glands are decreased leading to a lack of sexual sensation. 

Prolonged exposure to perceived stressful situations can have grave side effects. Therefore it is necessary to invoke the actions of the parasympathetic system, through the relaxation response, to deal with stress on a regular basis. 
The parasympathetic system is the part of the autonomic nervous system that shuts down the stress response i.e. it controls the relaxation response. Red alert status is on stand down and everything returns to normal. Unlike the sympathetic system, which reacts in a split second, the parasympathetic system takes 15 – 20 minutes to relax you once the perceived threat is extinguished. 

These are the effects on the individual organs in the body once the parasympathetic system has engaged:

Iris: The pupils narrow.Tear ducts: Tear ducts are stimulated leading to moist bright eyes.
Sweat Glands: Sweat production is halted resulting in comfortably dry skin.
Arteries: The arteries dilate resulting in a good healthy colour.Skin: The hair looses the bristle effect resulting in smooth skin.
Heart: The heart slows down. No more palpitations or racing resulting in a slower pulse.
Lungs: Breathing becomes slower and deeper.
Digestive System: Secretion begins in the digestive glands. The gut muscles start to work again. This results in salivation.
Adrenal glands: Secretion of stress hormones is inhibited.
Bladder: Bladder muscles relax again resulting in an open bladder.
Anus: Muscles around the anus unclench.
Sex organs: Blood flow is increased to the sex organs, gland activity is increased resulting in increased sexual sensation.

In western thought it has generally been assumed that the Autonomic Nervous System is beyond our conscious control. However eastern philosophies such as Zen, Mindfulness and yoga would purport that through relaxation we can heal the negative effects of stress on our bodies, by invoking the actions of the parasympathetic system. Over the last fifty years it has become more evident that this is the case (Davis, M. et al. 2000).

I find a variety of techniques useful to bring on the relaxation response. I find breathing techniques very good and a quick method to diffuse stress. However for a full relaxation response I have recently started using Autogenic Training. I find AT particularly useful because you can bring it about through simple repeating to yourself without the use of outside stimuli such as CDs, outside voices etc. The formulae are particularly easy to memorise. 

Before one can attempt any relaxation technique there are certain criteria one should have in place. You need a quiet environment. This is necessary to help you concentrate and eliminate outside distractions. One needs something to concentrate on. In AT the constant repetition of your own inner voice is the concentration device. You need to maintain a passive attitude as concentrating on not doing the exercise right will act as a distraction. Finally a comfortable position is necessary to aid relaxation. I usually practice AT by lying on a yoga mat with my head supported by a pillow.

Autogenic Training is a form of self induced hypnosis. It involves relaxing in one of three positions and concentrating passively on verbal formulae that suggest warmth and heaviness, which bring on the relaxation response in the striped muscles in the body. There is no need to repeat out loud, the formulae are repeated in your head only. By use of further formulae the relaxation response is brought about in the cardiac system; the respiratory system; the abdominal region and also one can reduce blood flow to the head. (Davis et al 2000). 

Autogenic training is just one of an array of stress reducing techniques. There are a lot of helpful books on the subject of stress and of course there is always the option of seeking professional advice on reducing stress and learning progressive relaxation. 

The use of a stress diary can be used to monitor stress levels and keep a written record of feelings of stress. This can improve your awareness of stress. One can look back through a stress diary and pinpoint the reasons why for instance you might have a cold that you cannot shake off. Sometimes instances like this can happen due to a build up of stress. Through the use of a diary one can actively eradicate some of the sources of stress and actively seek more positive activities to replace them. 

References:
Davis, M., Robbins Eshelman, E. & McKay, M. (2000). The relaxation & stress reduction workbook. Oakland CA: New Harbringer Publications.

Fishbein. (1978). Illustrated medical and health encyclopedia. Westport CT: H.S.

Grieving and Bereavement

Posted on April 3, 2013 at 3:54 PM Comments comments (6209)
In this essay I will explain the difference between the normal grieving process and pathological grieving or complicated grieving. I will then outline tasks or phases of grieving. By using these tasks one can identify if there is a complication to the normal grieving process, leading to pathological grieving, and I will demonstrate how this applies. 

