unempathic NHS mental health counsellor services

[missabc123]

Hi all, I have some long term mental health issues (10+ years) that are severely impacting on my life (all areas of). The issues are of a very personal nature and very difficult for me to talk about - and I have never been able to discuss with anyone to date, just locked them away inside driving myself nuts to the point of crisis.

I have tried NHS counselling a year or so ago and had 6 sessions of CBT / talking therapy with an intermediary mental health worker (you can get this in place of the longer term proper counselling as the waiting lists for that are so long!) which kind of helped but I didn't feel able to discuss root cause of what is bothering me. Probably because I had a young baby and was just going through a terrible time with his dad made it too difficult to get to the longer term issues on top. In addition to this although the lady was quite nice I never felt she was particularly empathic so could not open up fully.

Now my baby is two and the life situation slightly easier I am ready to discuss my real issues and have just gone for my mental health assessment. I have opened up to the mental health worker about the reasons but she seems professional but emotionally cold. This seems to be my issue to date with both the counsellors I have seen. As the issues are so personal and deep seated opening up to anyone is very hard. What I really want is some level of empathy and understanding yet when discussing the issues is done in a clinical manner it leaves me feeling worse about things and like I am a bother to them.

I do understand they have to maintain professional boundaries but I find the lack of warmth difficult to deal with. Particularly as I have been unable to discuss this to date. I feel that their professional distance somehow trivialises my issues and makes me less inclined to discuss.

I know that there can be issues with getting "close" to clients as a counsellor but I really do feel I need some level of empathy and recognition about what I have been through other than a clinical distanced approach from a therapist. What is the best way to achieve this? Is there any way to get this through an NHS Service?

I think it's just I have been "out in the cold" so long I need a warm approach to open up. This doesn't mean I want to be best mates with the counsellor but more that I just want recognition, and feedback on it, so I can process it. I'm also keen to properly move on, I am not wanting to have therapy forever, I just need to process this stuff that has been locked up so long driving me nuts, and get it done with in the right way.

I'm also aware that maybe them going too far into issues on an empathic level can somehow stick you further into them, by focussing on the issues more, but I think for my situation a little empathy would help.

At present the mental health worker is discussing my needs with the next level of therapists and there are three different options I may be given - 1) further sessions with her (up to 6) or 2) counselling - longer term -or 3) CBT - longer term. The longer term options may take several months to get availability but I am desperate for help now.

Does anyone have any feedback about the NHS mental health services process, if an empathic based service would help, if it is possible to get such a thing through the NHS or maybe I need to go private (not ideal for cash flow reasons but could consider if necessary). I would also welcome thoughts about why the NHS service maintain such a professional distance, if they can cater to individual needs a bit better (probably wishful thinking given their budgets!), and if anyone else has had a similar experience...

Many thanks :-)

[Seriouslyffs]

No advice.
I researched training as a counsellor and decided against it for many reasons, not least because every account of therapy seems to include that awkward 'stepping over a boundary' moment, so the calm uninvolved boundaries approach obviously does throw many problems.
I know work in a support role and have had some counselling/ advice/ listening training and tbh not having those rules has problems too! If you're uncertain about the options offered after assessment then I'd go with the CBT. It's not rocket science but it's effective and you're not going to be 'going deep' with someone whose empathy you doubt.

[wfrances]

hi miss
have you seen a psychiatrist got a diagnosis?

[missabc123]

thanks both - I will consider the CBT for sure if it's offered to me (doesn't sound like I have too much of a choice).

Wfrances - not seen a psychiatrist - all that's happened is seeing these mental health workers, they seem to be the gatekeepers to the further psychology / psychiatrists departments from what I can tell. I think the mental health workers think I have just got depression and anxiety issues, but it goes a lot deeper than that (at least i think it does). How do I get to get a psychiatrist diagnosis via NHS? Do i need one?

[wfrances]

i can only say how i got to see mine.
went to see gp ,who referred me for assessment.
assessment guy thought i needed to see a psychiatrist.
saw him 4 weeks later.
took 2 x 1 hr appointments with him for diagnosis.

i would have thought youd need a diagnosis before a treatment plan-

have you asked to see a psychiatrist? no harm in asking the assessment team if you havent.
i think a gp can diagnose depression and anxiety but if the treatments they provide dont work (or it could be something else) i think your supposed to see a specialist.

