Therapy Today October 2014



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Therapy Today
October 2014
Volume 25
Issue 8

NB +++ indicates the start of a new section

Contents

Features
Bringing death back into our lives

Catherine Jackson previews Kicking the Bucket, a festival of living and dying.
The changing role of the university counselling service

Clare Pointon reports on the challenges facing university counselling services today.


Student–tutor conflict in counsellor training

Jayne Godward explores the difficulties in the dual role of course tutor and counsellor.


A story of falling

A walking accident has taught Alistair Ross a tough lesson about vulnerability.


Feedback in supervision

Emma Redfern explains why feedback is essential to a healthy supervisory relationship.


Making meaning in a third language

Gala Connell finds she can share meaning even if she doesn’t share a client’s language.

Regulars
Editorial
News
Columns

In practice: Jeanine Connor

In the client’s chair: Nina Burrowes
Talking point

Jackee Holder


Dilemmas
The interview

Mick Cooper


How I became a therapist

Jeremy Christey


Letters
Reviews
Film reviews

BACP
From the Chair


Public affairs
BACP News
Professional standards
Professional conduct
BACP Research

TherapyToday.net


Eva Bee describes what inspired her illustrations for this issue in ‘Behind the pictures’; plus online reviews and the TherapyToday.net Noticeboard.

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Editorial

My daughter has just applied to university to do a five-year course. If she gets in she will leave with a minimum debt of £45,000, which is a scary prospect. I wonder how well she will cope with the pressures of the course, living away from home, managing her social life and the whole transition into adulthood. There is certainly more emotional support available for students today; we are much more aware of students’ needs, and university counselling services are well established, offering all sorts of holistic support for students, helping them to cope with exam pressures or to manage their time effectively. But in many cases university counselling services themselves are under pressure because of huge increases in the number of students seeking their help.


In an article documenting how her role as a university student counsellor has changed over the years, Clare Pointon explains that one of the most significant changes has been an increase in the number of students presenting with issues that she and her colleagues are not equipped to deal with. They regularly have to immediately refer students with severe mental health problems to the NHS for long-term or specialist help. The reasons behind this increase are many and complex but include the facts that mental health problems have risen among young people in the general population, and that widening participation in Higher Education (HE) means that more young people with pre-existing mental health problems are going to university. The extent to which other factors like student debt, higher rates of family breakdown and the economic recession contribute to this increase is debatable.
Another perspective on the state of student mental health comes from one of the article’s interviewees, Alan Percy. He suggests that counselling may be developing a new form of dependency. Our society’s shift towards more child-centred parenting, he argues, may have a tendency to make some young people more emotionally dependent on their parents, so they come to university expecting to be looked after. In this scenario, he says it’s important that HE clinicians are clear about what they can and cannot offer.

Sarah Browne


Editor

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News

Exams top student worries


Academic pressure, jobs and money are the three biggest anxieties concerning UK students today, the 2014 Endsleigh Student Survey reveals. And nearly half say they would seek help from their university counselling service if they felt they weren’t coping.
The survey of 2,128 students asked them to rank their greatest fears out of 10. The top three were keeping up with exams and academic deadlines (89%), applying for jobs (78%) and managing their money (69%), followed by physical health and fitness (62%), and their mental health and wellbeing (60%). Only 20 per cent reported homesickness as a problem but more than half (52%) worried about making friends.
Female students were more likely than men to report anxieties about these issues. On average, eight per cent more women were concerned about achieving academic success; seven per cent more were concerned about applying for jobs and 14 per cent more were concerned about exams and academic deadlines. Women were also more likely than men to talk about their worries with their family or with their friends or a partner (69% compared with 57% and 83% compared with 72%, respectively), while male students were more likely to relieve anxiety by exercising (60% compared with 50%).
Some 41 per cent of students said they would consider visiting their university counselling services; 35 per cent of women said they went shopping to relieve stress and 37 per cent of men said playing computer games helped them to relax.
www.endsleigh.co.uk