I am going to start by giving a rather clinical definition of grief: “a complex constellation of psychological, physiological, and behavioural responses that accompany the human awareness of an irrevocable loss…….Bereavement is the term applied to loss specifically through death” (Kennedy, E & Charles, S.C. 2001).  I do not believe this definition provides us with an understanding of the depth of the emotional effect that grief can have on us. Kennedy & Charles go further to give us an insight into the profound effect normal grief can have “bereavement rubs us raw, assaulting us as a rapist might, bearing away by violence the kingdoms of our souls. Bereavement rips us, leaving us, as the dictionary definition puts it, desolate”.

The death of someone close to us is for everyone, at some stage of their lives, a fact of life. However not everyone has the same reaction to bereavement. Normal mourning can manifest in a variety of ways.  We can be prone to experience certain feelings, physical sensations, cognitive processes and behavioural changes, all of which may seem abnormal and certainly strange.  

Even though this process is quite normal it may seem confusing, the intensity of the feelings may be overwhelming, and there may be a regressive feeling of helplessness. One of the most confusing feelings can be anger. It is hard to imagine feeling anger towards someone you loved, and we live in a society where you do not speak ill of the dead. This anger may be caused by the upset of abandonment. This confusing anger can lead to a sense of guilt. One may indeed feel guilty that one did not do enough to prevent the death. Bereavement may cause anxiety. The bereaved may feel they cannot cope without the person they have lost or they may become anxious as the death may evoke their own sense of mortality. Loneliness without the other person is also a common feature, especially in the case of a bereaved spouse. The bereaved may tire easily. This can be a distressing feeling. There may be a feeling of shock especially in the case of a sudden death. One may pine for the deceased. This feeling can help to gauge what stage the bereaved person is at. Another confusing feeling can be emancipation. The person may feel they have more freedom because of the death. Alternatively some may feel relief for the deceased person especially in the case of a long standing degenerative illness. Finally numbness to feelings and emotions can occur as a defense against the overwhelming impact of the loss (Worden. 2001). 

There are also many physical sensations associated with the grieving process. Among these are: hollowness in the stomach; tightness in the chest; tightness in the throat; oversensitivity to noise; a sense of depersonalisation; breathlessness; muscular weakness; lack of energy and a dry mouth (Lindermann c.f. Worden 2001). All of these symptoms are very similar to a stress response. 

There may also be certain thoughts associated with the grieving process. There may be disbelief that the person has died. There may be confused thinking or inability to concentrate. The bereaved may be preoccupied with thoughts of the deceased person. The bereaved may cognitively believe that the deceased is still physically present. 
There may also be some behavioural changes experienced by the bereaved. Normal sleeping patterns may suffer. So too can appetite. The person may become forgetful. There can be an inclination to social withdrawal. The bereaved may dream about the deceased. The content of the dream can indicate to the therapist where the person is in the mourning process.  There can be an avoidance of items that remind people of the deceased. However the rapid disposal of items may indicate a complicated grieving process to follow. Conversely hanging on to things and keeping things as they were before the person died may also indicate pathological grief. Bereaved people may find themselves searching for or calling out to the dead person. They may also try to keep themselves as busy as possible to avoid having to dwell on the loss. This too could lead to abnormal grieving.

However all of these reactions to loss are normal and part of the healthy grieving process. In normal grief they dissipate over time. When these symptoms are prolonged or sublimated it can be an indication of pathological grief. Normal grief can be summed up as “the blues that healthy people sing when they suffer a major loss” Kennedy & Charles (2001).

There is almost a societal taboo to fully experiencing the grieving process “the Western world treats mourning as though it were a weakness rather than a functional and necessary human experience” (Kennedy & Charles 2001). It can take time to work through the process, while others close to you may try to distract you from thoughts of the deceased or believe it is time you got over it. This may explain why some people do not complete a normal grieving process. If we feel we cannot allow ourselves to experience the reactions to bereavement, these feelings may become repressed. This can lead to a state of complicated/delayed/displaced/pathological or abnormal grief. 

