Chapter 5: Counselling skills

The Macquarie Dictionary says that counselling is ‘giving advice’: that it is ‘opinion or instruction given in directing the judgment or conduct of another’. In the clinical context counselling can be defined as ‘the therapeutic process of helping a patient to explore the nature of his or her problem in such a way that he or she determines his or her decisions about what to do, without direct advice or reassurance from the counsellor’.

The counselling process in general practice is based on the therapeutic effect of the doctor. There is an enormous and ever-increasing need for people in the community to have many of their emotional and social problems addressed by the health profession. Modern medicine has acquired a much more scientific face over recent years at the expense of its once respected humanistic one. Medicine is primarily a humanitarian pursuit, not an economic or scientific one, and uses science as a tool. Many feel that medicine is losing sight of this, at the considerable expense of its standing in the community.¹

The public perceives that GPs can and do counsel people because more people go to their GP for counselling than to any other group of health workers, including psychologists, psychiatrists, social workers, marriage guidance counsellors and clergy.¹ People do not generally tell the doctor or even realise that counselling is exactly what led them to come to the doctor in the first place. The GP is, therefore, ideally placed in the community to make the most significant contribution to fill the community’s needs in this area.

GPs can be effective counsellors for the following reasons:²

• They have the opportunity to observe and understand patients and their environment.

• They are ideally placed to treat the whole patient.

• Their generalist skills and holistic approach permit GPs to have a broad grasp of a patient’s problems and a multifaceted approach to treatment.

• They can provide treatment in comfortable and familiar surroundings, including the doctor’s rooms and the patient’s home.

• They are skilled at working as a member of a professional team and directing patients to more expert members of the team as necessary.

• They can readily organise ‘contracts’ with the patient.

• They often have an intimate knowledge of the family and the family dynamics.

• They fit comfortably into continuing patient care with appropriate follow-up treatment programs.

To be an effective counsellor the GP must prepare for this role, first by making a commitment to its importance, then by acquiring the knowledge and skills for basic counselling by reading, attending workshops and discussing cases with colleagues who are skilled in counselling.² Appropriate workshops are those based on the seminal model of therapy by Balint,³ which aim to teach the patient new coping skills and so alleviate symptoms and improve the patient’s functioning in social and occupational roles. Well-developed interviewing skills are essential, as is self-discipline to appreciate one’s strengths and limitations.

Doctors can respond to patients’ problems and distress by a spectrum of behaviours from doctor-centred, directive behavior (directed psychotherapy) or advice at one end, to patient-centred, non-directive behaviour at the other, where the patient does most of the talking (expressive psychotherapy).² In handling psychosocial problems, advice-giving is at one end of the spectrum and psychotherapy at the other.

Counselling, as an activity in general practice, can be represented by a moving point between these two extremes.¹

Counselling can be seen as having the following features:¹

• It is a clear-cut treatment option, like a course of antibiotics.

• It is a cooperative problem-solving process.

• It is an educational venture where patients learn new information and new activities.

• It is a developmental process for patients.

• It is a change process—often moving a patient from a ‘stuck state’.

• It is a goal-directed activity.

• It is a process of energising patients and lifting their morale.

• It is a sensitive response to problems within a caring relationship.

Defining the problem (what the matter really is) is the most important step in the process of patient care. The following outline is one approach to counselling that is applicable to a general practice context.¹

1. Listen to the problem of first presentation: this involves listening not only to issues, events and experiences, but also to the patient’s feelings and distress. The emphasis here is more on the communication skills of facilitation, silence, clarification, reflection, paraphrasing, confrontation and summary, than on questioning. In many cases this phase of the counselling constitutes the major part of the therapy; for example, in grief or bereavement counselling, the doctor supports the patient through a natural but distressing process.

2. Define the problem, if possible in behavioural terms:

   Beneath the feeling is the experience, beneath the experience is the event, the event is related to a problem.⁴

3. Establish a contract for counselling, with an agreed number of visits initially (e.g. weekly half-hour or hour appointments for 4 to 6 weeks).

4. Define short-term and long-term goals for action.

5. Decide on one option—‘experimental action’.

6. Build an action program with the patient—negotiate ‘homework’ for the patient between visits.

7. Evaluate progress.

8. Continue action or select another option.

9. Evaluate progress.

10. Terminate or refer.

The PLISSIT model

The PLISSIT model, developed by Annon (1974)⁵ as an aid in therapy for sexual problems, is a very useful model for problems presented as feelings where there is limited scope for intervention by the therapist.

