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

Psychological Approaches in Psychological Approaches in Primary CarePrimary Care

Dr Andrew WilsonDr Andrew Wilson

Bradford GP VTSBradford GP VTS

AimsAims

To broaden the nomenclature of psychological problems To broaden the nomenclature of psychological problems beyond anxiety and depressionbeyond anxiety and depressionTo work in a patient centered as opposed to a diagnosis To work in a patient centered as opposed to a diagnosis centered waycentered wayTo identify and have some understanding of the To identify and have some understanding of the mainstream psychological therapiesmainstream psychological therapiesReview the evidence base for psychological helpReview the evidence base for psychological helpTo identify more consciously some effective things we To identify more consciously some effective things we do/can do in psychological helping as GP’sdo/can do in psychological helping as GP’sLabel and validate what we do already that is goodLabel and validate what we do already that is goodIdentify ways of developing some of our good behaviorsIdentify ways of developing some of our good behaviorsBegin to explore these and/or new areas of competenceBegin to explore these and/or new areas of competence

Psychological Problems in GPPsychological Problems in GP

Of patients presenting in primary careOf patients presenting in primary care5% Major Depression5% Major Depression5% Milder Depression5% Milder Depression10%have some depressive features10%have some depressive features

If looking at other psychological distress as If looking at other psychological distress as being significant part of presentationbeing significant part of presentation40% of presentations to GP40% of presentations to GP

What do we do with it?What do we do with it?

50% not picked up or after several 50% not picked up or after several attendances attendances

10% psychological diagnosis referred to 10% psychological diagnosis referred to secondary caresecondary care

So what about the 90%?So what about the 90%?

The 90% what should we call it?The 90% what should we call it?

In pairs list descriptions for how In pairs list descriptions for how psychological problems present other than psychological problems present other than “depression” and “anxiety” e.g. work “depression” and “anxiety” e.g. work stress, exam anxiety, bereavement….stress, exam anxiety, bereavement….

Write on post it’s and put on one of the 4 Write on post it’s and put on one of the 4 Flip chart sheetsFlip chart sheets

The 90% what did we call it?The 90% what did we call it?

CognitionsCognitions

BehavioursBehaviours

EmotionsEmotions

PhysiologicalPhysiological

Rational TherapiesRational Therapies

Cognitive Behavioural TherapyCognitive Behavioural TherapyUtilises cognitive techniques (e.g. to challenge Utilises cognitive techniques (e.g. to challenge

“automatic negative thoughts” and maladaptive “automatic negative thoughts” and maladaptive beliefs) and structure approaches to modify beliefs) and structure approaches to modify dysfunctional patterns of behaviour. Patients are dysfunctional patterns of behaviour. Patients are required to do homework. Treatment can involve required to do homework. Treatment can involve up to 10- 20 sessions with a trained therapist, so up to 10- 20 sessions with a trained therapist, so is relatively expensive intervention.is relatively expensive intervention.

Rational TherapiesRational Therapies

Interpersonal TherapyInterpersonal TherapyFocuses on the relationship between current Focuses on the relationship between current

interpersonal experiences and depressed mood, interpersonal experiences and depressed mood, and aims to reduce depressive symptoms by and aims to reduce depressive symptoms by improving the quality of relationships and social improving the quality of relationships and social functioning. More widespread in the USfunctioning. More widespread in the US

Rational TherapiesRational Therapies

Problem solving therapyProblem solving therapyAims to identify significant problems in the Aims to identify significant problems in the

patient’s life and to generate practical and patient’s life and to generate practical and achievable solutions for the patient to implement achievable solutions for the patient to implement between sessions. between sessions.

Rational TherapiesRational Therapies

Dialectical Behavioural TherapyDialectical Behavioural TherapyHas some similarities to CBT – mostly used with Has some similarities to CBT – mostly used with

patients with borderline personality disorder. It patients with borderline personality disorder. It seeks work in 4 skills areas.seeks work in 4 skills areas.

Core mindfulness skills. Core mindfulness skills.

Interpersonal effectiveness skills. Interpersonal effectiveness skills.

Emotion modulation skills. Emotion modulation skills.

Distress tolerance skills.Distress tolerance skills.

Rational TherapiesRational Therapies

Behavioural TherapyBehavioural TherapyModern day behavioural techniques continue to Modern day behavioural techniques continue to

work on the premise of changing what people do work on the premise of changing what people do by teaching them to respond to things in a by teaching them to respond to things in a different way. different way.

Behaviour therapy aims solely at changing what Behaviour therapy aims solely at changing what people do, it's not really interested in what's people do, it's not really interested in what's going on in your head. going on in your head.

So What Works?So What Works?