Usually in pathological grief, a considerable amount of time has passed since the death. Clients may come to therapy with no idea why they need help. During the therapeutic process one may find a recurring theme of loss. The bereaved may be consciously aware that they have not dealt with the loss. On the other hand they may feel that it was so far in the past that they must be over it. Due to the circumstances of the death they may find it impossible to accept the fact that the person is gone. They may have a relatively excessive reaction to a current loss. These may be indicators of pathological grief.
Horowitz (c.f. Worden, 2001, p.89) describes abnormal or pathological grief as “the intensification of grief to a level where the person is overwhelmed, resorts to maladaptive behaviour, or remains interminably in a state of grief without progression of the mourning process towards completion……..[It] involves processes that do not move progressively toward assimilation or accommodation but, instead, lead to stereotyped repetitions or extensive interruptions of healing”. 

There is a difference in how the grieving processes are dealt with in therapy. Grief counselling is used to facilitate the client to go through a normal grieving or mourning process. Worden (2001) tells us that the goal of grief counselling is to facilitate the tasks of mourning in the recently bereaved in order that the bereavement process comes to a successful termination. However grief therapy is applied in complicated or pathological cases of bereavement. The goal, of which, is to identify and resolve the conflicts of separation which preclude the completion of mourning tasks in persons whose grief is absent, delayed, excessive or prolonged.  

I am now going to outline Worden’s (2001) tasks or phases of grieving. These tasks are in order but not necessarily sequential. These tasks can be used to resolve pathological grief and they can be worked through separately and revisited over time.  When all these tasks are completed then the grieving process is over. If someone gets stuck at one or more tasks then complicated/pathological grief will result.  By using these tasks we can see if there are unresolved issues around bereavement, leading to pathological grief. As stated previously usually a substantial period of time needs to elapse, since the death, before one is able to assess if the grief reaction is pathological.

Task I: To Accept the Reality of the Loss. 
One of the reactions to death is not to accept the finality of it or to accept that a mortal event has occurred. This is represented by denial and an inability to accept the loss. During this phase the person goes through a period of numbness. The successful completion of this task will result in the bereaved accepting the intellectual and emotional reality of the loss. 

If however there is some confusion around the issue of the death of the deceased or if the client is uncomfortable and resistant about talking about the dead person, this may indicate a lack of acceptance concerning the loss. People may use present tense. They may keep personal belongings, for years, in the (sometimes unconscious) hope the deceased will return. The opposite is also true; people may discard the deceased personal belongings to facilitate them in not having to face the reality of a loss. The way or location in which a person died can affect the resolution of this task.

Task II: To Work Through the Pain of Grief. 
The pain of bereavement manifests itself emotionally and physically. In this task it is necessary to acknowledge the pain and feel it. However this experience may be at odds with societal conventions. If this task is unresolved people may carry this pain for life.

The therapist looks for signs of the person cutting off their feelings around the bereavement and hence denying the pain. People can also use their rationality to suppress the emotional pain.  A person who intellectualises consistently may be a candidate for one who has not worked through the pain. As mentioned earlier anger can play a part in the normal grief process. One should look for signs of displaced anger. To feel this emotion towards the deceased may be too painful.

Task III: To Adjust to the Environment in Which the Deceased is Missing. 
Firstly one needs to learn to function without the deceased. This may mean taking on roles that the deceased performed. Then one must evaluate your sense of self and who you are without the deceased. Then one needs to work through how the death affects one's spiritual assumptions about how the world is. 

Pathological grief in relation to this task manifests itself in the person presenting as helpless, showing an inability to cope with life and or withdrawing from social responsibilities. The person finds it difficult or indeed does not want to move forward. 

Task IV: To Emotionally Relocate the Deceased and Move on With Life.
To find a place for the deceased that will enable the mourner to be connected with the deceased but in a way that will not preclude them from getting on with life.

Pathology would take the form of a person having an inability to form new relationships. They may have a sense of guilt or unfaithfulness. An inability to love or find love again may indicate the non resolution of this task. 

