An HGV driver was involved in a serious road traffic accident, in which the vehicle turned over onto its side, and continued to travel along the road. The driver was convinced that he was going to die as his head was only inches from the road. He was referred to me 18 months or so after the event and he was low in mood, irritable, and preoccupied with that moment in his cab. He could not stop thinking about his wife and two children and he would have brief involuntary images of them alone, without him. He had not returned to his old lifestyle and could not think of the future. He agreed that a part of him had not accepted that he had survived.

I encouraged him during the assessment to think through carefully what would have happened had he died, and I guided him through the images of the news being broken to his family, the funeral, and the time beyond. This may sound cruel, but the preoccupation was maintained by these personally taboo ideas for him. He appeared calm at the end of our meeting. At the next appointment his mood had normalised, and all other symptoms had gone or were diminishing. He appeared brighter, relaxed and he told me that the accident was now behind him.

Unfortunately most treatments are not so brief and straightforward, but my experience told me that an effective solution was available at the first appointment.

An attractive woman in her mid 20s had never had a boyfriend. In spite of previous therapies, she remained severely anxious about being near men of her own age. She avoided going out to pubs, bars, or parties. Using cognitive therapy we looked at some unpleasant early encounters with boys, and ideas she had about herself and how she believed she came across to lads. We systematically looked at the accuracy of her thoughts, and she saw that there were alternative perspectives. Using carefully paced tasks outside of our sessions, she gradually confronted feared situations, by recruiting the help of female friends. She had opportunities to role play with me some useful responses in the event of any difficult encounters. She experienced some positive brief encounters towards the end of our work, and by the 10th and final session she had started going out with someone.

A fireman in his late thirties was involved in an accident on the way to an emergency. The fire engine took a corner badly and toppled onto its side, colliding with railings. A metal rail smashed through the window and narrowly missed my client. By the time of the assessment most of the expected trauma symptoms such as flashbacks and nightmares had stopped. He was still suffering with insomnia, resulting in irritability, rows with his girlfriend, and he was using alcohol to try to get to sleep. Alcohol unfortunately interferes with a good sleep pattern, and my client agreed to experiment with a reduction. We looked at his thoughts and behaviour when trying to get off to sleep, and from this information a treatment plan was organised. The main approach was to re-establish his bed as a trigger for sleepiness, and to do this he was advised not to remain in bed unless he was asleep or had the feeling he was close to nodding off. He also learnt to reduce any mental or physical tension, by banning clock watching, cultivating an attitude of acceptance, releasing muscle tension, and learning how to passively pay attention to his breathing (a meditation technique). The problem resolved in 4 sessions.

This woman in her late forties was referred to me 4 years after the death of her twenty two year old son. He had been assaulted, fell into the road and he was hit by a car; the driver did not stop to assist. My client was called to the scene, and she held her son as he was dying. He was still conscious, and there was nothing she could do to help him. She had received 2 previous courses of counselling, without success. She was experiencing panic attacks, flashbacks, low mood, memory problems, guilt feelings, anger and bitterness towards the men who had caused the death, loss of intimacy with her husband, over-protectiveness towards her surviving children, and a deep sense of unresolved loss.

The first sessions were used to establish a strong therapeutic rapport, and to demonstrate that I was fully available and committed to work with her and her profound emotional pain. I saw that the quality of relatedness was fundamental in this case. Once trust was present we worked on the panic attacks which were associated with the idea that her symptoms might lead to death, so abandoning her other children. We had to do the painful work of reliving the incident during sessions, in order for her to make sense of it and to allow the strong emotions of guilt and anger to become less powerful. As is common when people who have lost a loved one, she had a sense of her son’s presence, and I encouraged her to have dialogues with him to allow her to process some difficult questions and for support; her son had been an important confidante.

One reason for the ‘stuck’ grief was that all members of the family had become protective over each other, understandably, and as my client started to progress, and naturally cry more the family saw this as a sign of worsening and would encourage her to stop. There were a series of family crises and my client’s visits to me became unpopular. To cut a long story short, having this shared understanding about the family dynamics allowed my client to continue her therapeutic work. She re-established her role as a strong loving mother figure, but who was not restrictive, allowing her children to develop their own lives.

She attended 17 sessions over a 1 year period, with a drastic reduction in symptoms. She has recently started training in basic counselling skills, and intends using her experiences to help others.

This gentleman was referred to me after a lengthy period of sick leave for stress. He had not been coping at work following a take-over by another company, and during the same period his brother had committed suicide. He had been haunted by images of his deceased brother, and how he appeared just before the funeral. The more he tried to suppress the pictures the more they occurred which is a well known psychological effect. He went off sick with anxiety and associated insomnia. He had lost his meaning in life having always worked. My client elected to work on his brother’s death, and some regrets he had that he had not picked up how distressed his brother had been feeling. Using cognitive therapy techniques, it became apparent that my client had mixed up what he knew in hindsight with the information that was available to him just before the death. He saw that his guilt feelings were unfounded. He was then able to grieve for the lost relationship with his brother. He was encouraged to talk openly with his surviving brother, about their shared loss. Some specific techniques were taught to establish good sleep.

Therapy was then directed to the work stress situation and it was apparent that there were indeed realistic problems there. My client had high standards, which did not accord with new unrealistic demands. We used a problem solving technique to demonstrate that there were a variety of solutions to return to work, including the possibility of self-employment. I liaised with his company which seemed to be slow in processing my client’s case. Towards the end of our work, he was keen to take a look at his life from a bigger perspective and I recommended some tapes and books which supported him in this. He was discharged with a positive outlook on life, and a marked reduction in symptoms. He was to return to work on a trial basis, and if the same demands were to be placed on him, my client was planning alternative work having made arrangements elsewhere. In all 10 sessions were required.

This man in his early thirties was struggling to get out of the house in the mornings because of compulsive rituals, such as having to fold towels in a very specific way, arranging his clothing in a set manner, and conducting numerous safety checks (windows, doors, electric sockets etc). He imagined that if he did not perform his growing number of rituals properly he would have bad luck in his personal or business life. I helped him to conduct experiments with not performing his compulsions, starting with the easiest. He believed that if he did not go through with the routine he would be completely preoccupied for the rest of the day. He kept a record of his urges to complete tasks and he was surprised to see that the mental discomfort was short-lived. I supported him to systematically reduce the time he spent on unnecessary rituals. Therapy was successful and he eventually found work elsewhere, realising that some of the obsessionality was to do with dissatisfaction at work.