Talking and listening
The following information aims to provide a detailed overview of the Specialist Palliative Counselling, Psychology and Bereavement Service at Barnsley Hospice, and greater depth of understanding about the Service and the potential benefit to clients. This information aims to define each of the three individual Services, Counselling, Bereavement and Clinical Psychology which are closely interlinked and can be grouped together under the heading of ‘Psychological Services’ within the Hospice. The report will illustrate how the Service currently complies with both local and national recommendations and guidance. Although not unique, the Counselling and Psychology Service at Barnsley Hospice is very different from similar Services both within this region and nationally who primarily provide Bereavement Counselling and Support Services. However the Counsellors and Psychologists at Barnsley Hospice can provide bereavement counselling for more complex referrals whilst also offering a separate Bereavement Support Service.
The Counselling and Psychology Service accepts referrals for people who have been diagnosed with cancer or a life limiting illness, and also their family and carers. Referrals are accepted from Specialist Palliative Professionals within Barnsley Hospice, Barnsley District General Hospital and also Community Macmillan Clinical Nurse Specialists and GPs. Self referrals are also accepted by contacting the Service direct (01226 323624) The NICE (National Institute for Health and Care Excellence) guidance for “Improving Supportive and Palliative Care for Adults with Cancer” recommends that “All health and social care professionals should be able to recognise psychological distress – They should know when they have reached the boundary of their competence and should refer the patient to a more specialist Service”
The NICE guidance also recommends that a “four-level model of professional psychological assessment and intervention should be developed and implemented and managed by a variety of psychological specialists…. including Counsellors and Psychologists… working across primary care, hospitals, hospices and the community to achieve this model of care ”.
|1||All health and Social Care Professionals||Recognition of psychological need||Effective information giving, compassionate communication and general psychological support|
|2||Health and social Care professionals with additional expertise||Screening for Psychological distress||Psychological techniques such as problem solving|
|3||Trained and accredited professionals||Assessed for psychological distress and diagnosis of some psychopathology||Counselling and specific psychological interventions such as anxiety management and solution focused therapy delivered according to an explicit theoretical framework|
|4||Mental Health Specialists||Diagnosis of psychopathology||Specialist psychological and psychiatric interventions such as psychotherapy including CBT|
It is important to note that within the Psychological Services at Barnsley Hospice, these principles also apply not just to adults with cancer, but also to adults with any life limiting illnesses. The Counsellors and Psychologists can provide couples counselling. This could be any variation of two people who are having difficulties within their relationship, including partners, parents, siblings, friends, arising from diagnosis of cancer or a life limiting illness. If the relationship difficulties are more long standing and complex the couple may be signposted to another organisation following assessment. The Psychologist can also facilitate family therapy, sometimes in collaboration with one of the Counsellors or the Specialist Palliative Care Social Worker. The Counsellors and Psychologists are available on a consultative basis for professionals who need information or reflective space to consider referrals. Support and ‘informal supervision’ and assistance can also be provided for professionals who are working with complex individuals who may have declined a referral, intervention or engagement with a Counsellor or Psychologist.
When referrals are received, clients are screened for urgency and appropriateness to the Service. For non-urgent referrals, our aim is to provide an initial assessment appointment within 20 working days Aviva’s recently published Health of the Nation (2013) report has highlighted that:- “85% of people surveyed are worried that having to wait for talking therapy could worsen any mental illness they have. BACP is a member of the We Need to Talk coalition, along with other organisations, which has called on the NHS in England to offer a full range of evidence-based psychological therapies to all who need them”
There are continuing reviews of our standard waiting times and a recognition that often patients, carers and family members have a resilience and emotional ability to meet their own psychological needs, and an intervention may not be needed urgently or at all. Anecdotally, there is a sense that people who are referred can benefit from transition time without a professional intervention and NICE guidance for palliative and supportive care comments that;- “The four tier model should be underpinned by a recognition that patients and carers can often assess their own emotional status and meet their own needs for support. They might choose support from family, friends or self-help and support groups”
It is also important to reiterate that the Psychological Service provided at Barnsley Hospice is not an emergency Service.
All the qualified Counsellors working within the team are members of the British Association of Counsellors and Psychotherapy (www.bacp.co.uk) and are accredited members or eligible to be accredited. All the Counsellors abide by the BACP ethical framework and have both regular external clinical supervision and internal peer supervision. Our Counsellors are committed to both professional and personal development and attend regular Continuing Professional Development (CPD) events It can often be a difficult question to answer when people ask “What is counselling?” or “How will it help me?”
