Counselling

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COUNSELLING People in distress have always turned to others for support, advice, and other forms of help, traditionally family, friends, community members, doctors, or priests. In many non-Western cultures, traditional healers work with troubled ‘clients', incorporating many different methods of healing, including those more akin to Western ideas of counselling, as well as a variety of ritual healing methods. In Western countries, social changes over the past few decades have led to increased social mobility and reduced social cohesion. External sources of support are sought where previously family, neighbours, and community sufficed. At the same time there has been a shift away from the unquestioning acceptance of external authority towards a more egalitarian and collaborative relationship between helper and helped. These social changes have promoted the emergence and growth of counselling; in its turn, the growth of counselling and the spread of its underlying philosophies has promoted a new set of expectations, a new value system. Counselling as a profession and professional activity has emerged since the Second World War in economically advanced countries, initially within the voluntary sector. As the scope, acceptability, and provision of counselling have increased, its attractions as a career have been enhanced and training programmes in counselling have mushroomed in response to demand. Standards of practice, ethics, and accountability have been established through accrediting organizations. Spinelli indicated that in 1993, there were around 30 000 people earning their living from counselling in the United Kingdom, with a further 270 000 in the voluntary sector. The Department of Employment suggests that over 2.5 million people use counselling as a major component of their work. The continued growth in counselling results, in part, from increased emotional openness and readiness to seek psychological support, which is apparent now in many cultures. At its worst, however, counselling is purveyed indiscriminately as if a panacea for all human suffering. This devalues its purpose and potential benefits, and undermines the commitment and professionalism of trained counsellors. The rapid increase in counselling as an activity and profession, and as a treatment offered for a range of psychological difficulties, requires careful evaluation and attention to standards of training. Much of the counselling literature comments on the lack of specificity and control in studies, the diversity of patient groups who are offered counselling, and variation in the approaches offered. Counselling skills are integral to the practice of psychiatry, indeed for all the ‘helping professions', being basic ingredients of effective patient interviewing, essential for accurate history-taking and diagnosis, and central to the way in which psychiatry manages and helps patients. Counselling as a specific intervention is important in many areas of mental health practice, both in primary care and a

range of specialized settings. As therapeutic interventions, the different models of counselling interface with specific psychotherapies, leading to much debate and at times lack of clarity about the distinctions between counselling and psychotherapy. The aim of this chapter is to examine the place of counselling in mental health services; and to consider the modifications required for its effective application to psychiatric populations. We look at the definitions of counselling, and the role of counselling in medicine and psychiatry. The chapter goes on to define different models of counselling, and its applications to specific problems including common mental health problems, grief and adjustment, trauma, and relationship difficulties. We then consider counselling in different settings, including primary care, mental health settings, student counselling, and the workplace. The chapter concludes by looking at issues of training, quality, and standards, commenting on the need for the control of an ever-developing profession without loss of the growing availability of effective counselling services to those in need. Definition of counselling The term counselling is broadly used and defined, and arriving at a concise definition can be difficult. Fundamental problems include the lack of definition of the boundaries between counselling and psychotherapy, and the lack of clear indications of the methods used.There are many uses of the words ‘counselling' and ‘counsellor', and Feltham points out that neither the British Association of Counselling nor the American Counseling Association have either proprietary rights of the terms or even official definitions. At its broadest, counselling is conceptualized as a way of helping or assisting others to make their own adjustment and decisions in the face of life problems. The Oxford Modern English Dictionary offers the following definitions:
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counsel: advice, plan of action counselling: 1. the act or process of giving counsel; 2. the process of assisting and guiding clients, especially by a trained person on a professional basis, to resolve especially personal, social, or psychological problems and difficulties.

Burnard defines the process of counselling as ‘the means by which one person helps another to clarify his or her life situation and to decide further lines of action'. The term counselling embraces diverse functions, including information-giving, advice, guidance, and helping activities, which merge imperceptibly into specific psychological therapies. It is usual to differentiate counselling as a method of practice from counselling skills, the learned interpersonal techniques of helping which are

fundamental to good clinical practice. Most health professionals use counselling skills, but are not employed as counsellors and would not describe their work as counselling. For professional counsellors, counselling skills are central to their work. Nelson-Jones further distinguishes counselling as a special kind of helping relationship embodying counsellor qualities known as the ‘core conditions', counselling as a set of activities representing different theoretical viewpoints, and counselling as special area for providing services. He defines counselling, as opposed to psychotherapy or psychiatric treatments, in terms of differing client populations and settings. In addition, the area of counselling psychology, now developing in the United Kingdom in line with other parts of the world, is a broad-based specialty of applied psychology, aiming to foster the psychological development of the individual and help people develop more effective and fulfilled lives. Counselling psychology is based on the fundamental tenets of counselling, but in addition aims to integrate the application of psychological theory and research into its practice. Gelder et al. make a helpful distinction between counselling about risk and counselling to relieve distress. The former, exemplified by genetic counselling, involves the provision of information, an opportunity to reflect on the problem and different courses of action, and a collaborative approach to devising decisions or solutions. In the latter the ‘counsellor' listens, offers the patient an opportunity for emotional release, and again helps to mobilize adaptive ways of coping. Gelder et al. identify four features that are common to all forms of counselling: the relationship between client and counsellor, information-giving, emotional release, and examination of the patient's situation and potential solutions. Is counselling a method of treatment? If treatment implies a form of care, and embodies the attitude and behaviour of a professional helper towards the client or patient, the answer is yes. The philosophy of counselling is very different from the medical model conventions of psychiatry, however, in that the helper is not doing something to the patient so much as being with him or her while they make their own adjustment or decisions. Whether practised formally by a designated counsellor, or as counselling techniques integral to another clinician's practice, the counselling process is collaborative and patient-centred. Hershenson and Power identify a number of basic tenets that are fundamental to the counselling process, including the following.



Human behaviour is a function of the interaction between an individual and that individual's environment at a particular point in time. This perspective gives primacy to the person's subjective experience of their context, but recognizes their reciprocal influence in shaping their situation.



Human development naturally tends towards healthy growth. Mental health difficulties can be conceptualized as ‘problems in living', in contrast with the conventional medical model.



The counselling process derives from a collaborative relationship between counsellor and client, where both work to assist the client to cope with the problems of living for which help is sought.



Counselling involves identifying and mobilizing the client's relevant assets or strengths, identifying or developing needed skills in the client, and utilizing relevant resources in the client's environment.

This way of conceptualizing counselling fits readily with both social psychiatry and the psychobiological perspective of Adolf Meyer, which remains influential in British psychiatry. In our multicultural world, counselling has to be greatly aware of the cultural assumptions inherent in the counselling models and approaches used, and how these must be able to take into account the needs of people from different ethnic groups and cultures. Whilst counsellors are trained to work in a sensitive and skilled way with individuals seeking help, counsellors also need an understanding of the social and cultural structures within which these individuals operate. For example, what is defined as ‘problematic', the way individuals attempt to cope, what is acceptable to discuss with someone outside the social group, and the expression of psychological distress vary enormously between different ethnic groups. The challenge for counsellors is to be aware of the assumptions they bring to counselling, and how the individual client's make-up is shaped by cultural as well as individual psychological factors. Counselling in medicine and psychiatry Burnard begins his text on counselling skills for health professionals with the statement, ‘We are all counsellors'. He goes on to say: Anyone who works in one of the health professions and comes into regular contact with people who are distressed in any way, whether psychologically, physically, spiritually or practically, offers counselling help. Counselling is something familiar to everyone: there need be no mystique about it.

Nor should it be something that is reserved for a particular group of professionals who call themselves counsellors. We would argue that this statement, whilst enthusiastically promoting the role of counselling in good medical practice, is misleading in that it fails to distinguish between counselling skills and specialized counselling. Counselling skills are a learned extension to those interpersonal skills fundamental to interviewing and treating patients in all branches of medicine, but perhaps particularly in general medical practice and psychiatry. The skills of listening, summarizing, reflecting, and checking understanding enable the patient to feel understood. They are essential for engaging the patient and eliciting information, especially when the patient is afraid, in pain, or mistrustful; so these skills contribute to effective history taking, diagnosis, and general clinical management. The health worker's counselling skills may influence the patient's compliance, or ‘concordance' as the more collaborative approach to treatment planning is now termed, and thereby the outcome of a wide range of medical and even surgical treatments. Counselling as a specific planned intervention in psychiatry can be differentiated into two broad and overlapping categories, defined by aims into decision-making and treatment. It is evident that decision-making is an important ingredient in many forms of therapeutic counselling but, conversely, some forms of decision-oriented counselling (e.g. genetic counselling) embody no explicit therapeutic intention. More specifically therapeutic applications of counselling are employed in the management of a range of psychiatric conditions as an adjunct to other interventions including medication, as an integral component of a multimodal treatment method (e.g. crisis intervention), or as a specific treatment in its own right (e.g. for postnatal depression). Counselling has a close, complex, and often unclear relationship to psychotherapy, or more accurately the psychotherapies. There are several models of counselling, which are related both in underlying theory and in clinical practice to specific models of psychotherapy, for example psychodynamic counselling, cognitive–behavioural counselling, and interpersonal counselling. Critics might suggest that counselling is just a diluted form of psychotherapy, or psychotherapy practised at a more informal level, but this is erroneous. Counselling has its own history, philosophy, and rationale. While there is within each model an area of indistinct overlap, counselling and psychotherapy can and should be differentiated.

The choice for a particular patient of counselling or psychotherapy is determined by a number of factors, which should have more to do with the attributes and needs of the patient than the training, experience, and interests of the professional. Within the psychodynamic domain, for example, this choice may be determined by the degree of deprivation in the patient's early life, or the identified stage of developmental failure.The application of evidence-based treatments to specific problems requires careful matching between the patient's difficulties and known, effective treatments. As evaluation and research in counselling develops, more careful targeting of specific counselling approaches to specific problems will become more precise. Counselling methods and techniques The core conditions of counselling There is no unitary model of counselling, and there is no universal set of technical skills. Each model of counselling has its own theoretical base, rationale, and specific techniques. However, there are fundamental principles and non-specific technical factors common to all models of counselling and psychotherapy. Empirical research confirms that these core factors exert a powerful influence, and may account for the repeated finding that, for some clinical conditions, markedly different models of counselling and psychotherapy have equivalent therapeutic effects, the so-called ‘equivalence paradox'. The core conditions required of the counsellor are unconditional positive regard, expressed through genuineness, empathy, and non-possessive warmth, and congruence in the therapeutic relationship. Such core conditions owe much to the work of Rogers, and have been used and developed in many models of counselling. Whilst Rogers took the view that such core conditions are both necessary and sufficient for therapeutic change to occur, other models of counselling have defined such conditions as necessary but not in themselves sufficient for change to occur. However, the core conditions remain the bedrock upon which counselling is practised. The importance of the relationship between counsellor or therapist and client is widely recognized, and research has identified the great importance of the therapeutic relationship alongside therapeutic technique. The analysis by Horvarth and Symonds of 24 studies concerning the therapeutic relationship show that a strong relationship makes a positive contribution to the outcome of therapeutic intervention, regardless of the model used.

Models of counselling Specific models of counselling are usually differentiated by their theoretical base or traditions. The most relevant models for psychiatry are information-giving, reflective or client-centred, problemsolving, cognitive–behavioural, interpersonal, and psychodynamic counselling. Each of these will be described in turn. Information-giving Giving information is an important part of contemporary psychiatric practice. This reflects a more open and collaborative approach to treating patients, and the ethical requirement to provide patients and their carers with the material necessary for informed decision-making. For example, for patients with schizophrenia or alcohol misuse, the provision of information about the diagnosis, causes, and potential consequences of their condition is essential for mobilizing their motivation and compliance with treatment. Indeed information-giving is always crucial when communicating a diagnosis. Information-giving is also fundamental to counselling for risk, as in genetic counselling, and to any intervention in which the patient is helped to make decisions, for example crisis intervention. Psychoeducative methods have a place in most models of counselling and psychotherapy, but have specific importance in problem-solving and cognitive–behavioural counselling. However, information-giving involves more than just giving information. Wherever possible the patient's curiosity and enquiry about their condition is promoted, encouraging them to ask questions and, when appropriate, to find their own answers. The technique of guided learning is central to cognitive therapy and counselling, as will be described below. Sometimes the practitioner assists by providing information, but not so much in a didactic fashion as in response to the patient's questions, for patient and therapist are engaged in collaborative enquiry. There are many forms of information in psychiatry, for example, information about the genetic or neurochemical basis of an illness, or the actions and potential side-effects of a prescribed medication. A psychologist or counsellor may present a psychological model of a specific condition, such as the cognitive model of panic. Whatever the information imparted, good practice requires that the practitioner checks whether the patient has understood the information given and that its meaning is comprehended, for otherwise it will not be utilized. Information-giving is rarely the endpoint of an intervention, serving instead as the basis for decision-making or continuing therapeutic work.