People may exhibit signs of clinical depression due to the normal grieving process. However the main distinction between depression and a grief reaction is that there is no loss of self esteem. It is possible that the person is clinically depressed if there is an associated loss of self esteem. Worden (2001) describes this as an exaggerated grief reaction. High levels of anxiety manifested by panic attacks and phobias may also indicate an underlying disorder. Agoraphobia or a generalised irrational fear of things or people may have to be treated by psychotherapy. If the person is manifesting alcohol or substance abuse, due to or exacerbated by the death, this will have to be treated. Due to the nature of a particular death, i.e. a traumatic or violent death, or indeed exposure to trauma or violence, the client may suffer from post traumatic stress disorder (P.T.S.D.) The classic symptoms of P.T.S.D. are: hyper arousal; constriction; dissociation (where one feels detached from the reality of ones life, like you are an observer looking at what is happening to yourself); denial and feelings of helplessness, immobility or freezing. (Levine, P. 1999).  There is also an association of mania with grief. The main symptoms to look out for in the case of mania are: agitated or enthusiastic activity, a person always on the go, difficult to contain, and in their conversations are easily distracted and quickly shift the gears of content (Kennedy & Charles 2001).

I would like to conclude the essay by giving an example of prolonged or pathological grief from my own experience. My mother died when I was 20, from cancer. She spent her last 3 months in St. James Hospital. I watched her deteriorate physically from the cancer, mentally form the palliative drugs and emotionally from the fear of not knowing what was happening to her. I spent hours each day in the hospital with her. I was strong for her and for everyone else who saw her, as a person that they did not know.  I was holding her hand at the time she died. Even though I saw and felt her die I could not accept what was happening. Even when the doctor brought my father and I into the tea room to confirm the death I was still in denial. My reality became very blurred. The funeral was another blur; I was numb, expressionless and emotionless. I comforted myself by remaining busy and organising the funeral. The only emotions I remember were my father handing me a cigarette as we drove over Rialto Bridge away from the Hospital). I also remember two teenagers, in heavy metal gear, waving goodbye to the hearse as we drove behind it along the canals on the way out of Dublin. I saw this as a sweet gesture.

I remember all the fine details about the funeral, but I couldn’t tell you how I felt. Why? Because I didn’t allow myself to feel, I didn’t allow myself to cry, I was numb. I remained like that for a long time, always participating but feeling nothing. I was haunted by recurring nightmares where my mother was neither alive nor dead. After these nightmares I found it very hard to tell fantasy from reality. Sometimes I would ring home expecting to talk to my mother and I found it very hard to convince myself that there was some reason that I couldn’t speak to her. Driving home on weekends I would have problems accepting that she was not in the house and I remember thinking thoughts like "did we move?" "Are my parents separated and no one is telling me?"

As I said this continued occasionally for about 7 years the intensity and frequency diminished over time to be replaced by new nightmares. Every time since, when someone I know has died or I experience loss I am revisited by that special numbness. 
I worked through this in my own personal therapy. The first time I even allowed myself to cry was 15 years after the event. I have now learned to accept the loss, acknowledge and work through the pain, find my way without my mother and I will always have a place for her in my heart. However this process took me fifteen years. 




References:

Kennedy, E. & Charles, S.C. (2001). On becoming a counsellor. Dublin: Newleaf.

Levine, P. (1999). Healing trauma restoring the wisdom of the body. Boulder: SoundsTrue, Inc.

Worden, J.W. (2001). Grief counselling and grief therapy third edition. New York: Springer Publishing Company Inc.

A study of the relationship between General Medical Practitioners and Counsellors & Psychotherapists in the treatment of Depression and Anxiety. (Entire Text)

Posted on March 7, 2013 at 9:00 AM Comments comments (82)
A study of the relationship between General Medical Practitioners and Counsellors & Psychotherapists in the treatment of Depression and Anxiety.


A study of a sample of General Medical Practitioners and Counsellors & Psychotherapists in Wicklow, Wexford, Galway and Clare, in regard to multidisciplinary co-operation and referrals, in relation to the treatment of Depression and Anxiety. 


 





Patrick Kelly BA (Hons) Counselling and Psychotherapy 2008






Acknowledgments
This research project is not just a result of my work over the last few months. It is a result of a four year journey. I have had lots of help and support along the way. 