Talking therapy best for social anxiety disorder


Psychological therapy is more effective than antidepressants for social anxiety disorder and has longer lasting benefits, new research suggests.
Social anxiety disorder affects an estimated 13 per cent of people. But many are not offered treatment with a trained therapist or choose medication or no treatment at all, the joint study by researchers at Johns Hopkins Bloomberg School of Public Health, Oxford University and University College London found.
The meta-analysis of 101 clinical trials found that 9,000 of the 13,164 participants in the studies received medication or a placebo pill, and some 4,000 received psychological therapy. Few of the trials tested combined medication and talking therapy, and there was no evidence that this was better than talking therapy alone.
Individual CBT was the most effective talking treatment – better than psychodynamic, interpersonal and supportive therapy and mindfulness. For patients who didn’t want or couldn’t access talking therapies, selective serotonin re-uptake inhibitors (SSRIs) were the most effective medication.
Based on these findings, the researchers say that medication should only be used if a patient has refused talking therapy. ‘Greater investment in psychological therapies would improve quality of life, increase workplace productivity, and reduce health care costs,’ said lead researcher Dr Evan Mayo-Wilson. ‘Now that we know what works best, we need to improve access to psychotherapy for those who are suffering.’
Lancet Psychiatry

Mentally ill denied non-medical care


Fewer than half of people receiving community mental healthcare say they have been offered non-medical treatments, a survey by the national Care Quality Commission has discovered.
In its annual national survey of more than 13,500 people with severe mental illness in the care of community mental health services, just 47 per cent said they had received any treatments or therapies that did not involve medicines and 26 per cent said they would have liked them.
The survey also found that fewer than half the respondents felt that the NHS mental health staff they saw always understood and helped them with what was important to them, and always helped them to feel hopeful about the things that were important to them.
The CQC says effective care for mental health conditions can include many treatments other than the medications and psychological therapies recommended by NICE, such as relaxation and art therapies, massage and acupuncture.
‘As it is a government priority that more people should benefit from psychological therapies, we hope that future surveys will find a greater proportion of people receiving therapies other than, or in addition to, medicines,’ said Dr Paul Lelliott, Deputy Chief Inspector of Hospitals and CQC lead for mental health.
www.cqc.org.uk

IAPT 2013/14 waiting times


Huge regional variations in waiting times are revealed in the 2013/14 data on access to IAPT psychological therapies from the Health and Social Care Information Centre.
Nearly a million (947,640) people were referred to IAPT services in 2013/14 with anxiety and depression. Overall 61 per cent were seen within 28 days of referral, but this varied by Clinical Commissioning Group (CCG) from 96 per cent to just three per cent. Most (89%) were seen within 90 days.
But, of the 40 per cent of referrals recorded as having completed treatment, 37 per cent never saw a therapist for an assessment or treatment at all, and 24 per cent ended treatment after just one assessment and one treatment session or just an assessment.
The majority (63%) of referrals were women and the largest user group was aged 25–29. The most common diagnosis was ‘depressive disorder’ (a quarter of new referrals), and cognitive behavioural therapy (CBT) was the most frequent treatment (38% of appointments).
The average number of sessions was six, although 20 per cent received just two. Of the 364,343 referrals that finished a course of treatment, 60 per cent were recorded as showing ‘reliable improvement’, and 13 per cent of those prescribed and taking medication at the start of treatment were no longer taking it when their course of treatment ended.
The Liberal Democrats have said they will include the first ever waiting time targets for access to talking therapies in their manifesto for next year’s election: six weeks for 75 per cent of referrals and 18 weeks for 98 per cent.
www.hscic.gov.uk/pubs/psycther1314