The British Association of Counsellors and Psychotherapy have defined counselling as:- “Counselling and Psychotherapy are umbrella terms that cover a range of talking therapies. They are delivered by trained practitioners who work with people over a short or long term to help them bring about effective change or enhance their wellbeing.”
Within the Specialist Palliative Service at Barnsley all the Counsellors primarily work within an integrative model. This means the Counsellors have developed a way of working following initial training, and have acquired the experience to draw upon the relevant theories that may suit the Counsellor’s own preference, style and capability. The following theories constitute some of the main theoretical approaches that the Hospice Counsellors integrate and use to inform Practice. The list is not exhaustive and other theories may be considered and developed as appropriate. Counselling can be disseminated into three main schools of ideas, concepts and evidence based theories which include, Psychodynamic, Humanistic and Cognitive Behavioural Counselling. It is important to note that counselling skills are integral to any counselling role but not the defining element. Much of the recent counselling research has found that there is inconclusive evidence to support that one counselling model is more beneficial or superior to another. It is the quality of the ‘relationship’ that is often the key factor in the therapy which is understandably extremely difficult to quantify or fully comprehend. All the Counsellors at Barnsley Hospice have the ability to work at ‘relational depth’ and the narrative feedback within client satisfaction questionnaires highly supports this claim. Each Counsellor works within their own unique model of practice which is often hard to articulate, explain or sometimes justify when working within a primarily medical model.
The following information is quoted from the BACP and hopefully gives a brief insight into some of the theories and approaches currently used to inform Psychotherapeutic practice within the Counselling Service at Barnsley Hospice.
This is sometimes called individual psychology and uses the personality theory and system of counselling originated by Alfred Adler. Rather than psychoanalysis, Adler placed greater emphasis on infantile experiences of power and powerlessness and the goal-orientation of human behaviour. He created the terms “inferiority complex” and “superiority complex”.
This therapy is based on the belief that behaviour is learnt in response to past experience and can be unlearnt, or reconditioned, without analysing the past to find the reason for the behaviour. It works well for compulsive and obsessive behaviour, fears, phobias and addictions.
Brief Therapy (see also Solution Focused Brief Therapy)
This uses the Cognitive Behavioural approach with a small, planned number of sessions and possibly a single follow-up session after some time has elapsed.
Cognitive Analytical Therapy
This combines Cognitive Therapy with Psychotherapy and encourages clients to draw on their own resources to develop skills to change destructive patterns of behaviour. Negative ways of thinking are explored and treatment is structured and directive involving diary-keeping, progress charts etc.
Cognitive Behavioural Therapy
This combines cognitive and behavioural techniques. Clients are taught ways to change thoughts and expectations and relaxation techniques are used. It has been effective for stress-related ailments, phobias, obsessions, eating disorders and (at the same time as drug treatment) major depression.
This approach uses the power of the mind to influence behaviour. It is based on the theory that previous experiences can adversely affect self-perception and condition attitude, emotions and ability to deal with certain situations. It works by helping the client to identify, question and change self-denigrating thoughts, thus altering habitual responses and behaviour. It can help pessimistic or depressed people to view things from a more optimistic perspective.
Existentialists believe that life has no essential (given) meaning: any meaning has to be found or created. Existential counselling involves making sense of life through a personal world view and includes a willingness to face one’s life and life problems.
This is used to treat a family system rather than individual members of the family. A form of systemic therapy, it requires specifically trained Counsellors.
The name is derived from the German for “organised whole”. Developed by Fritz Perls, it is based on his belief that the human response to experiences is summed up in a person’s thoughts, feeling and actions. The client gains self-awareness by analysing behaviour and body language and giving expression to repressed feelings. Treatment often includes acting out scenarios and dream recall.
This embraces techniques coming from the “personal growth movement” and encourages people to explore their feelings and take responsibility for their thoughts and actions. Emphasis is on the self-development and achieving highest potential rather than dysfunctional behaviour. “Client-Centred” or “Non-Directive” approach is often used and the therapy can be described as “holistic”. The client’s creative instincts may be used to explore and resolve personal issues.
Carl Jung was the originator of Analytical Psychology; a disciple of Sigmund Freud and a pioneer of psychoanalysis.