The mnemonic PLISSIT stands for the following:

• P is for permission giving

• LI is for limited information

• SS is for specific suggestion

• IT is for intensive therapy

Annon emphasises that every primary care practitioner should be competent to offer ‘permission giving’ and ‘limited information’.

The Colagiuri and Craig model

The medical counselling model was developed by Colagiuri and Craig (see FIG. 5.1)⁶ as a useful tool for teaching contraceptive, abortion and sterilisation counselling. It can be applied in most situations as it empowers the patients to make their own decisions through facilitation as opposed to the directive and advisory learning model.

There is evidence that the use of non-directive counselling techniques leads to more accurate diagnosis and therefore to more appropriate management and an improved outcome.⁷

Jerome Frank wrote in 1967: ‘The field of counselling and psychotherapy has for years presented the puzzling spectacle of unabating enthusiasm for forms of treatment where effectiveness could not be objectively demonstrated’.⁸ Traux and Carkhuff⁹ measured important aspects of the psychotherapeutic relationship and demonstrated what had long been recognised: the outcome was enhanced if practitioners had such qualities as accurate and sensitive awareness of the patient’s feelings, deep concern for the patient’s welfare (without attempting to dominate) and openness about their own reactions.

The essential feature of the patient-centred approach is that the counsellor is more like a facilitator; that is, by the asking of well-directed questions it is hoped that patients can realise their own solutions for their problems.¹ This encourages patients to attain understanding and personal growth themselves rather than just put their personal affairs in the hands of someone else. This does not mean to say that the facilitator is passive in the process of assessing the relative merit of various solutions produced by the patient. The doctor-centred approach is most applicable for patients who are so confused or distraught that their ability to reflect usefully is temporarily or permanently inaccessible. Here, taking a more active and authoritarian role may be just what is required. It is therefore important to be flexible and move between the two ends of the spectrum as needed.

• Listening and empathy are the beginning of counselling.

• Good communication is the basis of counselling.

• The therapist must really care about the patient.

• Always be aware of the family context.

• It is important for therapists to handle and monitor their own feelings and emotions.

• Maintain eye contact.

• The therapist must tolerate and be comfortable with what the patient says.

• Confidentiality is essential.

• Counselling is easier if there is a good rapport with the patient, especially if a long-standing relationship exists.

• Counselling is difficult if a social relationship is present.

• Don’t say to the patient ‘I’m counselling you’ or ‘I’m giving you psychotherapy’—make it a natural communication process.

• The therapist must be versatile and adapt a counselling style to the clinical occasion.

• Characteristics of the effective counsellor have been demonstrated to be genuineness, non-possessive warmth for the patient, and accurate and empathetic understanding.

Some useful interviewing skills used in counselling are summarised in TABLE 5.1.

Counselling strategies^4,7

• The therapy should be patient-centred.

• Use gentle, clever, probing questions.

• Facilitate the discussion to draw out relevant areas.

• It is important to be non-judgmental.

• Counsel through intuition and base it on common sense.

• Do not tell the patient what to do.

• Do not try to rush patients into achieving a happy ending.

• Provide guidance to allow the patient to gain insight.

• Wherever possible, make therapy non-authoritarian and non-directional.

• Use appropriate ‘gentle’ confrontation to allow self-examination.

• Help patients to explore their own situation and express emotions, such as anxiety, guilt, fear, anger, hope, sadness, self-hate, hostility to others and hurt feelings.

• Explore possible feelings of insecurity and allow free expression of such feelings.

• Explore patients’ belief systems and consider and respect their spiritual aspirations and conflicts.

• Ask key searching questions, such as:

  • – ‘What would be different in your life if you were well?’

  • – ‘Who are you mad at?’

  • – ‘If I understand you correctly you are telling me that …’

  • – ‘You seem to be telling me that …’

  • – ‘Correct me if I’m on the wrong track, but you are saying that …’

  • – ‘What do you think deep down is the cause of your problem?’

  • – ‘What does your illness do to you?’

  • – ‘Do you really worry about any things in particular?’

  • – ‘How do you think your problem should be treated?’

  • – ‘If you could change anything in your life, what would it be?’

• Empower your patient. Better outcomes are likely if your patients are active participants in their care and take responsibility for change.

