editorial€¦ · provide evidence of therapy’s quality, effectiveness and efficiency grows,...
TRANSCRIPT
HCPJ July 2011 1
A sking clients to complete outcome measures is an everyday occurrencefor most practitioners working in healthcare. As the requirement toprovide evidence of therapy’s quality, effectiveness and efficiency
grows, collecting outcome measures is increasingly a service requirement.When I began as a practitioner, I asked clients to complete measures at thebeginning, middle and end of therapy; now it is every session, and, on top of the minimum requirements, I can also choose from a range of disorder-specific questionnaires.
It is increasingly necessary to use outcome measures, so how can we makethem work for us and, more importantly, for our clients? Nic Streatfield’s articleasks – how do you use yours? He takes us through the three broad categorieswe can fall into – ignore (pretend they don’t exist and don’t use them), append(tag them on to the beginning or end of the session) or integrate (use themactively and collaboratively to aid therapy). Nic puts forward a persuasive caseto us all to try the latter, showing us how measures can enhance the work wedo and sharing his own personal journey from being someone who gave innameless statistics to the administrator to someone who uses measures for, ashe puts it, ‘the dialogical possibilities they contain’ If, spurred on by Nic’s article,you want to breathe life into your testing procedures, and ensure you keepwithin recommended benchmarks and competencies, Tina Thomas outlines how.
Elsewhere on the subject, Alex Mitchell’s research group asks whetherclinical skills in diagnosis are adequate without screening questionnaires;outcome measures find a supporter in GP John Hague; and our brief guidetakes you through some of the most widely used outcome measures fordepression and anxiety.
On a service-related, but different subject, Brian Rock and Helen Brindleyexamine the impact of record-keeping on the therapeutic relationship,particularly in light of the increasing use of electronic patient records (EPRs).Adding a consideration of the issues from a psychoanalytic perspective, thisthought-provoking article recounts some of the clinical dilemmas that arisein the context of the continuing implementation of systems.
Collecting data is integral to continued commissioning of services, andnon-IAPT counselling and psychotherapy services are increasingly seeing thevalue in proving their worth to commissioners by proving their effectiveness.Southwark Counselling and Psychotherapy Services (PCCPS) is a superb exampleof good practice in this area. As Peter Thomas outlines, by valuing thepractitioners, collecting outcome data, and celebrating their work publicly,the PCCPS has secured its place in psychological services in Southwark.
Away from service issues, Maxine Aston provides valuable guidance inapproaching work with people with Asperger syndrome. Depression, as Maxinewrites, has a high incidence in this section of the population, so it’s likely thatmany of you will have seen people with AS. In a further anecdote to a service-based issue, Ewan Davidson takes us on a personal journey through the patchwhere he lives and works, giving words to experiences which will resonatewith many of us.
As ever, we welcome contributions from readers, whether throughcorrespondence, or ideas for articles. Perhaps you have a personal practitioner’sperspective to share? Or are engaged in work or study-based research whichcould be of interest to others? Please do get in touch with me at the emailbelow if you’d like to submit a letter or idea.
Sarah [email protected]
Editorial
Contribute to HCPJHCPJ welcomes feedback, original articles and suggestions for featuresand themes for future issues. Pleasesend your emails, views and opinions to [email protected]
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Healthcare advice from BACP BACP and the BACP Healthcare Teamwelcome your queries on healthcarecounselling and psychotherapy relatedissues. To get in touch, please email us at [email protected] ortelephone 01455 883300 (ext 331) to leave a message for a member ofthe team. Please remember to quoteyour BACP membership number.
2 HCPJ July 2011
Apartner is four times more likely toleave because of a mental health
condition like depression than becauseof a physical disability. This is one ofthe main findings of research carriedout for Time to Change (www.time-to-change.org.uk), the nationwide campaignled by Mental Health Media, Mind andRethink, to end the stigma faced by
people with mentalhealth problems.
The research, which examinedcurrent attitudes to mental healthproblems, found the stigma, which is often identified in the workplace,extends to close relationships. Attitudesto more severe mental illnesses such asschizophrenia are even worse; the survey
asked people about issues thatwould make them break off a
romantic relationship andfound that 20 per cent ofBritish women wouldn’tstay with someone if theywere diagnosed with
schizophrenia, yet only oneper cent would break up with
someone who became disabledand needed to use a wheelchair.However, the picture wasn’tall bad, with many sayingthey wouldn’t dream ofleaving a partner with amental health condition.Source: Press Association/
Aware Defeat Depression
Veterans with mental healthproblems are receiving targeted
support via the Combat StressSupport Helpline, a one-year pilotservice delivered by Rethink andfunded by the Government.
The 24-hour freephone helpline– 0800 138 1619 – aims to helpveterans and their families accessexpert advice from people trainedand experienced in dealing withex-Service men and women andtheir often complex mental healthneeds. The helpline aims to provideround-the-clock support, as well as helping callers to access mentalhealth services in their local area,and providing assistance inaccessing further advice on othersocial problems affecting veterans,including housing and employmentadvice. A text and email servicewill be added later this year. Source: Rethink
News
Two trials aimed atimproving the treatment
of children and adolescentswith obsessive-compulsivedisorder (OCD) have beenlaunched by South London and Maudsley NHS FoundationTrust (SLaM). In the first trial,the effectiveness of cognitivebehavioural therapy (CBT)carried out over the telephoneis being compared to face-to-face treatment. The secondtrial is investigating whetherthe efficiency of CBT is enhancedwhen combined with a drugcalled D-cycloserine; the drughas previously been found toenhance CBT outcomes byspeeding up the process inwhich people become lessafraid of their feared stimulus.Source: Mental Health Today
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Mental health stigma hits relationships
Antidepressants may not improve all symptoms of depression
Veteran supporthelpline launched
OCD trials underway
Even people who show a clear treatment response with
antidepressant medications continue to experience symptoms like insomnia,sadness and decreased concentration,researchers at UT Southwestern MedicalCenter in the US have found.
The researchers analysed data from theSequenced treatment alternatives to relievedepression, or STAR*D study, the largestever study on the treatment of majordepression disorder which took six yearsto complete and included more than 4,000patients with major depressive disorder.
The findings of the analysis suggest thatwidely used antidepressants, while workingoverall, miss certain symptoms. Theresearchers tracked a range of symptomsat the start of the trial and at the end of the antidepressant treatment course,including sadness, suicidal thoughts, andchanges in sleep patterns, appetite/weight,concentration, outlook and energy/fatigue.
All responders reported between threeto 13 residual depressive symptoms, and75 per cent of participants reported fiveresidual symptoms or more. Some of theirsymptoms included insomnia that occursin the middle of the night (nearly 79 percent), sadness (nearly 71 per cent), anddecreased concentration and decision-making skills (nearly 70 per cent).Thoughts of suicide rarely persisted oremerged during treatment, providing, say the researchers, evidence to counterfears that antidepressant medicationsincrease thoughts of suicide. The next step,the authors conclude, will be to developmore targeted antidepressant therapiesto decrease depressive symptoms. Source: ScienceDaily
News in brief
• A report by Carers UK shows thereare half a million Black AsianMinority Ethnic (BAME) carers inEngland. Half a million voices,improving support for BAME carers,explains that BAME carers faceadditional difficulties, such asstruggling with language barriersand accessing culturally appropriateservices, putting them at greater riskof ill health, poverty, and socialexclusion. Source: Carers UK
• New guidance from The NationalInstitute for Health and ClinicalExcellence (NICE), Psychosis withcoexisting substance misuse:assessment and management inadults and young people, offers bestpractice advice on the assessment andmanagement of people with psychosisand coexisting substance misuse.Source: NICE
• Bottling up emotions could makepeople more aggressive, a study has found. Researchers useddisturbing scenes fromthe films The Meaningof Life andTrainspottingand asked somesubjects to suppress or show no emotionalreaction. Those whowere allowed todemonstrate theirrevulsion at the scenes were far less inclined to showexaggerated aggression.Source: Clinical Psychology News
• Cleaning could be making peopledepressed. So says a study that haslinked offices and homes whichcontain lower levels of dirt andbacteria to weaker immune systemsand, in turn, brain functionimpairment. The study suggestsweaker immune systems tend toover-react to dust and dirt in theform of inflammations/allergieswhich can slow the brain’sproduction of ‘happy’ chemicals suchas serotonin, and cause depression.Source: The Daily Telegraph
HCPJ July 2011 3
news
BACP has announced details of itsawards scheme for this year and
is now welcoming applications frommembers wishing to inform the widerprofessional community about theexcellent and innovative work theyhave achieved within their sectors.
Previous winners of the BACP awardshave received significant recognitionwithin the public arena as well as theprofessional context. BACP hopes thatmore of its members – whether theyare individual practitioners, researchers,or acting on behalf of their counsellingand psychotherapy organisations, willtake this opportunity to highlight theirachievements and share their successstories with others.
In this year’s awards, BACP will belooking to recognise individuals orservices in the following categories:
Innovation in counselling andpsychotherapyThis category aims to recognise andcelebrate innovative work which has:� increased access to therapy within a community� helped to better meet the needs ofclients and potential clients� challenged thinking or adopted newtechniques or models within a specifictherapeutic setting/sector.
Commitment to excellence incounselling and psychotherapy This is an evidence-based practiceaward and aims to:� reward an individual/organisation who/
which demonstrates evidence of theirlong-term commitment to improvingquality of life through therapy withina community, group of individuals or organisation� recognise counselling andpsychotherapy projects, initiatives orservices that demonstrate consistentlyhigh standards and excellence incounselling and psychotherapy practice.(All applications must include supportingevidence/results.)
Promoting the counselling andpsychotherapy professionThis category aims to recognise anindividual or service that has:� proactively promoted the professionto the public with the aim of increasingpositive attitudes towards therapy� raised awareness of the benefits oftherapy or their service within acommunity.
Outstanding research project This category aims to:� reward excellence in counselling andpsychotherapy research� enhance awareness of the evidencebase for counselling, psychotherapyand its guiding principles� improve the overall quality ofcounselling and psychotherapyresearch by example.
To apply, please email [email protected] or tel 01455 883300 or visitwww.bacp.co.uk/awards. The deadline forapplications is Monday 15 August 2011.
If you are interested in finding out more about research, BACP’s academic journalCounselling and Psychotherapy Research (CPR) can be a valuable resource. Along
with its quarterly publication of the latest research, it hosts a web portal athttp://www.cprjournal.com/. This contains information and resources about how toconduct research, together with selected abstracts from past journal issues. BACPmembers can access the full journal articles from all past CPR publications in pdfformat, via the BACP home page. Just log in and select ‘CPR online’ and this takesyou to the informaworld site which manages the CPR journal publication.
For those who would like to know what is happening in research, but find itdifficult to keep up to date with the full articles in the journal, there is a user-friendly e-alert of upcoming articles which you can subscribe to. A summary ofarticles appearing in the forthcoming issue is sent out quarterly to all thosewho subscribe. To receive your copy of the e-alert (also available to non-BACPmembers), go to: http://www.bacp.co.uk/forms/rNewsletter.php
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2011 BACP awards
4 HCPJ July 2011
Are you fully aware of policyupdates and developments in thecounselling and psychotherapy
healthcare sector? What do we meanby the terms ‘counselling’ and‘psychotherapy’? What is our role inthe face of further changes to come,and do we need to re-establish ourprofessional identity?
You are warmly invited to join theBACP Healthcare Executive at a seminarplanned for autumn this year, whichaims to explore these questions. Thepurpose of the one-day event, whichwill take place in York in the autumn,is to inform members of developmentsand reforms in primary care at a timeof anxiety which started with theintroduction of the Improving Accessto Psychological Therapies (IAPT)programme and is likely to continuein the face of policy changes to come.
Aimed at practitioners employedand contracted by the NHS indifferent settings, the day will equippractitioners to play a part in drivingthe future agenda, and will link inwith developments regarding GPcommissioning: what does it mean?What will it look like? How can weprepare for it?
The seminar will also provide a forumfor members to share directly withBACP Healthcare any challenges theyare facing in their role as healthcarecounsellors and psychotherapists.During the day, with feedback fromservices and individual members, wehope to find ways to celebrate ouridentity, as well as consider how todefine our roles and evolve as aprofession.
We look forward to seeing you there.To register interest (or for more
information and costs when available),tel Jessica Baxter on 01455 883321 or email [email protected] �
Ignore, append or integrate:how do you use yours?Nic Streatfield considers differing therapistattitudes to outcome measures, and argues that their active use can greatly benefit clients
Healthcare in transition: strengthening ourprofessional identity
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Recent research by mental healthservice users detailing theirexperience of psychological
outcome measures stressed theimportance of the social skills of themental health professional asking thequestions. The study also recommendedthat mental health professionalsshould be properly trained to administerthe questionnaire1. How many healthprofessionals reading this would saythey have been properly trained toadminister the outcome measuresthey have been asked to use?
There is a wide range of psychologicaloutcome measures available. TheNational Institute of Mental Health in England (NIMHE) published anOutcomes Compendium2 rating 188measures. These range from generalmeasures of psychological wellbeingsuch as Clinical Outcomes in RoutineEvaluation (CORE), to disorder-specificmeasures such as the Impact of EventScale – Revised (IES-R) for PTSD. Theincreased interest in using outcomemeasures however, is not concernedwith their quantity, but the changingway they are being used. The drive ofsuccessive governments to save moneyand increase accountability has createda strong trend towards measuring theoutcome effectiveness of all healthservices. The NHS has to provide thebest outcomes for the least cost, amantra that is likely to intensify overthe next decade as rising populationssqueeze current budgets even further.
The Improving Access to PsychologicalTherapies (IAPT) programme is anexample of a healthcare system seekingto provide accountable cost-effectivetherapy. One of the central tenets ofIAPT has been the systematic use ofoutcome measures, and the Departmentof Health (DH)3 recommends that IAPT services focus on collectingpatient-reported outcome measures at each clinical session as part of a commitment to quality andproductivity, as well as providing vitalevidence to commissioners and othersin demonstrating the return oninvestment made in services that arebenchmarked against clear outcomemeasures. It stresses: ‘This data isintended to be primarily useful topatients in providing tangible evidenceof the progression they are makingthrough their care pathway; and to
their clinicians in monitoring anddeveloping their skills, and as part ofthe clinical governance process.’
This is a laudable statement fromthe DH and sounds as though it is awin-win situation. Yet the practice ofcollecting patient-reported outcomemeasures every session can be quite acultural change for many and is alwaysa challenge. I have experienced thischallenge both in my role as a cognitiveanalytic (CAT) therapist working in ahigher education setting and as abusiness development manager forCORE supporting both IAPT and non-IAPT services in establishing routineoutcome measure collection.
In this article I will introduce threetypes of engagement with usingoutcome measures. I will discusstherapist resistance and ways toovercome this and talk about my ownpractice, where I believe my active useof OMs greatly benefits my clients.
How therapists use outcomemeasuresIt is often a difficult process to askpeople to change their establishedways of working. Therapists can bewary of the reasons why outcomemeasures are being introduced.Management may explain outcomemeasures are needed to increaseaccountability and transparency, helppatient choice, and help managers toimprove services, supervisors to helpstaff, and commissioners to commissionservices, but many therapists can viewtheir introduction as a ‘top down’imposition that will serve only to hindertheir practice.
Yet I take the opposite view: that ifoutcome measures are used carefully,deliberately, and collaboratively withthe client, then they will aid therapy,not hinder it. This is a view supportedby Duncan4. ‘Soliciting systematicfeedback is a living, ongoing processthat engages clients in the collaborativemonitoring of outcome, heightens hopefor improvement, fits client preferences,maximises therapist-client fit andclient participation, and is itself a corefeature of therapeutic change.’
However, to learn to use outcomemeasures effectively as part of thetherapeutic process requires a certainproclivity. If the measures are notvalued by the therapist, it is easy to
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see how they may be ignored. If themeasures are seen simply as anadministrative chore, then the measuresmay be only half-heartedly appendedto the beginning or end of the session.It is only if therapists can develop waysto integrate the measures into theireveryday practice that the multi-levelbenefits as envisaged by the DH willbe generated. Therapist attitudes tooutcome measures are really importantto understand and people tend to fallinto one of three categories:
� Ignore and hope you are never askedto do them. Some therapists, whetherthrough a belief that collectingoutcome measures in session will get inthe way of the counselling process, orbecause of their own anxieties aboutthe measurement of their performance,view outcome measures as anirrelevance or a threat, so they ignorethem. If management do not spot thisor also choose to ignore it, then manyof the benefits of the measures will bemissed. This attitude does bring to mindone of Winston Churchill’s acerbicremarks, ‘However beautiful thestrategy, you should occasionally look atthe results’. In one IAPT service I haveworked with, there was a concern thatthe clients wouldn’t like doing themeasures, so they asked for anexception list to be created. This allowedtherapists to choose a reason why theclient did not complete the requiredoutcome measures. CORE provided adata review workshop for the serviceand saw that the exception list wasrarely completed. The exception was oneunlucky outlier who had an enormousnumber of clients who seemingly hadtold the therapist that they didn’t wantto complete the IAPT measures. Whenmanagement went to discuss the issuethey found that it was the therapistwho was very resistant to the use ofoutcome measures, not the clients.
� Append and keep the measuresseparate from the therapy. Therapistswho fit into this category do followinstruction and collect the measures butthey do so with no great enthusiasm.They might see the collection of themeasures as solely an administrativetask, so they simply append them tothe beginning of sessions withoutdiscussing with the client what theiranswers mean to them or reviewingthe client’s progress or lack thereof.Perhaps they simply refer to the riskindicators on the form or maybe makeassumptions about the client by onlylooking at the total score. Most outcomemeasures ask pretty challengingquestions of the client and it seemsplain rude to not discuss their answerswith them. By not actively using theclient’s outcome measures, does thisnot convey the message to the clientthat it is not relevant to the therapeuticprocess? And if the client does pick upthis message, how will they feel aboutbeing asked to complete it again andagain?
