his is a two part assignment looking at clients with a range of bereavement and mental issues, how person centred therapy could be used. It will also examine other theories and systems that are available to clients outside of the therapy room.
John is 42; 3 years ago he lost his partner of 15 years to cancer which had only recently been diagnosed. Since then he tells me that he has lost his job as a car mechanic and his house and has an increasing struggle with everyday tasks such as getting up in the morning and basic hygiene. Most days he feels worthless and has no place in the world anymore.
John recently went to see his G.P. about his situation, was assessed and prescribed anti-depressants by way of sertraline and was referred for counselling. After an initial assessment by the primary mental health team he was put on an 18 month long waiting list.
Two months after seeing his G.P. he had decided to seek counselling privately.
With so many losses in the last 3 years, his partner, job and house, it would be easy to make assumptions about how John has come to be where he is at this moment. It is important to allow the client to lead as ‘person-centred therapists take their direction from their clients’ (Wilkins 2010:257) and as with any client, to provide the core conditions of congruence, unconditional positive regard and empathy in a non directive way. John expressed how, after losing his partner, he has been unable to accept her loss at such a young age and how he feels his life has fallen apart since.
Knowledge of the specific theories surrounding any life experience, and in this case bereavement, is useful in the same way that knowledge of person centred theory harbours good person centred practice. Extra theory helps to change our awareness and is useful as it can help us understand how we feel about a subject. The change of awareness that this extra theory gives us is illustrated by Wilkins (2010) as he states ‘…this has less to do with how the client feels…and more to do with aiding therapists to deal with their own uncertainties.’
The knowledge of other theories surrounding this subject should not change how we are with any client as every client is an individual and the processes and experiences that have led to their way of being are unique to them. It is important during the therapeutic session not to dwell on this knowledge but to have it integrated into ourselves. It could be said that ‘theory influences how we see the world and, therefore, our way of being’ (Haugh 2011:15). Haugh (2011) also suggests that this extra theory can aid our understanding of what may be happening to the client and help us to stay in the room with them.
Currently in the U.K. there are 3 theories that draw a significant amount of attention. These are the ‘stage’ theory proposed by Elizabeth Kubler-Ross, the ‘phases’ by Colin Murray Parks and the ‘tasks’ of William Worden. Although these theories have an ‘order’ to them the authors of each has written that this order is not necessarily followed and there is often a toing and froing through the order, a revisiting of a stage that has been experienced already and the ability to be at more than one stage at any particular time with Parkes (1998) stating ‘the phases of grief should not be regarded as a rigid sequence that is passed through only once’. It should also be considered that not all bereaving clients will go through each stage or the stage may be so brief as to not be seen. That said; person centred therapy means that we should not expect the client to pass through and out the other side of any process but we stay with the client wherever they are at that time.
For John, it has been 3 years since the death of his partner. The fact that John has gone to his G.P. of his own accord after this time demonstrates some kind of recent movement or change. He has also made the effort to find counselling privately and not to simply wait for his NHS referral. Anti-depressant drugs such as sertraline are often used for ‘…combating the most deliberating effects of clinical depression [and often] take several weeks to have any demonstrable effect’ Kinsella and Kinsella (2006:58). This step to counselling has come around 2 months after starting his anti-depressant treatment and this could be a sign that they have had some positive affect.
John tells of how his loss has affected his life and his ability to function as a person. He describes his current situation as a direct consequence of his bereavement with the sense of anger being empathically felt. John understands that his partner is gone so the denial stage as described by Elizabeth Kubler-Ross (1969) as ‘a buffer after unexpected shocking news [that] allows the patient to collect himself and, with time, mobilize other, less radical defences’ has at this point most probably passed. Kubler-Ross (1969) says ‘when the first stage of denial cannot be maintained any longer, it is replaced by feelings of anger, rage, envy and resentment’. It could also be that John is in the depression stage of the Kubler-Ross theory. Having not had the support he needed immediately after the loss he has now lost motivation for life and as a consequence his job and his home.
In contrast to Kubler-Ross, William Worden in his four tasks of mourning may define John as continuing to experience the pain of the grief. This is said to be ‘…a period of intense despair [with] the survivor [withdrawing] his or her energy from daily life and [devoting] it to the contemplation of the loss’ (Thompson 2002:247).
Regardless of the 3 years that have passed the best way to offer unconditional positive regard is through empathy. Haugh (2011) describes this process by empathy as ‘expressed through empathically following responses, is the most uncontaminated way of expressing unconditional positive regard’.
Being congruent with ourselves by understanding our own beliefs will help us stay congruent with our client.
Haugh (2011) states of herself:
Congruence requires that I have awareness of my own losses and how they may be impacting on me. It requires that I am not closed to their dynamic within me and so not blocking my empathy.
The organismic approach of the person centred counsellor sees the client as open and developing. This includes all aspects be it past or present. We should never assume how a client may be feeling or how those feelings may be affecting them and have belief that the actualising tendency will prevail even through the times of severe anguish that grief can cause.
By creating a climate suitable for the client to express himself without fear of judgment positive change can occur.
Wilkins (2011) explains:
The client begins to feel safer and their self-concept begins to loosen because they do not protect those aspects of themselves that were previously met with conditional positive regard.