First and foremost I wish to thank Caroline for putting up with me for so long during and before this course. I also wish to thank my parents who provided that support before Caroline and particularly my father who still does. I want to thank Eve and Ferdia, their light kept me going when the road seemed too dark to travel on. 

I want to mention those who left along the way. I only knew Shane for a short while, I remember Sinéad fondly. I really miss Jennifer and I also miss the chats with “Gran”.During this journey 

I have met lots of people who have inspired me and supported me in so many ways. In this regard, I really want to thank all my former lecturers, Supervisors and Therapists. I can’t express my gratitude enough, in the language available to me, for the warmth, friendship and new ways of looking at life that my former classmates have provided.  

I wish to thank Dr. Michael Carroll, Dr. Elaine Neville and Ms. Caroline Whiriskey for taking part in the pilot study. I would also like to extend my gratitude to all the GPs and Therapists who took the time to complete the questionnaires that contributed to this study. 

I would also like to thank Dr. Nick Buggle and Dr. Siobhán McCabe for providing me with a place to practice from when I was starting out. 

Patrick Kelly April 2008

Abstract
The object of this research project was to discover general attitudes that GPs had towards the Counselling & Psychotherapeutic profession. It also set out to discover how the GPs saw Psychological Therapy as beneficial in practical terms by the frequency they refer to or would prefer to refer to these services. It also aimed to discover general attitudes Therapists held towards GPs. To this end two questionnaires were devised and sent out to 100 GPs and 40 Counsellors & Psychotherapists in Wexford, Wicklow, Galway and Clare. The study found that 4.7% of GPs list referral to a counsellor as a preferred treatment for the various diagnoses of Depression. 11.6% of GPs consider Psychotherapy as a valid treatment option for the various diagnoses of Depression. 29.3% favour prescribing medication as a treatment option for the various levels of Depression. 27% considered the option of treating with a combination of Psychotherapy and medication. It also found that there did not seem to be enough knowledge among GPs about the qualifications and accreditations of various psychological service providers to make an informed and confident decision to refer to these services. The study concluded that more education was needed to be provided to the GPs in regard to the service provision, qualifications and accreditation processes of the various psychological therapy providers.  


CONTENTS             
                                              1.1        

    CHAPTER TWO – LITERATURE REVIEW
                         2.1 Introduction. 
                         2.2 What are Mood Disorders? 
                         2.3 What are Anxiety Disorders? 
                         2.4 Recommendations for Treatment in the UK. 
                         2.5 Recommendations for treatment in Ireland.                                    
                         2.6 Limitations of this Literature review.                                      
                         2.7 Conclusion from the Literature Review.                 

    CHAPTER THREE - METHODOLOGY
                         3.1 Introduction.                                                                
                         3.2 Population.                                                         
                         3.3 Method.                                               
                         3.4 GP Questionnaire Analyses.               
                         3.5 Analysis of the questionnaire for Therapists.            
                         3.6 Limitations.                                              
                         3.7 Ethical Considerations.               
    
    CHAPTER FOUR – RESEARCH FINDINGS
                         4.1 Introduction.                 
                         4.2 Findings from the GP questionnaire.              
                                   4.2.1 Age and Gender.                                     
                        .          4.2.2 Qualifications in a Mental Health Discipline. 
                                   4.2.3 Referrals to Specialist Mental Health Services. 
                                   4.2.4 The Services which GPs are most likely to refer to.
                                   4.2.5 How frequently would a GP refer for Psychotherapy and                                                                                                                                                                                                       
                                               Counselling?
                                              Psychotherapist. 
                                  4.2.7 The relationship of the GPs with Counsellors and/or                                                 
                                             of view. 
                                  4.2.8 Familiarity with the counselling/psychotherapy services and                                                  
                                            theory frameworks used.   
                                  4.2.9 Analysis of the understanding that GPs have of the difference                                                  
                                              between Counselling and Psychotherapy. 
                                  4.2.10 The barriers to referring to Counselling and Psychotherapy                                                 
                                               from a GP’s perspective.
                                  4.2.11 The preferred method of treatment for a patient with a                                                 
                                               diagnosis of Mild Depression
                                  4.2.12 The preferred method of treatment for a patient with a                                                
                                                diagnosis of Moderate Depression.                                                                 
                                               diagnosis of Severe Depression. 
                                 4.2.14 The preferred method of treatment for a Patient with a                                               
                                              episodes. 
                                 4.2.16 The preferred method of treatment for a patient with a                                                
                                              mental health disorders. 
                                4.2.17 The preferred method of treatment for a patient with a                                               
                                             diagnosis of an Anxiety Disorder. 
                     