� Integrate the measures into thetherapy. This is the way I believe will bemost successful in helping clients getbetter. I think outcome measures needto be used actively and collaborativelyto improve the therapeutic experienceand allow the therapeutic dyad to beable to visually monitor the client’sprogress. Just as we wouldn’t hesitateif our GP asked to check our bloodpressure every time we visited the
surgery, so my clients now expect tocomplete a CORE measure and expectthe measure to be a springboard for acreative conversation. After all, theclient has invested time in answeringthese often difficult questions and itis another part of their voice.
Using measures effectivelyI do not have space here to provide acomprehensive discussion of all theways that using outcome measurescan be used beneficially, so I havepicked three examples:
1 How was it for you to complete?Where do you think you might be onthe chart? These simple questionsoften open up into really interestingdiscussions about the client’s currentsense of self eg if a client thinks theyhave scored badly this week but thechart indicates a more positive result,then the conversation would be aboutthat dichotomy and is always an insightinto how they see themselves.
2 Discuss the trend lines on thesummary chart. This visualrepresentation is a tangible tool tohelp to collaboratively talk about whenthings are not going well, stagnatingor improving. The client and therapistcan easily view and reflect on currentprogress. Hawkins et al3 found thatproviding feedback data on treatmentprogress to both clients and therapistswas associated with statisticallysignificant gains in treatment outcome.
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CORE Net progress chart
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If OMs are usedcarefully, deliberately,and collaborativelywith the client, thenthey will aid therapy,not hinder it ‘
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3 Reflect on the client’s scores. I havefound outcome measurement to be an excellent addition to help me reflecton my work, both in looking back onwhat I might have missed in individualsessions and also on my overallperformance. I have used my outcomedata to focus my continuing professionaldevelopment (CPD) activities to improveareas of my practice.
NIMHE’s support of collecting patient-reported feedback states: ‘Perhaps themost important reason is that it is theright thing to do in order to providegood treatment and care which cancontinually improve. Reflective practicerequires us to get better at measuringthe things that matter so that progressfor individuals who use services (as wellas the service provision itself) can beproperly understood.’5
As a therapist myself I haveexperienced the often anxiety-provoking journey along the feedbacktrail (see Nic’s personal journey). I don’t know how else it could be for anyone seeking to change theirpractice. Often as anxiety levels rise,so too does therapist resistance. It isbeing able to work through thisresistance that is the key to services,and individuals, moving towards theIntegration stage.
Reasons cited for not usingmeasuresI have heard many reasons whytherapists say collecting outcomes willbe detrimental to clients. Pick yourfavourite:
1 I don’t have enough time to do themeasuresNew technology means clients candirectly enter the data on a computereither in the session or before it.When therapists see the benefits toclients of using outcome measuresthen they make time because theprocess becomes an integral part ofthe therapy.
2 The client will not like itThe data available from a range ofservices using CORE Net, the web-based clinical management system,suggests 82 to 93 per cent of clientsare either ‘quite happy’ or ‘didn’tmind’ being asked to complete the
measures. Overall, clients are muchmore positive than their therapistsabout the use of CORE Net6.
3 It will threaten the therapeuticallianceI have found in my own practice andthrough a small practitioner researchproject4, that because the outcomemeasure is a tangible tool, itscollaborative use can help develop a shared focus and speed up theestablishment of a good alliance. Miller,Hubble and Duncan’s Supershrinkspaper7 claims that providing therapistswith real-time feedback improvesoutcomes by nearly 65 per cent.Dropouts, the single greatest threat to therapeutic success, are cut in half.At the same time, outcomes improveyet again, in particular among thoseat greatest risk of treatment failure.
4 The outcomes may not really reflecthow much my clients have been helpedThis is very true and is the reason whyoutcome measures are not the only waysuccessful therapy should be judged.However, by taking an interest in yourresults this can increase your confidenceand help you to see where you canimprove.
5 The data will be misinterpreted andmisused by managers as a stick tobeat therapists withThis depends on the manager. However,if you take a keen interest in your data,you will know what it is saying betterthan anyone else. Knowing where youare working well and where you needto improve is fantastic reflectivedevelopment.
Introducing and embeddingmeasures into servicesIt takes courage to make changes topractice and for these to be successfulrequires a cultural shift when allstakeholders are persuaded of the useand relevance of outcome measures. It helps if the beneficial reasons whythe measures are being used areproperly explained to staff and toclients. In my experience many servicessimply tell their staff that they needto collect outcome measures andexpect that to simply happen. Thereality is that the move to successfullyembedding outcome measures into
practice is a journey that can takethree years or so. Simply deciding to implement a measurement systemis not enough. A common mistake is for planners to focus solely on thetechnology or administrative systemsbeing implemented. Instead,experience teaches that the leveragefor a successful organisational changeof any kind is to focus on the people.Winning over the sceptics is critical.
If there is staff resistance, there arelikely to be therapists Ignoring or atbest Appending outcome measures sothe data quantity and quality canoften be poor. If this is the case, thenthe usefulness to the individuals andthe service is limited. This can bedispiriting and lead to increasedresentment of the measures, thusreinforcing the resistance. Yet ratherthan let this downward spiral continue,careful planning can lead to animproving data cycle. Find thosedynamic individuals who are Integratingoutcome measures into their dailywork, spread that enthusiasm and bestpractice, provide training and ensuremanagement use the data positively,as this will help increase the value ofthe measures to all.
Orlinsky and Ronnestaad’s research8
emphasises the importance of continuedtherapist development. Paying closeattention to your own outcome datais but one way of doing this. It helpsto reflect on and question your currentpractice. For example, a few years agoI had a sense that I was seeing a highnumber of depressed men. I was ableto interrogate my CORE data to seethat, unusually, I saw more men thanwomen (the service norm at the timewas two women for every man). I couldalso see that I was not as effectivehelping depressed men as I was withother presentations and this allowedme to tailor my CPD to address this.
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The dialogicalpossibilities thatemerge fromoutcome measuresare the reason I haveintegrated them into my therapy ‘
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It is taking that anxiety-provokingstep and being curious about howoutcome measures can help the clientand the therapist that seems to be thestarting point on the feedbackfreeway. Unsworth et al’s study9 foundthat although therapists were initiallyresistant to routine outcome measurecollection in principle, through practiceand over time, they could see thebenefits. For example, the therapistsbecame more aware of the need toprovide ongoing evaluation of theirclients’ progress; clients were morepositive about using routine outcomemeasures and they particularly likedthe visual presentations of theirmental state.
For this virtuous circle to begin,therapists are required to pay moreattention to how they use outcomemeasures with clients. The systematiccollection of client feedback will notadequately happen if therapists Ignoreor Append the measures to their work.Therapists who integrate outcomemeasures into their everyday practicedo so because they have found waysto make it relevant to their therapeuticwork. They see that the measurescomplement clinical judgement, notreplace it. They see that clients respondwell to being able to track theirprogress. This positive attitude is likelyto be conveyed to the client, who thenalso sees the value of the measures,
the results they show and the curiousconversations they generate. They areseen as a normal, helpful and integralpart of therapy. �
Nic Streatfield currently works for COREIMS as a business development managerand for the University of Sheffield as acounsellor. He also has a small cognitiveanalytical therapy (CAT) private practice. Nic has spoken at conferences on the activeuse of outcome measures in therapy and,through CORE IMS, provides training onintroducing and using outcome measures.
References1 National Institute for Health Research.Who decides the definition of a goodoutcome? NIHR Mental Health ResearchNetwork News Summary; July 2010.Available via http://www.mhrn.info/data/files/MHRN_PUBLICATIONS/mhrn_A4_news_who_decides_a_good_outcome.pdfAccessed 07/03/112 The National Institute for Mental Healthin England. Outcomes compendium:NIMHE; 2008.3 Department of Health. Realising thebenefits. DH; February 2010. Available viahttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_112982 4 Duncan B. On becoming a bettertherapist. Washington DC: AmericanPsychological Association; 2010. 5 Hawkins EJ, Lambert MJ, Vermeersch DA,Slade KL, Tuttle KC. The therapeuticeffects of providing patient progressinformation to therapists and patients.Psychotherapy Research. 2004; 14(3):308-327.6 Unsworth G, Cowie H, Green A.Therapists’ and clients’ perceptions ofroutine outcome measurement in theNHS: a qualitative study. Counselling andPsychotherapy Research. 2011. 7 Miller S, Hubble M, Duncan B. Supershrinks.What is the secret of their success? Availablevia http://www.psychotherapy.net/article/successful-psychotherapists8 Orlinsky DE, Ronnestad MH. Howpsychotherapists develop: a study oftherapeutic work and professional growth.Washington DC: American PsychologicalAssociation; 2011. 9 Unsworth G. CORE-Net and ARM 5. Arethey worth using? Counselling at Work.2008; summer: 6-10.
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Nic’s personal journey
When I first collected outcome measures, it was in paper form and the paperwas processed by the administration team, often many months after theclients had left my therapy room. I didn’t know quantitatively how many ofmy clients were improving. I didn’t know much about the validity or reliabilityof the measure I was using, and I certainly had never been told how to use iteffectively.
It is never a good idea when you are new in a team to agitate for changebut that is what I did. Surely it should be the therapists who enter the dataonto the reporting software as it would mean much more to us? Therapistswould see a real person reflected in the data, not just the set of numbersadmin did months later.
This process, with its inevitable resistance, meant that suddenly the datawas accessible and it allowed me a different way of reflecting upon my client.I noticed areas (eg sleep problems) I’d hitherto neglected, and armed with theoutcome measure, could go back and ask the client to explain more.
The ability to analyse my own data made it seem much more real for me. I was then fortunate to be involved in a small Practitioner Research Network(PRN) where we wanted to test how clients reacted to being asked to completean outcome measure, not just pre and post therapy, but during it as well. Atthe time it felt revolutionary and was certainly anxiety-provoking. All of uswere worried that it might threaten the alliance, yet it did the opposite, andour clients seemed to really like being able to track their progress and talkthrough their answers.
I did worry I might be ‘found out’ to be a hopeless therapist, but my datasuggests that I’m doing OK. The challenge of systematic feedback though is that there is always more to learn. It can still be hard when a client is notimproving and, while difficult to admit my input is not being helpful, beingable to recognise it and discuss it seems to be extremely useful for thetherapeutic process.
As technology has improved, I can ask clients to enter data themselvesdirectly onto CORE Net either in the room, where I find people’s physicalresponse to the questions fascinating, or they can complete the measures in the waiting room, or even via email. It is not the numbers that interest me,but the reasons why clients scored the outcome measure that way at thattime: the dialogical possibilities that emerge from outcome measures are thereason why I have integrated them into my therapy.
Reader responseHCPJ welcomes feedback on this
article. If you would like to contact Nic Streatfield, or HCPJ, please email
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Is your testing protocol wobbly? Is your testing procedure fit forpurpose? How sure are you that your
testing boundaries have not become a little stretched and squeezed witheverything else you need to fit into a session? Summer is here and afterall that holiday indulgence it’s time to put your testing on a diet! Whilstwe all know that dieting is never easyor something we look forward to, itwill become increasingly difficult toavoid focusing on this issue. The worldof testing is moving into a moreintegrated and streamlined practicethat includes the development ofbenchmarks and competencies tocover all aspects of test use regardlessof their context.
In 1995, the International TestCommission (ITC) broadened its work toencompass a responsibility to produceinternational guidelines on the fair andethical use of tests1. These guidelinesare intended as a benchmark for thetraining and competencies that testusers are expected to achieve.Internationally it was felt that theseguidelines were needed as countriesdiffered greatly in the way in whichthey used tests and the standards towhich test users were expected toadhere. The regulation of who hasaccess to different tests for use indifferent countries also differed greatly.Potentially this could result inindividuals being treated differentlyand, therefore, possibly unfairly, indifferent geographic locations. Theproduction of these guidelines was amultinational collaborative project andat the Council of the International TestCommission meeting in June 1999 theguidelines were formally adopted asthe new international standards fortest use. The European Federation ofPsychologists’ Associations’ (EFPA) TaskForce on Tests and Testing2 (now theEFPA Standing Committee on Tests and
Testing) established in the Athensmeeting, 1995, also endorsed theguidelines at its July 1999 meeting inRome. The British Psychological Society’s(BPS) Psychological Testing Centre(PTC)3 is nearing completion of its newtraining programmes for qualificationsin testing which is based on the ITCguidelines for best practice in test use.
The international guidelines shouldbe considered by all who use any formof testing in their work as benchmarksagainst which their existing standardscan be compared. The guidelines’ keypurpose is to provide a framework thatcan be used to ensure that all testusers will use tests in a professionaland ethical manner whilst respectingthe needs and rights of people involved,the purpose of the test, and the broadercontext in which the testing occurs.The guidelines recognise that the terms‘test’ and ‘testing’ are used in a varietyof contexts and ways that vary greatlygiven the scope and purpose of theassessment. However, they are clear thatthese guidelines apply to all situationswhere assessments take place, eventhose that do not involve proceduresthat are called a ‘test’. The guidelinestherefore apply to any procedure usedfor ‘testing’, regardless of its mode ofadministration; regardless of whether itwas developed by a professional testdeveloper; and regardless of domainor context. This explicitly includesprocedures for use in psychological,occupational and educationalassessment, and procedures for themeasurement of both normal andabnormal or dysfunctional behaviours.The following ‘diet’ is not intended togive you an exhaustive and definitiveguide to best practice but rather togive you an overview of the practicalelements of the guidelines that willenable you to make some easy changes,if necessary, to streamline your ownwork in this area.
D... is for data protection, andthis does deserve its capital letter! Aspart of the benchmarks for ethicalpractice fall under the Data ProtectionAct (1998)4 in this country, it is not aguide to best practice here but astatutory requirement of how youtreat, store and handle other people’spersonal data.
The Data Protection Act is based oneight principles. The first of these isthat personal data shall be processedfairly and lawfully. This could be seenas fairly open-ended. However, it doesgo on to state that data cannot beprocessed unless that data meets thesecond and third principles of the Act:personal data shall be obtained onlyfor one or more specified and lawfulpurposes, and shall not be furtherprocessed in any manner incompatiblewith that purpose or those purposes;and that in the case of sensitive datathe information stored should beadequate, relevant and not excessivein relation to the purpose or purposesfor which they are processed. Inpractical terms this means that clients
The testingTina Thomas shares her knowledge of best practice and guidance in testing procedures
must be told the purpose of thetesting session and that you shouldonly collect and store data from thissession that provides an accurateassessment of that purpose; collectsinformation that is relevant to thatpurpose; and does not containinformation that is not relevant tothat purpose. The importance of beingclear about the purpose of the testingis an important issue.
For the purposes of the Act, thisdata handling is termed‘Processing’ and it includes theobtaining, recording, holding orstoring of information in any form;and carrying out any operations onthe data, including adaptation,alteration, use, disclosure, transfer,erasure, and destruction. These areimportant distinctions to make as youmay be required to submit a summaryof the data you have collected inanother form, for example, into anelectronic data base. The rationale forthis needs to be quite clear; you mustbe sure that not only do youunderstand what will happen to thisdata (what purpose it will be used forin the future), how it will be stored(whether it is anonymous), and howlong it will be kept for, but also youneed to convey this to the individualthe data relates to. This will beelaborated on later in the article.
The fourth principle dictates that anypersonal data held will be accurateand, where necessary, kept up to date.If the data held becomes outdated interms of serving its original purposein any meaningful way then we must
question the validity of keeping it. Tothis end the fifth principle specifiesthat any personal data shall not bekept for longer than is necessary forthat purpose or those purposes. Againthis may seem a little open-ended butif the data held no longer contributesto the original purpose, or perhapshas been stored in another form (egelectronic), we have a duty to securelyand confidentially destroy whatever isno longer needed. As a rule of thumband where it is the case that historicalpersonal data is no longer needed, aperiod of six months is the norm forpaper-based test results storage. Thereshould be regular reviews carried outof the stored data to ensure that datais not held for any longer than isnecessary.
The sixth principle of the DataProtection Act states that any personaldata should be treated in accordancewith the Rights of Data Subjects andOthers under this Act. The act itselfconveys rights to individuals in respectof the data held about them. Theindividual is entitled to be suppliedwith a copy of all personal data held.No personal data should be held orobtained unless they have given theirconsent, and this must only be heldand obtained in relation to the statedpurpose. Principle 7 specifies themeasures that can be taken againstunlawful or unauthorised processingof personal data which includesaccidental loss or destruction of, ordamage to data held. The unlawfuland unauthorised use also includesdirect marketing and any actionsdeemed to cause damage or distress,including any decisions made on thebasis of the data held. A point worthconsidering here is being clear notjust about the purpose of the testingsession but also the purpose of thetest itself. If a test has been designedas a screening tool, and not as adiagnostic tool, make sure that anytreatment decisions are able to beevidentially based on a broader set ofinformation rather than the testresults themselves. In fact, theguidelines to good practice do statethat any test results should only forma part of any decision-making processas they are all subject to a margin oferror and some degree of fallibility.
The eighth principle dictates that
personal data shall not be transferredto a country or territory outside theEuropean Economic Area unless thatcountry or territory ensures anadequate level of protection for therights and freedoms of data subjectsin relation to the processing ofpersonal data.
I... is for informed consent. Thisextends the minimum requirementsembedded in the principles of the DataProtection Act to include additionalguidelines on how individuals involvedin testing should be treated fairly andethically. A fundamental point here isthat the individual feels that theyhave been adequately informed, notthat you feel you have given themadequate information. To this endmanaging the whole process of thetesting session has to be based onensuring this is the case. The easiestway to manage this is to provideclients with an information sheet thatnot only details the items required fordata protection but also tells themabout the test, how long it mighttake, whether there are right andwrong answers or whether the testjust asks for their opinion, and whatkind of things it asks or is assessing.Without this they cannot know whatthey are expected to do. It is notsufficient to just tell them that theywill be doing a test on depression and
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The guidelines togood practice dostate that any testresults should onlyform a part of anydecision-makingprocess as they areall subject to a marginof error and somedegree of fallibility ‘
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anxiety, for example. The very idea of testing can invoke stress oranxiety so giving your client as muchreassurance about this not only putsthem at ease but means that you areless likely to get socially desirablerather than honest responses.
