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 :-)

hi all, some interesting opinions here all of which seem valid...and are useful to me in my journey.

in terms of empathy I don't mean someone going "poor you..." and simpering but maybe more like Mamadoc says saying something like "I can see how that would be difficult for you" would help, at least at the beginning. When there's a complete absence of that kind of emoting and it's all cold, hard clinicalism it feels like you are being judged on your issues, and wasting their time as you have nothing to go on, no flicker of understanding.

Having said that my experience of the counselling process is minimal so maybe there is more value in the professional cold approach than I understand yet. I also think there's no "one size fits all" approach - e.g. one person might latch on to what they perceive as friendliness or warmth from the counsellor in an unhelpful way, whereas another person needs a bit to move on.

Stripytees I agree with this point "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." Patients need a level of warmth and human understanding even on a professional basis to give them trust enough to delve into issues that are hard. I think the vast majority of patients would not grasp onto this but appreciate it for its human value, and not expect the therapist to hold their hand or go to the pub for a beer etc.

Things like 'poor you' is sympathy and that isnt what therapy is about. Anyone can offer sympathy.
Empathy, however, is very different and I've seen it defined as being able to enter another persons inner world and to experience it as if it were your own. That can make all the difference, because you begin to see that someone else has at least an understanding of how you feel/felt.
Person-centred psychotherapy is heavily based on this, along with congruence and unconditional positive regard. Perhaps look up Carl Rogers and you can read more about it.

hi Bisley

Many thanks - you are bang on there, i need empathy (I don't want to receive a "poor you" in sympathy - I would find this really patronsing - hopefully I explained this in my post above, just some human understanding).

Changeasgoodas - I really appreciate this comprehensive reply - really valuable stuff. I'm based in England so any info on how I navigate would be really helpful. It's some sort of "wellbeing service" so am not sure if that is IAPT (presume so) - I think its run by the local PCT. Not sure if it's peculiar to this area.

I think me approaching my therapist and stating what I need will be a great start as at least they know the approach that I think would work with me (whether they give it to me that way is another matter).

Flying response as a bit crazy busy today but will come back to it all later!! :-)

I think your well-being service is probably a service run under IAPT - improving access to psychological therapies. It will be listed on this website if it is www.iapt.nhs.uk

Your mental health worker is probably a psychological wellbeing practitioner. These are people trained to coach you in helpful CBT methods. Only the minority of them have a full therapy training behind them and those that do can't actually use it fully within the confines of the job.

IAPT runs on what is called a Stepped Care method. In services that stick with the rules...You start with the "least burdensome intervention", which is considered to be this CBT coaching, it is Step 2. What the powers that be who put this system in place (I suspect they have never needed proper therapy) don't seem to understand is that seeing someone about simple tools when you need to work on something more complex is damn burdensome! Not that basic management isn't vital to be able to carry on and these workers do a great job for many, but in no way does one size fit all. I expect you are filling in questionnaires regularly. Your practitioner is working to extremely tough targets and must, at the beginning especially, fill in a structured assessment; they should be empathic though. If you qualify as "not recovered" after your Step 2 intervention (still scoring highly on your questionnaires) you should be stepped up to step 3. At this point most services offer CBT but should offer the range of therapies listed in this booklet www.iapt.nhs.uk/silo/files/which-talking-therapy-for-depression.pdf

Of these therapies - If you are wanting to look at the past and how it impacts on your relationships today, DIT would probably suit you best, your relationship with the therapist and how you experience them (as cold for instance) would form a part of the therapy. If you think that, at this stage, talking and understanding and processing your emotions is what you need, counselling would probably work best. To get a chance to access either of these you will need to be scoring probably around 15 or above on the PHQ-9 a the end of your step 2 treatment.

If the service in your area only offers CBT and CBT is not helping you, it would be good to point out to the commissioners, who are probably your local CCG group (this government got rid of PCTs in favour of GP led CCGs) that they are not offering choice and choice is being enshrined in new mental health bills. Change may not be forthcoming quick enough to help you though and private may be your best option.

changeasgoodas - wow, thank you for this amazingly helpful information. I'm pretty sure from what you have said it's the IAPT service I am in at the moment. I am filling in these questionnaires as you say (that I feel are an overly simplistic (and poorly worded) way of gaining a real understanding about somone's mental health - having said that I do appreciate budgets are low and time of the essence so this may be all that is possible!).

I think based on what you have said, counselling is the way forward for me. I hope I manage to get a referral for it. If I get the opportunity, what I might do is go for CBT via the NHS in addition to private counselling, running side by side for the next few months.