                         4.3 Findings from the Counsellor and Psychotherapist questionnaire.   
                                4.3.1 Percentage of referrals from GPs.   
                                4.3.2 Relationship with Local GPs. 
                                4.3.3 How familiar are GPs with the services provided? 
                                4.4 Conclusion from the Research Findings. 
    
    CHAPTER FIVE – DISCUSSION     
                                5.1 Strengths and weaknesses of this study. 
                                5.2 An overview of question 12 from the GP questionnaire.  
                                5.3 An overview of the general comments from the GP questionnaire.
                                5.4 An overview of question 4 from the Therapist questionnaire. 
                                5.5 General Conclusions.                
REFERENCES

LIST OF FIGURES                     
Figure 1 -Frequency of referrals of a patient with a mental health issue to primary or secondary care that specialises in mental health. 
Figure 2 - Which service GPs are most likely to refer a patient with mental health difficulties to. 
Figure 3 - Frequency of referral for Counselling or Psychotherapy. 
Figure 4 - Preferred theoretical orientation when referring for Counselling and/or Psychotherapy. 
Figure 5 - The relationship between GPs and local Counsellors and Psychotherapists.
Figure 6 - Familiarity with the process of Counselling and Psychotherapy
Figure 7 - Statistical representations of the scored responses to question 10. 
Figure 8 - The barriers to referring for Counselling and Psychotherapy
Figure 9 - The preferred method of treatment for a diagnosis of Mild Depression.
Figure 10 - The preferred method of treatment for a diagnosis of Moderate Depression. 
Figure 11 - The preferred method of treatment for a diagnosis of Severe Depression. 
Figure 12 - The preferred method of treatment for a diagnosis of Severe Depression with Psychotic symptoms. 
Figure 13 - The preferred method of treatment for a patient with mixed episodes. 
Figure 14 - The preferred method of treatment for a diagnosis of Depression comorbid with one or more other mental health disorders. 
Figure 15 - The preferred method of treatment for a diagnosis of an Anxiety Disorder. 
Figure 16 – Relationship with local GPs. 
Figure 17 – GP familiarity with the services provided from a Therapist’s perspective. 


LIST OF TABLES               
Table 1 - Age and Gender analysis of GP respondents. 
Table 2 Breakdown of GPs who refer a patient with a mental health issue to primary or secondary care that specialises in mental health. 
Table 3 - Breakdown of the services a GP is most likely to refer to, for a patient with mental health difficulties, in relation to the age and gender of the GPs. 
Table 4 - Frequency of referral for Counselling or Psychotherapy by age and gender. 
Table 5 - Analysis of the relationship between GPs and Counsellors and/ or Psychotherapists in the community in terms of age and gender. 
Table 6 - Familiarity with the process of Counselling and Psychotherapy in relation to age and gender. 
Table 7 Scored responses to question 10 in relation to age and gender. 


APPENDICES
APPENDIX ONE       –          LETTER SENT TO GENERAL PRACTITIONERS.

APPENDIX TWO     –          QUESTIONNAIRE SENT TO GENERAL PRACTITIONERS.

APPENDIX THREE  –          LETTER SENT TO THERAPISTS.

APPENDIX FOUR    –          QUESTIONNAIRE SENT TO THERAPISTS.

APPENDIX FIVE      –          GENERAL PRACTITIONERS VERBATIM RESPONSES                                                                        
                                                 TO QUESTION 12.
                                                  PRACTITIONERS.

APPENDIX SEVEN –          THERAPISTS VERBATIM RESPONSES   TO QUESTION                                                   
                                                 4.


                          

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