In respect of the data you arecollecting from the test, the clientneeds to know what will happen tothis. Not only is this necessary fromthe point of consideration of the dataprotection issues but is also bestpractice in giving information to theclient. You will need to reassure themthat any data will be held securelyand that no other person will haveaccess to this, unless they haveconsented otherwise. Confirm thatany paper form of data collected willbe destroyed as soon as the data is nolonger required and how, if appropriate,the data is going to be adapted ortransferred and then held. Will it beanonymous? What will it be used for?It is expected that if the data were tobe utilised in this way that it wouldcontain no information that allowsthe data within to be attributed toany individual, or for them to beidentified from it. The electronic formof the data should only be held untilit is no longer needed then securelydestroyed. Using data to create normgroups or other reference groups fromit is perfectly acceptable but only ifyour client is aware of this and is toldwhy and how the resultant data istreated before consenting. Think ofthis as a form of contracting fortesting with your client in the sameway you would for therapy. They mustknow what the information will beused for (ie for discussion during their session or for benchmarkingprogression of symptoms etc) andhave the opportunity to ask anyquestions about the information theyhave been given before completingthe test. If the test is not beingcompleted in a face-to-face settingbecause the client is expected to havethe test completed in advance of yoursession, then the required informationshould be sent to the client before orwith the test. This should then alsohave contact details included in casethe client wishes to ask any questionsor have any queries in advance of testcompletion.
E… is for environment, theactual setting that the testing takesplace in. This is different in differentsettings. Assuming that the testing is in a face-to-face situation, thencertain considerations as to theeffects that the environment can haveon the accuracy and validity of thetest results need to be considered.Almost all tests can have a margin oferror in the results. If the test-takerhad completed the test on a differentday or in different circumstances, theresults may vary slightly. This marginof error is not likely to yield asignificant movement away from theoriginal test result if the test isreliable and properly constructed;however, the setting up of the testingsession and the distractions that mayoccur should be minimised in order toensure that the test results you obtainare less likely to differ in this respect.This may be particularly importantwhere the test has been designed fordiagnosis and you need to be able todemonstrate, from a data protectionpoint of view, that the test was carriedout in as robust a manner as possibleto ensure the utmost accuracy of theresults. The obvious distractors arenoise, excessive or insufficient heatand light, and interruptions.
There are also factors that relate tothe individual that you may not beable to control but perhaps are ableto note for reference, such as mood,hunger and tiredness. Having the
room set up appropriately in advance with no need torearrange furniture or movearound in order to carry outthe test can reduce anxietywhich may affect test results.Spare pens and papers seemobvious as does checking thatthe test-taker understandswhat they are expected to do during the test from theinformation they have beengiven. A best practice way todeal with this is to read outthe instructions to the clientand explain the responseformat they are expected
to use. If appropriate, givethem an opportunity
to do some practicequestions and to ask
any questions about theseafterwards. Of course if the testing isto be carried out prior to the sessionand in their own time, you may wantto consider giving them instructionsto try and find a time and a placethat is free from as many distractionsas possible to do the test.
Think about when in your sessionyou are going to carry out the test –will they know they are going to bedoing a test in advance of coming ornot? Will the test be carried out atthe beginning of your session, andused as a basis for discussion, or atthe end of the session? If it is goingto be done at the end then some level
The effects that theenvironment can haveon the accuracy andvalidity of the testresults need to beconsidered... If the test-taker had completedthe test on a differentday, or in differentcircumstances, theresults may varyslightly ‘
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of feedback is needed to reduceanxiety about the test results beforethe next time you see them, giving aform of closure on them. If the testingis carried out partway through thesession, it is possible that the priordiscussions you have had influencethe answers they may give. If thetesting is to be repeated to monitorsymptoms or progress, it should beplaced at the same juncture in thesession as previously carried out andany effects of repeated exposure, ielearnt answers, should be investigatedin discussions and noted.
T… is for issues relating to thetesting itself. All tests are designedfor a purpose: at a very basic level do you know what your test wasdesigned to measure? There aremultiple measures of many constructs:depression, anxiety, ability, etc. Thesewill have been designed and constructedusing different populations and fordifferent purposes (ie screening vsdiagnosis). They will have differingreliability and validity statistics indifferent populations. Are you, forexample, comparing minority group
members’ results to a norm groupthat was created using white,
middle class American males?Using this informationthat is available in
published articles and testmanuals can help to ensure
that the test you are using is the most appropriate for your
client. This will not only allow you to obtain the most robust test
results but also give you a findingthat is most relevant to your clientneeds.
The characteristics of your clientsthemselves are also importantconsiderations: testing people withdisabilities needs particular attentionin testing practice. If your client has a disability that may affect theirability to understand and/or respond
appropriately to the testinformation and you do not
account for this, you could bedrawing invalid conclusions from
the test results you have gained. Inrespect of issues such as dyslexia anddyspraxia, reading the instructions toaid understandability and practicequestions, as discussed above, willhelp. For other disabilities a case-by-case judgement must be consideredand if deviations are made from astandardised approach as advocatedby the test publishers, such as differentresponse formats and more simplisticlanguage in the questions asked, theseshould be justifiable and noted forfuture reference, if needed. If thedeviations are likely to significantlydetract from the reliability and validityof the test results, then alternativesshould be found. If in doubt, it isrecommended that you contact thetest publisher directly and/or refer tothe information in the test manual.
A final word on issues surroundingthe test relates to the standardisationof the test procedure. The tests youuse will have certain response formatsand instructions to follow, perhaps forboth you and your client. It is importantthat you do not vary these in a waywhich changes their meaning; it is theclient’s interpretation that is needed.In order that the test results have agood degree of rigour it is importantthat each participant’s experience of completing the test is the same,particularly where the tests results arebeing used to create a norm group orsome form of pooled comparisonpopulation. �
Tina Thomas is a chartered psychologist andsenior lecturer at the University of Chester.Tina holds certificates of competencein psychometric testing and is chairpersonof the British Psychological Society NorthWest Branch. She works commercially asan independent consultant carryingout assessments and testing in a variety of settings and with a range of clients. Her particular interests are in testing anddisability and organisational use of tests.
References
1 International Test Commission (ITC). The ITC guidelines on test use. ITC; 2000.See http://www.intestcom.org
2 See http://www.efpa.eu/
3 See http://www.psychtesting.org.uk/
4 Her Majesty’s Stationery Office (HMSO).Data Protection Act (1998). Seehttp://www.hmso.gov.uk/acts/acts1998/19980029.htm
Reader responseWas this article useful? Will it help you to make changes to the way you test?
Do you have any further questions? The author welcomes questions and/orfeedback. Please contact Tina Thomas
If your client has a disability that mayaffect their ability tounderstand and/orrespond appropriately to the test informationand you do notaccount for this, youcould be drawinginvalid conclusionsfrom the test results ‘
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Avariety of expert guidelineshave addressed screening fordepression, but unfortunately
few agree, leaving most cliniciansuncertain what approach to take1,2.Impressive data from the US suggeststhat without incentives, screening fordepression takes place in only threeper cent of primary care consultations3
and in about one per cent ofconsultations with specialists4. In theUK, the 2006 Quality and OutcomesFramework (QoF) specificallyencouraged screening for depressionin patients with diabetes and/orcoronary heart disease (CHD). Twoaudits suggest that between 79 percent and 84 per cent of patients withthese conditions are screened fordepression5,6. Outside of diabetes/CHD,rates of screening for depression inroutine care survey data suggest thatmost clinicians are not using formaltools but prefer to rely on their ownclinical skills7. The most importantquestion, therefore, may be not howwell do screening tools perform, buthow well can clinicians diagnosedepression using their day-to-dayclinical skills?
The diagnostic accuracy of GPsRecently, our group undertook ameta-analysis in order to betterunderstand the diagnostic accuracy of general practitioners (GPs) andnurses8,9. GPs have been subject to far more scrutiny in their diagnostichabits than any other professional
group, whereasnurses are themost numerousclinicians in the NHS.Both groups have avital role as front linehealthcare professionals inthe management of mental healthproblems. We found 41 robust studiesof GPs’ clinical ability to diagnosedepression, 23 of which regarded theirability to detect broadly defineddistress, and nine reporting on milddepression. We located 22 studiesregarding the ability of nurses toidentify depression clinically. Fromthese studies, both GPs and nursescorrectly identified depression in abouthalf of true cases although there wasa correct entry in the medical recordsin about one third of cases.
Clinicians correctly reassured eightout of 10 healthy individuals but withsubstantial false alarms. In a typicalurban practice (where the prevalenceis 20 per cent) the error rate would be25 per cent (10 per cent missed casesand 15 per cent false alarms). Althoughresults are likely to be representativeof most primary care practices, thereis one important caveat. Data aregenerated from studies where physiciansvolunteered to participate in a studyand were therefore aware of beingobserved and (presumably) trying todetect cases. It seems reasonable toconclude that these results may beunduly favourable compared toroutine care. Indeed, in a handful
of retrospective studies where GPs didnot know they were being observed, it was found that GPs would moretypically detect only one in threecases, but correctly identify nine outof 10 non-depressed people. In otherwords, in the real world, there arelikely to be more false negatives thanfalse positives.
Yet these possible misidentificationsare not necessarily errors unless theyare followed by an inappropriate action.Indeed, we know that clinicians tendto prescribe antidepressants to peoplewhose diagnosis is more certain. Fromstudies of prescribing habits, we know
How well can clinicians diagnosedepression using their day-to-dayclinical skills? Research by AlexMitchell and colleagues examinesdiagnostic capabilities without the use of screening tools
Impressive data fromthe US suggests thatwithout incentives,screening fordepression takesplace in only three percent of primary careconsultations ‘
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Recognition of depression and distress in primary care: are clinical skills adequate in the absence of screening?
that GPs prescribe to about two thirdsof patients in whom any depressiondiagnosis is recorded but only a quarterin whom either no diagnosis is recordedor those with very mild symptoms butstill considered to be depressed10-12.Therefore, taking into account boththe diagnostic difficulties and thetherapeutic difficulties, then clinicallythe maximum proportion of therapeuticerrors should be no higher than 10 percent (those with no depression ontreatment) plus 7.5 per cent (the missedcases who receive no treatment). This isillustrated in figure 1. Preliminary datafrom a recent survey of Scottish GPsappears to support this calculation13.
Looking for distress vs depressionIt has been argued that the reason forerror is that astute clinicians increasinglylook for distress rather than depressionand hence focus on a broad spectrumof severity rather than the narrowermajor depression concept. Furthermore,mild depression is now recognised asimportant largely because of theprognostic implications, and theAmerican term of ‘minor depression’ is becoming more widely accepted.Although it is certainly the case thatdistress is an increasingly popularscreening target, largely due to thehigh acceptability and understandability
of the term, it cannot be assumedthat GPs correctly target this condition.Our group recently examined whetherGPs were really able to accuratelyidentify distress as well as milddepression14. We found that detectionof mild depression was inferior to thedetection of more severe depression,which is intuitively correct becausedifferentiating mild from normaldepends on fewest symptoms orsigns15,16. Furthermore, their ability to detect broadly defined distress was no better than their ability todefine depression itself with about 50 per cent sensitivity and 80 per cent specificity.
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Figure 1. Illustration of yield from clinicians looking for depression in clinical practice
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Table 1. GPs’ ability to detect depression and distress using clinical judgement
However, there was one majordifference between looking fordepression and looking for distress.Distress is at least twice as common as clinical depression (approximately40 per cent vs 20 per cent) and thisinfluences accuracy by reducing falsepositive errors but at the expense offalse negative errors (see table 1).Overall, when both the frequency and the discrimination of clinicaljudgements are taken into account,clinicians have average to good ruleout abilities, but rather poor rule inabilities.
Looking more closely at types ofdiagnostic error, many areunderestimates or overestimates ofseverity rather than completemisidentifications. In many casesclinicians recognise symptoms but donot believe psychological issues areclinically significant17,18. For example,Tiemens and colleagues18 found thatonly 26 per cent of missed cases (falsenegatives) were complete omissionswhilst 25 per cent were underestimatesof severity (eg diagnosing sub thresholdinstead of mild) and 38 per cent weremisidentifications. Conversely of falsepositive diagnoses, 35 per cent wereoverestimates of severity, 24 per centwere misdiagnoses and 41 per centcomplete errors. In the MAGPIE study,
Bushnell et al17 found that reasons for failures in diagnosis were notcategorising their psychological issuesas clinically significant (23.4 per cent);recognising clinical significance butnot ascribing a particular diagnosis(7.1 per cent); or the GP making anexplicit diagnosis of something otherthan depression (7.7 per cent).
Varying performance ofindividual practitionersOne interesting observation from theserecognition studies is that theperformance of individual practitionersvaries considerably. In one of the mostcomprehensive studies to date, carriedout in Australia, Hickie and colleagues19
looked at 46,515 patients attending386 GPs, of whom 56 per cent werenot recognised as depressed. Patients were more likely to be assessedpsychologically if they were middle-aged, female, Australian-born,unemployed, single, and presentingwith mainly psychological symptomsor for psychological reasons. Doctorcharacteristics associated withwillingness to assess were being agedover 35 years, having an interest inmental health, having had previousmental health training, being in part-time practice, seeing fewer than 100patients per week, and working inregional centres.
Five other key factors appear toinfluence the ability of clinicians toadequately detect depression. The firstis the ability to maintain appropriateclinical suspicion, that is, the propensityto look for the condition in questionand act on verbal and non-verbalsignals when presented. In an audiotapestudy by Adelman et al20, depressionwas discussed in only 7.3 per cent ofmedical visits. Of these, physicians
raised the subject of depression in 41per cent of visits, patients raised thesubject of depression in 48 per cent ofvisits, and accompanying persons raisedit in 10 per cent of visits. Depressionwas raised almost exclusively in thefirst 2.5 years of the patient-physicianrelationship.
The second factor is physicalcomorbidity. If background somaticsymptoms are incorrectly assumed tobe depression, there is a risk of falsepositives, and if true depression-related somatic symptoms are ignored,there is a risk of false negatives. Thisissue can only be resolved clinically ifthe origin of somatic symptoms canbe established, for example, by askingwhether they were present before thedepression began.
The third factor influencingdiagnosis (or diagnostic disclosure) isthe availability of effective treatmentand, linked with this, the likelihoodthat a patient will accept the diagnosisand affiliated treatment. Effectivecontinuing care is an important pieceof the puzzle that influences promptdiagnosis in a subtle way. In short, ifno effective and acceptable treatmentis available then physicians arereluctant to give a diagnostic label,even if that label is medically accurate21.
A fourth factor in the difficultydealing with depression in primarycare is that a surprising number ofpeople with clear distress or depressiondo not accept professional help andthis influences whether clinicians usethe diagnosis22,23. For example, Waltersand colleagues24 found that only halfof participants reported wanting help.Most preferred informal sources ofhelp such as friends/family support, andcomplementary treatments, togetherwith general advice from their GP.
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PPV = Positive Predictive Value; NPV = Negative Predictive Value; Clinical Utility Index (CUI)
Detection of Prevalence of conditionunder study
Proportion ofcases detected(GP sensitivity)
Proportion of non-casesdetected GPspecificity
GP predictiveaccuracy whenthey judge a case aspresent (PPV)
GP predictiveaccuracy whenthey judge a case asabsent (NPV)
GP clinicalability toconfirm thecondition(CUI+)
GP clinicalability torefute thecondition(CUI-)
Depression 20% 50% 80% 38.5% 86.5% 19.2% (poor) 69.2% (good)
Distress 40% 50% 80% 62.5% 70.6% 31.3% (poor) 56.5% (average)
One interestingobservation is that the performance ofindividual practitionersvaries considerably ‘‘
Primary care and mental health servicesneed to continue to develop ways ofhelping people who decline initial help,for example, by offering self-help tools,bibliotherapy, internet programmesand open follow-up.
The fifth and perhaps mostimportant influence on detection ishaving adequate time. The longer theconsultation, the more comprehensivethe assessment and the more likely a correct diagnosis will be made3.Unfortunately many clinicians arepressured to use short appointments,often the result of an organisationalpush for quantity at the expense ofquality.
ConclusionIn conclusion, both depression anddistress can be both under-detectedand over-detected. However, it isimportant to acknowledge thatdepression can be difficult to diagnoseaccurately using existing criteria andit is not clear that primary carephysicians perform any worse thanother medical colleagues. Currentcriteria are somewhat arbitrary anddifficult to remember. A relatively newapproach is to start with broad conceptssuch as distress and then assess unmetneeds and desire for professional help.This approach is not uncommon inclinical practice and is being formallytested in screening studies. Severalgroups are also trying to use evidenceto develop simpler criteria for majordepression that are memorable, butstill clinically meaningful25. �
Alex J Mitchell is consultant in liaisonpsychiatry at Leicester General Hospital andhonorary senior lecturer in liaison psychiatryat the Department of Cancer and MolecularMedicine, Leicester Royal Infirmary.
References1 US Preventive Services Task Force.Screening for depression in adults: US Preventive Services Task Forcerecommendation statement. Ann InternMed. 2009; 151(11):784-792.
2 Kilbourne AM, Daugherty B, Pincus HA.What do general medical guidelines sayabout depression care? Depressiontreatment recommendations in generalmedical practice guidelines. Curr OpinPsychiatry. 2007; 20(6):626-631.
3 Schmitt MR, Miller MJ, Harrison DL,Touchet BK. Relationship of depression
screening and physician office visitduration in a national sample. PsychiatricServices. 2010; 61(11):1126-1131.
4 Harrison DL, Miller MJ, Schmitt MR,Touchet BK. Variations in the probabilityof depression screening at community-based physician practice visits. PrimaryCare Companion Journal of ClinicalPsychiatry. 2010; 12(5);pii: PCC.09m00911.
5 Subramanian DN, Hopayian K. An auditof the first year of screening fordepression in patients with diabetes andischaemic heart disease under the Qualityand Outcomes Framework. Quality inPrimary Care. 2008; 16(5):341-344.
6 Croxford AM. An evaluation of routinescreening, assessment and treatment ofdepression for patients on the diabetesand/or coronary heart disease registers in a primary care practice in Norfolk.Reinventional Journal. 2010; 3(1). (Epub.)