Client-centred counselling Reflective or client-centred counselling originates from the work of Carl Rogers, whose emphasis on the recognition and empowerment of the help-seeker challenged the perceived authoritarianism of both the medical model and psychoanalysis. This model highlights respect for the person, and adopts the optimistic assumptions that each person has an inner potential for healthy development and achievement, or ‘self-actualization'. Rogers highlighted the importance of the ‘core conditions' of empathy, warmth, unconditional positive regard, and genuineness in human relationships, including the counselling relationship. Research has repeatedly confirmed that these non-specific factors are indeed fundamental to the change process in counselling and psychotherapy. Rogers' model of counselling is non-directive. The counsellor's task is to create the core relationship conditions in which the client's inner resources and potentials will be unlocked, leading to the spontaneous resolution of problems and developmental growth. The central features of client-centred counselling can be incorporated into other models with advantage, especially respect for the client and the other core conditions. While a non-directive and reflective approach has value, and may be useful for initial data-gathering and supportive work, caution must be applied to the use of Rogerian counselling in psychiatry. Severe resource constraints require practitioners to impose time limits on counselling, which therefore must be more focused and ‘active'. Furthermore, very disturbed or dysfunctional patients may be unable to access an inner potential for spontaneous change and growth, implicit within the client-centred model. There are some patients for whom a reflective non-directive approach may be harmful, for this may promote an overwhelming upsurge of avoided or forgotten recollections of traumatic experiences without providing methods for coping with them. As will be described below, victims of childhood sexual abuse or other destructive experiences may be retraumatized by unstructured reflective counselling. Problem-solving counselling Although problem-solving is integral to cognitive–behavioural therapy or counselling, it is considered separately here because it has been utilized and empirically validated as a specific treatment model, particularly for depression. The basic tenets of problem-solving have also been extended into the interpersonal domain, specifically with the development of ‘Interpersonal cognitive problem-solving therapy'. Egan,whose models have been influential in counselling training and practice, described his three-stage counselling approach as a problem-management model. Like Rogers, he assumes that people are essentially responsible and capable, and that they can resolve

their problems if they obtain the necessary ‘working knowledge'. The counsellor helps the client by establishing a collaborative relationship in which problem-solving is promoted in three stages: (i) problem clarification; (ii) setting goals; (iii) facilitating action. Problem-solving therapy was first described as a form of behavioural modification by D'Zurilla and Goldfried. Problem-solving therapy or counselling has developed into a collaborative and focused method, which involves several stages:
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identification and formulation of the patient's problem(s) setting clear and achievable goals generation of alternatives for coping selection and operationalization of a preferred solution evaluation of progress, with further problem-solving as necessary.

From a problem-solving perspective, depression results from the interaction between negative life events, current problems, and deficient problem-solving activities or coping. This model of depression is supported by empirical evidence. Furthermore, problem-solving therapy has been shown to be an effective treatment for depression. Research in the United Kingdom has demonstrated the effectiveness of brief problem-solving therapy or counselling as a treatment for emotional disorder and depression in the primary care setting. Catalan et al., in a randomized study of poor-prognosis emotional disorder, compared four sessions of problem-solving conducted by a psychiatrist with ‘treatment as usual' (pharmacological and/or psychological) given by the primary care physician. The patients selected had recent-onset depression, anxiety, or related symptoms, and were still unwell without treatment 4 weeks after presentation. Patients in the problem-solving group showed a significantly greater reduction in symptoms than those in the control group. This difference was maintained after 16 weeks, during which time the control-group patients had a significantly higher rate of consultation with their general practitioners. No patients dropped out of the index group, confirming that problem-solving was an acceptable treatment. A second study in the primary care setting showed that problem-solving therapy was an effective and feasible treatment for major depression. Depressed patients were randomly allocated to problemsolving therapy, amitriptyline plus standard clinical management, or drug placebo and standard clinical management. Each treatment was delivered in six sessions over 12 weeks, by either a

psychiatrist or a general practitioner. At the end of treatment significantly more patients in the problem-solving group had recovered than in the placebo group, but amitriptyline was not superior to placebo. However, there was no significant difference in recovery rates between the problem-solving and amitriptyline groups. Patients were satisfied with problem-solving therapy, and there was no difference in outcome between patients treated by the psychiatrist or the general practitioner. These studies confirm that problem-solving therapy or counselling is a feasible, acceptable, and effective treatment in the primary care setting for depression and other emotional disorders. It can be learned by general practitioners, but can also be offered by other trained professionals including counsellors. Cognitive–behavioural approaches The cognitive models of counselling propose, in brief, that the sense we make of the world depends on how we structure and perceive our experience; our feelings are related to our thoughts and behaviours; and therapy is aimed at changing the thought, belief, and behaviour elements of functioning. Cognitive approaches are highly structured, looking at specific problems and aiming to enable the client to learn skills to help them deal with present and future problems. Rational-emotive behaviour therapy, developed by Ellis,has traditionally been one of the most influential of the cognitive approaches in the counselling world. It is based on the view that our problems stem not from events themselves but from our irrational thinking about events. If the client holds strong convictions that life should be fair, comfortable, or painless, when it is not, then suffering can only result. The client will then be locked into responding in a dysfunctional manner to adverse life events. Rational-emotive behaviour therapy involves disputing such ‘irrational' thoughts and conducting experiments to discover new ways of behaving. The cognitive approaches to counselling have been introduced relatively recently to the counselling world, for a number of reasons as outlined by Wills and Sanders.The highly structured approach, focusing on techniques, rested uncomfortably with counsellors trained in client-centred approaches, and many reacted to its overtly behavioural roots. Furthermore, cognitive therapy was felt to pay insufficient attention to the therapeutic relationship and to the influence of past events on current problems. However, the last few years have seen a major change in the way cognitive therapy is being adopted within counselling, and a large proportion of counsellors integrate at least some of the approaches into their work.

The basic tenets of the cognitive–behavioural approach are the development of a collaborative relationship in which client and counsellor work together to understand and resolve problems. The counselling revolves around the development of a cognitive conceptualization or formulation of the problems, which determines the approaches and techniques used in counselling. The method is structured, generally but not always short term, and uses a variety of techniques developed in cognitive and other disciplines. The attraction of cognitive therapy to counsellors is increasing, with more overt focus placed on the therapeutic relationship, long-term approaches, and schema-focused work inherent in newer models. There is enormous scope for counsellors to adopt cognitive therapy in a more systematic and rigorous manner, particularly in light of the empirical evidence supporting its effectiveness and increasing demand for briefer interventions. Interpersonal counselling Interpersonal counselling is a modified version of interpersonal therapy, which has its own origins in the interpersonal psychology of Meyer and Stack-Sullivan, as described by Klerman et al.This perspective reasons that much human behaviour is influenced by the basic need for fulfilling mutual relationships. Abnormal mental functioning and behaviour is often associated with disturbances in relationships; therefore the major focus in interpersonal therapy is on the patient's current interpersonal relationships. Interpersonal therapy has been shown in successive research studies to be an effective treatment for depression, dysthymia, and bulimia nervosa. It is a collaborative, focused, and time-limited therapy usually involving between 10 and 20 sessions. In interpersonal counselling, the therapeutic focus is on the patient's current interpersonal relationships rather than the presenting symptoms. During the assessment phase links are established to a disturbance in one or more interpersonal domains: grief; interpersonal disputes; interpersonal role transitions; and interpersonal deficits. Particular attention is given to recent changes in the patient's domestic, work, and social relationships. Interpersonal counselling assumes that such events provide the interpersonal context in which the emotional and somatic problems associated with anxiety, distress, and depression occur. The patient's interpersonal problems are explored, including their expectations of specific relationships. In a problem-solving manner, alternative interpersonal strategies are identified, rehearsed between treatment sessions, and modified as necessary. Interpersonal counselling was developed in primary health care as a brief, and therefore feasible, psychosocial treatment to be undertaken by nurse practitioners for patients presenting with stress and distress, in whom there was no formal psychiatric disorder. It involved a maximum of six sessions, of

half an hour or less. In a randomized controlled study, interpersonal counselling was shown to produce significantly greater symptom relief than a ‘usual care' control condition, particularly in terms of more rapid reduction in symptoms, improved mood, and improved psychosocial functioning. Interestingly, interpersonal counselling led to the increased use of mental health facilities, but this was seen as a positive and adaptive outcome. Psychodynamic counselling Psychodynamic counselling draws from the theoretical traditions of psychoanalysis, but has limited resemblance to it in practice. Psychodynamic approaches accord significance to past experience, the continuing influence of which may be mediated by unconscious processes, and particularly to adverse experiences in relationships during early life. This is seen to influence attachment patterns, psychosocial development, and later psychological functioning. Unconscious processes derived from early experiences contribute to the generation and maintenance of abnormal psychological states. In psychodynamic counselling and psychotherapy, these unconscious processes may be identified through examination of transference and countertransference developments in the therapeutic relationship. The historical emphasis in psychoanalysis of unconscious conflict still has relevance for current practice, but psychodynamic counselling and psychotherapy has been greatly influenced by the contemporary perspectives of object relations and attachment theories. Both theories give prominence to the lasting interpersonal influence of earlier relationship experiences, as internal sources both of security or self-reliance and of repeating destructive relationship patterns. These theoretical positions fit readily with the interpersonal and person-centred traditions of counselling. Psychodynamic theory also emphasizes a developmental perspective, recognizing the successive tasks of psychosocial development associated both with individuation and the family life cycle. This perspective is highly relevant for mental health counselling, since psychiatric problems (most obviously adjustment disorders) often emerge at points of transition in individual or family development. The search for the personal meaning of the patient's problem or symptoms is central to psychodynamic counselling. The counsellor encourages patients to talk about their difficulties, but also to reflect on their spontaneous associations and their attitudes towards the counsellor as potential sources of information about the presenting problems. For example, the anxious patient who becomes

irritable towards the counsellor may be giving expression to unacknowledged angry feelings that conflict uncomfortably with her view of herself as gentle and tolerant. The patient may then be helped to recognize how her submissive and placatory traits originated in childhood in response to her mother's hostile and rejecting behaviour, as if to avoid her mother's anger while maintaining closeness to her. This interpersonal pattern, which is characteristic of anxious–insecure attachments, may have been evident in the patient's other relationships, as with the counsellor. Through discussion with the counsellor, the patient may come to see her anxiety as a product of the tension between her unacknowledged resentment of her mother and her self-protective compliance, and that this defensive strategy is now outdated and self-defeating. The relationship with the counsellor is potentially the source of a ‘corrective emotional experience', particularly if the counsellor's attentiveness to, and non-judgemental acceptance of, the client offsets an earlier formative experience of humiliation and rejection. The generation of insight, as illustrated in the above example, may be sufficient to enable patients spontaneously to bring about the required changes in their lives. Psychodynamic counselling may also incorporate an element of problem-solving and behavioural experimentation to assist with the identification and rehearsal of new and more adaptive interpersonal strategies. The use of different strategies may not be possible if counselling is very brief, but may not be necessary if the patient has the psychological-mindedness and motivation to experiment independently with new strategies. Crisis counselling Crisis counselling is an eclectic treatment approach for patients presenting in psychological crisis. It is a short active intervention that draws on a range of different treatment models, including problemsolving, with the aim of mobilizing the patients own coping resources. In psychological terms, crisis is the response of an individual, family, or other group to challenges (stressors) that threaten or overwhelm usual coping resources. Crisis embodies both danger and opportunity, for successful resolution of crises promotes coping resources and psychological growth. Thus the successful resolution of crises may be both important in developmental terms and also in the prevention of psychiatric disorders. The inability to cope with critical challenges, however, may lead to adjustment disorder or other stress-induced psychiatric states. Post-traumatic disorders, for example, result from exposure to certain extremely stressful (traumatizing) experiences.