[BisleyBoy]

A similar thing happened for me. I went to gp, who referred me to mental health team. I was assessed by a really lovely psychiatric nurse who thought I needed to see a psychiatrist. The nurse so referred me for long term psychotherapy but after 3-4 months I still hadn't heard anything. The next time I went to see my psychiatrist, he filled out another referral form himself and I had a telephone assessment 2 weeks later. I'm going to start open-ended psychotherapy next month.
I think the fact that my psychiatrist referred me made a difference. Maybe ask to be referred to a psychiatrist?

[BisleyBoy]

So=also!

[BisleyBoy]

Tbh my experience so far has been that the psychiatrists are actually much nicer/empathic/understanding than the nurses/mental health workers (apart from the one I mentioned above-she was lovely) so you might have more luck with a psych. However, it may just be that it's just mone that is like that!

[BisleyBoy]

Mine!

[missabc123]

thanks so much everyone!! for the info; maybe I should try to see a psychiatrist - I won't hold out too much hope but fingers crossed they will let me!! I will certainly ask to see one.

I might pursue some private counselling as well if I can find someone suitable I click with....just need to get this sorted out.

If anyone has any feedback on the counselling procedure in general I would really appreciate it. Is it generally very "distanced" and a hard process to go through? I find it strange to think that people in need are treated in this clinical manner when surely for a lot of them something a bit friendlier might help them more. Maybe I need to look into alternative therapies... arg all so difficult.

[SandorClegane]

It depends what kind of counselling you get and also on the counsellor but to be honest, being empathic is a pretty essential quality for a counsellor from any approach I would have thought I wonder if the person you dealt with was maybe not a qualified counsellor but a health worker administering a standard cbt package of some sort?

A person centred counsellor might suit you better, you can find them through the BACP, it's a less structured approach than cbt and counsellor empathy is one of the basis of it.

www.itsgoodtotalk.org.uk/therapists

[missabc123]

thank you sandor - I think person centred is a good idea if it's empathic - I will definitely take a look and try to find someone local.

I think an all angles approach will work for me...I am going to try everything - CBT, person centred counselling, alternative therapies - you name it...I will try. Am so sick of being stuck in a rut. It's now or never.

I just hope I can find the right person to help me through it on the counselling side. :-)

[elementofsurprise]

I think the mental health workers think I have just got depression and anxiety issues, but it goes a lot deeper than that

They are fully aware that these are broad terms. Psychiatry is sort of 100yrs or so behind the rest of medicine - this is not a joke, the way they've mapped out diagnoses are so... inadequate and fairly clueless as to cause and effect. Part of this is the nature of MH probems and the desire to fit things into neat boxes that don't go. Psychiatrits can be the worst at this, due to their medical way of looking at it/preference for medication (it can be hard to see a psychiatrist if medication isn't indicated), and due to the the NHS recruitment problems for psychiatrists they have to go with what they can get. There's some gems out there though - just trying to fill in the bigger picture a bit.

Re. diagnosis... there is a murky area in diagnoses where those who struggle due to interpersonal trauma/prolonged stressful situations lurk. IMO it's not adequately captured by any existing diagnoses, though professionals realise it relates to most people they see. The closest diagnosis is the proposed "complex-PTSD" which is used by some profesionals but not others. Others with these kinds of issues get labelled BPD, depression, anxiety, PTSD (sometimes) and other things depending how they present. So you get the 'closest fit' of diagnosis, iyswim.