Irritable bowel syndrome


Psychotherapy can be helpful for people with irritable bowel syndrome (IBS), a review of published studies has found.
The review analysed 48 randomised controlled trials of treatments for IBS. The studies included comparisons of psychological therapies with a control therapy or usual care, antidepressants with placebo, and combined psychological therapy and antidepressants with placebo.
Antidepressants were only very slightly more effective than psychological therapies. In the psychological therapy trials, cognitive behavioural therapy, hypnotherapy, multi-component psychological therapy, and dynamic psychotherapy all had similar success rates.
The American Journal of Gastroenterology

Antidepressant use in Scotland


One in seven people in Scotland are now taking antidepressants, according to Scottish Government figures.
Prescriptions rates in Scotland for antidepressants, antipsychotics, drugs for ADHD and drugs for dementia have all increased sharply in the past four years.
A total of 778,180 patients were dispensed at least one antidepressant during 2013/14, an increase of 4.2 per cent from 2012/13. Women and people aged 45–49 years were most likely to be prescribed antidepressants, and those living in urban deprived areas – the highest prescribing rates were found in Greater Glasgow and Clyde and Ayrshire and Arran.
A Scottish Government spokeswoman said it is ‘also committed to improving access to alternatives, such as psychological therapies’.

Go to work on your feet, study says


Walking or cycling to work is better for people’s mental health than driving, according to new research by the University of East Anglia and the Centre for Diet and Activity Research (CEDAR).
The researchers say the benefits are both physical and psychosocial.
The research team studied 18 years of data on almost 18,000 commuters in Britain aged 18–65 to gauge levels of feelings of worthlessness and unhappiness, sleepless nights and feeling unable to face problems in relation to their mode of getting to work.
They found that the more time commuters spent in cars, the worse their psychological wellbeing. Conversely, the longer their walk to work, the better their mental health. Commuters also reported feeling psychologically better if they travelled by public transport.
‘As buses or trains also give people time to relax, read, socialise, and there is usually an associated walk to the bus stop or railway station, it appears to cheer people up,’ said lead researcher Adam Martin.
According to the 2011 census, 67.1 per cent of commuters use cars or vans as their usual main means of getting to work, compared with 17.8 per cent who use public transport, 10.9 per cent who walk and just 3.1 per cent who cycle.
www.cedar.iph.cam.ac.uk

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In practice
Thinking about dying
Jeanine Connor

I live in a small town close to a slightly larger town in a semi-rural part of the UK. Yet, despite my whereabouts, I can’t travel far without passing an impromptu shrine apparently marking the site of a recent fatality, forcing personal loss into the public domain.