The stressors that generate crisis may be divided into developmental or accidental. The former are associated with those transitional phases of psychosocial development characterizing the lifecycle, such as adolescence, leaving home, childbirth, and retirement. ‘Accidental' stressors are those associated with unexpected or non-developmental life events such as injury, bereavement, relationship breakdown, or redundancy. The coincidence of accidental and developmental stressors is a particularly potent trigger for crisis. All crises involve actual or threatened loss. Certain factors may render people vulnerable to such stressors, including previous unresolved loss, social isolation, and cultural alienation. Conversely, secure early attachment, family and social support, and previous success in coping with adversity, confers some protection against the challenge of crisis. Crisis is not a pathological state, though its outcome might be. Psychiatric illness may be precipitated in those who are predisposed by constitution, previous adversity, or social isolation. Crisis might present in one person, or in a family, group (e.g. a social group or work team), or even a community (e.g. following a murder). Crisis represents challenge, but it also presents an opportunity for resolving old maladaptive coping patterns and for psychological growth in the individual, family, or social network. Crisis counselling is an active, focused, and short-term intervention, usually involving no more than a few sessions in the days and weeks after the onset of crisis. It is indicated for those who, though in danger of decompensating, have identifiable coping resources (ego strengths), family or other social support, and a history of adaptive functioning. Early intervention is important in order to avert the psychiatric symptoms and maladaptive patterns of coping (e.g. excessive alcohol consumption, selfharm) that are characteristic of adjustment disorders, or frank psychiatric breakdown. It may be practised as an adjunct to physical methods of treatment. Crisis intervention embraces a spectrum of approaches, from emergency inpatient psychiatric treatment to crisis counselling in the patient's own home. The task in crisis counselling is to help the patient redefine the challenge and to mobilize resources for its resolution. The therapeutic relationship offers security for this task, particularly for patients who are isolated. The help of family and friends is enlisted whenever possible. Psychodynamic exploration may be helpful in assessing the nature of the crisis, but the techniques of cognitive appraisal and problem-solving are more relevant for overcoming it. The first step in crisis counselling is assessment, and wherever possible this will involve the patient's family or other social network, including friends or neighbours. Ideally, in keeping with the

collaborative principles of crisis counselling, the patient and the social network participate actively in the assessment process. This addresses the nature of the stressor, the nature and severity of the patient's initial response, an assessment of risk, and his or her available coping resources including external supports. Relevant historical data are taken into account, to elucidate both previous coping resources and specific vulnerability factors. Psychodynamic processes may be highlighted, for example when maladaptive reactions to earlier crises obstruct resolution of the current problem. A shared formulation of the crisis is then agreed, forming the basis for a redefinition of the problem. Patient and counsellor work together to identify the aims of counselling, who from within the social network will participate in it, and the methods by which resolution may be achieved. Problemsolving, cognitive, and interpersonal methods may be employed in an eclectic fashion within an individualized programme. Appropriate emotional expression is encouraged, but maladaptive responses are gently discouraged. Active cognitive appraisal of the crisis permits mobilization of the personal and social resources necessary for its resolution. The counsellor encourages rehearsal of new coping strategies, first within the security of the counselling relationship where possible, then in the patient's real-life context. Except in the briefest crisis counselling, attention is paid to the significance for the patient of ending. This permits examination of those issues of loss inherent to most crises. Crisis counselling is an important component of community mental health provision. It may be provided at self-referral counselling centres, operated by psychiatric services or voluntary agencies. Its relevance has again been recognized as resource constraints have led to increased pressure for alternatives to hospital admission. Application of counselling to specific conditions When should counselling be offered, rather than specific psychotherapies, psychological treatments, medication, or psychiatric management? Unfortunately, such a question is very difficult to answer.Whilst there is high-quality outcome research linking specific therapies (e.g. cognitive therapy) to specific conditions such as depression, anxiety, and obsessive–compulsive disorder, the research for counselling models is much less clear. Depending on the settings in which they work, counsellors need to be equipped to work with clients with a range of psychological difficulties. For example, the primary care counsellor's caseload is likely to include client difficulties ranging from mild to moderate anxiety or depression to bereavement and relationship problems. However, there are some psychological difficulties for which counselling may be a more effective intervention:

stress-induced disorders, including adjustment disorder, grief, and trauma, postnatal depression, and relationship difficulties. Stress-induced disorders Counselling has an important role in helping people to adapt to stressful life changes, and may play a part in the treatment of those in whom stress-related psychiatric problems have emerged. In the latter case, counselling may be offered in conjunction with medication. Specific psychological therapies may be required, however, for patients in whom severe psychiatric problems have developed. The place of counselling in the management of a number of stress-induced disorders is considered in this section. Counselling for adjustment disorder Adjustment disorders arise when people experience serious difficulty in adapting to significant life changes (‘life events'), including normal transitions such as leaving home, migration, adverse interpersonal experiences (e.g. relationship breakdown or bereavement), and unexpected losses such as redundancy. Specific individual vulnerability can play a part in a person's reaction to life changes. Risk factors may include previous loss or other adversity, social or cultural isolation, and concurrent stressors such as economic deprivation or physical illness. The treatment of adjustment disorders incorporates the principles of crisis counselling. The counselling relationship is an important source of security when so much has changed in the patient's life. The patient is helped to identify the stressors, to explore the personal significance of the changes experienced, and to express the emotions so generated. Problem-solving methods are used to identify adaptive goals and strategies for their achievement; and maladaptive solutions are actively discouraged. The aim is for the patient to resolve the crisis themselves. Psychodynamic principles have a place in counselling for adjustment disorders, particularly when past adversities or interpersonal conflicts have rendered the patient vulnerable to the present life challenge. Indeed, it may be necessary to examine unresolved past experiences in order to tackle the present problems successfully. For example, a patient may not begin to come to terms with redundancy until he recognizes and addresses his unresolved feelings about being abandoned by a

parent in childhood. Or again, as will be developed below, a patient with a pathological grief reaction may not recover until they acknowledge the ambivalence felt towards the deceased. Grief counselling Grief is not a pathological state in itself, and most people grieve effectively with the support of family, friends, and perhaps community figures in the form of a priest or family doctor. Counselling has a role in facilitating grief for the minority of bereaved persons who are at risk. These may include people whose loss is sudden or traumatic, who are isolated, or who are unsure of the normality of their symptoms. When complications of grieving occur, however, specific psychological therapies may be required. Parkes showed that counselling can reduce the risk level of ‘high-risk' widows to that of a ‘low-risk' group. Relf found that support by hospice volunteers of high-risk bereaved relatives substantially reduced their levels of anxiety and need for medical care. Worden identified four tasks of mourning: to accept the reality of the loss; to acknowledge the pain of grief; to adjust to an environment in which the deceased is missing; and to internalize the deceased in order to move on with life. If each of these psychological tasks is not achieved spontaneously within a reasonable time, problems of grieving may ensue. Counselling has a place in facilitating the natural process and progress of grieving, and might involve more than one person in a bereaved family or other grouping, for example the college friends of a student killed in an accident. The principles of grief counselling are described in detail by Worden, but include the following. Most fundamental is helping the bereaved person to talk about the deceased, and the circumstances of the death, and thereby to express the normal emotions triggered by the loss, including sadness, anger, and guilt. If involved at a very early stage, the counsellor may help the bereaved to view the deceased's body, if they have not already done so, and this requires a period of decision-oriented work. In similar fashion, the bereaved may be encouraged to participate in those other rituals that facilitate normal mourning, such as the funeral or commemoration service, visiting the grave or place of death, or erecting a memorial. The counsellor may encourage the bereaved to arrange all necessary practical supports (e.g. child care), particularly when needed to allow time for mourning. Encouraging the bereaved to sort out the deceased's belongings at the appropriate time promotes the grieving process.

Psychoeducative work is another important component of grief counselling: information about the normal features and course of grieving may be very reassuring, particularly when the client is frightened by the perceptual abnormalities that are normal aspects of grief. In contrast, psychodynamic work may be required if past issues are reactivated by the death, or if ambivalence towards the deceased obstructs mourning. The counsellor can also play an important role in encouraging the maintenance or re-establishment of social contacts. In due course, it may be necessary to help the bereaved to accept their loss and move on to new relationships. Grief counselling is modified for particular populations, for example couples who have suffered a stillbirth, those who are traumatically bereaved, or the survivors of an accident in which a loved one died. For those at high risk it also permits the early identification and response to signs of pathology, such as clinical depression or delusional states. This may lead to referral for medication or psychotherapy. In health settings grief counselling is undertaken by trained professionals or volunteers, and in the community by self-help voluntary agencies such as Cruse (in the United Kingdom). Voluntary agencies are often staffed by people who have themselves experienced bereavement, and group counselling in this context affords valuable opportunities for acceptance, sharing of experience, and the hope borne out of talking with others who have already come to terms with their loss. Counselling for recent and past trauma Just as counselling has an important role in promoting normal grieving, particularly in those at high risk of complications, so it may help those who are at risk of developing post-traumatic illness following exposure to highly destructive experiences. More controversial is the value of counselling as a treatment for post-traumatic stress disorder or those psychiatric problems which follow traumatizing experiences in childhood, including sexual abuse. Prevention of psychiatric disorder The increasing interest in post-traumatic disorders over recent years, and the growing evidence for their high prevalence, has led to the evaluation of psychological interventions designed to prevent the onset of psychiatric disorders in those exposed to potentially traumatizing events. There is no evidence for the effectiveness of active single-session ‘debriefing' interventions for individuals, and little evidence for the preventive effectiveness of group interventions. There is no evidence that non-

directive counselling is effective in treating acute stress disorder, which itself constitutes a risk factor for post-traumatic stress disorder. In a randomized controlled comparison of cognitive– behavioural therapy and ‘supportive' counselling for acute stress disorder, the former was superior to counselling in reducing all symptoms except anxiety, for which both were equal. Short individualized preventive interventions in the style of crisis counselling may be most effective. The rationale for early counselling is that it might help the trauma victim face, and come to terms with, their ordeal without maladaptive outcomes such as substance misuse or social withdrawal. In addition, it might limit the destructive interpersonal impact of common emotional reactions such as anger, blame, guilt, and shame. Treatment of post-traumatic disorders As for the role of counselling in the treatment of acute stress disorder, there is no evidence that nondirective or reflective counselling is effective in the treatment of post-traumatic stress disorder. Indeed, there is substantial anecdotal evidence to suggest that reflective counselling may be destructive in this disorder, apparently because patients are ‘retraumatized' by those memories of the traumatic experience that are inevitably recalled, dwelt on, but not actively ‘processed' in this form of work. The advocates of counselling for post-traumatic stress disorder describe active focused methods such as cognitive–behavioural counselling.Such methods need to be used within the context of a sound therapeutic relationship, meeting the core counselling conditions. Given that many clients with posttraumatic stress disorder are, understandably, mistrustful or avoidant, it is likely that, without such core conditions being met, engagement in counselling and commitment to a desensitization approach would be difficult. The same arguments apply in relation to the counselling of adults who were sexually abused in childhood who present with a wide range of psychiatric problems, and where shame, guilt, and mistrust are common. Women and men who were abused in childhood may value the empathic skills of counsellors, but again there is anecdotal evidence to suggest that a non-directive and reflective approach can retraumatize patients. Unstructured counselling may promote recollection of the abusive experiences, but without providing an opportunity for emotional and co gnitive ‘processing' of the traumatic experience. Sometimes this can activate powerful intrusive imagery, including flashbacks. There may also be a risk of promoting the unconscious elaboration or distortion of recalled memories in a manner that supports the vexed notion of ‘false' memories. The clarity of