Also, the relatively recent rolling out of CBT, Mindfulness and counselling in primary care is focussed on 'coping' and techniques and things, rather than digging deep - although again, it depends, some (geographical) areas are better than others. It is apparently possible to get more in-depth therapy whist still in primary care but often seems to require referral to secondary MH services. These are now so overstretched it's more 'fire-fighting' so they're used to people with psychosis and severe risk etc. so can seem like they don't 'get' interpersonal/psychological stuff or don't seem to think it's important (sorry that's an awful way of puting it, not sure how else to!) My impression when I first approached services was how shockingly un-psychologically informed they seemed to be - very 'meds and cope with it' attitude. This is changing as younger staff take over and controlling dinosaurs leave

Sorry if that sounds a bit bleak, just trying to give a picture so you don't end up thinking it's you. Perhaps explain your concerns around 'deeper' issues and diagnosis to your mental health worker? That would hopefully help gauge what other therapies might be available?

I would suggest looking into private counselling/therapy too, if it is possible in any way, for the waiting lists as much as anything (can be up to 2 yrs for pychodynamic/other in-depth approaches on NHS, and they have a very precise criteria). There are places/individuals that offer concessions depending on income, I pay just unde £40 per session.

Good luck with it all, you sound like you have a pretty good idea of what you need which is a good start :)

[MaccaPaccaismyNemesis]

Some of the problem you describe stem from a desire to seek closeness with your counsellor, and possibly a confusion between sympathy and empathy. As a mental health worker you aim not to sympathise, but to enable a person to make sustainable and life enhancing changes. Cbt and other therapies are hard going, and require the patient to do a lot of work.

I hate to say it, but after seeing 10 patients a day, my own capacity for emotional engagement dwindled to the point where my personal life suffered. I left the NHS because the expectation of what I could give was so far beyond what could be given from anyone.

I wish you all the very best in your search for fulfilment. I had cbt and it changed my life. My therapist was able and good at his job, but his empathy and sympathy were not in question, my emotions and traumatic experiences were.

[missabc123]

many thanks element, a really helpful post which is enlightening!

I have been so shocked to date of the inadequacy of the MH services where I live, with extreme waiting lists for people who are desperate. Such a shame.

I definitely need some talking therapy and might well do the private route as you suggest, even if it costs something it's more important to move forward quickly right now.

Re. the "take the meds" thing - my MH worker did ask me about this in my assessment but it's not a path I want to go down - I don't see it as helping the problem in the long run - possibly more like making it worse - like a bandaid covering a wound that needs air. There's a time and a place for meds for some but for me, no thanks!!

I think the CBT stuff will have to go hand in hand with the counselling stuff on a parallel level. I am lucky that I can afford to get some private counselling, at least for the short to medium term.

All very useful, thanks so much.

[missabc123]

Many thanks for insights Macca, i do understand the burnout issues you might have experienced working for the NHS, and also how it might affect the capacity for engagement. I also am trying to appreciate the need for them to maintain a professional distance, especially bearing in mind their workload. It seems fairly clear that the MH services are vastly understaffed, underbudgeted or mismanaged or all of those things....which doesn't help the patient or the NHS employees.

And you are right that my own issues need questioning and turning on their head! So maybe the harder / colder route might help in that respect.

I still ideally would like something slightly warm though, be that a bit of empathy / sympathy / both combined! Not in bucketloads, but enough at the beginning just to allow some trust / understanding to develop rather than feeling alienated by the process. I appreciate this might be asking too much from the NHS services - and that maybe that's not what counselling is about. And possibly maybe what I want isn't what I need!! (which is kind of why I started this thread so I could get a bit more insight into the process!)....

All very helpful, thank you... :-)

[RonaldMcDonald]

Macca you were seeing 10 patients a day?
For therapy?

[mamadoc]

By empathic what do you mean exactly?

I am a psychiatrist. It is hard. I genuinely care about my patients and often feel moved to tears by what they tell me but it would be terribly unprofessional to show that. Any touch is limited to a handshake.

I say things that sound a bit cliched written down 'that must have been very hard for you'
But I would not say 'yes, he certainly was an abusive bastard' ie I would validate the persons feelings but not add in my judgement of the situation.
Sometimes people want back up, reassurance that they are 'right' to feel a particular way and I can't give that because in fact my opinion is not as important as the person's own.