EmpathyEmpathy

GenuinessGenuiness

WarmthWarmth

negotiation of Goalsnegotiation of Goals

ReflectingReflecting

So What Works?So What Works?

Repairing rupture in therapeutic Repairing rupture in therapeutic relationshiprelationship

If patient satisfiedIf patient satisfied

AllianceAlliance

Cohesion between pt and therapistCohesion between pt and therapist

So What Works?So What Works?

Emotional expressionEmotional expression

Changing view of selfChanging view of self

In SummaryIn Summary

ValidationValidation

Goal orientationGoal orientation

Validation – the evidenceValidation – the evidence

Headache Study Group Western Ontario Headache Study Group Western Ontario University (1986) University (1986) – Better symptom controlBetter symptom control

Orth et al (1987), Orth et al (1987), – Better blood pressure controlBetter blood pressure control

Validation – the evidenceValidation – the evidence

Little et al (1997) Little et al (1997) – ?better than antibiotics for sore throats?better than antibiotics for sore throats

Henbest and Stewart (1990) Henbest and Stewart (1990) – Patient centeredness correlates with Patient centeredness correlates with

resolution of patients concernsresolution of patients concerns

Personal Reflections on ValidationPersonal Reflections on Validation

StoriesStories

Unhappy patientsUnhappy patients

Miguel de Unamuno Miguel de Unamuno

Group Work on ValidationGroup Work on Validation

Brainstorming stuff that validates patientsBrainstorming stuff that validates patients

Discussion and framing validating types of Discussion and framing validating types of questionsquestions

Validating QuestionsValidating Questions

Ideas (beliefs)Ideas (beliefs)

““Tell me about what you think is causing it”Tell me about what you think is causing it”

ConcernsConcerns

““What are you concerned that it might be”What are you concerned that it might be”

ExpectationsExpectations

““What were you hoping we might be able What were you hoping we might be able to do for this?to do for this?

Validating QuestionsValidating Questions

Repetition of cuesRepetition of cues““upset….?”upset….?”

Picking up and checking out verbal cuesPicking up and checking out verbal cues““you said that you were worried that the pain you said that you were worried that the pain

might be something serious; what theories did you have might be something serious; what theories did you have yourself about what it might be?”yourself about what it might be?”

Picking up and checking out non-verbal cuesPicking up and checking out non-verbal cues““I sense that you’re not quite happy with the I sense that you’re not quite happy with the

explanations you’ve been given in the past. Is that right?”explanations you’ve been given in the past. Is that right?”

Validating QuestionsValidating Questions

Picking up and checking out verbal cuesPicking up and checking out verbal cues““you said you felt miserable, could you tell me more about you said you felt miserable, could you tell me more about

how you’ve been feeling?”how you’ve been feeling?”

Repetition of cuesRepetition of cues““angry…?”angry…?”

Picking up and reflecting non-verbal cuesPicking up and reflecting non-verbal cues““I sense that you’re very tense; would it help to talk about I sense that you’re very tense; would it help to talk about

it?it?

Validating QuestionsValidating Questions

Direct questions (open)Direct questions (open)Now did that leave you feeling?Now did that leave you feeling?

Asking for particular examplesAsking for particular examples““Can you remember a time when you felt like that? What Can you remember a time when you felt like that? What

actually happened?actually happened?

Asking permission to enter the feelings realmAsking permission to enter the feelings realm““Could you bear to tell me just how you have been feeling?”Could you bear to tell me just how you have been feeling?”

Validating QuestionsValidating Questions

Empathic StatementEmpathic Statement

Those I and you questionsThose I and you questions

““II can see that can see that youyou have been very upset by have been very upset by her behaviour”her behaviour”

Problems with Validation Problems with Validation

RuminateRuminate By repeating his or her complaints and refusing to consider By repeating his or her complaints and refusing to consider

other topics of discussionother topics of discussion

Escalate the intensityEscalate the intensityThis can take the form of raising the voice or of arguing that This can take the form of raising the voice or of arguing that

things are even worse than the patient first stated they things are even worse than the patient first stated they were. Thus the patients becomes personally invested in were. Thus the patients becomes personally invested in catastrophising.catastrophising.

Problems with ValidationProblems with Validation

Negative Feelings elicitedNegative Feelings elicitedBy punishing or devaluing the therapist. “you’re not helping By punishing or devaluing the therapist. “you’re not helping

me” “I’ wasting my time”……me” “I’ wasting my time”……

Emotional distancingEmotional distancingSilence communicates the belief that the therapist will not Silence communicates the belief that the therapist will not

be able to appreciate what the patient is feeling, so “why be able to appreciate what the patient is feeling, so “why bother?”bother?”

Problems with ValidationProblems with Validation

Viewing needs as weaknessViewing needs as weakness

Apologising for needsApologising for needs

SomatizingSomatizing