thinking required in this fraught clinical field is not assisted by texts that advocate counselling without qualification. The treatment of sexual abuse survivors requires active therapeutic techniques in conjunction with a secure therapeutic relationship. Cognitive, behavioural, and psychodynamic methods have a place for different patients, as do group, couple, and family interventions. Where counselling skills are required most conspicuously is when the patient needs help in making decisions in relation to their abusive experience, but this would often be in the context of active treatment. For example, the patient may be thinking about confronting their abuser, initiating legal action against them, or warning others that they could abuse again. Here the counsellor or therapist will need to work carefully within the parameters of decision-oriented counselling, neither directly advising the patient nor shrinking from the task presented. This is a difficult area from an ethical standpoint, most particularly when the therapist believes that others might be at risk. Postnatal depression Postnatal depression is one of the few psychiatric disorders for which counselling has been shown scientifically to be an effective treatment. In view of the strong evidence for social and psychological factors in the aetiology of postnatal depression, there is a compelling rationale for counselling. Although postnatal depression is mild and remits spontaneously in many cases, effective treatment is important because of its adverse effect on the emotional and cognitive development of the child. At 18 months of age, the children (especially boys) of mothers with postnatal depression perform less well on cognitive tasks, display poorer emotional adjustment, and are more likely to be insecurely attached than the children of non-depressed mothers. These problems are still evident at 4 to 5 years of age, particularly in socio-economically disadvantaged families, and are associated with increased rates of behavioural disturbance. There is evidence that these associations are mediated by the impaired pattern of relationship and communication between mother and infant resulting from depression in the former. For this reason, psychological interventions involving both mother and baby are of particular interest. In a study of infants with a range of behavioural disorders (e.g. sleeping, eating, fears), Cramer compared a psychodynamic approach with a psychoeducational intervention. Cramer's ‘brief mother– baby psychotherapy' is a psychodynamic treatment that focuses on the mother's perceptions of her

infant and their relationship, both of which are influenced unconsciously by internal representations of her childhood experience with her own mother. The mother is encouraged to examine the ways in which she re-enacts unconscious themes from her past in the relationship with her own infant. As the mother's perceptions of her infant became more positive, her subjective state and self-esteem were improved, and sleep disturbance and distress in the infant were reduced. The psychoeducative ‘interactional guidance' engaged the mother in an examination of video-recordings of her play with the infant, aiming to encourage more responsive interaction. The mean duration of both treatments was six to seven 1-hour sessions, and both were found to be promising; however, effectiveness has not been confirmed by randomized controlled trial. Neither of these interventions were described as counselling, but it is likely that both could be undertaken within a counselling framework. Psychological treatment is as effective as antidepressant medication in the treatment of postnatal depression, and better accepted. A controlled factorial study compared fluoxetine or placebo in combination with either one or six sessions of cognitive–behavioural counselling. This demonstrated that both treatments had a powerful and equal antidepressant effect, but that there was no additive effect. Fewer than half of the 188 women invited to take part in the study agreed to do so, and the most common reason for refusal was their reluctance to take medication. This is hardly surprising in the puerperium. It is evident that psychological methods are the treatments of choice for postnatal depression, but they must be feasible in practice and effective. There have been three studies reported of effective home-based counselling for postnatal depression. The earliest was a randomized controlled trial in the United Kingdom of eight once-weekly sessions of non-directive counselling undertaken by experienced health visitors. After 3 months, more women in the counselled group had recovered than in the control group. In a similar study in Sweden, women were randomly allocated either to a study group which received six, once-weekly counselling visits by a child health-clinic nurse or a control group which received routine primary health care. Again, more counselled women recovered fully from depression than controls. In the third study, again from the United Kingdom, consecutive women who delivered babies at a maternity hospital were screened for depression over a prolonged period, during which local health visitors received training in basic counselling and cognitive–behavioural skills. Women diagnosed as depressed in the ‘pretraining' period, who received routine primary health care, served as a control group. Those diagnosed after the training programme received up to eight home visits from a health

visitor, who used counselling and simple cognitive techniques (e.g. problem-solving) to help the mothers explore their feelings and cope with practical problems, including problems with their babies. The counselled women experienced a significantly greater reduction in depression over the following 8 weeks than did the controls, and a significantly greater reduction in reported problems in their relationships with their babies. At 18 months, significantly fewer child behaviour problems were reported by the mothers who had received the counselling intervention. These findings are important both for the treatment of postnatally depressed mothers and for the healthy psychological development of their babies. These findings suggest that depressed mothers benefit from an opportunity to talk about their concerns, not all of which necessarily focus on their baby, with a receptive and non-judgemental professional person. The possibility that the other technical aspects of counselling for postnatal depression which were incorporated into the above studies, i.e. psychodynamic and cognitive– behavioural methods, may augment the effectiveness of counselling has not yet been satisfactorily evaluated. Counselling settings Counselling takes place in a large number of settings relevant to psychiatry. These include primary health care, general hospital settings, student counselling services, and workplace counselling services. These settings will be described below, aiming to discuss the ways in which counselling may be best adapted to the individual settings, with indications of outcome data on effectiveness. Counselling in primary care One of the most conspicuous areas of growth in counselling has been within the primary health care setting, perhaps following Balint's seminal work with general practitioners 40 years ago. The upsurge in the demand for counselling in primary care has been stimulated by greater demands for the nondrug treatment of emotional disorders, and by continuing debate about the most effective way of managing emotional difficulties and mental health problems in primary care. In the United Kingdom National Health Service, for example, more than one-third of general practices employ counsellors from a variety of disciplines and offering a range of counselling models. A survey of general practitioners in England and Wales found that 31 per cent had ‘counsellors', including community psychiatric nurses, clinical and counselling psychologists, and practice counsellors. Community psychiatric nurses were more likely to see patients with moderate to severe mental illness and

psychoses; patients with psychosexual disorders, eating disorders, phobias or obsessive–compulsive disorder were referred to psychologists; bereaved patients were most likely to be referred to practice counsellors.In a more recent survey, 39 per cent of practices were found to employ counsellors, mainly offering short-term counselling for relationship problems, depression, anxiety, and bereavement. The data on the development of primary care counselling in the United Kingdom is no doubt part of a wider international trend towards more accessible counselling services at the primary care level. Counsellors in primary care are a widely diverse group, in the patients that they see, the counselling models used, and the length of counselling offered. Those identified as primary care counsellors include practice nurses trained in counselling skills, clinical and counselling psychologists, community psychiatric nurses, and qualified counsellors. The main models used include clientcentred counselling, brief solution-focused models, and cognitive counselling. All have various degrees of effectiveness and are applicable to different presenting problems. Counsellors are integral members of the primary care team, where they work alongside medical, nursing, and other staff. Counsellors are valued in primary care for a number of reasons: they provide time for patients to talk through and reflect on problems, where general practitioners are unable to spend the necessary time on individual patients; they are an extra resource for managing patients with mental health problems; they provide a valued alternative or addition to pharmacotherapy; they promote patient coping rather than dependence on general practitioners or medication; and they are a cheaper source of psychological work than referrals for psychological treatment. Counsellors in primary care may also manage traditionally ‘difficult to help' patients, repeated attenders, and somatizing patients. Counsellors may work alone, as a single-handed counselling service, or part of a wider primary-carebased mental health team including psychologists, community psychiatric nurses, or

psychotherapists. One strength of counselling in primary care is the ability to identify and intervene with mental health difficulties at an early stage; patients and staff value an in-house approach, avoiding referrals to secondary services where appropriate. The role of the counsellor is varied, and may include offering individual or group counselling, offering advice or training to primary care staff on managing mental health problems, and general consultation. Counselling in primary care requires adaptation of method.It is often short term, which requires greater problem definition and inattention to past issues. The counsellor requires an understanding of the patient and their social context, and a systemic understanding of the primary health care team as an organization. Counsellors need to be flexible in the way that they work, able to use different

models as appropriate to each patient, and flexible about boundaries and confidentiality, being able to work with general practitioners and other health professionals as appropriate. Despite the growth and popularity of counselling in primary care, serious concerns are expressed about effectiveness and standards of training. The effectiveness of counselling in primary care has been difficult to assess because of the lack of specificity and control in studies, the diversity of patient groups, and variation in treatments. Studies have shown mixed findings, with more consistently positive results for cognitive therapy in primary care, and a generally consistent reduction in the prescription of psychotropic medication in practices with counselling services. Cape and Parnham showed that the provision of practice counselling was associated with higher referral rates to clinical psychology. A number of studies have shown no difference in outcome between routine general practitioner treatment and practice counselling, patients in both groups improving; however, patients are in favour of counselling and report that it helps them with a variety of psychological problems. As well as referral to a practice counsellor, patients also welcome counselling from their general practitioner. Counselling appears to be most effective when offered to the least chronic and severely impaired individuals; however, this is not to dismiss the effectiveness of problem-solving counselling for those with severe mental health problems. Counselling in primary care can be cautiously reported as a valuable service, particularly for patients with mild to moderate emotional disturbance as well as bereavement and relationship difficulties. It is valued by general practitioners and patients, and is probably best offered as a range of mental health services, linking closely with community mental health services. Student health Counselling services in college and university settings cater for students with a wide range of problems. These include financial problems, difficulties with studying, interpersonal problems, and psychiatric presentations. Student counselling services are often arranged so that practical (e.g. financial guidance or careers counselling) and psychological problems are catered for separately. The latter facility is usually sited in a position that affords discreet and confidential access, so as not to deter those who are ashamed of seeking help. Services may accept referrals from academic staff or the student's doctor, but the usual expectation is that students will refer themselves. Student counselling services encounter the full range of psychiatric presentations characteristic of young people, although mature students may present differently. Services need to include or work

closely with psychiatrists and other mental health professionals in order to meet the needs of the minority of students with mental illness. The majority present with less severe emotional or psychological problems, but these may be highly disruptive to their studies and social integration. By virtue of their age and developmental stage, many students present with problems of adjustment to the new freedoms and demands of college life. The developmental challenges of adolescence and young adulthood include negotiation of dependence–independence conflicts and psychosexual development, so the psychological problems of students are often associated with interpersonal and sexual difficulties. Dependence and conflicts with parental figures may become transference issues within the counselling relationship, and student counsellors would be expected to recognize and work with such developments regardless of their preferred model of counselling. A short time-frame is usually appropriate for counselling young people, partly because of the impatient urgency of youthfulness and the structure of the academic year, but also because their natural developmental potential enables most young people quickly to achieve substantial momentum towards change. This process may be accelerated even more by the intelligence inherent in students, though emotional development lags far behind intellectual development in some. The task of counselling has been likened to helping the young person back on to the track of normal psychosexual development. More severe derailments, however, may require longer counselling, specialized psychotherapy, or other psychiatric treatment. Counselling in general hospital settings Counselling within medical settings has two aims: to offer counselling to patients and their relatives, and to work with health professionals. Many medical departments have counsellors as part of the team, although many have few formal counselling qualifications. The evidence to support the effectiveness of counselling as an adjunct to physical therapy is inconclusive; counsellors may have a role in improving patient's coping skills, and in offering training and advice to health professionals on counselling skills. Counselling is a valuable part of care within many medical arenas. Much of the psychological distress caused by medical problems can be conceptualized as forms of adjustment, described above. Examples include counselling for cancer, disfiguring surgery, HIV and AIDs, fertility problems, facial disfigurement, or cardiology. Many hospitals employ bereavement officers to help relatives

cope with the aftermath of a recent bereavement and also to offer longer-term support and counselling for the bereaved. Counsellors have an important role in working with patients following deliberate self-harm, offering an early assessment service to assess the level of risk and decide on appropriate management including referral to psychiatric services. Other aspects include providing social and psychological help for those with other psychosocial problems, through short-term interventions such as crisis intervention counselling and problem-solving. Such work can be carried out by clinical nurse specialists, such as in the Deliberate Self-harm Service at the Department of Psychological Medicine in Oxford. Other routes are for counselling to be offered by trained staff in accident and emergency settings as well as inpatient settings. Counselling in voluntary organizations Counselling within the voluntary sector has vastly increased, with a growing number of support groups and voluntary organizations offering counselling for a range of emotional and social problems. The most well known in the United Kingdom include Alcoholics Anonymous, Cruse which offers bereavement counselling, Relate for relationship difficulties, and the Samaritans,with equivalent organizations in other countries. Many mental health organizations offer support, befriending, and counselling at a ‘grassroots' level; some, such as the United Kingdom organization MIND, are organized nationally and others operate at a local level. These organizations contribute a great deal to helping those with mild emotional distress, offering the opportunity to talk through and reflect on problems, and in offering support to those with more severe mental health problems. The interface between voluntary and statutory services is varied and at times uncomfortable, with the two sharing different models of care, philosophies, and policies on issues such as confidentiality. Counselling in the workplace Employment and mental health are known to be significantly related, the unemployed reporting higher rates of mental health problems compared to the employed, and satisfaction at work is positively correlated with mental health. Counselling for work-related difficulties is effective in reducing stress-related problems at work and sickness. Counselling services at work include employee assistance programmes and specialized staff counselling services.

