 We demystify what goes on behind the therapy room door. Join us on this voyage of discovery and co-creative conversations. This is The Therapy Show, behind closed doors podcast with Bob Cook and Jackie Jones. Welcome back to episode 47 of The Therapy Show behind closed doors with the wonderful Bob Cook and myself Jackie Jones. And in this episode we're going to be talking about working with disturbed clients. Yes, working with disturbed clients. Yes. Okay. Is this another continuum that we're talking about Bob? Yeah, let's get that idea fixed in people's heads. There's a mental health continuum. On one side we've got the worried well. Yeah. People got quite good access to adult, the age they are in the present, ability to function. So basically less intense personality traits. So they may have, you know, traits, but they sort of are in the realm of most people's functioning. Yeah. And then we go right the way up to the other end of the spectrum, which we can call personality disorders, where people are more fixed in these qualities and features. And they have less ability to function. They have less spontaneity. They see things in very black and white terms, very rigid. And usually the disorder comes with an element of psychosis. Yeah. Psychosis is when you're not in touch with reality. So it could be fluid psychosis, or you could be psychosis that lasts, you know, over time where people get sectioned, for example, right at the sort of extreme end of disturbance and and a good sort of discussion point, perhaps to start, Jackie, would be one that's raged on for a long time. And that is whether psychotherapy in itself works with the stream, you know, disturb people at the psychotic end, you know, the highly disturbed end where they where there's challenges in functioning and difficulties in being in life. And there's often bouts of psychosis. Does psychotherapy actually work with that type of person, you know, rigid personality disorder, that population? Or is it much more a population where their functioning is enhanced by medication, for example. So, you know, some people might argue, well, with that population, psychotherapy may do more harm than it actually, you know, would do good. So it's a debate that's been going on for a long time. I don't know what you think. And I've never had any clients with an actual diagnosed disorder, the traits. Yeah. I'm kind of down the other end of the continuum, so to speak. What do you think? What do you think on a sort of general level? Do you think psychotherapy? Well, it's important because the first question is whether psychotherapy will be suitable for working with that population. And secondly, if people are more towards the middle of that continuum, not, you know, really severely disturbed, but more so than just traits, the argument might be that psychotherapy might work with a combination of medication. Yeah. And so some therapists would go for that process. Yes. Yeah. I can see that working, but people with a, you know, a diagnosed disorder usually, this is just my knowledge of it, would be hospitalised. And I think my concern as a psychotherapist working in a private practice at home would be what happens in between the sessions, keeping themselves safe in that interim period. Yeah. Well, just put that bit, you know, when you say hospitalised, they'd have to be very, very, very disturbed at the right of the top end for that. And they would then be what is called sectioned. So they're not able to harm to themselves and other people. And you can't be sectioned for good. So, you know, you go section for 28 days or a month or whatever it is, and then people put on medication and then they're managed in the community. Yeah. So they don't end up sort of like years and years being in the hospital. No, they are managed eventually in the community. And interestingly, I was talking to someone only the other day who lived in a very obscure geographical location in the United Kingdom, where the friend or person who was quite disturbed at the level we're talking about was managed in the community. So it isn't that they stay in hospital forever, they are managed. Now, you won't see that type of person because their levels and challenging around functioning is very high. So they probably will never get to your waiting room anyway. Yeah, you're gonna, you're gonna be dealing with people on the worried well, more like traits. And maybe a little maybe sometimes you might be faced with people who've got psychiatrists that function quite well under medication. And they want to just talk about, you know, their symptoms and how things are and enhance their life. So the question will be with you would be thinking about what the psychotherapy work of that population, and is it more sort of counselling or, or perhaps doesn't work at all. Yeah, because you where you are correct is the majority of the people you will see will probably be on the worried well section. Yeah, they have quite a good access to the adults and function quite well in society. But they just want a higher quality of life. Yes. Yeah. And, you know, theoretically, because I work in private practice, then they're going to have to have access to funds to pay for that. So theoretically, they would be in employment, you know, whereas if they're going down the NHS route and getting help and support that way, then yes, there's long waiting list, but it's free. Yeah, and again, you're correct when you say if you with the high level of the continuum, it's like you won't have the resources to be able to take care, let alone anything else. Yeah, people who are very disturbed at that level. The question of whether psychotherapy anyway, works with that type of population is another question from where I sit, if we see a definition of psychotherapy is looking at how the past effects are present, then there's a lot of questions around inviting people back into their own