I write this piece in the wake of the actor Robin Williams’ suicide, with images bombarding our screens of floral tributes outside his Californian home, on the Hollywood Walk of Fame and at various film locations around the US. Meanwhile the social media are awash with homages to the ‘acting genius’, mostly from people who never met him. There is no escaping Public Displays of Grief (capital letters merited), the most striking example of which followed the death of Princess Diana in 1997. Images of waist-deep stacks of bouquets remain indelible in the minds of all who witnessed them. This seemed to set a precedent and signify a new cultural norm, but to what end?
Grief is a deeply personal emotional state, so the desire to demonstrate it publicly seems paradoxical. Perhaps the laying of floral tributes externalises, and therefore splits off, those feelings of personal grief that are too painful to contain. Maybe the shared mourning of a celebrity creates a socially acceptable outlet for the expression of individual loss, discouraged in our typically buttoned up society.
We have heard much about Robin Williams’ struggle with depression, which is in contrast to the more familiar face of the ‘comic legend’. Millions of people identify with this and with the urge to self-harm or to attempt suicide. When someone takes their own life opinion rages, and those who do so are branded as brave and tormented or insensitive and selfish. And all this occurs in the context of another debate currently being contested in the public sphere – that of assisted dying. The associated moral, ethical and legal considerations are too vast for the constraints of this column, but they do highlight issues that cannot be avoided: issues about how we manage death, personally, publicly and in practice.
Benjamin Franklin wrote in 1789: ‘In this world nothing can be said to be certain, except death and taxes.’ Death is certain of course, but the where and when and how are rarely known about in advance. How could we live with certainties about our own demise despite knowing, cognitively, that we and our loved ones are mortal? Some of our patients have fewer unknowns: those who live with terminal illness, whether their own or that of someone else in their family, and those who are contemplating assisted dying or suicide. This raises a further paradox in that, although these issues are in the public domain, personal suffering too frequently remains hidden: for example, few spoke about Robin Williams’ depression prior to it being cited as the cause of his death.
In my psychotherapy practice, I have worked with many patients for whom death is an ‘alive’ reality. Their ages and circumstances vary enormously but all are beset by physical and/or psychological pain, often accompanied by a heavy dose of shame. Talking helps. Having a space to verbalise fears, fantasies, what-ifs and if-onlys helps. Not being judged, persuaded, discouraged or emotionally blackmailed helps. Humour helps. Of course I have an urge to keep my patients alive physically, but the crux of my work is to facilitate psychological aliveness. I have witnessed transformation in the most fragile individuals as they gradually become more robust. I have rejoiced as, after numerous overdoses, a client begins to make alternative, safer choices to manage their despair. I have reflected on life after death with children whose parents have completed suicide and who thought there was no alternative for them. I have explored treatment choices and decisions to terminate treatment with those who are terminally ill. I have helped manage the psychological ache of termination. One very ill young man summed up our work with a metaphor: ‘There’s a ton of bricks hanging over me. You haven’t taken them away, but you’ve climbed under here with me and are helping me hold the weight. I’m ready now. I’m ready to go.’

Jeanine Connor MBACP works as a specialist child and adolescent psychodynamic psychotherapist in private practice and in specialist Tier 3 CAMHS and is also a writer. Events and individuals described here are anonymised and are not identifiable. Visit www.seapsychotherapy.co.uk

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In the client’s chair


Gaining the courage to be me
Nina Burrowes

I am a psychologist who uses cartoons to help people understand how the human mind and emotions work. The Courage To Be Me is an illustrated book for people who are in the early stages of disclosure of sexual abuse. I wrote it as a simple guide to help people make sense of their own behaviour and give them some hope that life can get better. These responses from readers explain why the graphic book format has worked for them.


‘When I saw this book it was like seeing my life illustrated on its pages. It’s like the book was made about me and for me. There were thoughts in there that I had never dared to share with anyone – and there they were, facing me on the page. I had never told anyone about my abuse and had resigned myself to the fact that this “secret” of mine would die with me. I felt so ashamed and alone. In the book it says about shining a light on things. That’s how it felt. The book helped me understand my shame. And I could see I wasn’t alone. It helped me do the one thing I never thought I would do. I phoned a helpline and now I have an appointment for counselling. It’s true what the book says about hope being scary – but I’m grateful for it.’
‘I am a very visual person and so this book just made so much sense to me. Books that are too wordy or clinical get into my logical brain and I try and analyse the things I feel and think… This book gets to a part of your brain that you cannot easily reach. Because all the elements of you can understand, they can ‘see’ and ‘hear’ the words and the pictures. Many would have been much younger when they were abused and the way the book is made, it felt like it was talking directly to those younger damaged elements of myself.’
‘Particularly useful to me was the “I’m Not Mad?” chapter – the scientific explanation of the stress reactions and crossed wires that I was experiencing. As a scientist-type, this wholly resonated and I only wish I’d understood it sooner as I’d have been kinder to myself. Having revisited the book several times, I actually found myself giving myself broader permission to be forgiven – essentially to “indulge” in some of the more emotional stuff I am far less comfortable with.’
‘After being raped in January I can honestly say that The Courage To Be Me has got me through the last few months, giving me the courage to remain in the judicial system...To know I am not going mad and that I am not alone has given me so much strength… There are no words to describe the power of this book. I am just so glad I found it.’
‘I’m dyslexic and had actually given up on trying to find a book about sexual abuse that I’d be able to get through. This is the first book I’ve been able to read all of the way through. The pictures helped me understand information without triggering me. I was able to “see” this side of myself for the first time. It helped make this part of me not invisible anymore. I struggle to find the words to say how I feel, but my counsellor and I now use the images in the book. I’ve even started drawing myself. I think the best thing about this book is that I don’t feel alone and I don’t feel so weird anymore. Thank you.’