  Avoid:

• telling patients what they must do/offering solutions

• giving advice based on your own personal experiences and beliefs

• bringing up problems that the patient does not produce voluntarily

What counselling is not

• Giving information

• Giving advice

• Being judgmental

• Imposing one’s own values, behaviour and practices

• The same as interviewing

• Handing out patient education material

Cautions¹

• Individual doctors cannot be useful to all patients, so be selective.

• We cannot solve patients’ problems for them.

• Patients’ problems belong to them and not to their counsellors.

• Patients often have to change by only an inch in order to move a mile.

• If a counselling relationship is no longer productive, then terminate and refer.

• Most patients in primary care need information, support and a lift in morale, not long-term psychotherapy.

The following groups of patients are not likely to benefit from counselling therapy¹ (i.e. relative contraindications):

• psychotic patients

• patients who have had an unrewarding experience with psychiatrists and other psychotherapists

• people who are antagonistic to the notion of a psychosocial diagnosis, subsequently found to be organic

• patients with little awareness or language to express emotional difficulty

• patients who do not believe doctors can treat psychosocial problems

• patients with a vested interest in remaining unwell who are therefore resistant to change (e.g. patients with work-related disabilities awaiting legal settlement)

• patients with chronic psychosomatic tendencies who are willing to do almost anything to maintain the relationship

• those in an intractable life situation who are unable or unwilling to change

• Interpersonal psychotherapy/counselling, ideal for primary care and the treatment of depression, is therapy for interpersonal problems.

• Mindfulness based on intervention therapy.

• Behaviour therapy (BT) is where the patient is directed to do something.

• Cognitive therapy (CT) is based on the identification of automatic thoughts that are invariably negative. Cognitions are thoughts, beliefs and perceptions.

• Cognitive behaviour therapy (CBT), which combines BT and CT.

The psychotherapy continuum is illustrated in FIGURE 5.2.²

Cognitive behaviour therapy

CBT is a form of non-pharmacologic treatment emphasising self-help and aiming to change perceptions and behaviour that may perpetuate symptoms and disability. It is basically a system of graded exposure (systematic desensitisation). It can be applied in any area of medical practice as a form of psychotherapy and is suitable in general practice for the treatment of depression, insomnia, eating disorders, delusions and hallucinations in psychotic disorders and anxiety in all forms, especially social anxiety disorder and phobias—in all of which CBT has proved to be better than a placebo.¹¹

It is a relatively brief, active, directive and practical form of therapy. However, not all therapists or patients are suited to CBT.

The basic processes of CBT are to:

• define specific and concrete goals for functional activities and moods, e.g. pain control

• educate the patient

• teach basic skills for symptom control, relaxation and breathing control (especially for hyperventilation)

• identify, challenge and change maladaptive thoughts, feelings, perceptions and behaviour

Some basic principles and objectives of CBT are to:

• aim to bring about a desired change in patients’ lives, i.e. aim to achieve desired goals

• assess, monitor and attempt to modify thoughts and behaviour

• reinforce positive behaviour and discourage negative behaviour

• educate about any misconceptions about a patient’s illness

• encourage the patient to be an active participant (not a passive recipient)

• get patients to establish a problem list and hierarchy of problems

• aim for more realistic thinking and more adaptive responses

Mindfulness

Mindfulness, which is based on meditation, is the process about raising awareness and a special way of paying attention to help the person cope with the daily events in their life.

The basic processes of mindfulness are to:

• train people to focus on the positive aspects of their lives and shut out distraction and negativity, i.e. attention training

• learn to concentrate in a restful way and cope with stress

• emphasise attentiveness to the present moment

• voluntarily reign in a wandering attention time and again

Opportunities for basic counselling by the GP are ubiquitous in medical practice. Complex problems require referral but, even then, the GP still has an important role in continuing management.

Areas demanding counselling include:

• any crisis situation—breaking bad news

• bereavement or grief

• terminal illness/palliative care (CHAPTER 11)

• marital problems (CHAPTER 2)

• family problems (CHAPTER 2)

• sexual dysfunction (CHAPTER 116)

• chronic pain

• anxiety and stress (CHAPTER 81)

• depression (CHAPTER 19)

• intellectual handicap in a child

• infertility (CHAPTER 115)

• any disease or illness, especially severe illness

• sexual abuse/child abuse (CHAPTER 95)

• intimate partner violence (CHAPTER 118)

• insomnia and other sleep disturbances (CHAPTER 74)

Crisis situations are not uncommon in general practice and people in crisis are usually highly aroused and demanding. Examples include tragic deaths, such as children drowning or sudden infant death syndrome (SIDS), unexpected marital break-up and breaking bad news.

