Core Knowledge and Skills for Primary Mental Health Care Practice

Depression has been described as the common cold of mental health problems (Hotopf, 1996) and 90 % of depression is managed in primary care (Mann, 1992). The National Service Framework (NSF, DoH, 1999) identifies cognitive behavioural therapy (CBT) as a major component of primary mental health care services, as it has a strong effectiveness research tradition (Salkovskis, 2002). CBT is a short term, structured form of therapy that provides clients with a rationale for understanding their problems (Blackburn & Davidson, 1990). CBT requires a sound therapeutic alliance; the therapist should demonstrate warmth, genuine regard and competence (Beck, 1995). It follows the premise that psychological problems arise as a direct consequence of faulty patterns of thinking and behaviour (Maphosa et al, 2000). In mild depression the person ruminates on negative themes and CBT examines the effects of people’s thoughts on how they feel and what they do (J. Williams, 1997). It is now common to draw out the central elements of CBT to offer a more condensed intervention (Teasdale, 1985). Self-help materials are usually given to clients as homework (Richards et al, 2003). Bower et al (2001) found that self-help techniques can have considerable impact on a broad range of mental health problems. Guided self-help should be considered for clients with mild depression. It is a collaborative form of psychotherapy; the client learns new skills of self-management that they can put into practice in their daily lives (DoH, 2003). The following analysis examines the role-play of a primary care graduate mental health worker (PCGMHW). These workers were part of a government plan to enhance mental health services in primary care (DoH, 2000). Throughout this analysis strengths and weaknesses of the therapist will be discussed and what improvements can be made to the demonstrated clinical skills.

Introduction to the session
The objective of assessment is to find out about the difficulties that are impacting upon a client’s life and to inform decisions of interventions to be offered, taking into consideration the client’s own perceptions of the nature and cause of the problems (Maphosa et al, 2000). The referral letter can lead preliminary decisions about the assessment; usually the information provided in the letter is quite restricted so an
assessment is necessary to build on this (Maphosa et al, 2000). The initial meeting is a critical part of the session as this is when the therapeutic relationship begins (Newell, 1994). The therapist began the role-play by greeting the client and introducing herself and then ascertained by what name the client preferred to be known. She immediately gave an overview of the session, as small talk may prolong the client’s anxiety around divulging personal information to a stranger (Newell, 2000). She proceeded to explain her role though only briefly and did not explain comprehensively the nature of self-help and in what way she would act as a facilitator to these sessions; this is a crucial part of acquainting the client to the sessions, as the client may be unaware of why his referral was made and what is to be expected throughout the session. A therapist would want to remove uncertainty in this situation as it detracts the client’s attention away from the session (Newell, 2000). Session length was clarified; this helps to reduce anxiety and to give the client the opportunity to prioritise the issues to be discussed (Newell, 2000). An agenda was touched on at the start, though the therapist ought to have outlined the procedures to be followed during the process and exactly why the information was needed and to what purpose it would be put. This helps motivate the client to cooperate and improves trust (Purtilo & Haddad, 1996). Within primary care the number of sessions a client should expect is six, recent studies have illustrated that this had comparable outcomes to 12 sessions (Newman et al, 1997). However, this, and how often future sessions would be was not made clear to the client. In forthcoming sessions the therapist will incorporate this information, as Barkham et al. (1996) determined that improvements were more rapid when limits were placed on the number of sessions.

An essential part of initiating the client to the session is establishing the rules around confidentiality. The client should feel that their privacy is respected but also understand that confidence needs to be broken if theirs or someone else’s safety is at risk (Davies, 1997). In this role-play the client was advised of issues in relation to confidentiality, he was made aware of when confidentiality may be broken and why notes were being taken and assured they would be kept locked away. Note taking
should not interfere with the communication process (Munro et al, 1989). The therapist demonstrated good verbal interaction while note taking.