hell. Yeah. Because they've got a very traumatic history, which is brought to, say, you know, part of the process to bring the psychosis, then you're inviting them to go back to a very dark place. And secondly, they could get stuck in that massive place. And again, you may not have the resources to deal with that process. So for me, you know, I think a person has to have for psychotherapy to work has to have some energy or ability to be able to touch with their adults and to day today functioning. Yeah, for me to go down that road. Yeah. And I think I think that's kind of, you know, similar thing is about knowing your own abilities and the skills that you have and the clients that you actually work with. You know, I know we've touched on in past podcasts about eating disorders and anorexia and things like that. That's not somebody that I would probably work with because I haven't had, you know, training along those lines. So it's about maybe me as a psychotherapist knowing where my skills are and being able to refer on if somebody wants to contact me. Yes. And if you have an assessment system, and I'm sure you do have some sort of assessment system. The one of the functions of that assessment system is to see where they are in this process. In other words, what access have they got to their adult thinking and functioning here in our reality? And I'm assuming if somebody came in to your, you know, your assessment and they were, you know, started speaking gobbledygook or a process where it clearly added touch with reality, you would do something, I suspect you wouldn't take them on. Would you for psychotherapy? No, no. What would you do? Well, it depends how far they were. I would recommend them getting in touch with their GP and, you know, going down that road, I would presume that the GP is in contact with them. Yeah, and it depends how bad they were on the telephone conversation or whatever that we were having. My, my assessments are face to face. So I'll give you an example from only two weeks ago. Someone came in through for an assessment for psychotherapy, and they were clearly out of touch with reality quite a lot of them. So as they started to get more and more out of touch with reality, I told them to put their feet on the ground. And I didn't techniques to get them back into their adult in terms of grounding us. And then I said, have you got a psychiatrist? Yeah. Have you got your own psychiatrist? Do you have medication? So asking the adult questions to find out if they're in the NHS system. And usually they are usually they have a psychiatrist. And if they say I haven't got a psychiatrist, they usually followed up by saying, well, I've actually just moved or something. So I have in between psychiatrists or something like that. Yeah. And then then then I would find out, well, does a psychiatrist know that you're here? If you, you know, is there some sort of consultation, even in team building around your mental health, functioning, keeping yourself safe? And usually 10, if they're very disturbed, those sorts of levels, they often have lost touch with the psychiatrist. Or they haven't been on medication for a while. Or, you know, or there are people who, who need to be in the NHS system. So usually, usually though, as you go down those sorts of questions, you find out have been in the NHS system, they have got a psychiatrist, perhaps they haven't been, but that's where they need to go to. And if they haven't, which would be very surprising, you need to then find out whether who their doctor is, and then send to the doctors, or back to their psychiatrist. And you wouldn't take someone like that, even if you believe psychopathy could help, unless you had a conversation with their psychiatrist or their doctor. Yeah. Talking about that, what are your views on, you know, whether it's ethical or not to have a client that's also seen something else? Well, I could quote ethical codes, but I can tell you what I think as well. I think it's I wouldn't do that. And primarily, I wouldn't do that because it would be confusing to the client. Yeah. Because you're going to get different styles, different ways of working, different information. And the client's going to get the client number one, the client will get confused, probably because they're going to have different sources of advice, they're going to have different styles of therapy, models, and the client will get confused. And we know sense of attachment and there being it just wouldn't work. No. And the reason why I'm asking that is because if that's happened to me in the past, where somebody's been on the NHS waiting list, and then they've had a phone call saying, you know, there's a counselor free, and they've wanted to continue seeing me. And I've said, you know, ethically, I wouldn't do that. You need to finish with me. I'm not going anywhere. If you, you know, go and do the six or eight weeks with the NHS, then you can get back in touch with me. Absolutely. And this is one of the questions you should be asking on an assessment system. Yeah. Exactly this. Have you and this is one of my questions. Have we had therapy before? That's one question that takes some music to the whole process of private or NHS. And then I often might say, and are you waiting for therapy from the NHS? So you've got, you know what's happening. But if you're in a situation where you haven't gone down that road for whatever reasons. And suddenly they say, well, my NHS now finally said that I can do some CBT or whatever it is. Then I say, well, the that's fine by me. And we'll be part in company. Yeah. You can't do both. No, that I just wondered where you stood on that. But I just thought I'd mention it for the listeners. Yeah, it is very common. Well, it's more common than you think. As I say, I try to circumvent that by the assessment process where that sort of question is in there. But if I haven't for some reasons, it's more