7 Mitchell AJ, Kaar S, Coggan C, Herdman J.Acceptability of common screeningmethods used to detect distress andrelated mood disorders – preferences of cancer specialists and non-specialists.Psychooncology. 2008; 17(3):226-36.
8 Mitchell AJ, Vaze A, Rao S. Clinicaldiagnosis of depression in primary care: a meta-analysis. The Lancet. 2009;374(9690):609-19.
9 Mitchell AJ, Kakkadasam V. Ability ofnurses to identify depression in primarycare, secondary care and nursing homes –a meta-analysis of routine clinical accuracy.International Journal of Nursing Studies.2010; June 24. (Epub ahead of print.)
10 Smolders M, Laurant M, Verhaak P et al.Adherence to evidence-based guidelinesfor depression and anxiety disorders isassociated with recording of the diagnosis.General Hospital Psychiatry. 2009;31(5):460.
11 Sewitch MJ, Blais R, Rahme E, Bexton B,Galarneau S. Receiving guideline-concordantpharmacotherapy for major depression:impact on ambulatory and inpatienthealth service use. Canadian Journal ofPsychiatry. 2007; 52(3):191-200.
12 Cameron IM, Lawton K, Reid IC.Recognition and subsequent treatment of patients with sub-threshold symptomsof depression in primary care. Journal of Affective Disorders. 2010; 3 Nov. (Epub ahead of print.)
13 Cameron IM, Lawton K, Reid IC.Appropriateness of antidepressantprescribing: an observational study in aScottish primary-care setting. British Journalof General Practice. 2009; 59(566):644-9.
14 Mitchell AJ, Rao S, Vaze A. Can generalpractitioners identify people with distressand mild depression? A meta-analysis of clinical accuracy. Journal of Affective
Disorders. 2010; 11 Aug. (Epub ahead of print.)
15 Olfson M, Gilbert T, Weissman M,Blacklow RS, Broadhead WE. Recognitionof emotional distress in physically healthyprimary care patients who perceive poorphysical health. General Hospital Psychiatry.1995; 17;173-180.
16 Perez Stable E, Miranda J, Munoz RF.Depression in medical outpatients:underrecognition and misdiagnosis. Archivesof Internal Medicine. 1990; 150:1083-1088.
17 Bushnell J. Frequency of consultationsand general practitioner recognition ofpsychological symptoms. British Journal of General Practice. 2004; (508):838-842.
18 Tiemens BG, VonKorff M, Lin EH. Diagnosisof depression by primary care physiciansversus a structured diagnostic interview.Understanding discordance. GeneralHospital Psychiatry. 1999; 21(2):87-96.
19 Hickie IB, Davenport TA, Scott EM,Hadzi-Pavlovic D, Naismith SL, Koschera A.Unmet need for recognition of commonmental disorders in Australian generalpractice. Medical Journal Of Australia.2001; 175:S18-S24 Suppl S.
20 Adelman RD, Greene MG, Friedmann E,Cook MA. Discussion of depression infollow-up medical visits with older patients.Journal of The American Geriatrics Society.2008; 56:16-22.
21 Mitchell AJ. Reluctance to disclosedifficult diagnosis: a narrative reviewcomparing communication by psychiatristsand oncologists. Supportive Care in Cancer.2007; 15(7):819-828.
22 Van Schaik DJF, Klijn AFJ, Van Hout HPJet al. Patients’ preferences in the treatmentof depressive disorder in primary care.General Hospital Psychiatry. 2004;26(3):184-189.
23 Prins MA, Verhaak PFM, Bensing JM, Vande Meer K. Health beliefs and perceivedneed for mental health care of anxietyand depression – the patients’ perspectiveexplored. Clinical Psychology Review.2008; 28(6):1038-1058.
24 Walters K, Buszewicz M, Weich S, King M.Help-seeking preferences for psychologicaldistress in primary care: Effect of currentmental state. British Journal of GeneralPractice. 2008; 58(555):694-698.
25 Zimmerman M, Galione JN, Chelminski Iet al. A simpler definition of majordepressive disorder. PsychologicalMedicine. First published online 2009.
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Reader responseHCPJ welcomes feedback on this
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HCPJ July 2011 17
There is a noticeable dearth,certainly in the UK literature, ofclinical perspectives on record-
keeping generally and on the impacton the therapeutic relationshipspecifically. To illustrate, one needonly refer to the helpful record-keeping guidelines published by theBritish Psychological Society1. Of the64 publications referenced, themajority are policy directives from the Department of Health (DH) andmost of the remaining references areguidelines issued by professionalbodies. This is especially noteworthygiven the introduction of electronicpatient record (EPR) systems acrossthe NHS. Colleagues frequently referto the ever-increasing administrativeload eroding time and space forreflection and processing of clinicalmaterial. In many cases, information is collected from patients in sessions,which is often felt to be intrusive andat odds with, or even disruptive of,the therapeutic frame. In some clinicalsituations, the attending professionalspends more time looking at a screenor typing than engaging directly withthe patient in the room. NonethelessEPRs and all associated developmentsand/or impingements are certainly notgoing away. On the contrary, there isan exponential growth, making this acentral feature in the work we do.
The issues, dilemmas, pitfalls andchallenges posed by EPRs are notentirely new. Since 1992, there hasbeen a raft of policy guidelinesaddressing various aspects of datacollection, protection and dissemination– a bewildering array for the busyclinician to keep pace with. Of immense
importance is the guidance emanatingfrom the Caldicott Report (1997)resulting from the review undertakenby the Caldicott Committee as it wascalled under the chairmanship of DameFiona Caldicott. The Chief MedicalOfficer requested this review in lightof concerns about confidentiality as aresult of the developing informationtechnology. This report resulted in sixkey principles, including informationbeing shared on a ‘need to know’ basisand 16 recommendations, whichincluded the appointment of a seniorperson across health organisations to actas a guardian of patient confidentiality– known as Caldicott Guardians.
Other related developments include:� Policy on copying correspondenceaimed at facilitating the importanceof greater service user involvement in treatment plans. This highlightedan interesting tendency to viewinformation about physical health as synonymous with mental health.Moreover, different professionals inmental health do not necessarily seepersonal information in the same way. � The centrality of the child protectionand safeguarding adult agendas andthe consequent responsibilities on theclinicians, which are often in conflictwith ensuring privacy and confidentialitybut exist for the greater good. � More broadly the fact that we livein the so-called ‘Information Age’ (inwhich personal information is readilyshared in all sorts of ways such as theinternet) might lower sensitivity tobreaches of privacy.� Overvaluing of the notion thatinformation alone can prevent harmto self or others.
Electronic patient record systems arecertainly here to stay, though whoknows what technological advancesmight lead to further developmentsaway from what many cliniciansalready feel is a step too far in themanagement of the clinical domain.The focus of this article will be on theconsideration of confidentiality andthe inevitable clinical dilemmas thatarise in the context of the localimplementation of interim systems.
Electronic patient records (EPRs)The House of Commons HealthCommittee’s report on The ElectronicPatient Record2 refers to the EPR as a‘potentially… transformativetechnology’ but also recognises thatpersonal health information is often‘highly sensitive’ and it is ‘ …thereforedifficult to repair the damage causedby a breach of privacy’. There are somelaudable aspects of the envisagedNational Programme for InformationTechnology, contained in its plans forthe Summary Care Record (SCR), suchas the availability of sealed envelopesof information, specific data sets thatcould be life-saving and help integratecare in emergency situations, and ofcourse the plans for greater serviceuser involvement via the envisagedinternet portal HealthSpace.
In a survey recently published bythe new economics foundation (NEF)and the Centre for Science Educationat Sheffield Hallam University(supported by the Wellcome Trust)3,6,000 people were asked about theirattitudes to the digitisation ofrecords. Of those surveyed, 57 percent of adults and 67 per cent of
Electronic patient records: the impact on the therapeutic relationshipBrian Rock and Helen Brindley look at confidentiality issues arising from the use of electronic records, adding a consideration of the subject from a psychoanalytic perspective
young people were enthusiastic aboutthe potential benefits to treatmentand healthcare from moving to digitalpatient records. However, the vastmajority of both groups believed thatpatients should be able to choosewhether or not to be included in anydigital database containing personalhealth data.
Almost all of those surveyed feltthat patients should have access totheir own records, but a much smallernumber (35 per cent of adults and 36 per cent of young people) were in support of online home access;even fewer (11 per cent) supportedproposals to enable patients to add
information to their own records. Stephen Whitehead, co-author of
the NEF report, said: ‘The NHS holdsincredibly private, sensitive informationabout almost every person in the UK,but there is little public understandingof what happens to that information.Unless the NHS takes decisive actionto narrow the divide between publicperception of how information is usedand the reality, the use of electronicpatient records risks seriouslyundermining public trust in its abilityto protect confidentiality.’
We certainly do not decry thephasing out of paper files/records aswe move to a paperless system;
however, many of the problems withpaper records have attracted far lessconcern than is being directed at EPRs4.Paper files can be removed from theservice, transported to another clinicalbase, can be incomplete/disorganised,or simply lost or stolen. Of course,there are also very real concerns inwhat represents a seismic shift in howrecords are now created, updated,stored and accessed. This is quiteseparate from the legitimate concernsabout the technical and humanfallibilities of the system – for example,is role-based access being effectivelyutilised? – and the questionableeffectiveness of audit trails to trackinappropriate record access. There isalso a distinct gap between some ofthe aspirations of the nationalinformation technology (IT) programmeand the realities of the interim systemsthat are in place at a local level.
One of the ways in which concernshave been negotiated about breachesof confidentiality and the sharing ofinformation beyond the therapeuticcontext is through the existence of aseparate clinical record for psychological
work. Newton1 clearly sets out in the guidelines mentioned
earlier that this is not anoption. However, there
are contradictionscontained in guidance
issued within specificprofessional bodiesas well as betweenprofessional bodies ofdifferent professions.Many mental health
professionals hold dualregistration, which
adds to the complexityand impedes the individual
clinician from knowing whichway to turn.
System of careIncreasingly mental health services are primarily team based, and in themental health trust in which we work,management’s perspective is that allparts of the patient record need to beaccessible for the team to functionsafely and effectively. Given that thereare no electronic sealed envelopesavailable, at least not in our trust, the question arises about how thisapproach to shared care is balanced
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Do clinicians have a part to play in shapingthese developments or are we merely sweptalong with the rising tide? Are EPRs simply a necessary evil, further evidence of theerosion of a valued therapeutic approach? ‘‘
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against the accessibility of sensitiveclient information.
There is typically an understandingbetween therapist and patient thatanything that the patient says will be treated in confidence unless thepatient alerts the therapist to the riskof danger to themselves or others.What does this mean in the contextof keeping a record that other teammembers will have access to? Whatguidance should be provided fortherapists regarding what is includedin the medical record and what shouldbe kept out of the record?
Within community mental healthteams (CMHTs) there is an expectationthat all information will be sharedwithin the team and patients areusually told that this is the way theservice works. Therapists working asintegrated team members have beenconcerned for a number of years aboutwhat amount of detail to record inthe shared record. The dilemma isheightened by the electronic recordwhere therapists may not be a memberof the team, certainly as identified bythe patient, but, by virtue of the easeof access to the electronic record,they suddenly are part of the virtualteam caring for the patient.
Where in the past, referringpsychiatrists would receive a dischargereport summarising the progress oftherapy and recommendations for futuretreatment, now they can access therecord that the clinician makes everytime the patient attends. Should thetherapist comply with the requirementto make an entry by noting whetherthe patient attended and nothing more(even this degree of recording may be of concern in some circumstanceswhere another involved professional mayput pressure on a patient to attend)?Should the therapist limit entries torecording concerns about risk?
Barbara Mitchels and Tim Bond, intheir excellent and comprehensive bookConfidentiality and Record Keeping inCounselling and Psychotherapy5,describe how clinicians are oftenrequired to walk a ‘tightrope’ betweenpreparing overly detailed notes andrecords that threaten to breachconfidentiality and privacy, or keepingsuch brief, scant notes as to renderthem meaningless and without value.
Nonetheless, we are of the view
that information arising from theclinical encounter with patients shouldbe shared with members of the treatingteam. Depending on the context, thismight involve sharing information withcolleagues in a psychological therapiesservice to facilitate the patient movingfrom assessment to treatment or indeedreturning to the service after havingcompleted a treatment or having beenpreviously assessed.
The clinical team can also be spreadacross a number of separate serviceswith more fluid boundaries, forexample, where a patient is receivingpsychotherapy in one service andCMHT input from another service. Thewider team will also include managersand by extension commissioners, aswell as referrers who may exist outsideof one’s organisational parameters andother involved parties.
EPRs tend to override these subtletiesand nuances where all information istreated as having an equal value. Thisintroduces a significant componentgoverning whether information isshared, how it is shared and with whom:namely anxiety and our efforts tocontain anxiety (through disclosureand through non-disclosure; oftenappropriate to the situation butperhaps manifest in breaches orbarricades at other times). This raisesan important question in relation tosharing information: is it better tohave 100 people contain one per centof the concern or anxiety or one personto contain 100 per cent? (Personalcommunication with Dr Rob, 2011.)This dynamic links to an inevitableand understandable tension in theclinical encounter that the patientand clinician has to negotiate – whatis said, what is unsaid, and why.
Confidentiality‘Whatsoever things I see or hearconcerning the life of man, in anyattendance on the sick or even aparttherefrom, which ought not to bevoiced about, I will keep silentthereon...’ (Oath of Hippocrates).
Mitchels and Bond5 define whatconfidentiality means within atherapeutic relationship: ’Confidentiality:to confide in someone is to put yourtrust in them. Confidentialitypresupposes trust between two peoplewithin a community of at least three
people. In a professional relationship‘confidentiality’ means protectinginformation that could only be disclosedat some cost to another’s privacy inorder to protect that privacy beingcompromised further.’
They explain that it is the privacy ofthe therapeutic space, the therapeuticcouple and their dialogue, thatconfidentiality protects: confidentialityis a patient’s right and the therapist’sobligation. Confidentiality is anessential characteristic of the containingproperty of therapy. Withoutconfidentiality, patients would feelconstrained in what they could say ormight feel that engaging in therapywas too risky until the need fortherapy overwhelmed their sense of self-protection.
They go on to discuss the complexissues that arise when confidentialityis considered in the wider societalcontext, where there are competingmoral interests. The way that legal andmoral systems deal with confidentialityinevitably changes over time. With theconflicting interests, there is a risk thatwhat appears to be simple and clearand what patients wish for is in factfar from straightforward and simple.
Where does the balance lie betweenavoiding deterring people from seekingtherapy because of fear of breaches inconfidentiality, and the benefits tosociety of enabling investigation anddetection of serious crime even whenthis requires therapists to breachconfidences? At what point do theprinciples of justice and fairnessbetween citizens require that courtcases are decided on the basis of allthe relevant information being madeavailable, even if this means intrudinginto what would otherwise beconfidential? Should informationdisclosed in therapeutic confidence be given legal privilege to protect itfrom being required to be disclosed in court cases?
Therapists have the same legalobligations as doctors, ministers ofreligion, accountants and journalists.The right to confidentiality is enforcedas a matter of benefit to society andcan be overridden when publicinterest would justify this. The legalposition is that there are times whenthe public interest in the disclosure ofinformation outweighs public interest
in preserving a patient’s confidentiality.Mitchels and Bond helpfully outline
the legal limitations of confidentiality:� prevention of serious harm to selfand others� legal requirements – eg court orders� disclosures to enhance the qualityof services offered by the therapist (eg professional supervision or sharinginformation with colleagues in a teamsetting).
There are many less than clear-cutcircumstances. For example, if a patientproposes to harm someone but thereis no past history, then the therapistmust make a judgement about risk (atherapist’s inability to contain anxietyis insufficient grounds for a breach ofconfidentiality).
When deciding whether to breachconfidentiality a therapist is requiredto make a considered judgement onthe basis of:� real risk – as opposed to fantasy� serious harm – eg threat to life,rape, child abuse� imminence – is it possible to takeeffective preventive action within thetherapy?� effective intervention – will a breachof confidentiality minimise the risk ofharm?
Confidentiality is at the heart of thework of psychoanalytic therapists andwith the implementation of electronicrecord-keeping there has been a greatdeal of unease among therapists whoare contractually required to makeroutine entries to update the patientrecord but who remain concernedabout the implications of this in termsof privacy.
Therapists working in the NHS arefaced with conflicting interests. Theanalytic stance to protect patientprivacy is at odds with the principlesand procedures of NHS-managed careand requests for increasing amountsof information. Should therapistscomply unquestioningly? There is animpact within the organisation giventhe changing nature of communicationand the way information is held, witha pressure to increase openness andan erosion of privacy.
Within the mental health trust inwhich we work, all psychologicaltherapists are required to make an
entry in the electronic record within24 hours of contact with each patient.In addition the electronic record willcontain:� core assessment� risk assessment – updated at leastevery six months� diagnosis (where a patient is assessedfor psychological therapy withoutinvolvement of a psychiatrist diagnosis,this must be entered by the therapist)� Health of the Nation OutcomeScales (HoNOS) � all correspondence.
Do patients know that they haveelectronic records? If not, then it is abreach of confidentiality to enterinformation onto the record withoutexplicitly discussing this with patients.Whilst they are able to withholdconsent for information to be uploadedonto the national spine, if they wishto receive treatment within aparticular trust, they must consent toa medical record being held, and thisis now an electronic record (which maybe supplemented with a paper recordfor particular documents includingthose which require a signature).
A psychoanalytic perspectiveThe psychoanalyst Christopher Bollasargues powerfully for the need toprotect absolute confidentiality forthe good of society6. However, he andanother analyst, Allanah Furlong, bothmake a case that confidentiality canbe expanded to be held by theprofession of psychoanalysis. Furlong7
argues that sharing information aboutpatients in supervision is imperativefor the good of the patient and forthe integrity of the treatment to ensurethat the analyst’s comprehension andinterpretive reach are optimised. Shecontrasts this treatment-orientedsharing with command disclosureswith non-analytic aims whichundermine the treatment. Her idea isthat confidentiality should be thoughtof as a skin rather than a lock. Whilstboth contain, a skin is a porous,dynamic, containing membrane thatenvelops the therapy, whereas a lockis a mechanical device impervious tothe ambience of a relationship. Shesuggests that confidentiality shouldnot be considered as an oath of non-disclosure but as a protective shield
for an analytic mode of listening. Theethical criterion for disclosure becomes:will it further the analytic listeningand thus the treatment, or is it forunrelated purposes that may disruptthis listening?