Information Gathering and Questioning Style
The body of the interview is aimed at attaining the objectives. In this role-play the therapist is interested in learning the causes of the client’s presenting depression and how it is affecting his daily routine. The interview is more than an information gathering process: it is the first stage of active management. This may be the first opportunity for a patient to tell his full story or to be taken seriously, and the experience should be cathartic in itself (Davies, 1997). Open questions are used at the beginning to get a general idea of the client’s difficulties at that time, these encourage clients to talk and to concentrate on the present situation and help establish a rapport (Davies, 1997). This was demonstrated when the therapist asked for the client’s view on how he sees life at the moment and if he thought the term depression “fits” with how he feels. Such questioning allows the client free rein to discuss issues of relevance to him. The therapist should proceed to specific open questions (Newell, 2000). These include the 4 Ws, the core essentials for a structured interview. These are questions used to identify ‘what’, ‘where’, ‘with whom’ and ‘when’ does the client notice his problems becoming worse or easier (Briddon et al, 2003). In this role-play they are not laid out in such an obvious, rote manner. For example, “do you have a good relationship with your manager?”, “how’s everything with your partner?” are used to identify if he is having any social or personal relationship difficulties. Questions relating to support networks give an understanding of how the patient organises his life and whether he has close confiding relationships. While knowledge of his occupation gives an insight into his life style, financial security and network of relationships. Lack of these has been found to be vulnerability factors for depression (Brown & Harris, 1978). In this situation the therapist asked about these issues to determine if anything else was impacting on the client’s depression. Throughout the role-play the therapist used the client’s answers to form the next question; this makes the session more interactive and not too formal. Clients with depression do not want to have to answer lists of questions but want an opportunity to talk comfortably, and
the therapist needs a chance to listen carefully (American Psychiatric Association, 2000).

Sessions delivered within a cognitive behavioural framework aim to elicit the client’s difficulties in terms of the autonomic, behavioural and cognitive (ABC) aspects surrounding depression. At this stage the therapist incorporates closed questions. These are used to elicit specific information and form a checklist of symptoms often found in depression (Davies, 1997), such as poor appetite, sleep, concentration (France & Robson, 1997). The effect these have on his work and home life and any other problems which may be contributing factors to the overall picture (France & Robson, 1997). The triggers for depression vary, for some there will be a clear reason but for others the reasons are less clear (Briddon et al, 2003). During the role-play the therapist asks questions about “talk of redundancy at work”, this is done in a circuitous way, e.g., “so it’s problems at work, that feeling of stress, would that be right?”, rather than directly asking the client if he thinks this is the trigger. In future situations it would be preferable to do so as it would further integrate the client into the session. Garland et al (2002) highlight key questions to establish the presence of reduced and unhelpful activity. The therapist in this role-play asks, “is there anything…you’ve stopped doing?” “have you started doing anything…more than you would have before?” Asking such questions helps the client begin to identify his own vicious circle of depression (Garland et al, 2002). This process of starting with open questions, then asking specific open questions and then closed questions is described as ‘funnelling’ (Briddon et al, 2003). To get to the key thoughts that the client is having about his present situation the therapist introduces Socratic questioning, which is aimed at guided discovery (Padesky, 1993). The client mentions that he feels useless and a failure, the therapist pursue this thought and asks, “if people did think you were a failure what would that mean for you?” In future sessions the therapist would examine these thoughts further with a view to helping the client challenge his negative thoughts, however, that was out of the scope of this role-play. At times the therapist was leading the client in his answers, e.g., “so it could be possible you’re
feeding off everyone else’s fears?” rather than guiding him to his answers, she could be more mindful of the Socratic technique in further sessions.

In this role-play the therapist asks about suicide and self-harm utilising a frank approach, while letting the client know that these thoughts are common. Dexter and Wash (1995) advocate considering all clients with depression as potentially suicidal. Such thoughts are common in people with mental health problems and can be frightening, sufferers are often relieved to find someone to share with and to learn that these thoughts are common (Davies, 1997). The therapist could have pursued this area further, although she asked the client if he felt he had a good support network, this does not necessarily mean that he had someone he felt he could confide in.