Another client, Paul, is 37. He has just left his partner after a relationship of 4 years. He had previously been in an unhappy marriage that lasted about the same time and he was divorced 6 years ago. He has been drinking alcohol, although he says not to excess, and is beginning to worry that he can’t cope anymore with work. Paul had become withdrawn and has been told by family members that they thought that he was just a bit down. Because of this he feels angry, alone and misunderstood. He says that he is tired and is weary to look at. He is rubbing his hands together anxiously. He says that at times he has had thoughts of killing himself as he feels that no one can love him or that he doesn’t know how to love someone properly.
His doctor, who he has had since he was a child, very recently prescribed clomipramine when Paul explained that he felt he was depressed. He did not tell his doctor of his suicidal feelings when he filled in a short, tick box sheet to describe how he was feeling. He has been assessed by the primary mental health team and is waiting for a further appointment. He has come to a person centred therapist after reading a magazine in the surgery waiting room.
As with all clients person centred therapy creates a safe environment for client issues to be explored using the core conditions of unconditional positive regard, empathy and congruence. The client has sought the therapist so it can be assumed that there is psychological contact. His family have left him feeling misunderstood and not openly accepted the severity of his feelings and at this early stage it will be vital for Paul to feel unconditional positive regard through empathic responses.
Paul has disclosed that he has had suicidal thoughts and this should be worked with as it comes up in order to assess the risk with regards to safe guarding the client and any confidentiality issues this may raise should it be necessary to disclose. According to Reeves and Seber (2010) ‘therapists need to be aware of the factors that might suggest their client is in a high-risk category’. They suggest that Paul’s age, gender, relationship status and mental health diagnoses are all high risk factors and should therefore be considered as a whole. With this in mind it may be necessary to access the risk as ‘expressing suicidal thoughts is generally in itself insufficient to justify breaking confidentiality’ (Reeves and Seber, 2010:03).
While counsellors are not in themselves qualified to make judgements about a client’s mental capacity they are expected to consider the clients right to autonomy and self determination. Risk itself can be assessed in many ways with Reeves and Seber (2010) suggesting that offering a simple 0 to 10 scale could be sufficient to understand the immediacy of risk. Some organisations have more scientific systems in place such as CORE or Client Outcomes in Routine Evaluation (CORE Systems Group, 1998).
Whether or not it is necessary to disclose information and break confidentiality will be down to each individual therapist ‘as there is no general duty to rescue in British Law’ (Bond and Mitchels, 2010:05). Should a therapist have strong views on suicide or self harm they should ‘make… information available in [their] pre-counselling information or… build in an appropriate agreement in the counselling contract’ (Bond and Mitchels, 2010:05). This is necessary in order to avoid any ethical or legal issues that could arise from disclosure.
Paul’s tiredness, anger towards his family, anxiety, low mood all suggest clinical depression and because of this Paul has been prescribed clomipramine which is a tricyclic anti-depressant. Side effects of this type of drug include ‘quite pronounced drowsiness…’ Kinsella and Kinsella (2006:59). This could be the cause of Paul’s weariness. As he has only been taking this medication for a short period they may not yet have taken full effect and that is why he continues to openly suffer from his other symptoms such as his anxiety. It is also important to note the fact that, unlike the newer selective serotonin reuptake inhibitors or SSRI’s, some types of tricyclic anti-depressant are ‘known to be dangerous in overdose’ Kinsella and Kinsella (2006:59) and therefore would not normally be prescribed to clients exhibiting suicidal thoughts.
When dealing with clients with depression NICE, National Institute for Health and Clinical Excellence, guidelines recommend a stepped care model (See appendix A). This framework organises the provision of services and is useful for practitioners, clients and carers to identify and access the most suitable interventions. ‘In stepped care the least intrusive, most effective intervention is provided first; if a person does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step’ (Nice, 2009:16). PCT, person centred therapy, is not the NICE therapy of choice. NICE (2009) seems to favour CBT, Cognitive Behavioural Therapy, as a first line of treatment for depression although other forms of treatment are available, including counselling at later stages should it be required.
The last couple of years have also seen the emergence of the IAPT or Improving Access to Psychological Therapies programme. This is part of a ‘cross-governmental mental health strategy… [that] outlines how the Government’s commitment to expanding access to psychological therapies will be achieved in the four years from April 2011’ (DoH, 2011:3). The aim which ‘is to develop talking therapies services that offer treatments for depression and anxiety disorders approved by the National Institute for Health and Clinical Excellence (NICE) across England by March 2015’ ((DoH, 2011:3). According to the DoH (2011) this should mean greater client choice and improved satisfaction for sufferers of depression and anxiety disorders.
As a conclusion it is easy to draw comparison with bereavement and depressive disorders. The various theories or loss and bereavement are similar in there structure to the processes involved with a depressive disorder in as much as there are yearnings, bargaining, despair and other such feelings and it is only at the point where the client finds some kind of acceptance with their situation that movement or recovery will occur. As a person centred counsellor it is my own faith in the actualising tendency and the belief that by providing the necessary and sufficient conditions that positive change will occur that makes me believe that person centred approach coupled with the ethical framework can be utilised with these types of psychological problems.