Counselling psychologist Melanie Phelps tells Clare Jerrom the key to success in treating mental health problems in adults
Using several strategies to tackle a mental health disorder is key to the success of the treatment, an eating disorder specialist has said.
Different combinations of therapy, medication, exercise and support should be used in conjunction with each other rather than as stand-alone treatments, said counselling psychologist Melanie Phelps, who provides therapy for a range of issues and specialises in ED. If one treatment is not working in tackling a client’s mental health problem, then psychologists should not be afraid to use or add a different technique or type of therapy, she added.
However, getting buy in from the client is also essential to any form of treatment being successful, says Phelps. “Some people want the therapist to do all the work for them and that’s just not realistic” she explained.
The highest rates of suicide are in psychology
Phelps trained to be a registered nurse and worked in the emergency department in a hospital where she was exposed to many of the issues she deals with using therapy today, such as people having over-dosed or suffering alcohol poisoning. From hospital work, she became a practice nurse running smoking cessation clinics where she learnt more about relaxation techniques for her clients as well as hypnotherapy.
This sparked a real interest for Phelps and she decided to undertake a Diploma in Hypnotherapy, having previously studied for a psychology degree. She scaled down her nursing work and worked one day a week at an alternative medicine and complimentary therapies centre where Hypnotherapy became increasingly popular.
Phelps admits she became “addicted to learning” following the diploma and went on to do a chartership to become a counselling psychologist which she concedes was “more difficult than I thought” having gone back to studying as a mature student. Phelps also completed a teaching qualification and the nursing, psychology, hypnotherapy and teaching skills have finally all come together for her current work which is spread across three different roles.
As a counselling psychologist, Phelps has her own private practice where she carries out therapy, she teaches the Diploma in Psychotherapeutic Counselling course for an Open University Accredited course provider and does independent work which includes psychological assessments and report writing.
“The teaching keeps me up-to-date and keeps my practice fresh. The report writing also ensures my analytical and formulation skills are strong. I couldn’t do any of the three aspects of my work full-time, psychologists and psychiatrists as well as doctors have high burnout and suicide rates of any profession, but a change is as good as a rest and I find the combination refreshing” she says.
Anxiety and depression are the ‘common colds’ of mental health
The teaching for the Open University Accredited course is for people who wish to change careers and move into counselling and therapy. While students may have covered issues such as relationships and grief and loss in their psychotherapy course, many have not covered mental health problems in much depth. As a result, Phelps teaches one and two day workshops at the weekends on issues such as personality disorder, Post-Traumatic Stress Disorder, OCD, depression and eating disorders which contributes towards Continuing Professional Development – a pre-requisite of registration with the Health and Care Professions Council.
Akin to this, Phelps acts as a mentor for under-graduates which is a voluntary role. She takes one or two psychology under-graduates and provides career mentoring, helps them to access placements and generally provides support.
Phelps’ private practice receives referrals from the bigger insurance companies such as BUPA and AXA. The insurance companies refer employees who are experiencing difficulties and need psychological support. “Many of the employees referred to me are in senior positions and are burnt out with issues like stress, problems with alcohol or relationship difficulties and I provide six or 12 sessions to help them to get through.”
GPs and rehab agencies also refer to Phelps, and people also self-refer and she treats issues including anxiety, depression, Obsessive Compulsive Disorder, phobias, Post-Traumatic Stress Disorder, Eating Disorders and relationship problems. Many of the patients are teenagers and young people.
“The most frequent referrals are for anxiety - or anxiety disorders such as situational anxiety, OCD, panic attacks - and depression which are the ‘common colds’ of mental health,” says Phelps. “After that, the majority of my referrals are for Eating Disorders as that is the area I specialise in.”
Teenagers are creative and imaginative
Phelps’ core training for therapy was in Cognitive Behavioural Techniques which tends to be short-term therapy involving talking about thoughts, feelings and behaviours with practical tasks and assignments between sessions. “Sometimes the insurance company wants a CBT practitioner but if I see the client is not going to buy into CBT, I may integrate something else – providing them the space to talk through their problems, hypnotherapy or learning breathing exercises as generally people can get overwhelmed by life.
“I also use Solution-Focused Therapy, a short-term model of therapy that concentrates on solutions rather than problems. Much therapy is centred round the problem but this flips the theory on its head and you just concentrate on the solution and what life would be like if that problem didn’t exist. So you ask questions such as, if you didn’t have such and such a problem, where would you live, who would you live with, what would you be doing for a job, who would you be friends with? I also use scaling questions and ask if 0 is rock bottom and 10 is high, where are you now in terms of your preferred future? If you are at 5 now, what would it take to reach 6, 7 or 8? What would need to change”
“It works really well with teens as they are creative and imaginative and they are often under a lot of pressure. This can really help with mild depression,” she adds.
Phelps also undertakes Eye Movement Desensitisation and Reprocessing therapy which is typically used to treat PTSD and involves the client sitting comfortably and following the movement of a pen or finger from left to right, backwards and forwards. Biometric beats may also be used on headphones where a noise is sounded in the left ear and the right ear alternatively.
