It is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried" Rogers, (1961).
This assignment will discuss and explore psychological therapeutic interventions and physical treatments available for people with MH problems. The efficacy of cognitive behavioural therapy (CBT) and medication will be evaluated with reference to treating the specific phobia, emetophobia. There will be examination as to whether physical and psychological treatments can be mutually exclusive. The principles underlining and participation in activities involved within therapeutic group work will be discussed along with how to assist clients in their daily activities. This will look at the theories but also the practical side of support. The principles of working with people who exhibit signs of challenging behaviour will also be explored. Reference will be made to a case study known as Lucy who has given consent for the details of her illness and experiences to be used in line with confidentiality policies.
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MH is defined by the World Health Organisation (WHO) (2007) as a positive state of wellbeing where individuals cope with everyday stresses, work productively contribute to their community and realise their potential. Mental ill health (MI) can occur when there is a deviation from the societal norm and can be permanent or temporary and is also subjective, Norman and Ryrie (2009). MH problems are not a recent phenomenon with suggestions that medicine, magic or religion were used as treatment as far back as 10,000 BC, Darton (1999). Early asylums included what is now called Bethlem Royal Hospital admitting mentally ill patients in 1357 and later becoming a dedicated psychiatric hospital. Treatment included little more than restraint and the conditions were appalling, Kring, Johnson, Davison and Neale (2010).
Witch-hunts and demonology showed peoples ignorance of MI and understanding and therefore improved treatment did not really begin until the 19th century, culminating in Kraepelin's research, Darton (1999). This led to a systematic classification of MI which is the basis of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and International Classification of Disease (ICD-10) used today the latter of which is more prevalent in the UK, Hippius and Muller (2008). Darton continues that despite earlier advances, Darwins theory of evolution and genetic links saw attitudes revert to there being no treatment options and therefore locking patients up was the only option.
These theories led to the development of the biomedical model (BM). McLeod (2007) states that the BM implies MI is a deviation from a measurable biological norm where biological causes portray outward signs and symptoms which can then be medically treated. Engel (1977), acknowledges the belief that the medical model and its treatment in psychiatry is well resourced, achieving successful results and devising new treatments. However he suggested the need for a new model which would incorporate the biological, psychological and social influences on MH and developed the bio-psycho-social model (BPS). He proposes that this helps to explain why some people react with an "illness" whereas others experience "problems with living". Wade and Halligan (2004) imply that the BM and BPS can work together where medicine can lead to successful treatment, especially for the likes of phenylketonuria which is biological in origin and acknowledging different stimuli which may benefit from alternative treatments.
The use of medication for MH expanded rapidly from the mid 20th century after observations were made from drugs used for other conditions having an impact on the clients' emotions. Gross (2009), lists medical treatment as including anti-depressant, anti-anxiety and antipsychotic drugs, electro-convulsive therapy (ECT) and psychosurgery. It could be argued that other physical treatments exist in the form exercise, diet and light exposure, as these influence serotonin and tryptophan levels known to be associated with mood changes, Young (2007) whilst Cottrell (2007) adds occupational therapy (OT). For the purpose of this assignment the use of anti-depressant drugs for specific phobia will be discussed.
Alternatively psychology is defined by Medline (2010) as the science of mind and behaviour. It is generally thought to have begun with Wundt, Kim (2006) and led in time to psychoanalysis developed by Freud from Breuers work, Rudnytsky (2008). Whilst Popper (1963) criticised psychoanalysis as not being able to be scientifically tested, Cohen (2007) reports that Freud and therefore psychoanalysis is a scientific interpretation.
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In the 20th century further progress in psychology saw Gestalt's holistic approach and Pavlov's stimulus-response come together to give the basis for CBT, Mandler (2007). In the 1960's Beck, a psychiatrist and psychotherapist in America noted that his clients seemed to have "internal dialogues" which could influence the way a session may go depending how they interpreted his responses, Bloch (2004). CBT is classed as a psychological talking therapy along with psychoanalysis and counselling. Evidence-based practice (EBT), has recently favoured CBT for many conditions, Lambert, Bergin and Garfield (2004) and in Great Britain the National Institute for Health and Clinical Excellence (NICE) (2008) recommends it as the primary treatment for post-traumatic stress disorder, obsessive-compulsive disorder, body-dysmorphic disorder, anxiety and depression.
According to Williams (2009) the theory behind CBT is to change individual attitudes and behaviour by focusing on the relation between beliefs and attitudes and how they affect behaviour. MH problems tend to occur when this becomes unbalanced so once this is identified it is hoped the negative influences can be changed. She continues that it is not the experiences themselves that upset individuals but the how they interpret them. If these interpretations become habitual, a vicious circle can occur due to alternative thoughts being blocked.