The boundaries of therapy are that you do not have a relationship outside the session. You have sessions at the same time, in the same place and for an agreed duration and you try really hard not to cancel at short notice, give long notice of any holiday etc. it is supposed to feel very safe but professional, not like a friendship. If it becomes like a friendship and boundaries are crossed it can be damaging rather than helpful eg person becomes dependant on the therapist. I don't greet my patients if I see them in another context unless they initiate it.

Maybe that sounds cold but it is for the protection of both parties.

[MaccaPaccaismyNemesis]

Hi, I should have made it clearer- I wasn't a therapist but worked in Occupational Therapy- the goals I described are a common thread amongst mental health staff. But yes, I would regularly run 1:1 sessions, groups and social/recreational sessions without breaks, supervision, time to eat and a high stress environment. I can't really disclose more for confidentiality purposes but suffice to say it wasn't the most relaxed decade of my life.

[BisleyBoy]

I've found that the professionals that I've opened up to the most have been the ones who show emotion towards me. If I see that they're behind a wall of professionalism then I shut down and am less likely to tell them very much.
My psych is an open book and what he feels tends to show on his face and in his body languish, he can't help it I think. I can tell when he's pleased/happy, when he's frustrated, when he's embarrassed/nervous. When I was describing how I felt suicidal on my last visit, he was incredibly gentle with me. All this makes me see him as a person and less of a 'professional' (not that he's not professional too!) and that makes me feel comfortable with him and open up to him more.
I think you can be human and professional at the same time.

[stripytees]

The people you have seen were not counsellors or therapists. You would do best finding someone who has done a proper training and all the experiential and personal work involved in that i.e. had at least 3 or 4 years of personal therapy. That way they will be both appropriately boundaried and yet not afraid to show warmth. All this stuff about therapists needing to be distant or doing everything to make sure the patient doesn't become attached to them is nonsense.

Look for a psychodynamic counsellor or psychotherapist.

[BisleyBoy]

Stripey is right, the best therapists are the ones that have undergone their own therapy as part of their training. How can you help others if you don't know yourself?

[RonaldMcDonald]

Afaik all except cbt therapist must undergo personal therapy as a minimum in their training
Get an accredited counsellor from theBACP
Or a counselling psychologist

[stripytees]

Some courses, especially the person centred ones, only require 20 or 30 sessions of personal therapy as part of the training. That's not enough.

[Changeasgoodas]

Hi Missabs - Your insight about what you need emotionally from your therapist (I will use that word rather than counsellor so as not to confuse terms) to feel accepted/able to open up is pure gold for an experienced practitioner working in the right approach for you. Please hold on to that knowledge as it could be a real key from you.

Are you in England rather than Wales or Scotland? If you are in England you are probably being seen by an IAPT service? If you come back and say you are in England I can tell you some more about how you can navigate the system to try to get what is best for you.

As far as the suggestion to see a psychiatrist, who are in incredibly short supply on the NHS, you are highly, highly unlikely to get access to one unless you are displaying severe mental health problems and/or an imminent risk to self or others, and it may well not be necessary. If you want to go and pay for a private assessment it will cost you the equivalent of a course of therapy with a good private therapist. Of course, if there is any possibility that you are suffering from a severe problem that needs expert input on medication or to get access to a specialist service (such as adult autism spectrum disorders for instance), do fight for one

As to the confusion as to who or who has not had personal therapy among those working in the therapeutic field today. It is true that some courses across the approaches do not have a high barrier on this however, statistically, of the therapists you will meet working in the NHS, the most likely to have not had personal therapy is a CBT therapist. This is because one can enter the advanced CBT training that qualifies one to work in the NHS with backgrounds that do not demand personal therapy such as occ therapist, mental health nurse, social worker, clinical psychology and increasingly, psychological well-being practitioner (not that none of these people have been through personal therapy of course). Indeed, the current "high intensity" CBT diploma that is sponsored by the Dept of Health contains no obligatory personal development section other than stipulating that a therapist should not ask a patient to do what they have not done themselves when conducting a behavioural experiment (these experiments are integral to CBT practice). i.e. ask someone with OCD to put their hand down the toilet, someone with social anxiety to make themselves visible in a public place..you should have done this yourself. However, there is no obligation on the course to write up an account and reflection of how you experienced this so you can get away with not doing it.