“The science behind it is that if we are traumatised, our mind, in a ‘fight or flight’ moment, freezes and cannot process the information and gets stuck. The left to right movement is to try and mimic the REM which occurs naturally during sleep when your eyes flit from left to right and mimicking this motion basically unfreezes the memory or image thus allowing the brain to process it,” she said.
People with OCD wait nine years before seeking help
“The type of therapy I deliver is based upon what the client wants, my clinical judgement and time available – if someone wants to analyse their childhood but we only have six sessions it’s going to be difficult. However, we may start out on one form of therapy and if we are not getting anywhere, I will try something else.”
“Most problems are complex and involve elements from childhood, personality, a life event, relationships, the cure is not one session, technique or batch of therapy. It might be that the client needs medication, exercise, relaxation techniques, initiating their own self-care, attending support groups. I treated one client with an eating disorder and she had medication at first, then one lot of therapy which was a stepping stone, she then changed her job, went back to college, went on a low dose of antidepressants, had CBT, went to a support group and took up yoga classes, the combination is what is helping her to get better” she said.
The success of the therapy is also dependent on when people ask for or receive help for their problems. “Research has shown that it can be nine years before someone with OCD asks for help because they are scared of being told they are ‘mad’ or they think it will get better on its own. People come to see me for therapy following a car accident and it turns out the accident was three years ago. By then it has become a chronic problem which has become very engrained. However, people with anxiety are more likely to have expressed concern to a doctor maybe thinking that they are having a heart attack when they are experiencing panic attacks and this often means that people with anxiety get help quicker and their problems can be successfully treated within a few months. After nine years, a problem is really entrenched” she adds.
“The success of the therapy is a combination of the type of person, how soon they seek help and how willing they are to attend and work hard – often people want the therapist to do it all,” she adds.
For example, people with addictions may need to change the fabric of their whole life: their friends, their social circle, their relationship if it is not supportive, sometimes even where they live, but many are not ready to do that, Phelps explains. In the same vein, Phelps would advise clients with depression to get outside, get some fresh air or exercise but often they don’t want to do it. “Exercise is well-known to help with mental health problems particularly meditative exercise like walking, running, swimming and even golf can be a real antidote. But some people are not willing to do their bit. The therapy session with me is for an hour a week – they have the rest of the week and have got to do their bit.”
The final prong to Phelps career is her independent work that she carries out for WillisPalmer, undertaking psychological assessments of parents and writing reports about their parenting ability. Problems may have arisen where the children are not attending school, or the neighbours have reported arguments. A psychological assessment is carried out alongside social worker intervention to ascertain whether there is something mentally that is affecting their capacity to be a good parent: depression, anxiety, personality disorder, anger management, eating disorders, domestic violence, addictions.
The ‘toxic trio’, Phelps explains, is substance misuse, domestic abuse and mental health problems. “How can a parent be a consistent, reliable person reinforcing consistent, definitive boundaries and looking after a child when they cannot look after themselves? Children are being exposed to violence that they can go on and emulate in their own relationship,” says Phelps.
These assessments require different skills than therapy and Phelps says she gains an insight into the parents’ background by asking them about their childhood, their first memory, their early attachments, how they got on with siblings, whether they experienced any losses or grief, whether they moved around a lot and so on, followed by questions about how they are today – do they cook, do they take substances or alcohol, have they been in trouble with the law etc. Phelps also carries out personality profiling and mental health screening which consists of a number of questions, many of which are similar but phrased slightly differently and which can ascertain whether the parent is being consistent in their answers or trying to ‘fool’ a professional. The screening can also indicate whether the client’s answers indicate that they are showing tendencies for ADHD or Autism for example as well as their personality style such as whether they are compliant, passive or erratic.
Leaving it to the judge
Phelps then combines the results of the screening with her interview results and looks at what other professionals have said about the client. She takes a view from how the client has presented themselves - have they turned up on time, how are they dressed, how do they appear, do they ask for breaks to have a cigarette for example, or are they too passive to ask? Phelps also accesses medical records which she says reveals a lot about a person.
Medical illnesses will be documented, but the medical records may reveal if the client has chronic pain, or severely anaemic which would impact on energy levels and parenting ability. If a client has diabetes, it could affect their mood and parenting skills. How frequently they present at the doctors also indicates as to whether the client may be neurotic or whether they only present at the doctors in emergency situations, maybe avoiding detection from professionals. Phelps also lists any discrepancies between what the client may have said in comparison to what their partner or other professionals may have reported.
All that information is gathered and written into a report which also makes recommendations as to what help the client may benefit from, for example, a woman experiencing domestic violence may be referred to the Freedom programme or she may recommend that someone displaying symptoms of PTSD has trauma counselling or that someone with alcohol problems attends AA and therapy sessions.
“The greatest challenge in my job is to put people at ease, to enable them to feel comfortable and safe to open up to me as often people have trust issues and are naturally concerned about the consequences of what they divulge. It is also important to write up any issues or problems respectfully and as compassionately as possible bearing in mind the clients will get to read the report too,” said Phelps.
“Whatever has happened – it is up to the Judge to judge,” she concludes.