A phobia is an irrational fear of a situation or object which induces an anxiety response or acute symptoms of panic, Beck, Emery and Greenberg (1985). Norman and Ryrie (2009) explain that phobia is classified within the IDC-10 under three sections. Agoraphobia is a cluster of phobias including fear of leaving home, travelling alone or being in public places. Panic disorder (PD), depression or obsessive behaviour characterise it and avoidance of trigger situations is the main coping strategy. Social phobia (SoP) is the anxiety of social settings and again avoidance is employed to cope. Finally specific phobia (SpP) is isolated to particular triggers such as heights, dentists or flying. While the trigger of SpP may seem discrete, reactions can be extreme and mimic those of agoraphobia and SoP. The SpP which Lucy suffers from is emetophobia which is the fear of either oneself or others or both suffering nausea and/or vomiting.
Hill (2004) explains that phobias incorporate feelings and behaviours of anxiety, panic, depression and even OCD occurring from an intense fear over a situation or object that in normal circumstances isn't considered a threat. The rationale behind phobia is linked to the "fight or flight" response to a perceived threatening situation. She goes on to explain that it may not even be the situation or object that is feared but the feelings clients experience when confronted with them. As the sufferer is aware that their response is irrational they are deemed to be neurotic rather than psychotic.
Whilst a phobia such as Lucy's emetophobia may appear specific the consequences of that fear may be extensive. Where avoidance is a natural response to a phobia with emetophobia it is difficult to avoid personal physical symptoms. Heaton-Harris (2007) explains that whilst sufferers of arachnophobia can avoid contact with spiders relatively easily, emetophobics cannot escape what they fear as it is internal i.e. their stomach. Stimuli to the fear response can be external too and crowds became threatening as she worried about what she would do if she or others became sick, how she would escape and if she needed to, where she could vomit without being seen. Therefore Lucy found herself increasingly avoiding social situations and developing SoP. Ironically people with emetophobia rarely vomit despite nausea tending to be constant and the last time Lucy vomited was after an accident when she was ten. It is widely accepted that emetophobia has an early age of onset which is also consistent with SpP, Lipsitz, Fyer, Paterniti and Klein (2001) and Heaton-Harris (2007).
Lucy limited her food intake attributing feelings of nausea to what or how much she had eaten, avoiding all foods with a reported high incidence of food-poisoning such as chicken, shellfish and fast food. She never ate out and was overly cautious of sell by dates and how food had been stored. At the worst point in her illness she survived on toast, cheese and Mars bars as she saw only these as "safe foods" and was 3 stone underweight. This can in turn lead to a misdiagnosis of anorexia-nervosa Veale (2009). She developed the use "safety behaviours" which she assumed prevented her from being or feeling sick such as consuming large amounts of antacids and mints and superstitious thoughts began to dominate her daily life. These "safety behaviours" and superstitions led to traits of OCD, she became increasingly anxious about everyday life and developed depression and agoraphobia. It is illustrated by this that Lucy's self-help measures were actually doing her more harm than good.
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Lucy recalls that she was unaware that what she suffered was a phobia until she was 32, assuming that she was just "weak" and "pathetic" in her ability to cope with something natural. Indeed emetophobia is only recently being recognised, Hunter and Antony (2009), despite figures suggesting that between 1.7% and 3.1% of men and as many as 7% of women suffer, Lipsitz et-al (2001). They continue to state that it "can be a chronic, pervasive and debilitating disorder" and as professionals themselves have very little, if any, knowledge, treatment may be delayed and restricted.
Whilst many people do not seek professional help general phobias Hill (2004), there are effective and pharmacological therapies available with a large body of evidence suggesting psychological interventions, especially CBT, being the most effective, Institute of Psychiatry, South London and Maudsley NHS Trust (SLMT) (2010). Veale, (2010), who works here refers to how little research has been conducted into this phobia and its treatment and is conducting his own study. SLMT suggest the possibilities of CBT, hypnotherapy and medication whilst Veale limits it to CBT and medication.
Whilst emetophobia is not widely understood the symptoms caused by it are. This leads doctors to assume that patients are suffering from the associated depression, anxiety, panic disorder, OCD and misdiagnosed anorexia-nervosa, and treat them accordingly. Some doctors may prescribe anti-emetics and this happened with Lucy. Whilst the sufferer may be grateful for this and it may enable them to start rebuilding living their lives, the medication is just another coping mechanism which is masking the symptoms and not helping to cure the problem. **** Whilst the favoured treatments used to be drug treatments, the recent development of talking therapies and CBT, have taken over.