Employee assistance programmes Counselling in the workplace was first introduced in the United States, after the Second World War, as Employee Assistance Programs (EAPs) designed to rehabilitate those oil-industry employees with alcohol problems. EAPs have become widespread in North America and are increasing in the United Kingdom, and now address a wide range of employee problems including stress. They are reported to achieve good results in terms of the percentage of employees who are rehabilitated for work, the reduction in alcohol consumption, improvement of work performance, and cost savings to the company. EAPs provide a comprehensive confidential counselling service to employees and their families, allowing employee's problems to be identified and resolved at an early stage, and are normally incorporated into the company's benefits package as a form of private emotional health care. EAPs include 24-hour access, telephone counselling, and helplines as well as individual counselling offered at short notice. The service is available to employees and their families. One of the advantages of counselling organized through EAPs as opposed to in-house staff counselling is improved confidentiality; staff may be reluctant to use counselling services at work if they are not convinced of full confidentiality, and if they fear their career prospects may be adversely affected. Staff counselling services A number of private and public sector organizations now have in-house counselling services. In the early 1980s the Post Office, one of the largest employers in the United Kingdom, recognized that there was a need to provide some form of emotional and psychological support to their employees. Mental health issues, mainly anxiety and depression, formed 46 per cent of the caseload to the inhouse counselling service, others being relationship problems, alcohol problems, bereavement, assault, physical illness or disability, and social problems. The effectiveness and benefits of the service from the individual client's viewpoint was assessed by comparing psychological test measurements of well being and attitudes of clients with a matched control group. After counselling, the client group showed improvements in all areas of psychological well being and behaviour. There was a decline in clinical anxiety levels, somatic anxiety, and depression and an increase in selfesteem. There was also a significant reduction in sickness absences. Other staff counselling services have also shown significant mental health benefits to employees. Staff counselling schemes are now promoted by the Royal College of Nursing, the British Medical Association, and MIND at Work, and

are set up by many health authorities. Problem-solving and cognitive methods of counselling appear to be the most valuable models for workplace settings. Overall, counselling at work is a valuable and effective service for individuals with a range of emotional and social difficulties. Counselling in workplace settings is short term, focused on problems and their solutions. Should the employee require longer-term counselling, referral to other agencies is necessary. Counselling training, accreditation, standards, and ethics Alongside the expansion of interest in counselling, the number of counselling courses rises each year. Their scope varies significantly, ranging from short evening classes in active listening and short courses in counselling skills for health professionals, to full-time training leading to professional accreditation or chartering. There are concerns about the quality and standards of training, and it is not surprising that many are confused about the qualifications of particular counsellors; for example, 20 per cent of general practitioners who employ counsellors do not know their qualifications. For full training and accreditation, professional counsellors are required to follow, as a minimum, a 3-year full-time training course in the theory and practice of counselling. The standards required are covered by three main organizations in the United Kingdom, with equivalents in other countries.


The British Association of Counselling, which offers accreditation for counsellors from a variety of disciplines, mainly humanistic and psychodynamic.



The British Psychological Society, which offers accredited chartered status for counselling psychologists, trained to meet standards in applied psychology.



The United Kingdom Council for Psychotherapy, which registers psychotherapists, including psychodynamic, psychodrama, and cognitive therapists.

The requirements for accreditation or registration vary between organizations. Common requirements are a minimum of 450 hours of supervised practice, evaluated via case studies and process reports; academic knowledge of counselling theory and research; personal counselling or psychotherapy; and, for the British Psychological Society, research skills and experience. The qualification requires that practitioners follow a code of practice and ethics, stipulating ethical practice, the need for supervision, appropriate confidentiality, and other standards for professional practice.

One major problem is that currently there is no statutory protection for using the terms ‘counsellor' or ‘psychotherapist', and therefore no means for the prevention of bad practice or abuse. Without registration through a professional body, clients may have no redress for incompetent practice. The registering organizations are now moving towards statutory registration and legal protection for the terms counsellor, psychologist, and psychotherapist; whilst these may take time to arrive, it is vital that the public and health professionals are aware of the need to seek help only from qualified practitioners of counselling. Conclusions Counselling is a major growth area within psychiatry. For the psychiatrist or other mental health professional, it can be difficult to make sense of the range of counselling models available; thus it is not surprising that the consumer is sometimes confused about the nature and advisability of counselling. Counselling has only recently been subject to the rigorous evaluation necessary to meet the standards of evidence-based practice. The most central aspects of counselling, the therapeutic relationship and qualitative nature of the work, can be difficult to evaluate using established research methodology. However, far more attention is being paid to evaluation, with the development of research paradigms suited to counselling. Systematic evaluation will eventually make it possible to identify, on the basis of clear evidence, the indications for specific models of counselling as well as their limitations. The relationship between specific models of counselling and psychotherapy needs to be further clarified. Lack of clarity confuses the potential purchasers and consumers of services. Furthermore, there is a growing tension in some areas between counsellors and established mental health practitioners of psychological therapies, including psychiatrists and psychologists, who may feel threatened by the development of this new profession. These concerns may be justified if health service commissioners see counselling as a cheaper source of psychological treatments. Counselling is a vital part of psychiatry for many reasons. Counsellors are equipped to offer a valuable service to those with mild to moderate mental health problems as well as social and relationship difficulties. It makes sense for interventions to be offered at an early stage of difficulties: whilst many problems do resolve on their own, patients welcome the support and understanding that counselling can offer, and it is valuable in hastening recovery from emotional distress. Counselling may be appropriate for some patients with serious mental illness, offered by psychiatric nurses, social workers, occupational therapists and workers in the voluntary sector. The expansion of counselling

raises the issues of training, standards, ethics, and accountability, which need to be addressed further before the place of counselling can be fully consolidated and integrated within psychiatry. References 1. Lago, C. and Thompson, J. (1996). Race, culture and counselling. Open University Press, Buckingham. 2. Tseng, W. and Hsu, J. (1979). Culture and psychotherapy. In Perspectives on cross cultural psychology (ed. A.J. Marsella, R.G. Tharp, and T.J. Ciborowski), pp. 333–45. Academic Press, New York. 3. Spinelli, E. (1994). Demystifying therapy. Constable, London. 4. Roth, A. and Fonagy, P. (1996). What works for whom? A critical review of psychotherapy research. Guilford Press, New York. 5. Feltham, C. (1995). What is counselling? Sage, London. 6. Oxford Modern English Dictionary (1992). Oxford University Press. 7. Burnard, P. (1994). Counselling skills for health professionals (2nd edn). Chapman & Hall, London. 8. Nelson-Jones, R. (1994). The theory and practice of counselling psychology. Cassell, London. 9. Woolfe, R. and Dryden, W. (ed.) (1996). Handbook of counselling psychology. Sage, London. 10. Gelder, M.G., Gath, D., Mayou, R., and Cowen, P. (1996). Oxford textbook of psychiatry (3rd edn). Oxford University Press.

INTERPERSONAL SKILLS Interpersonal psychotherapy (IPT) is a time-limited diagnosis-based treatment originally developed to treat patients with major depression. IPT was developed in the 1970s, defined in a manual, and tested in randomized clinical trials by the late Gerald Klerman, Myrna Weissman, and collaborators. Its success in research trials led to its modification for subtypes of mood disorders as well as nonmood disorders. IPT has also been adapted for use as a long-term treatment; into couples and group formats; as a telephone intervention; and in a patient self-help guide. A host of new research applications are under study. Begun as a research intervention, IPT has only lately been disseminated among clinicians and in residency training programmes. There have been increasing requests for training in IPT following IPT milestones including the publication of efficacy data, the promulgation of practice guidelines that embrace IPT among antidepressant treatments, and its endorsement by Consumer Reports. Managed care and economic pressures have also aroused growing interest in defined and proven time-limited treatments. IPT has been translated into several languages and appears to be spreading in non-English speaking countries. This chapter describes the concepts and techniques of IPT and its current status of adaptation, efficacy data, and training. The chapter provides a guide to developments and a reference list, but not a comprehensive review. (A complete description of the IPT method, some adaptations, and the patient guide are given elsewhere.) Practice guidelines In 1993, practice guidelines appeared for mental health professionals and primary care practitioners.The two sets of guidelines differed considerably in their scope, audience, and the level of scientific basis each required for treatment recommendation. Neither set of guidelines claimed to define the standard of care for individual patients. Each discussed IPT as an acute and maintenance treatment for depression, used alone and in combination with medication. American Psychiatric Association practice guidelines These guidelines for adults with major depression cited IPT among several psychotherapies. The guidelines did not require efficacy data from controlled clinical trials as criteria for inclusion. IPT is described as useful for patients in the ‘midst of recent conflicts with significant others and for those

having difficulty adjusting to an altered career or social role or other life transition'. Although many patients do present with such recent life changes, given the empirical support for IPT, some of which is documented below, these appear minimal conservative indications. The APA eating disorder guidelines also cite interpersonal psychotherapy among its recommended psychotherapeutic approaches. Primary care guidelines The extensive clinical practice guidelines for antidepressant treatment in primary care comprise four volumes. Both the physician and patient guides list IPT, cognitive–behavioural therapy (CBT), behavioural, brief dynamic, and marital therapy as treatments for depression. IPT is recommended as an acute treatment for non-psychotic depression, to remove symptoms, prevent relapse and recurrence, correct causal psychological problems with secondary symptom resolution, and correct secondary consequences of depression. The guidelines state that medication alone may suffice to prevent relapse or recurrence, and to maintain remitted patients with recurrent depression. The guidelines describe IPT, CBT, and behavioural treatments as ‘effective in most cases of mild -tomoderate depression', but indications ‘for continuation phase psychotherapy are unclear' despite the fact that ‘two studies are suggestive that continuation psychotherapy may reduce the relapse rate'.The patient guidelines list behavioural, cognitive, and IPT as the ‘most well-studied [sic] for their effectiveness in reducing symptoms of major depressive disorder'. Translations IPT has been translated into Italian, German, and Japanese. Descriptions of IPT have appeared in Spanish and Dutch. Adaptations As a general approach, IPT is recognizable across its diagnostic applications. For some study populations the standard IPT approach for major depression has been applied unchanged. In other instances, IPT has been adapted to meet the psychosocial needs of specific treatment populations. This process has generally involved a needs' assessment of the treatment population, the development of a treatment manual including those needs, and then testing of the adapted treatment in open and controlled clinical trials.

Background Theoretical sources; empirical sources IPT is based on interpersonal theory stemming from the post-Second World War work of Adolph Meyer, Harry Stack Sullivan, and later John Bowlby and others. The general principle derived from these theories is that life events occurring after the formative years influence psychopathology. IPT uses this principle in a non-aetiological fashion: it does not pretend to discern the cause of a depressive episode, but uses the connection between current life events and mood disorder to help the patient understand and deal with his or her episode of illness. IPT is further based on psychosocial and life events' research of depression that has bolstered these theories by demonstrating the relationships between depression and loss (complicated bereavement), role disputes (e.g. bad marriages), role transitions, and interpersonal deficits. Finally, IPT has an unusually strong empirical basis in the controlled studies that have systematically tested its efficacy for major depression, other mood disorders, and increasingly for non-mood disorders. Techniques Concept of depression Depression is defined as a medical illness, a treatable condition that is not the patient's fault. This definition of depression tends to displace the guilt of the depressed patient from the patient herself to the illness, making the symptoms egodystonic and discrete. It also provides the hope of response to treatment. The therapist uses diagnostic manuals such as DSM-IV or ICD-10, and rating scales such as the Hamilton Depression Rating Scale or Beck Depression Inventory, to help the patient recognize that he or she is dealing with a common malady—not the personal failing or weakness that the depressed patient often believes to be the problem. To implement this approach, IPT therapists formally give depressed patients the ‘sick role', excusing them from what their illness prevents them from doing, but also obliging them to work as patients in order to ultimately recover the healthy role they have lost.