Problem Formulation
When the therapist was satisfied that the relevant areas had been covered she ‘recapped’ what she considered to be pertinent information. The aim of the interview is to pull together the idiosyncratic components of the problem, to identify problem triggers and the overall impact so that the therapist and client are able to consider the next steps (Maphosa et al, 2000). Giving the client a clear conceptualisation of their problem has been associated with beneficial clinical outcome (Power & Brewin, 1997). At this point the therapist asked “do you think that’s everything, is there anything else that’s causing you stress?” and “do you think that fits with how you feel at the moment?” This allows the client to reflect on the information he has given the therapist and confirm whether the therapist has accurately captured it.

Once formulated the effects of the client’s problems should be illustrated to the client using a simple experiment (France & Robson, 1997). In this role-play the therapist introduced the client to the ABC model using a diagram (see appendix 1). The ABC model presents a visual representation of the meaning of emotion for both therapist and client and imparts a depiction of the client’s individual experience of emotion. It illustrates the ‘vicious circle’ of depression (Briddon et al, 2003). In the role-play the therapist explained to the client in what ways the different aspects impact on each
other. This association crucially enhances the client’s self-esteem and removes a sense of exclusion (France & Robson, 1997). The rationale of how depression comes about and how it can be treated can bring a feeling of control and hope (Blackburn & Davidson, 1990). Explanations of psychological symptoms and problems likely to be useful to clients include explanation of feedback mechanisms between thoughts, emotions and behaviour (Cape et al, 2000). In the role-play the therapist also looks at the effects the environment has on the model, as something in the environment is quite often the trigger for depression.

Decision Making
Once the links between A, B and C had been established the therapist introduced possible service options as a way to break the cycle of depression. However, these were only briefly introduced, e.g., “a good place to start would be your behaviour…maybe phone a friend.” In future sessions the therapist will explain why behaviour is a good place to start, as a rationale for interventions enhances greater client involvement and understanding of their difficulties (Newell, 2000). One of the main reasons that therapists’ instructions are not followed is due to inadequate communication skills (Sanson-Fisher & Maguire, 1980). Sleep hygiene, looking at negative thought patterns and problem solving were also offered as interventions. These are technical terms that could have been clarified further. Clear problems evolve from this; if the client cannot understand what is being explained to him important information may be missed (Purtilo & Haddad, 1996). It also excludes the client from the collaborative process of his own therapy. Furthermore, the client may feel his situation is not being taken seriously (Cassell, 1982). The therapist can further confuse the client by jumping from one topic to the next and failing to summarise or to ask the client to do so (Purtilo & Haddad, 1996). Anti-depressant medication had been discussed earlier in the session, further consideration was not given to this as an intervention as the client had decided not to pursue that option and NICE guidelines (2004) do not recommend anti-depressant medication for mild depression. While outlining the service options in future sessions, the therapist will give the client more time to consider each one as thinking processes are slowed and negatively biased in depression (Garland et al, 2002); and give the client an opportunity to feedback on each option. In the role-play the client was given a copy of the ABC-E model and the different service options available, this augments what has been discussed in the session, as it is unlikely that the client will have retained in detail what had been discussed (Garland et al, 2002). At the end of the session the therapist gave the client self-help booklets on sleep problems and information on depression, it was not within the scope of the role-play to discuss these booklets in detail, however, information in this format helps the client focus on issues discussed in session and areas of his life that he would like to prioritise. Use of self-help materials is helpful in enhancing suggestions for change (Kupshik & Fisher, 1999).