Following the influence of thearguments made by Bollas, Furlong7
reports that in 2001, the CanadianPsychoanalytic Society concludedthat, contrary to what is sometimesimplied, the aims of psychoanalyticand psychotherapeutic treatment donot conflict with society’s interest inpublic safety. The impact of disclosureon the treatment situation, Furlongreports, depends on the reasons forthe disclosure. When, for therapeuticreasons such as consultation/advice,professional secrecy is suspended, thedisclosure will have only a beneficialeffect on the therapeutic process.However, when this professional secrecyis lifted in the interests of a third party,the trust and security of the therapeuticrelationship are undermined.
Furlong goes on to report: ‘Thevalue of disclosure in potentiallydangerous situations has been greatlyexaggerated in recent years. If anindividual is dangerous, he is muchless dangerous in treatment thanwithout treatment. Too much emphasison the need for disclosure for reasonsof public safety may deter dangerousmembers of society from seekingtreatment and frighten inexperiencedpsychotherapists into makingunnecessary disclosures that will leadto the interruption or dilution oftreatment. Both of these eventualitieswill increase, not decrease, the potentialfor antisocial behaviour.’
These conclusions aboutconfidentiality are of relevance for usto consider in relation to the impactof electronic record-keeping. When isit the case that a therapist making anentry in an electronic record suspendsprofessional secrecy for therapeuticreasons? Sharing information forsupervision to overcome personal limitsof understanding is very different fromproviding an entry on an electronicrecord for the purposes of ensuringcompliance with trust policies regardingrecord-keeping and to ensure that ateam functions safely and effectively.
The arguments for maintainingstrict confidentiality in psychoanalysis
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and therapy are persuasive, but withinthe NHS we are not only, or normally,working as analysts, but in a numberof roles – assessors, consultants,psychologists, psychiatrists. When ourrole is as therapist we often do workvery closely with other team membersfrom our own or different disciplineswith all the opportunities for splittingthat go with this. The idea ofconfidentiality as a skin is a usefulconcept that can help guide ourinterventions. When should the skin stretch to encompass asupervisor, and when should it stretch to encompassother team members, or others beyond theimmediate team who share care, and when should it stretch further toencompass referrerssuch as GPs?
Case studyMr T is an asylum seekerwho had been an influentialfigure within a political partyin his country of origin, and whohad been arrested and torturedfollowing a change of regime. He wasclear that he did not want the details ofhis torture to be recorded in the notes.
He suffers from post-traumaticstress disorder with paranoid beliefsthat his torturers will seek him out.Mr T hallucinates their faces andbecomes dissociated with no consciousawareness of what happens duringthese episodes. He is fearful ofinteraction with others in case hebecomes dissociated and attacks them.His marriage has broken down as aresult of his symptoms, leaving himsocially isolated. He has plans to returnto his country of origin.
Whilst he has made some progress –with a decrease in suicidal ideation –progress has been very slow given histerror of his own violence. He hasmaintained a highly idealised view ofhis therapist.
Near the end of one therapy sessionhe reported that he was carrying aknife for self-protection and that thiswas his normal routine. Following thesession the therapist made an entry in the notes recording that Mr K hadreported that he carries a knife. The
therapist made a record because ofthe issue of risk and wanting to ensurethere was a clear record but confidentthat this could be managed within thecontext of therapy. She did not considerthat it was necessary to escalate toinvolve others at this stage.
Before he attended for his nexttherapy session, Mr T had anappointment with his psychiatrist whoworked in the same trust and who hadaccess to the progress notes held on theEPR. Having learned that Mr T carried aknife, she informed him that his actionwas illegal and that he must stop.
Mr T missed his next three therapyappointments and on returning to thefourth appointment, after the therapistwrote to him, his sense of havingbeen betrayed by his therapist, and hisrage at the betrayal, became evident.He was eventually able to report hisanger and to explain that, if thetherapist had not sent him the letter,he would have come and broken herconsulting room windows.
According to what I have said earlier,this is not a breach of confidence inthat, as a member of the team,confidentiality is maintained and held
Electronic patient record systems arecertainly here to stay, though who knows what technological advances might lead tofurther developments away from what manyclinicians already feel is a step too far in themanagement of the clinical domain ‘
‘
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within the trust. However, it wascertainly not within the understandingof this patient that anything that hetold his therapist could be seen by otherswithin the trust. Instead we could thinkthat the breach in confidentiality wasseen as yet another intrusion.Following his experience of beingtortured (with violent intrusion intohis body) he had lost his belief in thepredictability of the world, and hisbelief in the protective function of hisgood objects had been shattered. Thebreach of trust by his therapist raisedhis anxiety with fears about thecruelty and strength of bad objects,prompting a slide into primitiveparanoid beliefs that caused a rupturein the treatment.
This is one way of thinking about it. But might another be that thepsychiatrist, who was also idealised by the patient as having saved his life,was in fact able to play an importantrole as the ‘third’, ensuring that thepatient was unable to evade realityand acting as a valuable aid to thetherapist?
ConclusionThe use of electronic patient recordsystems does not entirely recast theclinical dilemmas that arise in thesharing of information with colleaguesand beyond, but it certainly adds to thecomplexity of the issues concerned. Inthe clinical example there is evidenceof an entry in the record being vieweddifferently by a colleague in themental health system. This provides aplatform for reviewing the utility ofthese records and the extent to whichthey can undermine the therapeuticprocess. It could also be argued thatsuch disclosures are a necessary partof working to protect people from
harming themselves and others, aswell as ensuring that our work in theconsulting room does not become tooremoved from the wider team contextand from truly multidisciplinarycollaboration.
Do clinicians have a part to play inshaping these developments or are wemerely swept along with the risingtide? Are EPRs simply a necessary evil,further evidence of the erosion of avalued therapeutic approach?
Both the authors are clinicalpsychologists and psychoanalysts. Theirinterest in this area leads to morespecific questions: do psychoanalyticallyinformed practitioners have moredifficulty adapting to thesedevelopments than practitioners usingother models? Might any scepticism or critical engagement on the part of psychodynamic practitioners simplybe construed as evidence of ananachronistic approach out of stepwith this brave new world?
In contrast, we would argue that ourabiding engagement and willingnessto struggle with complexity, ambiguity,uncertainty and our understanding ofthe mind, puts us in a unique positionto make a vital contribution. �
This article is based on a presentation givenby Brian Rock and Helen Brindley, entitledElectronic Patient Records: the impact on therelationship with the patient, at a conferenceorganised by the Tavistock and PortmanNHS Foundation Trust, in March 2011.
Brian Rock is the service lead for the Cityand Hackney Primary Care PsychotherapyConsultation Service (PCPCS). He is aconsultant clinical psychologist and hasworked in the NHS for the past 15 years.He also works for Barnet Enfield HaringeyMental Health NHS Trust and is a
psychoanalyst with the BritishPsychoanalytical Society.
Helen Brindley is a consultant clinicalpsychologist in Barnet, Enfield and HaringeyMental Health NHS Trust and a psychoanalystwith the British Psychoanalytical Society.
References
1 Newton S. Record keeping: guidance on good practice. British PsychologicalSociety; 2008. See http://www.bps.org.uk/dcp/the_dcp/faq/electronic_record_keeping$.cfm
2 House of Commons Health Committee.The electronic patient record. Sixth Reportof Session 2006-07. Volume 1. London: The Stationery Office; 2007.
3 Whitehead, S. Who sees what? Exploringpublic views on personal electronic healthrecords. NEF; 2010. See http://www.neweconomics.org/publications/who-sees-what
4 Skinner A, Berger M. Clinical psychologistsand electronic records: the new reality.BPS; 2008. See http://www.bps.org.uk//document-download-area/document-download$.cfm?restart=true&file_uuid=06251A96-1143-DFD0-7EB7-816F3710CCCB2008.
5 Mitchels B, Bond T. Essential law forcounsellors and psychotherapists. London:Sage; 2010.
6 Bollas C. First published in the newsletterof the International PsychoanalyticalAssociation (IPA). 1999; 8(2).
7 Furlong A. Confidentiality with respectto third parties: A psychoanalytic view. TheInternational Journal of Psychoanalysis.2005; 86:375-394.
Reader responseThe authors welcome questions and feedback about this article.
If you would like to contact Brian Rockand Helen Brindley, please email
With the implementation of electronicrecord-keeping there has been a greatdeal of unease among therapists who are contractually required to makeroutine entries to update the patientrecord but who remain concerned aboutthe implications of this in terms of privacy ‘
‘
At a time when many were full ofthe doom and gloom about theintroduction of the Improving
Access to Psychological Therapies(IAPT) programme, the counsellors inSouthwark decided to embark on acelebratory event to demonstratetheir worth to commissioners and GPs.I am often asked why the SouthwarkPrimary Care Counselling andPsychotherapy Service (PCCPS) is soeffective and I am happy to tell peopleit is because of the counsellorsthemselves, who bring such a breadthand depth to the service, as well as avast array of professional qualifications,life experience and learning throughtheir own personal therapy andsupervision. Compared to otherpsychological therapists, we are alsoextremely cost-effective.
A small working party combining theclinical counselling and psychotherapylead and two of the counsellors gottogether with an empty piece ofpaper to think about ways that thiscelebration could be achieved. One ofthe greatest strengths of mostcounselling teams is their diversityand our group consisted of a risingcomedian and a former actress. Aftermuch deliberation, the obvious solutionemerged: hire a theatre, put on acomedy show and sell enough ticketsso as not to make a loss, and while wehad a captive audience, let the clinicallead loose to tell everyone how brilliant
our service is. So that is what we didand on a Sunday night in September2010, we sold out the SouthwarkPlayhouse theatre and celebrated ourwork over the previous 25 years.
Our event coincided with thepublication of an independent reviewof the psychological therapies in theborough1 to assess the psychologicaltherapies and counselling servicesthey currently commission in primarycare with a specific focus on theextent to which the services are:� accessible to people living inSouthwark� acceptable to and meet the needsof the diverse local population in anequitable manner� National Institute for Health andClinical Excellence (NICE) compliant(where possible)� able to offer personalised care� able to offer service user choice anddemonstrate value for money.
The report had this to say:‘The GPs we communicated withwere strongly in favour of retainingthe GP practice-based counsellorsvia the primary care counsellingand psychotherapy services. Theirexperience of working withcounsellors based within theirpractice was very positive. GPs likethe primary care counselling andpsychotherapy services and wantedus to be aware that in their opinion
it is working well and shouldcontinue on unchanged.
‘In contrast, some of the GPs weinterviewed were less positive aboutIAPT, citing problems around waitingtimes to access high intensitytherapists. We do not support anycuts being made to the primarycare counselling and psychotherapyservices as we cannot see anyevidence of service duplicationwhich would not impact on thenumbers of local people being ableto access and being referred to thisservice. In addition, the supportfrom local GPs for the primary carecounselling and GPs who employcounsellors/therapists were describedby many stakeholders as valuingand liking the service.’
One GP stated: ‘I very much wantedto say, as a practising GP, that thereview should consider the strengthsof the GP-based counselling model. I am concerned at the idea ofcentralising all services in one largereferral centre... I would be grateful ifyou could feed back to the review myopinion that talking therapies should,by preference, be based in localgeneral practices. This is by far themost patient-centred option.’
A second GP commented: ‘We havealways found counselling to beextremely useful and effective and werefer patients with a wide range of
HCPJ July 2011 23
The continuing success of the Southwark Primary Care Counselling andPsychotherapy Service is due to the counsellors themselves, and the ability to demonstrate their worth to commissioners and GPs, says Peter Thomas
Celebrating 25 years of‘transforming lives’in Southwark
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conditions, ranging from stress, anxiety,bereavement, relationship problems,to patients with mild to moderatedepression. We find that patients arehappy with the service and that theirsymptoms improve and are even resolvedin some cases with counselling. Manytimes, this is the only psychologicalsupport they will require. The attendancerate is good, the DNA rate low, andpatients attend their sessions regularly.This will not be the case if the serviceis not based in the practice.’
Another stakeholder commented: ‘I am an advocate of practice-basedcounselling as it removes the stigmathat many patients associate withgoing to a mental health professionalelsewhere. The counsellors have first-hand access to GP records and thepatient’s own GP, something that doesnot happen when located elsewhere.’
Many stakeholders said that the GPpractice-based counsellors are linkingup with other practice staff, such ascare of the elderly coordinators andpractice nurses, regarding referrals ofolder people for counselling. In termsof the extent to which the needs ofyounger people are being met, wefound evidence of counsellors workingwithin the primary care counsellingand psychotherapy service practisingflexibly with young people. In order toincrease the attendance rates, youngpeople are being offered drop-inappointments in recognition thatsome young people may, for a rangeof reasons, be unable to stick to arigid appointment time.
One GP practice runs an art therapygroup. This group has been a great helpin identifying those who are depressed,vulnerable, lonely, or carers in need ofsupport. One of its representativesstated: ‘We very strongly wish thatthis invaluable service (practice-basedcounselling) be maintained long term.’
With regard to tendering out thecurrent service, the report stated: ‘It is unlikely that a new providerarrangement could match what is inexistence. Whilst they may be able tooffer a minimum cost service, thelikelihood is that service outcomes couldbe badly affected. A considerable degreeof risk is attached to this in as far asthe degree of experience, skills andknowledge within the existing serviceproviders in Southwark is very high.
HistoryIn 1998, a small group of counsellorsapproached the chief executive ofSouth Southwark Primary Care Group(PCG) to offer to help them developthe counselling services across thePCG. They received a warm welcomeand this started a relationship whichstill exists 13 years later. This workconsisted of producing a stocktake ofcounselling services, an options paperto be presented to the Board andcostings to support the developments.The upshot was an extra £39,000invested in GP counselling servicesand the counsellors coming togetherto form a counselling developmentgroup (CDG) which met monthly todevelop ideas about how to move theservice forward.
The CDG believed very strongly thatits work should reflect the work thatcounsellors do in a congruent wayand has always fought against amanagement structure being put inplace. Instead they tried to encouragecounsellors to work together anddevelop, and own, their work. Thisreflects the way we work with clientsin encouraging them to own theirjourneys rather than tell them whatjourneys to take. Of course this makesfor a more complex structure andrelies on all the counsellors workingtogether, a task that sometimes feelslike trying to herd cats!
Developments so far include:� a comprehensive mapping ofcounselling services� a mapping of counsellors’qualifications and experience� the development of a servicespecification� writing a comprehensive counsellingpack� developing links with localuniversities, resulting in the placing ofcounselling students into practices,and the production of writtenguidelines for students, mentors,supervisors, the practices themselvesand the university tutor lead� yearly away days � working with practices in theappointment and interviewing ofcounsellors� supporting counsellors working insurgeries undergoing difficulties� implementation of the CORE-OMaudit and evaluation system
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� liaising with third sector counsellingproviders� working with counsellors to developclinical governance best practice acrossall the surgeries� introduction of continuingprofessional development (CPD)� exploring best practices across theUK and how they can inform our ownservice� producing a yearly statistical reportof the counselling activity in theborough (see later)� developing a counselling site on thePrimary Care Trust (PCT) website� creating a model of senior, junior,student and honorary counsellorswithin practices.
In 2003, when both north and southPCGs merged, the CDG was asked towork across the whole of the boroughin the newly formed PCT. The teamconsisted of a clinical counselling leadand four counselling representativeswho each liaised with one of the fourlocalities.
The development group always tookan interest in trying to demonstratetheir effectiveness and worked withJohn Mellor-Clark to pilot CORE in theborough. The results of the COREevaluation enabled the clinical lead tobid for extra money to develop thecounselling service in new practiceswhere counselling did not exist. Thework was completed this year, with anextra £56,000 being invested, andSouthwark now has a counselling servicein all but two practices in the borough.
As clinical lead, I was asked to jointhe Southwark Psychological TherapiesCommittee to forge links with thesecondary care mental health services,including psychology and psychotherapy.I am also a member of the PCT’s PrimaryCare Subgroup, which reports to theMental Health Partnership Board. Thesubgroup is tasked with developingprimary care mental health and, morerecently, IAPT. I meet regularly withprimary care managers, mental healthcommissioners and the medical directorof the PCT to advise on psychologicaltherapies across the PCT. This has verymuch put counselling at the forefrontof developing psychological therapiesin Southwark rather than being aperipheral service. I am currentlyworking closely with the IAPT service to
make sure that our service and theirscomplement each other and that thecounsellors and IAPT workers remainin close dialogue so that patients getto see the person who can best meettheir needs. I also work with secondaryservices to make sure that the NICEguidelines are implemented across theborough, and maintain links with thethird sector services in the borough.
When most counselling serviceswere changed into managed servicesand became part of mental healthservices, the CDG argued strongly tokeep Southwark counsellors withinprimary care budgets and directlyemployed or self-employed by thepractices themselves. This reflects abelief that the link with the GPs isparamount and reflects a concept thata primary care counsellor has animportant role to play within a surgeryrather than someone who just comesin to see patients and then goes home.The GPs take more ownership of theservice and it can be adapted to thespecific needs of their surgery ratherthan having a ‘one fits all’ model.
Over the years, more than 40counsellors have served on thedevelopment group and given theirtime and energy to develop theservice. Each person brings his or herunique contribution. As clinical lead, I also facilitate a free yearly awaydayfor all the counsellors which hasproved very popular and helped thecounsellors to feel less isolated. Thisyear will be the 12th such day.
The clinical lead and representativesremain as self-employed consultantsrather than as employees of the PCT,which enables them to keep thethreefold focus of supporting thecounsellors, working directly withpractices, and working with the PCTto develop services. The role of therepresentatives is to liaise with thecounsellors and pass information in atwo-way process. At present we have46 counsellors, plus honorarycounsellors and students.