Thanks again, I will definitely come back to these posts as I move through the system and on my journey through counselling. Really, really helpful.

I've just read the link posted above about the different types of therapy and I'm a bit confused. Next month I'm going to be starting long-term psychoanalysis, but the link didn't say anything about that treatment being an option. Why did I get it then?

Bisley Analysis is not widely available on the NHS because the NHS is all about keeping costs down and long-term psychoanalysis is of course a lot more expensive than offering someone 10 sessions of CBT. You're very lucky to have been offered psychoanalysis.

Bisley - long term therapies are considered "step 4" and, as stripy says, access to them is extremely limited at the moment, there's been a lot of cuts to it. If someone "fails" primary care IAPT therapy or has a diagnosed disorder that affects attachments they can be referred to Step4 (as therapies of less than 3 months are contraindicated in this case due to short term attachments having the potential to harm). If you have entered the system straight to a psychiatrist they can refer straight to longterm if it exists in their area. It's good news that you have been offered this treatment.

You're welcome missabc (not abs :-) like I said before, the old dyslexia at play) Good luck, and would be great to hear how you get on. Do be aware though that it is not recommended to see two therapists concurrently so may be better to structure separately.

Because I've been referred for psychoanalysis, does that mean that they think I'm totally nuts then?

Because I've been referred for psychoanalysis, does that mean that they think I'm totally nuts then?
No. "Totally nuts" (to them) involves sectioning, secure units and high doses of medication.

You, on the other hand, have passed their mysterious selection process to receive treatment they keep hidden from the massess. They are likely to be viewing you as intelligent, articulate and insightful. Not messed up enough to need years of psychotherapy (then they don't want to start because of the funding), yet your issues recognised as serious enough for help.

tbh after the way I spoke to my psych I'm surprised they offered me anything at all.

Iawsin - yes, in a way. A therapeutic relationship is a relationship in a way, not a romantic one but a connection with another person. For some people, starting and ending connections with others can trigger really difficult emotions and it is beneficial for them to explore things in the security that, whatever the ups and downs of the relationship, the therapy will remain constant and consistent for more than a short period.

What I've said about IAPT services is not consistent across the country, some parts of the country have held on to non-IAPT services in some shape or form or offer even within IAPT, longer term "non IAPT endorsed" therapies but it seemed likely from what OP was saying that she is in an IAPT system.

Bisley - if you mean they think you are beyond help, like element said, not at all. It means probably that the psychiatrist judged that you have insight into your difficulties and good enough conditions to work on change. In general you should have received a letter following your assessment with a summary and recommendations that may include a diagnosis or provisional diagnosis.

change-what happened was that my psych got pissed off with the fact that I still had not heard anything from the referral for psychotherapy that the nurse had made who had initially assessed me when I was first referred to the cmht. He filled out another referral form himself with me there. Less than two weeks later I had a telephone assessment who said I was a good candidate for psychotherapy. She said it could take 6-12 months to hear anything. However, a month later I got a letter inviting me for an initial assessment. I had two meetings with the therapist and I was allowed to choose between seeing him once a week or a trainee twice a week. I chose the trainee. The second initial assessment was middle of this month and I will have my first session with the trainee next month. I was surprised at how quickly the process went as it was only about 2 months.

Agree there are other long-term non-IAPT services out there - I've had several years of very high-quality psychoanalytic therapy with a senior therapist within the NHS system, for which I will be eternally grateful.

BUt I think to access those kinds of services (where they exist at all, which is by no means everywhere) you need to be considered a good candidate as Change and Element say, AND have a GP and/or psychiatrist who are thoughtful, psychologically-minded, and have a good overview of how to work the system.

I would also agree with posters further down the thread that these kinds of analytic therapies might not always feel empathetic, if you are someone who is quite fragile or needs a lot of warmth and validation - you do need to have the ego strength to be able to cope with the emotions it stirs up.So good quality assessment is really important too.

Looks like you are in a well funded area Bisley so that's good news. Hope it all goes well for you.

No apparently my area is among one of the trusts that has seen some of the biggest funding cuts in the country.

I don't know what issues you are bringing into therapy but I wanted to share something of my own experience. I had six months of therapy in which I saw someone who seemed cold and uncaring.

I now see someone empathetic, warm and compassionate who reflects back to me - through tone of voice and facial expressions as well as words - empathy and understanding.