Interpersonal Skills
Rogers (1967) posited that the fundamental therapist manner of empathy, congruence and unconditional positive regard are both necessary and sufficient for implementing therapeutic change in clients. Empathy signifies to the client that the therapist has understood the feeling the client is experiencing. Balint (1969) described patient-centred medicine as “understanding the patient as a unique human being”. Concepts such as ‘user involvement’ and ‘patient empowerment’ became active in health policy during the late 1980s and 1990s (e.g., NHS Executive, 1996). Patients are considered to be active ‘consumers’ who have the right to a certain standard of treatment with access to information and should be actively involved in their treatment (Mead & Bower, 2000). In patient-centred care developing a therapeutic alliance is a prerequisite instead of an ’extra’ and enhances the sense of partnership and increases client perception of the relevance or potency of an intervention (Mead & Bower, 2000). Throughout the role-play the therapist makes reference to therapist and client collaboration when identifying the different service options available, she continually emphasised that the options would be something worked on together. Engaging in a positive therapeutic relationship allows the client to feel free to discuss emotional problems; an association of positive therapeutic relationship with clinical outcome is one of the most robust findings in psychological treatment research (Horvath & Luborsky, 1993).

Interpersonal skills are a crucial way of building on the therapeutic relationship. Therapist factors are active listening, empathy and a genuine concern for the client (Horvath & Luborsky, 1993). There are a number of ways of doing this. Reinforcement throughout the session is a beneficial way of ensuring relevant information. The therapist used such remarks as ‘yes’, and minimal prompts, e.g., head nods; this lets the client know that a particular piece of information is important (Burnard, 1999) and that the therapist is listening (Krasner, 1958). Reflection is a useful way of prompting the client for more information. The therapist used this process of repeating back the last few words or phrase that the client had used. Such remarks should be highlighted straight away and not kept for later on in the session as they may have lost their relevance (Burnard, 1999). The therapist maintained good eye contact throughout the session. Eye contact has a role in regulating and controlling the course of communication and is an important signal for turn taking in conversation. It is also a further way of indicating that the therapist is listening (D. Williams, 1997).

Structure to interviewing style is intended as a guideline, it can be confusing for a client if they cannot continue on a certain topic but are asked about a number of topics (Dillon, 1990). During this role-play the therapist got side tracked on occasions, e.g., she asked about his work situation and sleep at different points in the session instead of following through at the time these problems were mentioned. Throughout the interview process the therapist should ask for feedback from the client; it shows respect for the client in addition to making sure the therapist has all the relevant information, client understanding and reinforces the therapeutic relationship (Newell, 2000). Interviewing clients involves asking about feelings, thoughts, beliefs and behaviour, and relating the responses to the difficulties (Maphosa et al, 2000). These are quite complex issues and the therapist should ensure she has an idea of timings for each section so that some points aren’t discussed in a rushed manner, in this role-play the client didn’t leave enough time to discuss the service options, this is something to consider for subsequent sessions. It is also important to highlight to the client that the
way he is feeling is quite common, to remove feelings of isolation. The therapist utilised this approach throughout the session.

Information gathering should represent sufficiency and necessity. There should be sufficient information to glean necessary information from the client to ensure relevant client details are collected in terms of maintenance of their difficulties if interventions are to be successful (Newell, 2000). In the role-play the therapist was able to elicit key factors surrounding the client’s depression, such as stress at work. However, she lost sight of the structure at times, and although structure is used as a general guide, problems could arise if key ideas aren’t followed through, leading to inaccurate information and, therefore, inaccurate interventions. Awareness of using leading questions will also be something to take on board in the future, no one knows the client’s problems better than the client and the therapist doesn’t want to speak for the client, as this would not be beneficial for either the client or therapist. The importance of not using technical language can’t be emphasised enough, this can seriously hamper the therapeutic relationship and the client may disengage from the process. The relationship between the autonomic, behavioural and cognitive aspects of depression was illustrated well. It is essential that clients understand the maintaining factors of depression or they will not appreciate how the vicious circle of depression can be broken. In future sessions the therapist could go into more detail of how depression is maintained as it is very common for client’s to misinterpret situations in ways that undermine their coping, as summarised by Epictetus, “Men are disturbed not by things, but the views they take of them” (Enright, 1997)}.