This integrated way of working hasenabled counselling to be seen as anessential part of the services deliveredto the patients of Southwark and alsogiven a voice to a group of workersthat sometimes feel excluded andundervalued. All this has been achievedthrough a bottom-up approach ratherthan a top-down approach, and thedevelopment group remains focusedon developing the best service possiblefor the residents of one of the mostdeprived boroughs in the country.Frequently, students apply for juniorposts after qualifying and over timecan move on to more senior positions;some offer their skills as localityrepresentatives on the counsellingdevelopment group.
Current role of the clinicallead for counselling As clinical lead, my duties at presentare as follows:� to act as the professional counsellingadvisor within the PCT and advise thePCT on counselling policy and protocols,in conjunction with local, BACP andgovernment initiatives such as NICE,clinical governance, National MentalHealth Service Development (NMHSD)and national guidelines� to assist the practices with therecruitment and employment ofcounsellors� to link with third sector counsellingservices, GPs, mental healthcommissioners, South London andMaudsley NHS Foundation Trust(SLaM), and other health and socialcare professionals as necessary� to facilitate yearly counsellorprofessional development days� to maintain the professional profileof counselling with the PCT� to produce the yearly statisticalreport and evaluation results
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The link with GPs is paramount andreflects a conceptthat a primary carecounsellor has animportant role to playwithin a surgery ratherthan someone whojust comes in to seepatients and thengoes home ‘
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� to represent counselling on thePrimary Care Mental Health Subgroupand the IAPT Steering Group� to monitor and evaluate counsellingresources� to share with the individualpractices to explore the differences in performance compared to thestatus quo � to work closely with the director ofIAPT in Southwark so that the twoservices do not duplicate services. Anexample of this collaboration was thedirector offering free training in bothcognitive behavioural therapy (CBT)and mindfulness to primary carecounsellors.
Below, I have included this year’s frontpage of the report which gives the GPsand commissioners direct comparisonsbetween the national IAPT service andour service2.
Executive summaryThis report analyses the statisticalreturns completed by counsellors in 41GP surgeries in Southwark for the year2009/10. There were 44 part-time paidcounsellors working for the service.
For the fourth time, CORE evaluationstatistics are presented. Althoughcoverage is not complete, initial findingsshow the service to be effective, with anaverage reduction in distress levels of42 per cent when comparingoutcomes to initial assessments.
We have data on 15,274 sessionsoffered over the year – although somepractices have supplied returns for afull year. The cost per counsellinghour is about £37. Eighty per cent ofcounselling hours are spent in directpatient care compared to 50 per centof paid IAPT hours.
We have statistics on 3,334 peoplereferred for counselling during theyear, an increase of 15 per cent on2008/09 figures (2,901 people). Thisincrease is surprising, considering theintroduction of the IAPT service.
Both anxiety and depression referralsfell by 24 per cent and 27 per centrespectively, demonstrating that thePCCPS* service is NICE compliant andthat the referrers are using the serviceeffectively since the introduction ofIAPT. It also shows that many patientsin the borough seek psychological helpfor areas outside the remit of the IAPT
service which only sees people with adiagnosis of anxiety and/or depression.
The average number of days betweenreferral and first offered appointmentwas 35 days, a small increase on2008/9 (31 days). All except onepractice have average waiting timeswithin the NHS target of 90 days.
Seventy-six per cent of those referredare seen for at least an assessment.This is three per cent higher than lastyear and compares favourably withthe 48 per cent reported by IAPT. Thiswould suggest that people are muchmore likely to take up appointmentsoffered in their practice surgery thanthose further afield. This demonstratesthat 28 per cent more patients attendtheir primary care service assessmentsthan IAPT assessments, which could besaid to demonstrate that patients feelthe primary care service is more likelyto meet their needs than the IAPT CBTservice.
Of those who had actual contactwith a counsellor, 34 per cent had onlyone contact while 66 per cent went onto have two or more sessions. Thispresents a very different picture to thefigures recently reported by IAPT fortheir users3. Here 70 per cent (of the48 per cent who actually attended)had only one contact, with only 30 percent going onto have two or more. Itwould be useful to know how many ofthe 64 per cent of patients referred tothe IAPT service who do not engagewith CBT finish up being seen by theprimary care counselling service.
Patients seen by the serviceattended on average 4.2 sessionscompared with an average of 1.5sessions per patient reported by IAPTnationally. This demonstrates thatpatients are not only 28 per cent morelikely to engage with the counsellingservice compared to IAPT, but onceengaged are nearly three times morelikely to continue with their treatment.
Twenty-six per cent of thosedischarged were referred on: thisrepresents a four per cent increase on2008/09.
The percentage of the total number ofclients whose ages have been reportedremains static although the actual totalquantity measured has increased.There has been a further rise in theunder-19 age group referred (1.69 percent). The ethnicity of those seen for
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counselling broadly continues to reflectthe composition of the borough.
The statistics presented in this 2009/10report present a very substantial bodyof work with an estimated 4,142people being referred for counsellingto in-house services, representing a 10per cent increase on the previous year.About 80 per cent of those are seenat least once and of those, about 66per cent go on to be seen for moresessions. The CORE-OM evaluationdata suggest this work is very effectiveat reducing overall levels of distress,although there is considerable variancein the effectiveness evidenced betweenpractices. * Southwark Primary Care CounsellingService changed its name to includePsychotherapy on 1 April 2010.
The futureWhen the IAPT programme wasintroduced, its costs were initially ring-fenced. However, as of the 2011 taxyear, IAPT has needed to be fundedthrough mainstream budgets. FromApril 1 2011, in Southwark, the GPconsortia have been responsible forthe allocation of resources. However,at present, the consortia have topurchase IAPT, but have no obligationwhatsoever to purchase primary carepsychotherapy and counselling. Forthis reason, in many parts of the UK,primary care psychotherapy andcounselling services have now beensubsumed into IAPT. In this context,special attention will inevitably begiven to those remaining independentprimary care services that not only
survived the reorganisation, but alsomanaged to generate new programmesfor the future through the developmentof creative working relations with GPsand GP consortia.
At the moment in Southwark, thereare 1,000 patients who are currentlybeing seen by the community mentalhealth teams that are being transferredback to primary care. Local hospitaltrusts are disinvesting in psychologicaltherapies by making counsellors andpsychotherapists redundant. This islikely to lead to a rise in presentationsto GPs. In Southwark, we currentlyinvest £2,800,000 in IAPT and £600,000in primary care counselling.
So let us return to where we started.Martin Stanton, who was at the 25thcelebratory event, comments: ‘Thecelebratory evening chose to highlightthe creative ways in which the servicehas continuously engaged and workedwith GPs and the local community tode-stigmatise mental health issues. Inthis vein, the theatre event told us invarious ways that everyday “madness”was much more than an illness thatconfined people, but it should also becelebrated as oneiric and uplifting, nomore so than through humour – amain focus of the celebration. LizBentley, well-known poet andcomedian, as well as a senior therapistin the Southwark Service, showed ushow mental health diagnoses canentrap and depress people, as well asinspire them to explore and enjoytheir madness to the full. Crucial hereis the central dialogue between GPsand counsellors/therapists aroundpatients’ presenting and transforming“symptoms”, and their ongoingnegotiation together of themanagement and care of suchsymptoms, including the outcome ofmedication and therapeutic treatmentprogrammes. In Southwark, thisdialogue has been both experimentaland innovative, and supported byinter-professional groupwork, whichhas led to major mutual creativedevelopments in GP-psychologicaltherapy collaboration. In the bravenew era of promised combined andcollaborative treatment programmesin the NHS, this outstanding examplefrom Southwark may well inspire newprototypes for mental healthcare inthe quarter century to come.’
How many counsellors does it taketo change a light bulb? Only one butit really has to want to change! I shallleave the last word with the GPconsortia mental health lead, whorecently stated: ‘The primary carecounselling and psychotherapyservices are bomb-proof.’ �
Peter Thomas MSc has been the clinicalcounselling lead at Southwark Primary CareCounselling and Psychotherapy Service for13 years. Prior to this, he worked in theGardens Practice in Southwark as seniorcounsellor for 23 years. Together with Lizand Ellie, he produced the 25-year event atthe Southwark Playhouse. Peter also worksfor SLaM NHS Foundation Trust (a mentalhealth trust) as a professional developmentfacilitator, facilitating reflective practice andsupervision groups for mental health teams,the arts therapy team and the chaplaincy.He maintains a supervisory andconsultancy private practice.
AcknowledgementsLiz Bentley is touring her Arts Council-funded show Crash Bash Trash – CognitiveBehavioural Therapy – Can Box Tick/Can’tBox Tick. Dates and venues can be foundon her website www.lizbentley.co.uk
Ellie Tremain is a counsellor at Villa StPractice in Southwark. She is also a part-timeactress and has recently become a mother.
Martin Stanton is a freelance psychoanalystand supervisor.
References
1 Mental Health Strategies on behalf ofNHS Southwark. Strategic review andredesign of psychological and counsellingtherapies; October 2010.
2 Thomas P, Brown L. Clinical GovernanceReport April 2009-March 2010. SouthwarkPrimary Care Counselling Service; 2010.
3 Glover G, Webb M, Evison F. ImprovingAccess to Psychological Therapies: areview of the progress made by sites inthe first rollout year. IAPT; North EastPublic Health Observatory; 2010.
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Reader responseHCPJ welcomes feedback on this article.
If you would like to contact PeterThomas, or HCPJ, please email
Special attention will inevitably be givento those remainingindependent primarycare services that not only survived thereorganisation, but alsomanaged to generatenew programmes for the future ‘
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If your client told you they thoughtthey had Asperger syndrome (AS),how would you respond? Would you
know what to say, what to ask, orwhat to do? Would you understandwhat that meant for your client, fortheir family, or how you could bestwork with and support them?
I have worked with individuals,couples and families where one ormore are affected by AS for over 13years. In that time, I have seen manychanges as awareness of this complexsyndrome grows. The importance of supporting the whole family isbecoming a relevant concern totherapists and to health professionalsgenerally. Yet despite the mass ofinformation and books now available,I am still taken aback when I hearreports of damaging remarks made by professionals to clients with AS. For example, a middle-aged man wasasked by a therapist, professing towork in the area of AS, how long hehad been ‘affected by this disease’.Perhaps more damaging is when atherapist, who disagrees with the ideaof labelling, either does not informthe client that they may be on thespectrum or rebukes a client’s requestfor AS validation. Either of these maywell leave a client feeling that theyare responsible for the difficultiesaffecting them and their relationships.
I often use the example of dyslexiaby way of an analogy to AS, to explainthe importance of knowledge andawareness. If a person has spent yearsstruggling with reading and writing,impeding their confidence in theirintellectual abilities, it can come asquite a revelation when dyslexia isrecognised and diagnosed for them.They now have an explanation fortheir difficulties. In fact, they perhapsshould be proud of how well theyhave managed despite dyslexia. It is asimilar situation for someone with AS
when they become aware that theirstruggle with friendships, relationships,social interaction and communicationis the result of being affected bysomething they can do little about;and that they are not outcasts, as manyhave reported being made to feel1.
Having AS does not change aperson’s personality. It is a neurologicaldisorder, a difference in the wiring of the brain; not a defect, simply adifference. This difference often onlybecomes apparent when the ASindividual interacts and communicateswith others socially when looking toform friendships or relationships. ASwill cause difficulties in communication(verbally and in the reading of bodylanguage), social interaction, and inthe ability to empathise or to seethings from another’s point of view.Communication and empathy are keyin forming and maintaining friendshipsand relationships and it is often withinthis area that the AS individual willstruggle, causing feelings of inadequacy,isolation and loneliness; many findtheir confidence and self-esteemplummets. It is no wonder that a highincidence of depression has been foundwithin this section of the population2.
Therapists are often the first port ofcall for AS individuals, their partnersand/or family, making it crucial thatthey have the ability to recognise thepossibility of AS, have knowledge ofthe effects of the condition, and havean understanding as to how they canbest support the client.
Tools for therapistsSo what tools as a therapist do youneed in your box? What do you needto know? The first stage is readingand gaining knowledge. There aremany good books written on AS, bothby professionals and those affecteddirectly. A visit to the Jessica Kingsleywebsite (www.jkp.com) will illustrate
just how many books have beenwritten in the past decade alone thatoffer the reader an excellent selectionof material. The book I most highlyrecommend is Tony Attwood’s Completeguide to Asperger syndrome3, whichcovers all areas of AS and is packedfull of readable information.
To work with difference, there needsto be an understanding of exactlywhat that difference is, and how thiswill affect the interaction betweenyou and your client. To explain thisboth to my clients and professionals, I use an example of research carriedout by Rita Carter, author of Mappingthe Mind4, who wanted to discoverhow the brains of individuals with ASworked differently to individuals whowere classed as neuro-typical (NT). The following is taken from my bookThe Asperger Couple’s Workbook5.
‘Carter used Positron EmissionTomography (PET), a brain scanningtechnique that produces a three-dimensional, visual image of thefunctional processes of the brain.Carter used PET scans on peoplewho had been diagnosed withAsperger syndrome and people who were not affected by Aspergersyndrome. What she discovered wasparticularly enlightening, giving an insight into the differences inthought processing between the NT partner and the AS partner.First, Carter asked each group inthe study a logical problem-solvingquestion. Each group was able tocome up with the answer by usinglogic and for each group an area inthe left hemisphere of the frontallobes lit up on the scan. Second, sheasked each group a question thatrequired theory of mind to answerthe question correctly. Theory ofmind is the ability to appreciate theperception of another, the part of
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A different way of thinking:understanding Asperger syndromeMaxine Aston guides readers through the ability to recognise and work with this form of autism
the brain that governs empathy andinsight. Carter found that in the NTparticipants another part of the brainlit up on the scan. This area was justbelow the area of the brain thatgoverned logic. The NT participantswere quick to answer the questioncorrectly. However, in the ASparticipants this part of their braindid not show any activity. Insteadthe logical part of the brain becameactive. This suggests that the ASparticipants were attempting towork out another’s behaviour usinglogic, but people are not necessarilylogical when it comes to behaviour.It is therefore likely that the ASparticipant’s answer could be wrong(unless they had experienced asimilar situation and were able torecall an appropriate answer). It willusually take them longer to find an answer as it will be throughlogic rather than empathy thatthey find it.’*
* Reproduced with the kind permissionof Jessica Kingsley Publishers.
These results imply that an ASindividual is relying on the logicalroute in the brain rather than theempathic route to process informationfrom others that, in many cases, is notlogical. People often use doublemeanings, humour and innuendos incommunication and non-verbal (body)language is responsible for themajority of the communication weshare. Clients often say to me, ‘why isit that people cannot just say whatthey mean and mean what they say?’
AS individuals are non-verbal andmind reading is extremely difficult for
them to apply accurately; this canresult in many misunderstandings incommunication. When working withan AS individual, it is important toremember that in communicationtheir brains will be working very hardto work out what you are implying; a client will not be able to read younon-verbally. To make communicationless stressful for the client, you willneed to be very clear, precise and talkin a logical way rather than usingemotions. For example, asking theclient the question ‘…and how didthat make you feel?’ could create
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Therapists are often the first port of call forAS individuals, their partners and/or family,making it crucial that they have the ability to recognise the possibility of AS, haveknowledge of the effects of the condition, and have an understanding as to how they can best support the client ‘
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anxiety in them as their logical brainattempts to define, discover andexplain correctly the exact emotionsinside them. Find out from the clienthow they best prefer to communicate;they may prefer to write things downor you could suggest they use anothermedium to express feelings. I havefound with some clients that the useof colour to describe feelings andnumbers out of 10 to express theintensity of the feeling6 can be verysuccessful. AS individuals are oftengreat at visualising – seeing thingsdrawn or written down will eliminatehaving to mind read and so reducetheir stress.
Just as an AS client will havedifficulty reading you, likewise, youcannot presume you are accuratelyreading them! For some AS individuals,making or maintaining eye contactcan be very difficult; research studiesof two-year-old children have shownthat AS infants are more likely tostudy their mother’s mouth than hereyes6. Non-AS people will look atanother’s eyes because they are readingthe information the eyes are giving;
if you cannot mind read then there islittle point in making eye contact. Thebrains of AS individuals are alreadyworking hard just to keep up to speedin interactive communication; if theyhave to look at your eyes, or, withsome people, even just look at you,they might not be able to concentrateon what they are saying or be able toaccurately hear what you are saying.
Communicating in the therapyroomI have learnt over the years not to tryto read clients based on what I seeand I will give them permission not tolook at me. It is worth noting at thispoint that some AS individuals willmake too much eye contact and thiscan feel aggressive or like flirtingwhen in fact it is neither – often it
just means they have tuned out oftheir face and are no longer aware ofthe expression they are using, or havelearnt to overcompensate. This isoften a consequence of being teasedat school over poor eye contact. Youcannot read an AS person’s feeling by their facial expression or bodylanguage, in fact, trying to draw aconclusion from a client’s face couldlead you to believe that they are notfeeling anything at all. A client may notgive any expressions or indicators as towhat is going on inside emotionally forthem and this has the potential to befalsely recognised as a cutting offfrom feelings due to trauma orchildhood abuse. Although these areasmay need to be investigated, this needsto be done with caution as it is morelikely that a client is affected by a lowemotional quotient or alexithymia.
Alexithymia is reported to affect 85per cent of people with AS7. Alexithymiais a Greek word which simply means‘no words for feelings’ and peopleaffected by this condition may finddescribing their feelings almostimpossible; being asked to do so or to
connect with their feelings would belike asking a severely dyslexic client toperform multiple spelling tests in theroom. This could be damaging to theclient and would certainly not beworking towards maintaining theBACP Ethical Framework.
To work in a way that most benefitsthe AS client, it is important that thetherapist adapts the session andcommunication to fit in with theAsperger world. Communication needsto be clear and logical; it cannot beexpected that the client will suddenlyacquire insight into what it is they aresupposed to be doing; they will needclear instructions and logical optionsto consider. Counselling for AS clientsshould not be about trying to bringemotions to the surface; this couldcause the client distress – they may
not be able to put those emotionsinto context and leave them behindwhen they leave the room.