Strategies and techniques The overall strategy of IPT is that by solving an interpersonal problem —dealing with complicated bereavement, a role dispute or transition, or an interpersonal deficit—the patient will both improve his or her life situation and simultaneously relieve the symptoms of the depressive episode. This coupled formula has been validated by the randomized controlled trials in which IPT has been tested, hence it can be offered with confidence and optimism. This optimistic approach, while hardly specific to IPT, very likely provides part of its power in remoralizing the patient. IPT is an eclectic therapy, using techniques developed in various psychotherapies. It is not its specific techniques but rather its overall strategies that make it a unique and coherent approach. Although IPT overlaps to some degree with psychodynamic psychotherapies, it also differs from them in significant ways: in its focus on real life change, its medical model, and its avoidance of the transference and of genetic and dream interpretations. And while it shares with cognitive behavioural therapy a focus on a syndromal constellation (e.g. major depression), attention to the ‘here and now', and techniques like role playing, IPT is considerably less structured, requires no explicit homework, and has a very different feel. Each of the four IPT interpersonal problem areas—grief (complicated bereavement), role disputes, role transitions, and interpersonal deficits—has discrete, if to some degree overlapping, goals for the therapist and patient to pursue. The techniques of IPT aid the patient's pursuit of these interpersonal goals. The therapist repeatedly helps the patient to link life events to mood and symptoms. These techniques include the following:


an opening question—‘How have things been since we last met?'—which leads the patient to provide an interval history of mood and events

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a communication analysis, a re-creation of recent, affectively charged life circumstances an exploration of the patient's wishes and options to achieve those wishes in particular interpersonal situations

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decision analysis, to help the patient decide which options to employ role playing, to help patients rehearse tactics for real life.

Indications The indications for IPT have been established in sequential treatment studies. Empirical trials have validated the utility of IPT as both an acute and a maintenance treatment for non-psychotic major

depression. The IPT maintenance study is the only study for a psychotherapy of depression. IPT has also demonstrated efficacy as a treatment for depressed adolescents, depressed geriatric patients, depressed patients in primary care, depressed HIV patients, and for depressed women in marital disputes, as well as for non-depressed bulimic patients. Studies are underway to assess the utility of IPT for other patient populations: for patients with dysthymic disorder, as an adjunctive treatment for patients with bipolar disorders, for patients with a variety of anxiety disorders including panic, social phobia, and post-traumatic stress disorders, and for patients with borderline personality disorder. Contraindications IPT was never intended to function as a monotherapy for patients with psychotic depression or bipolar disorder. Two controlled trials have found no benefit for IPT as a treatment of psychopathology among methadone-maintained patients and as a treatment for cocaine abstinence. Managing treatment Making no aetiological assumptions, IPT uses the connection between the onset of depressive symptoms and current interpersonal problems as a pragmatic treatment focus. IPT deals with current rather than past interpersonal relationships, focusing on the patient's immediate social context. The IPT therapist attempts to intervene in symptom formation and social dysfunction associated with depression, rather than addressing enduring aspects of personality. Personality is, in any case, hard to assess during an episode of an Axis I disorder such as depression. Phases of treatment As an acute treatment, IPT has three phases. The first phase, usually one to three sessions, includes diagnostic evaluation and psychiatric history and sets the framework for the treatment. The therapist reviews symptoms, diagnoses the patient as depressed by standard criteria, and gives the patient the sick role. The sick role may excuse the patient from overwhelming social obligations, but requires the patient to work in treatment to recover full function. The psychiatric history includes the ‘interpersonal inventory', a review of the patient's current social functioning and close relationships, their patterns and mutual expectations. (The interpersonal inventory is a careful interpersonally focused anamnesis, not a semistructured interview.) Changes in relationships proximal to the onset of symptoms are elucidated (e.g. death of a loved one, children leaving home, worsening marital strife,

or isolation from a confidant). This review provides a framework for understanding the social and interpersonal context of the onset of depressive symptoms and defines the focus of treatment. Having assessed the need for medication based on symptom severity, past history and response to treatment, and patient preference, the therapist educates the patient about depression by explicitly discussing the diagnosis, including the constellation of symptoms that define major depression, and what the patient might expect from treatment. The therapist next links the depressive syndrome to the patient's interpersonal situation in a formulation that uses as a framework one of four interpersonal problem areas: 1. grief 2. interpersonal role disputes 3. role transitions 4. interpersonal deficits. In the middle phase, the therapist pursues strategies specific to the chosen interpersonal problem area, as described in the manual. For grief, defined as complicated bereavement following the death of a loved one, the therapist facilitates the catharsis of mourning and gradually helps the patient to find new activities and relationships to compensate for the loss. Role disputes are conflicts with a significant other: a spouse or other family members, co-worker, or close friend. The therapist helps the patient explore the relationship, the nature of the dispute, whether it has reached an impasse, and available options for its resolution. If these fail, therapist and patient may conclude that the relationship has reached an impasse and consider ways to change the impasse or to end the relationship. Role transition includes a change in life status—for example, beginning or ending a relationship or career, moving, promotion, retirement, graduation, or diagnosis of a medical illness. The patient learns to deal with the change by mourning the loss of the old role while recognizing positive and negative aspects of the new role they are assuming, and taking steps to gain mastery over the new role. Interpersonal deficits, the residual fourth IPT problem area, defines the patient as lacking social skills, including having problems in initiating or sustaining relationships, and helps the patient to develop new relationships and skills. IPT sessions address present ‘here and now' problems rather than childhood or developmental issues. Sessions open with the question: ‘How have things been since we last met?' This focuses the patient on recent interpersonal events and recent mood, which the therapist helps the patient to link. Therapists take an active, non-neutral, supportive, and hopeful stance to counter the depressed

patient's pessimism. They emphasize the options that exist for change in the patient's life, options that the depression may have kept the patient from seeing or exploring fully. Moreover, therapists stress the need for patients to test these options in order to improve their lives and simultaneously treat their depressive episodes. The final phase of IPT, occupying the last few of the 12 to 16 weeks of treatment, supports the patient's newly regained sense of independence and competence by recognizing and consolidating therapeutic gains. The therapist also helps the patient to anticipate and develop ways of identifying and countering depressive symptoms should they arise in the future. Compared to psychodynamic psychotherapy, IPT de-emphasizes termination: it is a graduation from successful treatment. The sadness of parting is distinguished from depressive feelings. If the patient has not improved, the therapist emphasizes that the treatment has failed and stresses the existence of alternative effective treatment options. Efficacy Use of IPT in mood disorders IPT is one of the most carefully studied psychotherapies for mood disorders, and the only psychotherapy tested in a maintenance treatment study. Acute treatment of major depression IPT was first tested as an acute antidepressant treatment in a four-cell 16-week randomized trial comparing IPT, amitriptyline, their combination, and a non-scheduled control treatment for 81 outpatients with major depression. Although amitriptyline alleviated symptoms more quickly, no significant difference appeared between IPT and amitriptyline in symptom reduction at the end of treatment. Each active treatment more effectively reduced symptoms than did the non-scheduled control group, and combined amitriptyline and IPT was more effective than either of the active monotherapies. Naturalistic follow-up at 1 year found that many patients sustained benefits from the brief IPT intervention, and that IPT patients developed significantly better psychosocial functioning whether or not they received medication. This effect on social function was neither found for amitriptyline alone, nor had been evident for IPT at the end of the 16-week trial. The multisite National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP) is the most ambitious acute treatment study to date. Investigators randomly

assigned 250 outpatients with major depression to 16 weeks of IPT, CBT, or either imipramine or placebo plus clinical management. Most subjects completed at least 15 weeks or 12 treatment sessions. Patients with milder depression—having a 17-item Hamilton Depression Rating Scale score of 19 or less—improved equally in all four treatments. Among more severely depressed patients, imipramine worked fastest and was most consistently superior to placebo. IPT was comparable to imipramine on several outcome measures, including the Hamilton Depression Scale, and superior to placebo for the more severely depressed patients. CBT was not superior to placebo for this group. Klein and Ross reanalysed the TDCRP data using the Johnson– Neyman technique. This yielded an ordering for treatment efficacy with ‘medication superior to psychotherapy, [and] the psychotherapies somewhat superior to placebo...particularly among the symptomatic and impaired patients'. The authors found ‘CBT relatively inferior to IPT for patients with Beck Depression Inventory scores greater than approximately 30, generally considered the boundary between moderate and severe depression'. The reanalysis is fairly consistent with the report of Elkin et al., but sharpens differences among treatments. In an 18-month naturalistic follow-up study of TDCRP subjects, Shea et al. found no significant difference in recovery among remitters (defined by the presence of minimal or no symptoms following the end of treatment, sustained during follow-up) among the four treatment groups. During that time, 30 per cent of CBT, 26 per cent of IPT, 19 per cent of imipramine, and 20 per cent of subjects prescribed placebo who had acutely remitted remained in remission. Among remitters at the end of the 16 weeks, relapse over the 18-month follow-up was 36 per cent for CBT, 33 per cent for IPT, 50 per cent for imipramine, and 33 per cent for placebo. The authors concluded that 16 weeks of specific treatments were insufficient to achieve full and lasting recovery for many patients. Hoencamp (personal communication, 1996) and colleagues in The Netherlands are undertaking a study of IPT versus nefazodone, alone and in combination, for the acute treatment of major depression. Predictors of response Large comparative studies such as the TDCRP and the Pittsburgh Maintenance Study allow the exploration of patient and therapist characteristics that may contribute to treatment outcome. Sotsky et al., analysing the TDCRP results, found that patients with low baseline levels of social dysfunction responded well to IPT, whereas those with severe social deficits (probably equivalent to the

‘interpersonal deficits' problem area) responded less well. Patients with greater symptom severity and difficulty in concentrating responded poorly to CBT. High initial depressive severity and impaired functioning predicted a superior response to IPT and to imipramine. Imipramine also worked most efficaciously for patients with difficulty functioning at work, perhaps reflecting its faster onset of action. Sotsky also reported that TDCRP subjects with symptoms of atypical depression, such as mood reactivity and reversed neurovegetative symptoms (hypersomnia, hyperphagia, or weight gain), responded poorly to imipramine but well to IPT and CBT. This outcome replicates previous research findings that tricyclic antidepressants are a suboptimal treatment for atypical depression. Other analyses have also sought predictive patient factors. Frank et al. found that the ‘purity' of IPT—the ability of the therapist to keep sessions focused on interpersonal themes—was significantly correlated with prevention of relapse in their maintenance study of IPT for recurrent major depression. Patients whose monthly IPT maintenance sessions had high interpersonal specificity survived a mean of 2 years before developing depression, whereas those whose therapy had a low interpersonal focus were afforded only 5 months of protection before relapse. Thase et al. found that depressed patients with abnormal electroencephalographic sleep profiles (sleep efficiency, rapid eye movement latency and density) responded significantly worse to IPT than did patients with undisturbed sleep parameters. This finding did not simply reflect symptom severity. Of the IPT non-responders, three-quarters subsequently responded to antidepressant medication. Continuation/maintenance treatment IPT was first developed and tested for an 8-month six-cell trial. Today this study would be considered a continuation rather than a maintenance treatment, as the concept of long-term antidepressant treatment has changed. Women who were acutely depressed and treated on an outpatient basis (n = 150) and who responded (> 50 per cent symptom reduction rated by a clinical interviewer) to a 4- to 6-week acute phase of amitriptyline were randomly assigned to receive 8 months of treatment with weekly IPT alone, amitriptyline alone, combined IPT and amitriptyline, IPT and placebo alone, or no pill. Randomization to IPT or a low-contact psychotherapy condition occurred at entry into the continuation phase, whereas randomization to medication, placebo, or no pill occurred at the end of the second month of continuation. Maintenance pharmacotherapy was found to prevent relapse and symptom exacerbation, whereas IPT improved social functioning. The