common. That's happened to me. And they've chosen either to stay with me. Yeah, as well. Yeah. And usually they do actually, if we get to that stage, because they prefer the therapy where the past affects the present and it is aimed at helping the person understand themselves, and how they got to where they are today, rather than a therapy which is more cognitively based. Yeah. However, it's very clear that they can't have both. No. Sometimes they pick the NHS mainly because of expense actually. Well, that's it. You know, I think it was a different type of therapy that they were having access to. They, you know, had it previously and, you know, CBT hadn't worked so they come back to me. But then they got I think it was EDMR. Is that what it is? That's a trauma based therapy. Yeah. There's the modern therapy actually for trauma. Yeah, they've been put on the list for that and that came up. So, you know, I obviously said that I need to stop working with you. Now EMDR will be limited usually to about 12 sessions, 12 sessions. So if somebody goes off to have EMDR, which means there's a lot of trauma about. Yeah. If I've got a relationship with the client and that's actually happened, I would say please come back here and we can talk about what you've learned in gain from the EMDR trauma based system. Yeah, which is exactly what we did. But, you know, this particular client was upset and couldn't understand why I wouldn't continue seeing them. Yeah, I think you just have to say, look, we can't do both at once. You're going to confuse this is specifically for trauma. It's not. It's repetitive eye movement. I don't do that. We can incorporate it in the process if you want to go and have it and then come back and we can process what you've learned. Yeah, which is what they did do. Yeah, it gets very boundaries. Now EMDR means there's a lot of trauma around. Yes, yeah. But it's just again, you know, obviously my skill set isn't around that I'm not qualified in that. So, you know, they were saying, well, can we not do that? And it's like, no, you know, and you've waited a long time for this appointment. I don't want you to miss out on the opportunity of, you know, seeing somebody for 12 weeks and potentially unlocking things. Yeah, I love a team approach to therapy. In other words, I love a team approach where we can get specialist skills all in the service of the clients. Yeah, therapeutic relationship. Yeah. Now, again, we're talking about disturbed people. Not only usually do they have a psychiatrist and they have a doctor. Usually they've been in an NHS. They may even been sectioned. And that type of person, you don't usually see, you know, you don't usually see Jackie. Yeah. As I say, it's a great, it's a really big debate whether psychotherapy is even useful with that type of person. I think that that leads to the question of medication. And would you work with clients who've got medication? For me, I may and I may not, but I would know one thing for certain. If I was going to work with that population, it would have to be in house. In other words, they have to be a place where there's lots of resources and they're there for three or four or five weeks, like the priori, for example. Yes. Yeah. Yeah. Because I haven't got the resources and no review for one hour a week. It's just totally, it's not sufficient. No, no. And you know, in my view, it would be unprofessional to take on somebody like that. We've got a duty of care to the clients that we see. Yeah. Medication is interesting because again, I suppose it's the levels of medication. I'd hazard a guess that there's an awful lot of, you know, people out there that are on medication and come to psychotherapy. Many. And if, but if you talk about highly disturbed people, they'll be on, they won't be just on medication given out for depression, particularly medication given out for stress. They'll be on much higher levels of medication and also different types of medication, specifically aimed to say skits, whatever it is, I don't know, schizophrenia or paranoia or delusions or whatever we're talking about. If it's at that level and there's a different orientation, medication and also much higher dosage. And they usually going to be offered at least a day in-house work with therapists in the NHS or whatever it is. And I say, if they're particularly bad, they're going to be sectioned anyway. Yeah. Now, at the end that you're talking about, which is the huge spectrum back again, to people who've got, you know, traits of paranoia or traits, the under stress I'm talking about, or traits of schizoid processes under stress, but they've got a quite a stable adult, if you like, or a robust adult, then psychotherapy is useful for that type of person. Even though under stress, they may have traits of disturbance, if you like, but they've got access to the adult to be able to have a level of functioning or take charge. Yes. Yeah. And, you know, those people, yes, I have seen, like you say, when they're under, you know, huge stress that they, you know, the traits of certain things will come out. And I, you know, to have support from somebody that they can access in a private practice, I think, is really useful. So, yeah, those people, I would say, and, you know, what you were saying earlier on about grounding techniques and, you know, them having somebody that they can contact, I think, is really useful. And sometimes even when I've had clients that are going through a particularly trying time, you know, we'll see each other twice a week as opposed to once a week until, you know, they're feeling more on an even keel again. Yeah. And I think if you do work with people who are sort of a bit higher up, the mental health continuum, say in the more in the middle, perhaps, and perhaps they've got medication to help themselves function or not. I think it's really important that the therapist has access to regular