Aims of crisis intervention

• Resolve the crisis and restore psychological equilibrium as quickly and constructively as possible.

• Encourage the person in crisis to regain control and take appropriate action.

Principles of management

• Intervene early—actively and directly.

• Establish an empathetic alliance.

• Be accessible.

• Attend to family and social supports.

• Be prepared for the difficult phase of 24–48 hours.

• Do not carry the burden of crisis.

• Aim for brief, time-limited intervention (no more than six interviews over 6 weeks).

• When necessary, be prepared to provide short-term use of psychotropic drugs (e.g. a hypnotic), for two or three nights of good sleep.

Ten rules to help those in distress

The following rules are given to those in crisis (personal explanation followed by a take-home hand-out):

1. Give expression to your emotions. You need to accept your reactions as normal and not be afraid to cry or call out. Try not to bottle up feelings.

2. Talk things over with your friends. Try not to overburden them but seek their advice and listen to them. Do not avoid talking about what has happened.

3. Focus on things as they are now—at this moment. Aim not to brood on the past and your misfortune. Concentrate on the future in a positive way.

4. Consider your problems one at a time. Try not to allow your mind to race wildly over a wide range of problems. You can cope with one problem at a time.

5. Act firmly and promptly to solve a problem. Once you have worked out a way to tackle a problem, go for it. Taking positive action is a step in allowing you to get on with life.

6. Occupy yourself and your mind as much as possible. Any social activity—sports, theatre, cards, discussion groups, club activity—is better than sitting around alone. Many people find benefit from a holiday visit to an understanding friend or relative. Religious people usually find their faith and prayer life a great source of strength at this time.

7. Try not to nurse grudges or blame other people. This is not easy but you need to avoid getting hostile. In particular, endeavour not to get angry with yourself and your family, especially your spouse.

8. Set aside some time every day for physical relaxation. Make a point of doing something physical, such as going for a walk, swimming or enjoying an easy exercise routine.

9. Stick to your daily routine as much as possible. At times of crisis a familiar pattern of regular meals and chores can bring a sense of order and security. Avoid taking your problems to bed and thus ensuring sleepless nights. Try to ‘switch off’ after 8 pm. Taking sleeping tablets for those few bad nights will help.

10. Consult your family doctor when you need help. Your doctor will clearly understand your problem because stress and crisis problems are probably the commonest he or she handles. Consult your doctor sooner rather than later.

    • Remember that there are many community resources to help you cope (e.g. your religious leader, social workers, community nurses, crisis centres and organisers within churches and other religious centres).

    • Take care: do drive carefully and avoid accidents, which are more common at this time.

Bereavement or grief may be defined as deep or intense sorrow or distress following loss.¹² Raphael uses the term to connote ‘the emotional response to loss: the complex amalgam of painful affects including sadness, anger, helplessness, guilt, despair’.¹³

The GP will see grief in all its forms over a wide variety of losses. Although the nature of loss and patient reaction to it varies enormously, the principles of management are similar.

Stages of normal bereavement

1. Shock or disbelief. Feelings include numbness and emptiness, searching, anxiety, fear and suicidal ideation, ‘I don’t believe it’. Concentration is difficult and spontaneous emotions, such as crying, screaming or laughing, tend to occur. There may be a sense of the deceased’s presence, and hallucinations (visual and auditory) may occur.

2. Grief and despair. Feelings include anger, ‘Why me?’, guilt and self-blame, and yearning. Social withdrawal and memory impairment may occur. The feeling of intense grief usually lasts about 6 weeks and the overall stage of grief and despair for about 6 months, but it can resurface occasionally for a few years. The last few months involve feelings of sadness and helplessness.

3. Adaptation and acceptance. Features of the third stage include significant feelings of apathy and depression. This phase takes a year or more. Physical illness is common and includes problems such as insomnia, asthma, bowel dysfunction, headache and appetite disturbances.