effects of IPT on social functioning were not apparent for 6 to 8 months. No negative treatment interactions were found, and combined psychotherapy and pharmacotherapy had the best outcome. The longest, and only, maintenance trial of psychotherapy for the prophylaxis of depression, studied 128 outpatients with multiply and rapidly recurrent depression. Patients were initially treated with combined high dose (> 200 mg/day) imipramine and weekly IPT. For responders, medication remained at high dosage, while IPT was tapered to a monthly frequency during a 4-month continuation phase. Patients who remained in remission were then randomly assigned to 3 years of one of the following: 1. ongoing high-dose imipramine plus clinical management 2. high-dose imipramine plus monthly IPT 3. monthly IPT alone 4. monthly IPT plus placebo 5. placebo plus clinical management. The investigators found high-dose imipramine to be the most effective treatment, whereas most patients on placebo relapsed, mainly in the first few months. Once-a-month IPT, while less effective than the medication, was statistically and clinically superior to the placebo arm in this high-risk patient population. Women of childbearing age are the modal patients with depression. The finding of an 82-week survival time without recurrence with IPT alone is an impressive duration, sufficient to protect many women with recurrent depression through pregnancy and nursing without medication. Further study is required to determine the efficacy of IPT relative to newer medications (e.g. selective serotoninreuptake inhibitors), and the efficacy of more frequent than monthly doses of maintenance IPT. A study of differing doses of maintenance IPT for depressed patients is underway in Pittsburgh. Geriatric depressed patients IPT was first used with geriatric depressed patients as an addition to a 6-week pharmacotherapy trial, in order to enhance compliance and to provide some treatment for the placebo control group. The investigators noted that grief and role transition specific to life changes were the prime focus of treatment, and suggested modifying IPT with a more flexible duration of sessions, greater use of

practical advice and support (e.g. arranging transportation, calling the physician), and the recognition that major role changes may be impractical and detrimental (e.g. divorce at age 75). A 6-week clinical trial compared standard IPT with nortriptyline in 30 geriatric depressed patients. Results showed some advantages for IPT, largely due to medication side-effects that produced higher attrition in the medication group. A 3-year maintenance study in Pittsburgh for geriatric patients with recurrent depression is using a similar design to the study by Frank et al. The investigators modified IPT for geriatric patients as IPT–Late Life Maintenance Treatment (IPT–LLM). During the acute phase, patients received combined nortriptyline and IPT. This study then compared random assignment with IPT –LLM alone, nortriptyline alone, IPT–LLM plus nortriptyline, IPT–LLM plus placebo, and placebo alone as maintenance therapies. The IPT manual was modified to allow a more flexible length of sessions, as elderly patients may not tolerate 50-minute sessions. Some of the authors found that older patients need to address early life relationships in their psychotherapy, a distinction from the typical ‘here and now' focus of IPT. Like Sholomskas et al., they felt that therapists needed to help patients solve practical problems and to acknowledge that some problems may not be amenable to resolutions, such as existential late-life issues or life-long psychopathology. Preliminary results showed that elderly depressed patients whose sleep quality normalized by early continuation phase had an 80 per cent chance of remaining well during the first year of maintenance treatment. The response rate was similar for patients receiving nortriptyline or IPT (Reynolds, personal communication, 1996). Bereavement-related depression An ongoing study in Pittsburgh compares IPT with nortriptyline for the acute treatment of bereavement-related major depression (Reynolds, personal communication, 1996). The IPT modification includes more detailed anamnesis in the initial phase of treatment on the quality of earlier and current relationships and roles, and determines available social supports for spousal bereavement. Detailed information on practical quality-of-life issues includes, for example, bill payment, financial burden, leisure activities, and children. Depressed adolescents Mufson et al. modified IPT to incorporate adolescent developmental issues (IPT-A), adding as a fifth problem area the single-parent family, an interpersonal situation frequently found among their

adolescent treatment population. Mufson and colleagues have successfully tested this approach in both an open and a controlled clinical trial. Depressed adolescent mothers Gillies and colleagues at the Clarke Institute in Toronto, Canada, are completing a pilot study of depressed pregnant adolescents aged between 15 and 19 years of age. In this study, 30 patients, all scoring 14 or higher on the Beck Depression Inventory, were randomly assigned to 12 once-weekly sessions of arts and crafts, a psychoeducational group, or individual IPT, with six monthly follow-up sessions. Of these 30 patients, 11 subjects terminated early, with attrition approximately equal across groups. Results are pending. Depressed HIV-positive patients Markowitz et al.modified IPT for depressed HIV patients (IPT-HIV), emphasizing common issues among this population including concern about illness and death, grief, and role transitions. In a pilot open trial, 21 of the 24 depressed patients responded with symptom reduction. A 16-week study randomized 101 subjects to IPT-HIV, CBT, supportive psychotherapy, and imipramine plus supportive psychotherapy. Echoing the results of the more severely depressed subjects in the TDCRP study, all treatments were associated with some symptom reduction, but IPT and imipramine produced improvement greater than the other two psychotherapies. Depressed primary care patients Schulberg and colleagues compared IPT with pharmacotherapy for depressed ambulatory medical patients in a primary care setting. The IPT manual was not modified, but IPT conformed with practices of the primary care centre: for example, nurses took vital signs before each session. If a patient was admitted to hospital for a medical condition, IPT was continued in the hospital when possible. Patients with current major depression (n = 276) were randomly assigned to IPT, nortriptyline, or the primary care physicians' usual care. They were seen weekly for 16 weeks and monthly thereafter for 4 months in IPT. Depressive severity declined more rapidly with either nortriptyline or IPT than in usual care. Among treatment completers, approximately 70 per cent receiving nortriptyline or IPT, but only 20 per cent in usual care, were judged recovered at 8 months. Brown et al. found that

patients with a lifetime history of comorbid panic disorder, compared to major depression alone, had a poorer response regardless of treatment. Conjoint IPT for depressed patients with marital disputes Marital conflict, separation, and divorce have been associated with the onset and course of depressive episodes. Individual psychotherapy for depressed patients in marital disputes may lead to premature termination of some marriages. For these reasons, a manual was developed for conjoint therapy of depressed patients with marital disputes (IPT-CM). IPT-CM focuses on the current marital dispute and includes the spouse in all sessions. A total of 18 patients with major depression linked to the onset or exacerbation of marital disputes were randomly assigned to 16 weeks of individual IPT or IPT-CM. Although patients in both treatments showed a similar reduction in depressive symptoms, patients receiving IPT-CM had significantly better marital adjustment, greater marital affection, and better sexual relations than did IPT-alone patients. These preliminary findings require replication with a larger sample and other control groups. Antepartum/postpartum depression Spinelli at Columbia University is using IPT to treat women with antepartum depression. Examination of this role transition addresses the depressed pregnant woman's self-evaluation as a parent, physiological changes of pregnancy, and altered relationships with the spouse or significant other and with other children. Spinelli has added ‘complicated pregnancy' as a fifth interpersonal problem area. Timing and duration of sessions shift in response to bed rest, delivery, obstetric complications, and child care. Young children may be brought to sessions and breast-fed by postpartum mothers. Telephone sessions and hospital visits are sometimes necessary. A controlled clinical trial is comparing IPT to a didactic parent education group in depressed pregnant women over 16 weeks of acute treatment and 6 monthly follow-up sessions. Swartz and colleagues at Cornell University studied IPT in a small pilot study for depressed pregnant HIV-positive patients. Stuart and O'Hara are currently comparing IPT with a waiting-list control for women with postpartum depression (Stuart, personal communication, 1996). Dysthymic disorder In a modification of IPT for dysthymic disorder (IPT-D), patients were encouraged to reconceptualize what they had seen as their lifelong character flaws as egodystonic chronic mood-

dependent symptoms, i.e. as a chronic but treatable ‘state' rather than an immutable ‘trait'. Therapy itself was defined as an iatrogenic role transition from believing oneself flawed in personality to recognizing and treating the mood disorder. Open treatment in 16 once-weekly IPT sessions yielded a reduction in depressive symptoms among dysthymic patients with lifelong chronicity. In a pilot study, Markowitz treated a total of 17 subjects; none worsened, and 11 remitted. Medication benefits roughly half of dysthymic patients, but non-responders may need psychotherapy, and even medication responders may benefit from combined treatment. Based on these pilot results, a comparative study of 16 weeks of IPT-D alone, supportive psychotherapy, or sertraline plus clinical management, as well as a combined IPT and sertraline cell, is underway at Cornell Medical Center. Browne, Steiner, and others at McMaster University in Hamilton, Canada, treated some 700 dysthymic patients in the community with either 12 sessions of standard IPT, sertraline, or their combination for 4 months. Patients were then followed up over 2 years. Results have not yet been published, but preliminary findings have been presented at several conferences (e.g. World Psychiatric Association, Jerusalem, 1997). Based on a 40 per cent reduction of the Montgomery– Asberg Depression Rating Scale score at 1-year follow-up, 51 per cent of IPT-alone subjects improved—a substantial percentage, but significantly less than the 63 per cent for sertraline and 62 per cent for combined treatment. Yet in the follow-up phase IPT was associated with significant economic savings in the direct use of health-care and social services: thus combined treatment was as efficacious as but less expensive than sertraline alone. Another trial underway in Toronto is comparing IPT with the short-term psychodynamic therapy of Luborsky in 72 patients who meet the criteria for dysthymia with or without major depression (double depression). Patients receive 12 once-weekly sessions followed by four once-monthly sessions (Gillies, personal communication, 1995). Initial results of IPT treatment indicate that most patients reported a reduction of symptoms (Frey and Gillies, personal communication, 1996). The authors found that dysthymic patients responded to IPT just as did patients with major depression, but that the long-standing nature of their illness made dysthymic patients more difficult to treat. Bipolar disorder Frank and colleagues in Pittsburgh are assessing the benefits for patients with bipolar disorders of adjunctive IPT modified by social zeitgeber theory—behavioural scheduling of daily and sleep patterns—as maintenance treatment for lithium-stabilized patients. Comparing interpersonal social

rhythms therapy with medication alone, the 3-year maintenance treatment study will initially include biweekly IPT visits, tapering to monthly sessions in the final 2 years. IPT for other disorders The success of IPT in treating mood disorders has led to its application to non-mood syndromes as well. Substance abuse IPT has not demonstrated efficacy in two clinical trials with substance-abusing patients. The first study found no additional benefit in reducing psychopathology when adjunctive IPT was added to standard treatment, compared to the standard programme alone, for 72 methadone-maintained opiate abusers. The same team found that 12 weeks of IPT was ineffective and marginally worse than behavioural treatment for 42 cocaine abusers attempting to achieve abstinence. The two negative studies suggest limits to the range of utility of IPT, but do not necessarily doom its use for substance abuse. IPT might be useful, for example, in treating newly abstinent, alcohol-dependent patients, who face numerous psychosocial stressors that have been shown to precipitate relapse. Bulimia Fairburn and colleagues altered IPT for studies of bulimic patients, eliminating the use of the sick role and of role playing, so that relatively distinct strategies could be used in a comparison of IPT and CBT. This research showed that although CBT worked faster, IPT had long-term benefits comparable with CBT and superior to a behavioural control condition. Group format for bulimia (IPT-G) Drawing on the work of Fairburn and colleagues, Wilfley et al.modified IPT in a group format, meeting once a week for 16 weeks, and compared it with group CBT and a waiting-list control for 56 women with non-purging bulimia. At termination, IPT-G and CBT each significantly reduced binge eating, whereas the waiting-list control did not. These results persisted at 1-year follow-up. A randomized clinical trial of 162 women is now comparing group IPT and CBT for 20 sessions over 20 weeks. The initial IPT phase, in which the therapist identifies the problem area and presents IPT concepts and the treatment contract, is conducted individually. Groups meet for 90 minutes.

