psychological approaches in primary care

1. Psychological Approaches in Primary Care Dr Andrew Wilson Bradford GP VTS

2. Aims To broaden the nomenclature of psychological problems beyond anxiety and depression To work in a patient centered as opposed to a diagnosis centered way To identify and have some understanding of the mainstream psychological therapies Review the evidence base for psychological help To identify more consciously some effective things we do/can do in psychological helping as GP’s Label and validate what we do already that is good Identify ways of developing some of our good behaviors Begin to explore these and/or new areas of competence

3. Psychological Problems in GP Of patients presenting in primary care 5% Major Depression 5% Milder Depression 10%have some depressive features If looking at other psychological distress as being significant part of presentation 40% of presentations to GP

4. What do we do with it? 50% not picked up or after several attendances 10% psychological diagnosis referred to secondary care So what about the 90%?

5. The 90% what should we call it? In pairs list descriptions for how psychological problems present other than “depression” and “anxiety” e.g. work stress, exam anxiety, bereavement…. Write on post it’s and put on one of the 4 Flip chart sheets

6. The 90% what did we call it? Cognitions Behaviours Emotions Physiological

7. Rational Therapies Cognitive Behavioural Therapy Utilises cognitive techniques (e.g. to challenge “automatic negative thoughts” and maladaptive beliefs) and structure approaches to modify dysfunctional patterns of behaviour. Patients are required to do homework. Treatment can involve up to 10- 20 sessions with a trained therapist, so is relatively expensive intervention.

8. Rational Therapies Interpersonal Therapy Focuses on the relationship between current interpersonal experiences and depressed mood, and aims to reduce depressive symptoms by improving the quality of relationships and social functioning. More widespread in the US

9. Rational Therapies Problem solving therapy Aims to identify significant problems in the patient’s life and to generate practical and achievable solutions for the patient to implement between sessions.

10. Rational Therapies Dialectical Behavioural Therapy Has some similarities to CBT – mostly used with patients with borderline personality disorder. It seeks work in 4 skills areas. Core mindfulness skills. Interpersonal effectiveness skills. Emotion modulation skills. Distress tolerance skills.

11. Rational Therapies Behavioural Therapy Modern day behavioural techniques continue to work on the premise of changing what people do by teaching them to respond to things in a different way. Behaviour therapy aims solely at changing what people do, it's not really interested in what's going on in your head.

12. So What Works? Empathy Genuiness Warmth negotiation of Goals Reflecting

13. So What Works? Repairing rupture in therapeutic relationship If patient satisfied Alliance Cohesion between pt and therapist

14. So What Works? Emotional expression Changing view of self

15. In Summary Validation Goal orientation

16. Validation – the evidence Headache Study Group Western Ontario University (1986) Better symptom control Orth et al (1987), Better blood pressure control

17. Validation – the evidence Little et al (1997) ?better than antibiotics for sore throats Henbest and Stewart (1990) Patient centeredness correlates with resolution of patients concerns

18. Personal Reflections on Validation Stories Unhappy patients Miguel de Unamuno

19. Group Work on Validation Brainstorming stuff that validates patients Discussion and framing validating types of questions

20. Validating Questions Ideas (beliefs) “Tell me about what you think is causing it” Concerns “What are you concerned that it might be” Expectations “What were you hoping we might be able to do for this?

21. Validating Questions Repetition of cues “upset….?” Picking up and checking out verbal cues “you said that you were worried that the pain might be something serious; what theories did you have yourself about what it might be?” Picking up and checking out non-verbal cues “I sense that you’re not quite happy with the explanations you’ve been given in the past. Is that right?”

22. Validating Questions Picking up and checking out verbal cues “you said you felt miserable, could you tell me more about how you’ve been feeling?” Repetition of cues “angry…?” Picking up and reflecting non-verbal cues “I sense that you’re very tense; would it help to talk about it?

23. Validating Questions Direct questions (open) Now did that leave you feeling? Asking for particular examples “Can you remember a time when you felt like that? What actually happened? Asking permission to enter the feelings realm “Could you bear to tell me just how you have been feeling?”

24. Validating Questions Empathic Statement Those I and you questions “I can see that you have been very upset by her behaviour”

25. Problems with Validation Ruminate By repeating his or her complaints and refusing to consider other topics of discussion Escalate the intensity This can take the form of raising the voice or of arguing that things are even worse than the patient first stated they were. Thus the patients becomes personally invested in catastrophising.

26. Problems with Validation Negative Feelings elicited By punishing or devaluing the therapist. “you’re not helping me” “I’ wasting my time”…… Emotional distancing Silence communicates the belief that the therapist will not be able to appreciate what the patient is feeling, so “why bother?”

27. Problems with Validation Viewing needs as weakness Apologising for needs Somatizing