Neuro-Linguistic Programming (NLP)
NLP combines cognitive behavioural and humanistic therapies with hypnotherapy. It works on the theory that life experiences, from birth onwards, programme the way a person sees the world. The practitioner helps the client to discover how he (or she) has learnt to think or feel so that he can take control of his actions. The client is taught how to change speech and body language in order to communicate better and bring about personal change.
Devised by Carl Rogers and also called “client centred” or “Rogerian” counselling, this is based on the assumption that an individual (client) seeking help in the resolution of a problem he or she is experiencing, can enter into a relationship with another individual (counsellor) who is sufficiently accepting and permissive to allow the client to freely express emotions and feelings. This will enable the client to come to terms with negative feelings, which may have caused emotional problems and develop inner resource. The objective is for the client to become able to perceive himself as a person, with power and freedom to change, rather than an object.
This is based on the work of Sigmund Freud, who believed that the unacceptable thoughts of early childhood are banished to the unconscious mind but continue to influence thoughts, emotions and behaviour. “Repressed” feelings can surface later as conflicts, depression etc or through dreams or creative activities. The analyst seeks to interpret and make acceptable to the client’s conscious mind, troublesome feelings and relationships from the past. “Transference” onto the analyst, of feelings about figures in the client’s life, is encouraged. This type of therapy is often used by clients suffering high levels of stress and can be a lengthy and intensive process.
This approach stresses the importance of the unconscious and past experience in determining current behaviour. The client is encouraged to talk about childhood relationships with parents and other significant people and the therapist focuses on the client/therapist relationship (the dynamics) and in particular on the transference. Transference is when the client projects onto the therapist feelings experienced in previous significant relationships. The psychodynamic approach is derived from psychoanalysis but usually provides a quicker solution to emotional problems.
Sometimes described as “psychology of the soul”, psychosynthesis aims to integrate or “synthesise” the level of consciousness at which thoughts and emotions are experienced, with a higher, spiritual level of consciousness. Painting, movement and other techniques can be used to recognise and value different facets of the personality. Psychosynthesis is useful for people seeking a new, more spiritually oriented vision of themselves.
Solution-Focused Brief Therapy
This promotes positive change rather than dwelling on past problems. Clients are encouraged to focus positively on what they do well and to set goals and work out how to achieve them. As little as 3 or 4 sessions may be beneficial.
These are therapies which have, as their aim, a change in the transactional pattern of members of the system. It can be used as the generic term for family therapy and marital therapy.
This describes any form of counselling or therapy which places emphasis on spirituality, human potential or heightened consciousness. It includes psychosynthesis.” www.bacp.co.uk
Clinical Psychology aims to provide specialist psychological assessment, formulation, intervention (including psychological therapy) and support of other professionals at Levels 3 and 4 of the NICE guidance. Work may involve direct or indirect assessment; intervention (which may include work with individuals, couples or families); consultation and/or supervision of health and social care professionals; and/or liaison with other Services who have worked with a client/ patient (particularly with mental health services). The Psychologist’s aim is to understand each client individually and develop formulations and/or interventions which draw on a range of psychological models and theoretical frameworks. Presenting difficulties and areas of work may include diagnosable disorders, organic and functional mental health problems, behavioural difficulties or issues around decision making and capacity. The Psychologists’ would also work with issues more specific to palliative care such as: adjustment to diagnosis, treatment, changing of roles (e.g. within the family), relationships, and issues which may occur within a context of other pre-existing or ongoing difficulties (particularly chronic mental health difficulties). The Psychologists’ are also able to provide cognitive assessment.
The Bereavement Support Service provides one to one support for any adults or children whose family or friends have died in the Hospice. Future plans to expand the Service to include both community and the Hospital are currently under review. Within the Hospice there is a capacity to provide bereavement groups for adults and children in the Barnsley area who are in need of bereavement support following the death of someone close to them who has died from cancer or a life limiting illness. The Service is provided by an experienced Family Support worker based at the Hospice and also volunteer Bereavement Support Workers who have received substantial training in grief and loss and who are committed to continuing professional and personal development.
Integrative and eclectic counselling and psychotherapy, (Palmer and Woolfe, 1999) Working at Relational Depth in Counselling and Psychotherapy (Mearns D, Cooper M, 2005) NICE guidance Improving Supportive and Palliative Care for Adults with Cancer (2004) Department of Health No Health without Mental Health (2012) BACP Ethical Framework for Good Practice in Counselling and Psychotherapy (2013) http://www.nhs.uk/Planners/end-of-life-care/Pages/your-wellbeing.aspx
How do I talk to those around me? http://www.dyingmatters.org/page/dying-matters-leaflets
There isn’t any universal advice on how to come to terms with a life-threatening illness. However, having a positive attitude towards the time the patient has left can help improve quality of life.