They are the same person. My therapist didn't change; I did. Some practitioners ARE cold and distant but sometimes those feelings have come in with us.

thanks Peppermint - appreciate what you are saying. I'm not used to the therapy process at all so maybe need time to acclimatise. It is also possibly due to self worth issues that I feel like this (in part or whole; too early to tell). Also this person isn't my therapist as such at this stage although I might see them again depending on what happens.

I just think that for the opening stages of any therapy or assessments a warmer and less clinical (yet still professional) approach would work better to put people at ease with the process. I didn't get that from the person I spoke to but it could be with time my opinion would change.

so I've been offered CBT; they felt this was most appropriate for me. I think it will help with some of the issues but I think I also need counselling too (I have not mentioned this to the service in the short phonecall I had with them).

I have to wait three weeks for an assessment then 2 months for the treatment to start! This feels like forever as even once I start it it will take some time for it to "kick in". I need help now.

I think maybe I should go for some short term counselling therapy in the meantime while waiting for CBT (I know someone said you're not meant to do two treatments concurrently) but I think a couple of months worth of counselling might help - does anyone think that might be too short or it would be difficult to cut off?

I'm also concerned about the nature of the issues being deeply held and very personal and that a CBT therapist wouldn't be trained in counselling or be able to listen to reasons I've locked this stuff away; more gloss over it with this CBT therapy? Anyone have any thoughts? I think the deeper issues need addressing too but having not had CBT I'm not sure what will happen there. I'm sure the CBT will be helpful but am still concerned it needs counterbalancing with talking therapy.

If anyone has any thoughts they would be welcomed.

Many thanks

Hmm CBT does not sound like what you are asking for.
CBT is primarily concerned with the here and now and making changes to current thinking patterns (although there would be some consideration of how these arose).
I am worried you will be disappointed.
On the other hand a lot of people have the idea that they need to talk a lot about past events and work through these but there's not much evidence that this really helps how they feel or function now and for some people it makes things worse.
You definitely can't have 2 therapies at the same time and NHS might use this to put you off if you mention you are having therapy privately.
As hard as it is I would probably wait and have the assessment. This does not commit you to going through with therapy and indeed they will not take you on if they think it will fail. They might refer you for something else instead or you might feel it is right after all.
I would say have the assessment and if it feels not right then consider private at that point.

I would say it is really important to get a therapist or counseller you 'gel' with. Otherwise it can't really get off the ground. Often on the NHS you don't have a choice.
I had private therapy last year and it was the best thing I have ever done, I chose the therapist, we worked together really well and I have now been 'undiagnosed' with my condition.
It cost me around £1000 (but could have been £600, I went for extra sessions) as it is a time limited therapy (16 or 24 sessions). It was cognitive analytic therapy if you are interested.
I think you get treated a bit better by private therapists sometimes as they recognise you're there through your own efforts, in the NHS you can have the attitude that you're lucky to get it for free (not always).
Also you will not have to go on waiting list.

If you can afford it, do it. Even if it means going without a holiday one year or something, it's well worth it to have a real holiday from all your issues.

hi Maggie

I'm looking for some private counselling at the moment - how did you choose your therapist - e.g. it's difficult to "try before you buy". And it's not often that friends can refer theirs over (also I'm not sure I would want to use the same therapist as a mate).

How did you find the right one for you? Was it just a case of calling to chat first?

My experience is that the cold types are not helpful. I saw a cold psychologist for about a year. I found out later they broke confidential relationship and told my dc school there was nothing physical going in with me and it was all mental health. I had a physical diagnosis and they knew as I was sent to a pain clinic course via them. I got further physical health conditions diagnosed and they wouldn't talk about it. They had me half convinced my symptoms were in my head as they thought. How I had the inner strength to get the physical diagnosis I will never know. I now have ptsd from what that psychologist and those they misinformed did to me and my dc who have like me real physical health conditions now diagnosed. She wrecked our health, ability to trust and their education. I wouldn't touch a cold professional with a barge pole and would advise others to give them a wide berth.

thanks everyone; your feedback is really useful. I think I definitely need counselling as well either before or after the CBT but am going to try it sooner rather than later if I can.

mamadoc - I take your point about how dipping too much into the past isn't always helpful but I've gone so long with everything inside I really feel I need to release it by talking it through at least for a few sessions. I'm not keen on staying stuck and talking it through forever though.

Maggie - if you could give info on finding the right counsellor you click with that would be great (as Blabba requested). I'm happy to pay for the right one. I will look into cognitive analytic therapy!

MyArks - sorry to hear about your experience - sounds awful. Sounds like you had a really awful therapist. I hope you are on the mend a bit now. I will take care to choose the right person for me.