It can be quite misleading if atherapist is working with an AS clientand neither are aware that this is thecase. The therapist may find themselvesfaced with a client who is unable totalk about their feelings and also hasextremely vague memories of theirchildhood due to the late developmentof theory of mind. Put these twothings together and childhood traumaand abuse may spring to mind, and itmight be easy to find yourself off onthe wrong track. Some clients who havecome to me have found themselvesinvolved in years of therapy, havingbecome convinced that their difficultiesare due to their childhood experiences.They are often left with feelings ofanger and resentment, and when thetrue reason for their difficulties isdiscovered, they can then become evenmore resentful over the cost and thetime they feel has been wasted inprevious therapy sessions.
As a therapist you are not in aposition to diagnose AS but you are in
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Asperger syndrome will cause difficulties in communication, body language, socialinteraction, and in the ability to empathise or to see things from another’s point of view ‘‘
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a position to signpost – just to suggestthe words Asperger syndrome can beenough. People with AS are often greatresearchers; if you give them the wordthey will go and look it up and maketheir own decisions on whether or notthey believe this is a possibility. If theydo want to explore this more, you willneed to discuss with them the nextstep and highlight their choices. Theymay choose to seek an assessment orthey may want to take time to read upand explore. What is important is thatif they decide to continue working withyou, you make them aware of thelevel of your understanding and whatyou are able to offer them.
Being aware of sensorysensitivityAnother important area to be aware ofand understand as a therapist iswhether your client is affected by anover or under-sensitivity to sensorystimuli. These could be in the areas of sound, sight, touch, taste or smell.Checking that the environment inwhich you are working with a client is comfortable for them can make adifference to their level of stress. Forexample, I used to have a clock in mycounselling room that had a noticeable,but not loud, tick. I moved it elsewhereafter a couple of clients commentedupon the ticking. Being distracted bynoise can be detrimental to a client’sconcentration on what is being said –many AS clients report finding it almostimpossible to hold a conversation in aplace where there is background noise.
Further, when considering sensorysensitivity, a therapist needs to try andunderstand a client’s level of sensorysensitivity, especially when working in the area of sexual therapy. Someclients with AS have reported beinghighly sensitive to being touched onspecific parts of their bodies; this couldbe the arms or legs, or it might be theerogenous zones. If as a therapist youare using techniques such as sensatefocus, understanding what feels goodfor your client needs to be very carefullyexplored and understood. It may simplybe the type of touch used that causesthe problem. One client explained tome that any form of light touchingwould make them feel like lashing outas it proved to be a source of totalfrustration and irritation.
Areas such as smell and taste are alsocrucial to check out. Some AS womenI have worked with have expressed astrong aversion to their partner’sbodily fluids; this can include kissing,ejaculation and oral sex. They can bephysically repulsed by any possibilityof exchange of fluids and theirpartners can be very hurt if this, as itcan, causes retching or obvious signsof repulsion. Understanding that this isdue to AS and not a personal issue canmake a difference and help alleviatemany hurt feelings. Understanding AScan make a profound difference to aclient’s intimate partner, as often theywill be struggling to make sense oftheir relationship and wondering whythe relationship is proving difficult tomaintain.
Understanding the impact on the familyIn order to work with AS clients, youwill need to have a clear understandingof both the client and of how AS willimpact on their partner/family. Manynon-AS partners report feelingemotionally deprived and can appearfrustrated and angry over therelationship; they may have spentyears trying to figure out what waswrong in the relationship. One non-ASpartner discussed with me how shehad been told by a therapist in couplecounselling that her husband was justbehaving like a man; this contributedto her decision to divorce as she felttheir situation was hopeless and thatno support was being offered. If youwork with couples, by the time yousee the non-AS partner, they may befeeling quite desperate to be heard orunderstood, and your validation oftheir feelings can be crucial to theirwellbeing. In addition, if your client isunaware that it may be AS that isaffecting the relationship, the abilityto signpost could make the differenceto whether or not the relationshipsurvives.
Discovering what works best foryour client can give them and you the best possible chance of having astress-free and beneficial therapeuticalliance. If your client is comfortableand relaxed within the environmentyou are offering, if they feel youunderstand them and your acceptanceof their difference is non-judgemental,
then you will be very privileged toexperience the different, unique andspecial world of Asperger syndrome. �
Maxine Aston is a BACP-accreditedcounsellor and has an MSc in healthpsychology. She runs her own counsellingcentre where she specialises in workingwith individuals, couples and familiesaffected by Asperger syndrome. Maxinealso offers assessments for adults wishingto discover whether they are on the autisticspectrum, in particular whether they haveAS. She is the author of three books, Theother half of Asperger syndrome (NationalAutistic Society, 2001), Aspergers in love(Jessica Kingsley, 2003), and The Aspergercouple’s workbook (Jessica Kingsley,2008). Maxine runs workshops to raiseawareness in Asperger syndrome forcounsellors and professionals who wish toincrease their understanding and be able tooffer their clients the support they need.www.maxineaston.co.uk
References
1 Holliday Willey L, Attwood T. Asperger’ssyndrome – crossing the bridge. USA:Michael Thompson Productions; 2000.
2 Kim JA, Szatmari P, Bryson SE, Streiner DL,Wilson F. The prevalence of anxiety andmood problems among children withautism and Asperger syndrome. Autism.2000; 4:117-132.
3 Attwood T. The complete guide toAsperger’s syndrome. London: JessicaKingsley Publishers; 2007.
4 Carter R. Mapping the mind. London:Weidenfeld and Nicolson; 1998.
5 Aston MC. The Asperger couple’sworkbook. London: Jessica KingsleyPublishers; 2009.
6 Jones W, Carr K, Klin A. Absence ofpreferential looking to the eyes ofapproaching adults predicts level of socialdisability in 2-year-old toddlers withautism spectrum disorder. Archives ofGeneral Psychiatry. 2008; 65(8):946-54.
7 Hill E, Berthoz S, Frith U. Brief report:cognitive processing of own emotions inindividuals with autistic spectrum disorderand in their relatives. Journal of Autism andDevelopmental Disorders. 2004; 34(2):29-235.
Reader responseHCPJ welcomes feedback on this article.
If you would like to contact MaxineAston, or HCPJ, please email
32 HCPJ July 2011
Imake maps. They’ve become moreabstract over time, and at somepoint stopped involving paper and
pens – perhaps once the need forconstant revision got too great. Butthe basic idea remains.
Reading accounts of what I do as acounsellor always disappoints. The lifegets squeezed out – and if we respectthe condition that allows us access tocolourful inner worlds, confidentiality,it needs to stay that way. I still feelthe need to remember and try torepresent the intensity and vitality ofwhat I am part of. This must in someway be symbolic, and in a semi-ruralarea like mine, I find it easy to linkthese empathic traces to geography.
My map of my patch contained a lotof contours and some notes about goodbird habitats and rock outcrops. SinceI began to work at ‘the doctors’, it isnow repeatedly embedded, overlainand eroded by traces of recountedexperiences from other people’s lives.
Clients’ life stories rapidlyoverdetermined local landmarks – thetop Pans, Woods, the queue at theHomeless, numerous cemeteries andshooting galleries, the HopetounMonument, the snug at the Pheasant.The healthy clean emblems of ourburghs have been replaced bycomposites of feuding, fighting andf****** – and with signs of real health,fleeting aspirations reached, as it hasalways been for us, through thrownnessand overcoming, conflict and crisis.
My service is currently trying topeddle a job description that describesmy work as being with people whoseresources have been overwhelmed.That would be a thankless task (albeitone which seems to keep a lot of healthservice managers busy) – instead, mywork feels like finding the glint ofresistance, and then letting go again.
The cost is that I walk through thesame landscapes, the same Tesco, asmy ex-clients, with the demeanour ofone whose psychological contact wastime-limited and has now expired.
And each of these relationships,however satisfactory and enabling,leaves a little scar, a little trace. Andthese condense into a memory packedto the extent that it dwarfs my ‘reallife’. Empathy, I think, leaves youfeeling you’ve been there – it canleave you very drained and tired ifyou let it, and one of the ways it cando this is if you look at the whole ofwhat you’ve done – open your cardindex, count and remember – facesand places, stories... novels... growinginto libraries; even, how many timesyou’ve sat in that bloody chair.
I experienced some of this before injobs in psychiatric care, but theopposite effect tended to happen.Patient X impacted on scores ofhealth professionals on his journey tocase-hood, and became a social gluebetween them. Here, as a practicecounsellor, the experience of the clientis unique to me, discreet and quickly
over. The sense of relating has grownsteadily in me, but it only operatesfleetingly. The client is usually incontact with me only to the extentthat they are reassured that they canbe in contact with their internal world.
I feel I am learning profound thingsabout my world and myself (theexperiences of others shape me – I growthrough them as they affect me). Theyare not easily generalised, containedor summarised. The specifics burst outof any framework I know, like a bulging,picaresque novel – a novel I am(fortuitously) debarred from writing.
I feel connected to a lineage of sorts.Participant-observers, dominees, witches,elders, diarists, witnesses to life goingon. I was doing this before I was acounsellor and I will be doing it wellafter I am replaced by a CBT computerprogramme.
It’s been good to be encouraged bya salary (of sorts) and a professionaldescription. It’s been a relief to others.A particular historical moment sendsyou somewhere – 20 years ago a picketline, now a doctor’s surgery. What onedoes to you allows you to do the other.When the going gets weird the weirdturn pro, as Hunter S Thompson oncenoted, which I suspect will probablynot be included in any future jobspec, but is always a maxim of hopein interesting times. �
Ewan Davidson is a person-centred therapistworking in GP practices in and around EastCentral Scotland. He has a long-standinginterest in writing about the effects ofexperience on his world view, and thispiece has grown out of his puzzlement atwhy that process has stalled since hebecame a counsellor.
Journeys in primary careAs a practice counsellor and local resident, Ewan Davidson walks through thesame landscapes as his clients, resulting in a memory packed with intense, butfleeting, contact with other people’s lives
Reader responseHCPJ welcomes feedback on this article.
If you would like to contact EwanDavidson, or HCPJ, please email
The cost is that I walkthrough the same landscapes,the same Tesco, as my ex-clients, with the demeanour of one whose psychologicalcontact was time-limited and has now expired ‘
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Love them or hate them, outcomemeasures are here to stay. It isabsolutely normal practice in
medicine to measure, for example,blood pressure and cholesterol, and itwould be quite unthinkable to attemptto manage diabetes without knowinga patient’s Glycosylated Haemoglobin.
Yet there is considerable resistanceamong many healthcare workers,including doctors, nurses and therapists,to regularly use outcome measures.Some of this is quite normal ‘newconcept denial’, some representsinsecurity at having one’s abilityexamined, and some workers just feelthat outcome measures ‘get in the way’of the normal flow of a consultationor therapy session.
In Ipswich we have been regularusers of outcome measures of anxietyand depression since 2005 – well beforethe Improving Access to PsychologicalTherapies (IAPT) programme came onthe scene. All the practices in thetown agreed to use the AustralianDepression, Anxiety and Stress Scale(DASS-21). GPs and patients loved it.Patients felt that they were being takenseriously, and having their concernsvalidated, GPs liked the differentiationof anxiety and depression. We allfound it useful to monitor a patient’sresponse to treatment. Practices didnot have to use the scale, but couldclaim extra payments for using it,along with other improvements in thecare of patients with anxiety anddepression. Everyone used it, andgradually came to value the clinicalutility of the scale. One great benefitwas that there were no copyright orcosts associated with the scale, as it isin the public domain1.
The scheme was a forerunner of theQuality and Outcomes Framework,which now rewards primary care forusing either the Hospital Anxiety andDepression Scale (HADS) (this costsslightly more than 60p per form touse)2, the Beck Depression Inventory II(this costs slightly more than £2 perform to use)3, or finally the PHQ-9. Ofthe three scales, the PHQ-9 is the
least expensive, being free at the pointof use4, provided the user agrees tosome simple licence conditions.
It will not surprise you to find thatmost practices have opted to use thePHQ-9! The PHQ Screeners website4
also includes links to download theGAD-7 for anxiety, and the PHQ-15for somatisation; also included is aninteresting new measure, the PHQ-SADS, which combines measures fordepression, anxiety, panic andsomatisation.
At present many IAPT services, andGP practices, use a combination of the PHQ-9 and the GAD-7 as initialmeasures before referral. It would beof great benefit to try and increaseuse of the PHQ-SADS, as this willincrease the profile and diagnosis ofsomatisation, and also increaseconversations about panic attackswithin consultations.
Other parts of mental health servicesare having to get used to usingoutcome measures, as HoNOS PBR(Health of the Nation Outcome Scalefor Payment by Results) becomesmore normal practice following workto introduce a tariff for mental healthservices. Initial resistance has beenchallenged by strong clinical leadership,leading to wider adoption, followedby acceptance and recognition of thevalue of the scales.
There is a value to measuring patientnumbers, severity, and outcomes – it isquite reasonable for commissioners,and the public at large, to wish toknow how many people have beentreated, and also how many havebenefited from services’ interventions.In the future the payment thatservices receive will be based on these.In mental health we are unable tomeasure distant proxies, such as bloodlevels, or X-ray results, so we have nochoice but to use patient reportedoutcome measures.
One of the great strengths of the IAPTprogramme has been the collection of the outcome data; we now havepriceless data on the natural history ofdepression and the anxiety disorderswhich was simply not known before,along with real world data on theeffectiveness of treatments, which has led to the confirmation of theeffectiveness of counselling indepression.
So we have a change in practice thatpatients like, allows us to prove howgood we are at getting them better,guides us when we might go wrong(by not spotting a deterioration, or theneed for a step up), and in future willbe the mechanism by which clinicianswill be paid. What’s not to like? �
Dr John Hague is a GP in Ipswich, and is adirector of the Ipscom GP-led CommissioningConsortium.
References
1 http://www.2.psy.unsw.edu.au/groups/dass/
2 http://shop.gl-assessment.co.uk/home.php?cat=417
3 http://www.psychcorp.co.uk/Psychology/AdultMentalHealth/AdultMentalHealth/BeckdepressionInventory-II
4 http://www.phqscreeners.com/
GP viewpoint
Reader responseHCPJ welcomes feedback on this article.
If you would like to contact the author, or HCPJ, please email
What’s not to like about outcome measures? asks John Hague
It is quite reasonablefor commissioners,and the public atlarge, to wish to knowhow many peoplehave been treated,and also how manyhave benefited fromservices’ interventions ‘
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34 HCPJ July 2011
There are, as Nic Streatfield pointsout in his article on page 4, 188measures listed in the Outcomes
Compendium1. The outcome measureslisted here give only a taster of what isavailable, and have been chosenbecause of their widespread use inscreening for and monitoring anxietyand depression in healthcare settings,or their usefulness to counselling andpsychotherapy practitioners.
BDI-II (Beck DepressionInventory) The BDI-II2 is a test for depression whichmeasures the severity of depressionsymptoms in the American PsychiatricAssociation’s DSM-IV3. It is not meant to be used to diagnose, but is aninstrument to identify the presence andseverity of depression and to detect andmonitor changes in symptoms. There are21 questions, with a total possible scoreof 63. Cut-off scores are given with the recommendation that thresholds be adjusted based on the client andpurpose of use. The BDI has been usedin some form for over 30 years – theoriginal BDI was revised to BDI-II tobring it into line with DSM-IV criteria. It has been reported to be highly reliableregardless of the population, with theability to differentiate depressed fromnon-depressed clients. There is also a21-question anxiety measure, the BeckAnxiety Inventory (BAI)4. These outcomemeasures are not free, and need to bepurchased before use.
CORE-OM (Clinical Outcomesin Routine EvaluationOutcome Measure)Extensively validated, the CORE-OM5
is a 35-item questionnaire whichmeasures a ‘core’ of clients’ globaldistress, including subjective wellbeing,commonly experienced problems orsymptoms, and life/social functioning.In addition, items on risk to self andothers are included. The measure is partof the CORE system which also featuresthe therapy assessment form and endof therapy form, the administrationform, and the system user manual.Other products include shorter versions
of CORE-OM designed for repeated use,the CORE-LD for use with people withlearning disabilities, and YP-CORE foruse with young people aged 11 to 16years. The system and its componentparts are free to be photocopied underthe terms of CORE copyright; a COREsystem user manual can be purchased.
GAD-7 (Patient HealthQuestionnaire)A seven-item report measure usedprimarily as a screening tool/severitymeasure for generalised anxietydisorder (GAD), the GAD-76 forms partof the Minimum Data Set (MDS) forthe Improving Access to PsychologicalTherapies (IAPT) programme7. Scoresof 5, 10, and 15 are taken as the cut-off points for mild, moderate, andsevere anxiety, respectively. Whenused as a screening tool, furtherassessment is recommended when thescore is 10 or greater. Evidence supportsthe GAD-7’s reliability and validity inprimary care, and it is also moderatelygood at screening three other commonanxiety disorders – panic disorder, socialanxiety disorder and post-traumaticstress disorder6.
HADS (Hospital Anxiety andDepression Scale)A screening instrument for measuringthe presence and severity of anxietyand depression separately (a separatescore is given for each). Cut-off pointsindicate whether a client is within thenormal range, or in the mild, moderateor severe range. HADS8 has been foundto perform well in assessing thesymptom severity and caseness ofanxiety and depression in psychiatricand primary care patients and in thegeneral population9. The use of HADSis licensed and a license agreementmust be completed and a user feepaid before use.
PHQ-9 (Patient healthquestionnaire)A nine-item self-report scale whichscores the DSM-IV criteria for majordepressive disorder, the PHQ-910 alsoforms part of IAPT’s MDS and is available
for use free of charge. The PHQ-9 hasbeen well validated for diagnosingmental disorders in primary care intwo large studies10 (although clinicaljudgement is recommended for adiagnosis) and is also well-validated as a reliable measure of depressiontreatment outcomes11. Scores of 0-4signal no depression, 5-9 mild, 15-19moderately severe and 20-27 severe.Major Depressive Episode is suggestedif either item 1 or 2 is marked as Morethan half the days or Nearly every day,or if five or more of the nine itemsare marked as, at least, More thanhalf the days or Nearly every day.