Pathological bereavement

Pathological bereavement can occur and may manifest as intense emotion, particularly anger, and multiple visits with somatic complaints; the patient often gets around to long dissertations about the deceased and the circumstances surrounding death. Extreme anger is likely when the sense of rejection is great, as with divorce or sudden death. Guilt can also be intense.¹²

Raphael’s classification of the patterns of pathological grief and its various resolutions are presented in TABLE 5.2.¹³

The GP as counsellor¹

Important rules to bear in mind:

• The bereaved may be feeling very guilty.

• They may be angry towards their doctor or the medical profession in general.

• They need a clear explanation as to the exact cause and manner of death. Autopsy reports should be obtained and discussed.

• The bereaved tend to view an apparent lack of concern and support as disinterest or guilt.¹²

• Early intervention averts pathological grief.

The GP probably had a close relationship with the deceased and the family. The GP will have a special awareness of those at risk and the nature of the relationships within the family. The family is likely to maintain the relationship with the GP, expressing the physical and psychological effects of grief and consulting about intercurrent problems.¹²

Working through the stages of grief with patients will allow GPs to reach some acceptance of their own emotions, as well as ensure that patients feel supported and cared for, rather than distanced by embarrassment.

Help from religious sources is highly valued as it can meet both spiritual and personal needs. Other resources include funeral directors, hospice (and other) counsellors, and support groups, such as those for SIDS.¹²

At least 30 minutes should be allowed for consultations.

Long-term counselling

Normal bereavement can persist for years. Ongoing counselling is indicated if it continues unabated or psychiatric referral sought if grief is extreme. Regular enquiries during routine consultations or meetings are important if the patient appears to be coping.

Good communication skills are fundamental to giving bad news appropriately. When bad news is broken insensitively or inadequately the impact can be distressing for both giver and recipient, leaving lasting scars for the latter. For the doctor it may represent professional failure, fear of people’s reaction and feelings of guilt. Doctors should have a plan for this difficult process and learn how to cope with the recipient’s reaction. Most of the circumstances described apply to unexpected death or anticipated death.¹⁴

Sharing bad news with a patient

This difficult task is based on sound communication skills and good dialogue. The meeting should be face to face, not over the phone or internet.

Basic guidelines

• Plan the consultation, review clinical data, set aside ample time.

• Meet in an appropriate room with privacy and no interruption.

• Ask the patient if they would like company (e.g. a relative or friend).

• Make good eye contact and be alert for non-verbal responses.

• Use simple, understandable language; avoid medical jargon, speak clearly and sensitively

• Be honest and diplomatically to the point (don’t cover up the issue).

• Allow time, silence, tears or anger.

• Avoid inappropriate methods (refer to ‘avoid’ in TABLE 5.4) and don’t give precise predictions about life expectancy.

• Write down significant points and use sketches or diagrams as appropriate.

Management

Follow the 10 basic steps of the management interview (see CHAPTER 3) with the emphasis on the patient’s understanding of the message and his/her feelings about it (see TABLE 5.3). Offer ongoing support and arrangements for continuing involvement including allied health professionals.

Coping with patient responses

• The responses cover a wide range—stunned silence, disbelief, acute distress, anger, extreme guilt.

• Be prepared for any of these responses.

• Appropriate training using simulated patients, video replays and skilled feedback improves communication skills.

• Give permission and encouragement for reactions, such as crying and screaming.

• Have a box of tissues available.

• A comforting hand on the shoulder or arm or holding a hand is an acceptable comfort zone.

• Offer a cup of tea or a cool drink if available.

• Ask the patients or relatives how they feel, what they would like to do and if they want you to contact anyone.

• Arrange follow-up.

• Give appropriate patient education material.

• Provide information about support services.

Children

Remember that there are two ‘patients’—child and family. The same ‘bad news’ principles apply. Talk in age-appropriate terms to the child with the aim of establishing their understanding of their illness and feelings.

Unexpected death

Some basic initial rules:¹⁶

• If relatives have to be contacted it is preferable for the doctor (if at all possible) or a sympathetic police officer to make the contact personally, rather than a relatively matter-of-fact telephone call from the hospital or elsewhere.

• If a telephone message is necessary, it should be given by an experienced person.

• The relatives or close friends should not drive to the clinic alone.

The setting for the interview:

• Use a suitable quiet private room if possible.

• See the recipients of the news alone in the room.

• Advise that the meeting should be undisturbed.

Guidelines for the doctor

• Be well prepared: check the facts and plan your approach.

• Always ask those involved if they have heard any news or know the reasons for the consultation.

• Always assess their understanding.