The Courage To Be Me costs £12 from Amazon. Bulk orders can be made from the author at www.ninaburrowes.com

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News feature


Bringing death back into our lives
Why do we find it so hard to talk about death? Catherine Jackson previews Kicking the Bucket, a festival of living and dying that aims to get people talking about death

Stephen Jenkinson was once director of a children’s grief and palliative care programme and assistant professor at a prominent Canadian medical school, responsible for running a home-based palliative care programme. He gave up working in what he calls ‘the death trade’ when he felt he could no longer continue with what he came to consider a deception, ‘a shell game’ – malpractice even. ‘I thought I was there to help people die well. What I discovered was that nobody wanted help to die well because no one wanted to die. I was trying to help people who had no intention of dying at all.’


Jenkinson is among the line-up of speakers, celebrants, performers and workshop leaders taking part in the Kicking the Bucket festival of living and dying, which takes place 22 October to 13 November in and around Oxford. These days he farms, teaches and seeks to spread the word worldwide, not just about dying well but about what he sees as its necessary corollary, living well. ‘Life has to continue, but you don’t. Every culture worth a damn knows that,’ he says. ‘It’s the end of life that gives life a chance.’ But in Western cultures we’re no longer taught that. The frogs we dissect in biology class are dead but not us. Instead, he argues, we’re taught ‘death phobia’ – to be terrified of death.
‘I thought the context for working with dying people was the individual and the family. Period,’ Jenkinson says. ‘Then I realised that all of these people I was working with were on the receiving end of this dominant cultural understanding about what dying is. That was when my willingness to work at an individual level very quickly waned. I found it was actually malpractice to work with death phobia in dying people who had never in their lives had any training in how to die.’
Jenkinson will be speaking at a showing of Griefwalker, a documentary film about his work with dying people, his teaching sessions with doctors and nurses and his counselling sessions with families. His message is, ultimately, very simple; it comprises just two questions that he asks the dying people with whom he works, and we can all ask ourselves: ‘Can we agree that you are dying now? And if we can, what is this time for?’
It’s a message that runs through the festival programme, which is explicitly about living as well as dying, as its title makes explicit. The programme is kaleidoscopic: a New Orleans Jazz Band; death cafés; art, writing and song workshops and exhibitions; discussions on how to plan and prepare for death, from home funerals to living wills; films and performances about death, loss and grieving; activities for children and young people, and opportunities for meditative silence and simply sharing experience.
This is the second Kicking the Bucket festival; the first was in 2012. ‘We are doing it again because we still see a huge need for open, creative conversations about death and dying,’ says Festival Director Liz Rothschild. ‘There is definitely a gradual shift in our attitudes towards death but it is still hard to access useful, honest and inspiring material on the subject and opportunities to share the experience with strangers, friends and family members are still very rare.’ Rothschild, a director, actor, writer and celebrant, also manages the Westmill Woodland Burial Ground in Oxfordshire. Too often people, and their families and friends, are not prepared for death, she says. ‘My work as a celebrant and burial ground manager has made me realise that, by the time I meet people, it’s too late. It’s made me passionate about the idea of death education. There’s a silence around death. People are concerned about confronting it but when they do they tell me they feel relief, less alone, less frightened, and empowered to make decisions. Sometimes these conversations are had more easily with strangers, and that is something that the festival can facilitate.


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