Social phobia Unlike CBT, IPT has not yet been tested in controlled studies as a treatment for anxiety disorders. IPT is being modified for social phobia independently by Lipsitz at Columbia and by Stuart and O'Hara at the University of Iowa, with open trials progressing at both sites. Lipsitz (personal communication, 1996), having completed nine pilot cases, reports that the standard IPT ingredients, including the medical model, provision of the sick role, and the supportive therapeutic stance, appear to benefit most patients. Social phobia in a group format Weissman and Jacobson (unpublished work) have adapted IPT in a group format for shy patients. The patients had social phobia in unstructured interpersonal situations (at parties, in intimate discussions with significant others), but not in defined work situations. Most patients were successful in professional or business careers despite their phobias. The 10-session time-limited group defined and described the diagnosis, gave patients the sick role, and developed practical strategies for dealing with shyness in specific situations: for example, developing scripts to initiate a more personal conversation with an estranged father, or a discussion with a spouse about having a baby. As Lipsitz noted, the chronicity of the disorder led to a focus on a iatrogenic role transition from an impaired to a less-impaired state. The group format seemed to provide a safe haven for patients to interact with others who had similar symptoms. Panic disorder Arzt and van Rijsoort (personal communication) in Maastricht, The Netherlands, are developing a manual for IPT of panic disorder. Body dysmorphic disorder Veale (personal communication) in London has conducted a 15-week clinical trial comparing CBT with IPT for patients with body dysmorphic disorder—a preoccupation with an imagined defect in appearance that causes distress in social functioning.

Chronic somatization in primary care patients Scott and Ikkos have modified IPT to manage patients with chronic somatization in primary care. This adaptation adds a fifth problem area, the patient's relationship with health professionals and the pursuit of medical care. Scott (personal communication, 1996) notes that the IPT medical model works readily with these patients because of their inappropriate use of the health-care system. Treatment-seeking is formulated as an interpersonal issue. Although these patients are easily recruited for IPT treatment, Scott and Ikkos note that 12 sessions may be insufficient to engage patients and develop a working alliance. The therapist emphasizes that he or she is not trying to modify the patient's experience of ‘pain', but to help the patient deal more effectively with the problem. An open trial of 20 to 30 patients is planned. Borderline personality disorder In Toronto, Gillies has adapted IPT for patients with borderline personality disorder. The focus in the initial phase is on the assessment of symptom patterns related to the disorder, such as anger and impulsivity in interpersonal relations. A fifth problem area, self-image, has been added to address the identity disturbance that is central to borderline personality disorder. Telephone contact is used during crises, but not encouraged in lieu of regular scheduled sessions. A pilot randomized trial of 24 patients comparing 12 once-weekly sessions of IPT to relationship management therapy (RMT), with monthly follow-up for 6 months, had to be converted into an open trial of IPT because of high attrition amongst RMT subjects. Initial results showed lower attrition in IPT (10 per cent) than in the control group (50 per cent). Comparison of pre- and post-treatment scores of IPT patients with borderline personality and those with dysthymic or double depression found similar and significant symptomatic improvement across diagnostic groups (Gillies and Frey, personal communication). It will be interesting to see whether time-limited psychotherapy alleviates a chronic syndrome like borderline personality disorder. Other applications A modification of IPT for patients with insomnia has been developed by Müller-Popkens in Hamburg, Germany. This research arose from the observation that insomnia is often associated with stressful interpersonal life events. The approach emphasizes management of insomnia and the regularizing of social rhythms adapted from the work of Frank et al.with bipolar patients. The initial phase presents information on sleep hygiene and rhythm, and patients keep a sleep diary.

IPT is being delivered by telephone to housebound patients with metastatic breast cancer by Donnelly, Holland, and others at the Memorial Sloan–Kettering Cancer Center in New York. A similar study is underway at Clarke Institute, Toronto (Gillies, personal communication, 1996). Stuart has modified IPT for patients with depression status postmyocardial infarction. The adaptation includes careful initial medical evaluation to ensure that symptoms of insomnia, anergia, and other vegetative symptoms represent clinical depression rather than cardiac illness. Stuart notes that care must be taken to ensure that the physical symptoms exceed those expected during convalescence from myocardial infarction. IPT confronts grief over loss of the healthy state, struggles with mortality, remorse over past unhealthy behaviour, the effects of the illness on marital relations and work, and often feelings of being forced into the passive role of receiving care after a life of independence. No other counselling trials of patients with postmyocardial infarction have focused on depression. Stuart and Cole report that although these patients acknowledge depression, they often refuse psychological intervention, even when treatment is labelled ‘stress reduction' or ‘coping skills'. Interpersonal counselling Distress Many patients presenting to primary care practices report psychiatric symptoms, yet do not meet the full criteria for a psychiatric disorder. Their symptoms can be debilitating and may result in high wasted utilization of medical procedures.Interpersonal counselling (IPC), based on IPT, was designed to treat distressed primary care patients who do not meet full syndromal criteria for psychiatric disorders. IPC is administered by health-care professionals, usually nurse practitioners who lack formal psychiatric training, for a maximum of six sessions. The first session can last up to 30 minutes; subsequent sessions are briefer. IPC therapists assess the patient's current functioning, recent life events, occupational and familial stress, and changes in interpersonal relationships. They assume that such events provide the context in which emotional and bodily symptoms occur. A total of 128 patients presenting to a primary care clinic and scoring six or higher on the Goldberg General Health Questionnaire were randomized to IPC or to usual care without psychological treatment. Over an average of 3 months, often involving only one or two IPC sessions, IPC subjects showed significantly greater symptom relief than controls on this General Health Questionnaire, especially improvement in depressed mood. IPC also led to

greater use of mental health services by patients newly attuned to the psychological aspect of their symptoms. Subsyndromally depressed elderly inpatients Mossey et al., noting that depressive symptoms that did not reach criteria for major depression nonetheless impeded the recovery of elderly inpatients, conducted a 10-session trial of IPC for elderly medical inpatients with depressive symptoms. They increased the number of IPC sessions from six to ten, increased their duration from 30 to 60 minutes, and increased the flexibility of scheduling from once weekly to a timetable that accommodated the patient's medical status. There were 76 inpatients over the age of 60 who did not meet criteria for major depression but had depressive symptoms on two consecutive assessments, and these patients were randomly assigned to receive either IPC administered by clinical nurse specialists, or usual care. Researchers also followed a non-depressed, untreated control group. Patients found IPC feasible and tolerable. Assessment after 3 months showed a non-significantly greater reduction in depressive symptoms and greater improvement on all outcome variables for IPC relative to usual care, whereas controls had a slight symptomatic worsening. Readmittance to hospital in the IPC and non-depressed control groups was virtually identical (11–15 per cent), and significantly less than the subsyndromally depressed group receiving usual care (50 per cent). At 6 months, differences between the IPC and usual care groups were statistically significant for reduction of depressive symptoms and self-rated health, but not for physical or social functioning. A 1-year evaluation is pending. The investigators felt 10 sessions insufficient for some patients, and that a maintenance phase might have been useful. The clinical nurse specialists were considered acceptable therapists. Fried, Pelcovitz, and Kochen (personal communication, 1996) at North Shore University Hospital, Manhasset, New York, completed a 6-week open IPC trial with 30 mothers or carers of children with cancer. IPC was administered by a clinical psychologist and focused on the mother's functioning and adaptation to the child's illness. IPT by telephone Because many patients avoid or have difficulty reaching an office for face-to-face treatment, IPC is being tested as a telephone treatment. An open trial underway at the Memorial Sloan–Kettering Cancer Center in New York offers IPT to severely medically, but not psychiatrically, ill patients with metastatic breast cancer who are receiving high-dose chemotherapy. Both the patient and partner

receive weekly 30-minute sessions for approximately 15 weeks. All patients have metastatic breast cancer considered incurable by standard treatments. Their chemotherapy regimen is unusually disabling, and patients must move to within minutes of the hospital for the 2 to 3 months of treatment, causing major disruptions for themselves and their families. They must take extended leaves from jobs and leave children and/or spouses at home. The purpose of the study was to adapt IPT to relieve cancer-related stress rather than depression, but the prevalence of depression and depressive symptoms is high. The investigators report that IPT fits a wide range of the patients' needs well (Kornbluth, Donnelly, and Holland, personal communication, 1996). Another pilot telephone trial underway compares IPT with no treatment in a naturalistic longitudinal study (Weissman and Miller, personal communication, 1996) in 30 patients who have had recurrent depression, but have not received regular treatment. IPT patient guide Weissman developed a user-friendly IPT patient guide with accompanying worksheets designed for depressed readers who want to learn about or are receiving IPT. It explains the treatment in simple language. Worksheets can be used to facilitate sessions or to monitor problem areas after treatment. Testing to determine whether the patient guide facilitates treatment has not been done. Informal reports by Gillies and Markowitz (personal communication, 1996) note that patient response has been positive, and that some therapists have found the patient guide useful during training in IPT. Training Until recently, IPT practitioners were few and almost exclusively limited to participants in research studies. In response to growing clinical demand, IPT training is now increasingly included in professional workshops and conferences, with training courses conducted at university centres in Canada, Europe, Asia, and New Zealand. A training videotape (Kingsley Communications, Houston, Texas) describes IPT and demonstrates the initial assessment phase of treatment. Training workshops for mental health professionals from a variety of disciplines have been held by Markowitz at Cornell Medical School, New York, Cornes at the University of Pittsburgh, and Gillies in Toronto, Canada. IPT is taught in a still small but growing number of psychiatric residency training programmes in the United States and has been included in family practice and primary care

training (Gillies, personal communication, 1996). IPT clinics have been established at the Clarke Institute in Toronto and at the New York Hospital–Cornell Medical Center in New York City. Although the principles of IPT are straightforward, training requires more than reading the manual. Candidates should have a graduate clinical degree (MD, PhD, MSW, RN), several years of experience conducting psychotherapy, and clinical familiarity with the diagnosis they plan to treat (major depression, bulimia, etc.). IPT training programmes are designed to help experienced therapists refocus their treatment by learning new techniques, not to teach novices psychotherapy. The training used in the TDCRP has become a model for subsequent research studies. This includes a brief didactic phase, reviewing the manual, and a longer practicum during which the therapist treats two or three patients under close videotape supervision of the sessions. Rounsaville et al.found that psychotherapists who performed well on a first supervised IPT case often did not require further intensive supervision, and that experienced therapists committed to the approach required less supervision.Some clinicians have taught themselves IPT using the IPT manual and peer supervision. For research certification, we continue to require at least two and preferably three successfully treated cases with hour-for-hour supervision of taped sessions. Conclusion IPT is a time-limited focused treatment originally designed to treat major depression. Its success in randomized clinical trials has led to growth in further research trials to test new populations, inclusion in clinical guidelines, and increasing clinical dissemination.

References 1. Klerman, G.L., Weissman, M.M., Rounsaville, B.J., and Chevron, E.S. (1984). Interpersonal psychotherapy of depression. Basic Books, New York. 2. Klerman, G.L. and Weissman, M.M. (1993). New applications of interpersonal psychotherapy. American Psychiatric Press, Washington, DC. 3. Weissman, M.M. (1995). Mastering depression: a patient guide to interpersonal psychotherapy. Graywind Publications, Albany, NY. 4. Consumer Reports (1995), November, p. 739. 5. Seligman, M.E.P. (1995). The effectiveness of psychotherapy: the Consumer Reports study. American Psychologist, 12, 965–74.

6. Weissman, M.M., Markowitz, J.C., and Klerman, G.L. (1999). Comprehensive guide to interpersonal psychotherapy. Basic Books, New York. 7. Karasu, T.B., Docherty, J.P., Gelenberg, A., Kupfer, D.J., Merriam, A.E., and Shadoan, R. (1993). Practice guideline for major depressive disorder in adults. American Journal of Psychiatry, 150 (Supplement), 1–26. 8. Depression Guideline Panel (1993). Clinical practice guideline. Depression in primary care, Vols 1–4. AHCPR Publications No. 93–0550–0553. US Department of Health and Human Services, Agency for Health Care Policy and Research, Rockville, MD. 9. American Psychiatric Association (1993). Practice guideline for eating disorders. American Journal of Psychiatry, 150, 212–28. 10. Frank, E., Kupfer, D.J., Perel, J.M., et al. (1990). Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry, 47, 1093–9.

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