• Give information in an unhurried, honest, balanced, empathetic manner.¹⁷

• Look directly at the person you are talking to, be honest and direct, and keep information simple (avoid technical language).

• The sad news must be accompanied by positive support, understanding and encouragement.

• Give recipients time to react (offer time and moments of silence to allow the facts to sink in) and opportunities to ask questions.

• Avoid false reassurance.

• Remember that relatives appreciate the truth and genuine empathy.

• In the event of death, relatives should be given a clear explanation of the cause of death.

A list of guidelines for the interview is summarised in TABLE 5.4.¹⁶

Studies have emphasised the importance and therapeutic efficacy of counselling in the management of the depressed patient.¹⁷ The most practical approach by the GP to the depressed patient is empathy, support and a logical explanation of their malaise. The author gives the following explanation to the patient.

Emphasising the ‘missing chemical’ theory really helps patients and family come to terms with an illness that tends to have socially embarrassing connotations. It also helps compliance with therapy when antidepressant medication is prescribed.

Ongoing contact, support and availability are an important component of counselling with appropriate referral to someone with more expertise, should that be required. CBT is a most effective and important approach to the management of depressive illness.

Patients suffering from long-term pain are a special problem, especially those with back pain who seem to be on a merry-go-round of failed multiple treatments and complex psychosocial problems. These patients are frequently treated in pain clinics. As family doctors we often observe an apparently normal, pleasant person transformed into a person who seems neurotic, pain-driven and doctor-dependent. The problem is very frustrating to the practitioner, often provoking feelings of suspicion, uncertainty and discomfort.

De Vaul and colleagues¹⁸ list five subgroups of patients where perplexing pain presents as the major symptom:

1. pain as a symptom of depression

2. pain as a delusional symptom of psychosis

3. pain as a conversion symptom of hysterical neurosis

4. pain as a symptom of an unresolved bereavement reaction

5. pain as a symptom of a ‘need to suffer’

Patients who somatise their symptoms present one of the most difficult challenges to our skills and usually require a multidisciplinary team approach.

Management involves:

• thorough medical assessment

• psychological assessment

• detailed explanations to the patient and family about treatment

• rational explanations about the cause of the pain

• management of associated problems (e.g. depression, sexual dysfunction)

• behavioural modification to encourage increased activity and a gradual return to normality

Problem or pathological gambling is persistent and recurrent maladaptive gambling behaviour despite its detrimental effect (disruption of personal, family or work life). It is undoubtedly a dependence disorder similar to alcohol and other drugs with a similar approach to management. Refer to DSM-5 criteria for pathological gambling. Prevalence: 0.5–1.5% adult population.

Dangers

• Suicide risk (high)

• Major depression (up to 75%)

• Stress-related problems

• Domestic violence

Key warning

• Gambling >$200 week

• Chasing losses

Other telltale signs

• Spending many hours gambling

• Placing larger, more frequent bets

• Lying about behaviour

• Being secretive

• Promising cutting back, but not doing it

• Impulsive activity

• Mood swings

• Gambling at the expense of other pleasant social activities

• Growing debts

• Excessive drinking

First-line management

• Ask (as part of social history).

• Consider South Oaks Gambling screen to support provisional diagnosis.¹⁹

• Confront firmly if suspected.

• Consider using the Prochaska and Di Clemente model of change (CHAPTER 21).

• Provide education material.

• Look into the family (domestic violence?) and provide support.

• Advise the family not to provide ‘rescue money’.

• There is no recommended pharmacological treatment.

Counselling approach

Problem gambling is a treatable condition and GPs can provide a central role in management. As for smoking and alcohol dependence, a brief intervention and education consultation session about the impact of excessive behaviour can be most effective. CBT is a very effective treatment for gambling. It combines systematic discussion and carefully structured behavioural assignments to help patients modify problematic thinking patterns and behaviours. ‘CBT directed towards correcting erroneous perceptions, irrational beliefs and misunderstanding of concepts of randomness and independence of chance events is a fundamental element of any therapeutic approach.’²⁰

It is appropriate to use specialist gambling counsellors when one’s intervention is not proving effective or where there is evidence of disturbing gambling problems. (Refer www.gamblersanonymous.org.)

If one feels out of one’s depth, then immediate referral to an expert is important. CBT is a most appropriate therapy for most conditions.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Depression

• Coping with a crisis

• Bereavement

• Gambling: problem gambling