Each person will deal with their situation in their own way. Some people take on activities and challenges. Others prefer to spend their time quietly with family, friends or on their own. A terminal diagnosis is an overwhelming shock for most people and their families. Even if they are surrounded by people who care, it might be difficult to cope.
Organisations such as Macmillan Cancer Support, Marie Curie Cancer Care and other Cancer Charities have cancer helplines. Specialist Cancer Nurses provide information about cancer and its treatments with practical advice and support. This includes information on ‘making a will’, making choices, how to get financial support etc as well as information and support available for carers.
For more in depth and individualised support attending a counselling service might be beneficial. Any health professional can refer to this therapy and might even be able to recommend a suitable therapist/service in the local area.
Barnsley Hospice can offer treatments for physical symptoms, psychological and spiritual support and bereavement care. It also provides a wide range of other services, including Complementary Therapy, Beauty Therapy, Lymphoedema Service, Counselling, etc available to patient staying in the Hospice as inpatients or patients attending Outpatient appointments.
Hospital or community Specialist Palliative Care Teams
Fatigue is experience by 75-90% of patients with cancer or other chronic illnesses. Fatigue is usually not relieved by rest and can affect the person feeling physically, mentally and emotionally tired. It interferes with the ability to manage normal activities of daily living. To support the patient to better understand and manage fatigue a Fatigue Management Programme offered by a multidisciplinary team might be beneficial and provide appropriate education.
The programme usually tries to find the causes and effects of fatigue, provides the patient with self-monitoring and energy conserving tools as well as explores appropriate exercises with patients. With the help of motivational techniques, relaxation, nutritional advice etc the sleeping and settling pattern could be improved and some of the causes of fatigue reversed.
Complementary Therapy, Nutritional Advice, Counselling, Psychotherapy, Occupational Therapy, Physiotherapy or similarly holistic orientated therapies could be beneficial to help the patient to achieve above.
Hospital or community Specialist Palliative Care Teams
British Association for Counselling and Psychotherapy
The most important thing for patients with End of Life Care needs is that they get the care they need and their symptoms are well controlled. Regardless if the patient is staying at home, in a hospice, hospital, nursing or residential home. Whatever the best place of care might be support is offered to maintain patient’s independence and Quality of Life enabling participation in those activities of daily living, which is most important to the patient.
Normally a District Nurse or Occupational Therapist will assess the needs, organise the appropriate specialised equipment according to the physical changes and symptoms of the patient. Some of the equipment a patient with end of life care needs might need are a commode, bedpan, hoists, special mattresses or chairs, wheelchairs, stair rails or bath and shower equipment. Smaller gadgets e.g. special cutlery, two-handed-mug can be purchased by the patient and he will be advised accordingly.
Some organisations like the British Red Cross hire out equipment like commodes and wheelchairs. .
Equipment and Adaptations Team
Physical Disability Team
Hospital or community Specialist Palliative Care Teams
British Red Cross
Complementary Therapy uses an holistic approach acknowledging all patients’ needs – physical, mental, emotional, social and cultural. In End of Life care referral reasons to Complementary Therapy are often pain, stress and fatigue related. But other symptoms and conditions might also benefit and might be easier to manage with Complementary Therapy input e.g. Constipation, Insomnia, Anxiety, immobility, Depression, Nausea, etc. Complementary Therapist will work with the patient, but also with their families and carers as necessary and indicated.
Therapy techniques they may use included different massage techniques like Indian Head, Remedial and Soft Tissue Massage, Aromatherapy, Reflexology, Reiki and Beauty Therapy.
The treatments are always relaxing and pleasant to receive, which has an immediate benefit of improving patient’s comfort and reduction in symptoms.
Patients can be referred to Complementary Therapy Services by any Healthcare Professional and attend Outpatient appointments. Treatments can be accessed by private practitioners, ideally registered with a professional body, e.g. CNHC, Complementary and Natural Healthcare, CTHA Complementary Therapists Association, FHT Federation of Holistic Therapists, BCMA British Complementary Medicine Association or similar.
The Well – Complementary Therapy Centre