supervision. Yes. Yeah. Yeah. Definitely. And, you know, again, with, you know, a duty of care to the client, I think if you are working with somebody in that area, that you're aware of how taking a week off can impact on them, you know, that there needs to be discussions around if you've got holiday coming up or one thing or another, it's, you know, we have got a duty of care to our clients. Absolutely. And then so supervision. And the other thing that you've actually has some training, the therapist has some training in their, you know, their training, whatever it is in, it has some training how to work with disturbed people, or at least how to work in that sort of area if the person shows disturbance or high disturbance and distress, that hopefully it has some training in their psychotherapy diploma or whatever it is they've got. Yeah. Because I think it's very useful for important people or therapists that are going to work with, I'm not talking definitely about, you know, talking about the high level, paranoia, schizophrenia, delusional personality disorders, but maybe working up there a little bit. So in the middle of that continuum, they needed to have some training, I think, in the different personality disorders and how you might work with them. Yeah. Yeah. Because it is, it's not like working with the worried well. No. And mainly because they haven't got access to their adult. Yeah. They have access to an adult, but it's not a robust or strong adult. They dip in and out of it. Yeah. I could remember it being a really heavy weekend when we did training on this towards the end of our qualification. But it was also said to us that it's highly unlikely that those sort of clients would be walking in through our door. That's absolutely true and some do. Yes. Yeah. And then the therapist's assessment system is crucial. Yeah. Absolutely crucial. And therapists who don't have a good well thought out structured assessment system, I think, are laying themselves open to problems. Yeah. With these types of clients, especially if they decide to take my mind, goodness knows why they would, someone would decide to do that. But anyway, you know, we will go into the story then. Yeah. Do I know we're both, you know, I'm a psychotherapist and a transactional analysis, and that's what I do. I've never worked with counsellors. So I'm just wondering, do counsellors go through the same processes? What we do? No, no, no. Oh, maybe with assessment. But one of the problems or differences between therapists and counsellors is counsellors don't have any real training on how to deal with psychosis and disturb people. OK. So if you went on a training program, maybe even the most in depth training program with counsellors, not I'm not talking about therapeutic counsellors here. I'm talking about counselling trainer here. In their training, they don't have any training on how to work with disturbance psychotic people. That's one of the huge big differences between psychotherapy training and counselling training. Yeah. So they should definitely, definitely refer on to a psychotherapist who's had some training in that particular area. Yeah. Because again, I know we spoke about it in the past, you know, the how many different forms of. Yeah, when we do, yeah, you're right. Wendy Dryden is a well known author of psychotherapy books and counselling books. And actually, he's the preferred type of therapy is rational emotional therapy. Anyway, he's written a tremendous lot of books. And I think one of his latest books, and I think it's I can't remember what it's called, but he said there was six hundred and fifty seven different variations of therapy and counselling in the United Kingdom. That's it's mind boggling when you think, yeah. I don't know how accurate that is, but I remember reading it. Yeah. And here's me just doing the one. Yeah, but you're doing a very significant, important model in my head. Transaction analysis and I think a very good model to look at how the past affects the present. And I particularly like the personality model. Transaction analysis splits the ego into three parent, adult and child. And I think it's a very good way of thinking about this would disturb people. In other words, disturb people don't have particularly good access to a robust adult. And when I say adult, I mean, you know, being a person being able to stay in here now and appropriate to their own age and function. So it's a good model for explaining, I think, and looking at levels of disturbance. Yeah. So you picked a good model, I think. I think I picked the best model. But having said that, I'm really interested in other areas as well, do you know what I mean? Yeah. So I'm constantly learning new things. But transactional analysis is always my base. I always, yeah. I think it's a good model to assess disturbance from. But I'll say it again, that in the training, the student needs to have had a good training on understanding how a therapist might work or not work for personnel to disturb, you know, people or even disturb people. Let them worried well. Yeah. And, you know, I know I've said it before, but we have a duty of care to our clients. But it's also about our own safety and security as practicing psychotherapists as well, that we are having a robust assessment process and, you know, making sure that we're seeing the people that we can actually facilitate change. I think of the key is the assessment process, adequate training in the air of disturbed people. Thank you so much for this, Bob. OK, you're welcome. OK, so what we're going to do in the next podcast is working with shame in the therapy relationship. Great. Which I'm really looking forward to. I am as well. Until next time. See you soon. Goodbye. You've been listening to the therapy show behind closed doors podcast. We hope you enjoyed the show. Don't forget to subscribe and leave us a review. We'll be back next week with another episode.