Shorter Psychotherapy andCounselling Evaluation (sPaCE)An alternative, free-to-use symptommeasure which is a shorter version ofthe PaCE-31 measure (developed todirectly address change in shorter-term counselling and psychotherapy).Designed to screen for changes inanxiety and depression, sPaCE12 can beused as a global symptom measure orby factor, of which there are six: generalanxiety, phobic anxiety, functionalcognitive problems, apathy, self-harmdepression, and general depression.The two depression scales, togetherwith functional cognitive problemsand apathy, form a scale ‘DepressionPlus’ that correlates with depressionas measured by the BDI or PHQ-913.
And a new scale...The Person-centred andExperiential PsychotherapyScale (PCEPS)A new scale denoting an attempt to operationalise person-centred/experiential counselling/psychotherapyin assessing treatment adherence/competence in randomised controlledtrials (RCTs) and other forms ofpsychotherapy research. The PCEPS14
is also intended as an aid to self-reflection and for use in supervisionand training. The current version,which has undergone a reliability trial, consists of 15 items with twosubscales – person-centred process,and experiential process. �
Abr
iefg
uide
to...
…outcome measures
HCPJ July 2011 35
References
1 The National Institute for MentalHealth in England. Outcomescompendium: NIMHE; 2008.
2 Beck AT, Steer RA, Brown GK. Manual for BDI-II. San Antonio, TX:Psychological Corporation; 1996.
3 American Psychiatric Association. Desk reference to the diagnostic criteriafrom DSM-IV-TR. Arlington: AmericanPsychiatric Association; 2000.
4 Beck AT, Steer RA. Manual for BeckAnxiety Inventory. San Antonio, TX:Psychological Corporation; 1993.
5 See www.coreims.co.uk
6 Spitzer RL, Kroenke K, Williams JBW,Lowe B. A brief measure for assessingGAD, the GAD-7. Archives of IntMedicine. 2006; 166(10):1092-7.
7 Improving Access to PsychologicalTherapies (IAPT). Outcomes toolkit2008/9. IAPT; 2008.
8 Snaith RP. The Hospital Anxiety andDepression Scale. Health and quality of life outcomes. 2003; 1:29.
9 Bjelland I, Dahl A, Tangen Haug T,Necklemann D. The validity of theHospital Anxiety and Depression Scale:an updated literature review. Journal of Psychometric Research. 2002; 52(2):69-77.
10 Kroenke K, Spitz RD, Williams JBW.Validity of a brief depression severitymeasure. Journal of General InternalMedicine. 2001; 16(9):600-613.
11 Lowe B, Unutzer J, Callahan CM,Perkins AL, Kroenke K. Monitoringdepression treatment outcomes withPHQ-9. Medical Care. 2004; 42(12):1194-1201.
12 Halstead J, Leach C, Tucker S. A brief history of sPaCE. Abstract from a poster delivered at the 17thannual BACP research conference 2011.
13 Halstead JE, Leach C, Rust R. Thedevelopment of a brief distress measurefor the evaluation of psychotherapy and counselling (sPaCE). PsychotherapyResearch. 2007; 17(6);656-672. Availablefrom [email protected]
14 Elliot R, Westwell G. The personcentred and experiential psychotherapyscale (PCEPS). Abstract from a symposiumdelivered at the 17th annual BACPresearch conference 2011.
Employmentmatters…Pat Seber, consultant to BACP on workforceissues and service development, updates readerson her work, and answers some common work-related queries
It is some time since I updated youon my work for BACP. I have reallyenjoyed the opportunities, as well
as the challenges, involved in helpingmembers with employment andservice issues; these range frominformation on TUPE (Transfer of Undertakings (Protection ofEmployment) Regulations 1981);self-employed and employedcontracts; and – would you believeit – continuing Agenda for Change(A4C) issues.
Without doubt this is a veryunsettling time for those employedor on self-employed contracts withinthe NHS, voluntary and privatehealthcare sectors. The changesproposed by the Government arecausing concern to many and, at thetime of writing, the Government is‘pausing’ to reflect on feedback fromnurses, GPs, research bodies, theunions and others.
Before sharing with you some of the queries sent in by members, I thought you would be interestedin some of the issues raised at the2011 Unison Health Conferencewhich I attended in Liverpool inApril. During the event, it wasacknowledged that the NHS doesneed some reworking and not allproposals are bad. However themajority of healthcare workers areworried about the consequences tostaff of the Government’s proposedchanges to the NHS.
Much of the discussion that tookplace would resonate with counsellorsand psychotherapists. Althoughsome individuals found that A4C did not meet their expectations,
the principle on which it is based:paying staff at a nationally agreedlevel (bands 1-9) for what they do,rather than the title they hold, is agood one. Currently, the Governmentis proposing that individual employersshould set staff pay and terms andconditions of service. This is worryingas regionally negotiated contractsare rarely as good as the nationallyagreed ones.
Over the next two years, the NHSis looking to make savings of over£20 billion. All trusts are to becomefoundation trusts by 2014 but alreadythese organisations are being given‘freedoms’ to make financial savings.Some of the proposed changes areaimed at the staff workforce:restrictions on sick pay (no pay forfirst three days), down-banding,freezing pay progression and notfilling vacancies.
In addition, employers would be given greater responsibility for planning and developing thehealthcare workforce. The emphasishere is on greater cooperationbetween professions and professionalsto allow cross-fertilisation of ideas,skills and training, resulting in agreater ‘skills mix’ and new roles.We are told this will prepare theworkforce to meet the healthcareneeds of the local population.
No doubt there will be much morebefore we know the totality of theGovernment’s NHS package. We willkeep you up to date as much aspossible but it would be good to hearfrom you about the changes in yourarea (see email at the end of thePostbag section, overleaf).
36 HCPJ July 2011
workforce issues
Recruitment Query: I have recently applied for a post in an NHS trust. As I readthrough the job application, I meetall but one of the criteria which is,‘must have relevant NHS experience’.I believe this is discriminatory andwanted to know if employers areallowed to ask for experience in a particular environment.
Pat’s reply: I cannot be 100 per centsure about this particular issue andso have approached NHS Careers, the UK Department of Business,Innovation and Skills (BIS), and theAdvisory, Conciliation and ArbitrationService (ACAS); they all say go toyour Strategic Health Authority withyour query. I am going to try theDepartment of Health (DH) to seewhat they can offer.
Reply from the DH: I can appreciatethe point you raise, but individualNHS organisations are responsiblefor the recruitment of their staff and must therefore decide on thewording of each job advertisement.The Department plays no role in therecruitment process. The NHS consultsthe NHS Employers organisation foradvice on workforce issues. Informationabout NHS job specifications can befound on the NHS Employers website,although I should point out thatadvisers can only respond to specificqueries from NHS employersthemselves. The website address is:http://www.nhsemployers.org
Pat: Sorry this may not be what youwanted to hear but at least it is clear.
Self-employed contractsQuery: I have worked on a self-employed contract in a primary caretrust (PCT) for about 10 years andhave been given notice that thecontract will end in six weeks’ timewith no indication of what servicewill be in place for clients. It lookslike all self-employed contracts willend but there will be counsellingjobs and I have been encouraged to apply. Is there any redress? PS. I have since applied for one ofthe counselling jobs but was notsuccessful.
Pat’s reply: Being self-employed can be both an advantage and adisadvantage and unfortunately onthis occasion it seems to be the latter.
The main thing is to look at yourcontract and who paid you, GP ortrust? Were you on a contract whichwas automatically renewed or didyou get a revised contract annuallystating a time limit to your ‘self-employment’?
As it stands, self-employedpractitioners have no automaticright to TUPE. I have contacted anexpert on this matter and I am toldthat the key is in the wording of yourcontract, the length of continuousservice and any changes made.Therefore I think if you could affordto pay for advice from an employmentlawyer it could be to your advantage.
Re: counselling interview – did youask for and receive feedback as towhy you did not get a post with thetrust?
I would be happy to talk thisthrough with you if you think itmight help.
Supervision Query: My colleagues and I havebeen told that due to budget cutswe must give up our externalsupervision and be part of in-housearrangements. This means givingand receiving supervision fromanother trust. The problem is thatnone of our counsellors is a trainedsupervisor so we feel at adisadvantage.
Pat’s reply: This is an issue which iscoming up in many parts of thecountry. External supervision does costtrusts thousands of pounds so they dolook for ways of cutting the cost andin-house or reciprocal supervision isone answer.
There is no harm in the counsellorsasking for a meeting with the managerto explain their concerns and ifpossible have some alternatives tooffer. This shows that you haveconsidered all sides of this problem,not only your own.
But beforehand, you and yourcolleagues need to think how you cancompromise, because I’m sorry butthat’s what I think you are going tohave to do.
Possible questions you could askyour manager: who in the other trustis going to provide the supervision?If they are not a qualified counsellingsupervisor (which your professionalbody would prefer but cannot insistupon) what does the individual knowabout counselling and the modalityyou work in? What happens if youfeel that the appointed supervisiondoes not meet your needs? As part ofcontinuing professional development(CPD) and staff development, wouldyour service pay for someone toundertake supervision training?
Pat’s postbagBelow are extracts from some of the most commonworkforce queries I have received; they are not fromany one individual but compiled using an amalgam ofquestions on the same theme.
HCPJ July 2011 37
workforce issues
Discussions for counsellors: ifmanagement would pay for externalsupervision, could you agree on thesame supervisor, or be willing towork in a group or in pairs? Couldyou ask the supervisor to meet withyou on site to save in travel costsand time? Would one of you bewilling to train as a supervisor?
TUPEQuery: I work for an organisationthat has both employed and self-employed counsellors. Due tochanges in counselling provision, anumber of self-employed counsellorshave effectively lost their work.Contracted employees have beenoffered employment under TUPE butthey are experiencing great changesto their working environment (changesto banding, working conditions etc).
Pat’s reply:a. Self-employedMy suggestion here would be foryour self-employed colleagues topool resources to get advice from anemployment lawyer. Much of whatcan and cannot be done depends onthe actual contract. Some contractsthat have been ‘rolling’ on for a longperiod of time may have more weightthan others.
b. EmployeesMy understanding of TUPE‘demployees is that their job description,employment contract, terms andconditions of service, and salaryband, including incremental rise,goes with them across to their newemployer.
Obviously anyone starting with anew employer is going to expectdifferences between the old and newservice but you should not be askedto do anything that is outside ofyour contract without consultation.
If you are working to a new contract,this should be up for negotiation.
However, services are allowed tomake changes in certain circumstancesunder ‘Operational Change’ but thisshould be done with the consent andagreement of all parties, eg employers,employees and union representatives.(See www.acas.org.uk for details of ahelpline service.)
Update (April 2011): Currently theunions are concerned that the newproposals to the NHS may negativelyaffect employee rights under TUPE.
c. If you were on A4C banding before,then it should continue. If you arenot on A4C then I think you wouldneed help in negotiating this withthe new employers. They don’t haveto offer it and in some places (egfoundation trusts) are already tryingto get rid of it.
d. Are you or any of your colleaguesin a union such as Unison? If so thenit may be helpful to get in touch andhave a discussion outlining yourconcerns. If no one is in a union thenit may be time to consider joining.There used to be a 13-week waitbefore they would offer any help butthat no longer applies and you canget help almost immediately afterjoining.
Down-bandingQuery: I am currently on an A4CBand 6 but my employer informs me that they do not have money tocontinue with my current post. If Iwould be willing to move to a Band5, then it is possible for the post tocontinue.
Pat’s reply: a. See www.acas.org.uk. There isquite a large section on changingemployee contracts which is what
your trust wants to do and it wouldseem that this is fraught withdifficulty for the employer.
b. If the job is downgraded, whatroles and responsibilities will you no longer perform? As I understandit, the employer must alter the jobdescription so that you do not dothe work of a Band 6 employee forthe pay of a Band 5.
c. Is the claim that the choice is ajob with a Band 5 salary or no job at all? If so, it seems as though yourtrust is going through major changeand needs to save money. Have alook on the trust website – it isamazing how much you mightdiscover this way. Usually unionrepresentatives have been involvedin the decision-making process whentrusts are going through organisationalchange – they may be able to shedsome light on this.
d. If asked to a meeting to discussthis situation, take someone withyou, as it is difficult to remembereverything that is said whenemotionally involved. Ask for thingsin writing so that both parties knowwhat is being said; verbal agreementscan be denied.
To contact PatI hope this has given you an insightinto what is happening to yourcolleagues across the country. Pleasecontact me at [email protected] I can be of help.
Please note that Pat Seber can only offersuggestions and information to individualsfor their consideration and does not claimto be an expert in employment law. BACPregrets that it is unable to go into thespecifics of individual contracts.
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Iscarcely believed my doctor when,nearly 20 years ago, he told me thatmy shaky and rigid legs were caused
by incorrect breathing. A communitypsychiatric nurse (CPN) I’d had contactwith had also acquainted me with thephysical effects of stress on the body.My anxiety had resulted from a stressfuland bullying work environment; overthe last few years, I have also sufferedfrom panic attacks.
Over time, I have seen counsellorsand tried alternative therapies in orderto try to solve the problem. The firstcounsellor I saw – arranged throughwork – had a good professionalmanner and I found the six sessionsvery helpful; it felt good to be listenedto and offload my concerns. I alsogained some insight into myself andthe dynamics of the office situation.
Another time, my doctor arrangedsome counselling for me – six sessions– but unfortunately this ended afterfour sessions due to the counsellorhaving an accident and I didn’t feelI’d learnt anything.
I eventually left my stressful job butmy anxiety continued. I read as much asI could about anxiety and this helped,but the condition continued to developso that I no longer wanted to socialise;it was a great effort to go out unless I knew I could sit down immediately I arrived, making it difficult to standin queues or wait for buses. I triedhypnotherapy but the therapistreminded me of a strict school teacherso I only went for two sessions.
After some years I decided to qualifyas a counsellor; the training would bean asset in my job and hopefully allowme to gain more understanding of myanxiety problem. Personal counsellingwas a course requirement and I hadthe same counsellor for four years. It was wonderful to be really listenedto and valued for who I was; I alsovalued the fact that everything wasconfidential. My self-confidence grew.We revisited the work trauma situationand did some inner child work. I grew
in understanding of the impact ofchildhood experiences. However, allthis discussion and exploration madeno impact on my rigid legs.
Occasionally, when I was feeling low and frustrated with the problem, I started to pursue other therapies. I tried hypnotherapy again which wasa much better experience this time.The therapist was a good listener andI loved the deeply relaxed ‘trance’ state.We also did some visualisation, butafter four sessions the therapist wasunable to help me further. I also triedtwo other counsellors but did not feelcomfortable with them as one seemedstressed and not very understandingand one was very passive, just smilingat me and offering very little feedbackor observation. I tried craniosacraltherapy – again, very relaxing but it hadno effect on my legs. I also consulteda Jungian psychologist but terminatedthe counselling after six sessions as Ifelt she was disinterested. Thinking abody-based therapy would be helpful,I then tried the Feldendkrais method.The therapist was very professional andthe therapy so relaxing, which providedmild but not lasting relief.
At that time, I was avidly readingeverything I could find regardinganxiety and panic attacks usingcognitive behavioural therapy (CBT) as a self-help tool. I discovered apsychologist who offered CBT. I hadread lots about CBT and it had beencovered in my counselling course, butI had never experienced it with acounsellor. There was immediate rapportbetween us and we worked throughthe Mind over Mood book1. I found it extremely useful to use the charts,along with the questions, in this book,to get a fix on how I functioned andmy sense of reality. This counsellorwas very supportive and my self-confidence increased, but I felt shelost interest when there was no changein my leg problem, her view being thatthe problem was caused by automaticthoughts. She recommended I see a
chiropractor and, again, this gavetemporary physical relief, especiallysince by now not only were my legstense and rigid, but also my lower back.
During this time I joined No Panic, a charitable organisation that supportspeople with anxiety disorders, andbegan to volunteer as a Help Liner.This has helped me enormously and I have realised, for the first time, thereal importance of correct breathing,relaxation and exercise.
More recently, I began to read aboutbioenergetic analysis, a specific form ofbody psychotherapy, found a therapistand have now had about 15 sessions.Usually half of the hourly session istalking therapy and the remaining halfis massage but I preferred at first tojust have talking therapy. However, forthe last two sessions we have includedthe massage, enabling me to releasesuppressed emotions. The therapist tooka thorough case history from me andalways seems to remember exactly whatI’ve said. I feel she is dealing with myconcerns at a much deeper level thanI have ever experienced before with atherapist and I feel very much supportedand understood. My body also feelsmuch more relaxed and I am hopefulthat, at last, I am getting to grips withmy anxiety problem. �
Maureen Downton began her working lifeas a secretary before her interest in mentalhealth led her to work for the charityRethink. She later qualified as a counsellorand presently volunteers as a counsellorworking with domestic violence and abuse,and as a Help Liner with No Panic.
Reference
1 Padesky CA, Greenburger D. Mind overmood: change how you feel by changing theway you think. New York: Guilford; 1995.
38 HCPJ July 2011
On the receiving endMaureen Downton’s quest to find a cure for the physical effects of stress on herbody led her on a journey through many types of therapy
Reader responseHCPJ welcomes feedback on this article.
If you would like to contact MaureenDownton, or HCPJ, please email
When I began my journey onthe counselling diploma, I wastold it would change my life.
It certainly did, with a roller coasterjourney towards understanding myself.However, I did not expect the next partof my journey – finding a job as acounsellor – to be quite as challenging.
It was halfway through my diplomathat I began to realise that counsellingjobs are very hard to come by, andthat passing the course was just thebeginning: I then had to go it alonewithout college support (althougharmed with my supervisor’s support)to work towards accreditation.
After combining my study years withlooking after my young family, due tochanged family circumstances, therewas a greater strain on my findingpaid work once qualified. I had hopedto carry on volunteering as acounsellor until I found work, but dueto my husband’s redundancy, I foundlooking for any job was urgent. I waslucky enough to find a temporary job(which could become permanent) asan achievement mentor, a non-counselling role but a role for which acounselling qualification was stated asessential. When I first started my newjob, I thought that perhaps using thecounselling skills I had might be enough;but quickly began to feel it wasn’t
enough for me to refer the students I was mentoring to counselling –I wanted to be the counsellor!
Due to my new working hours, I reluctantly stopped volunteering as a counsellor, but kept in touch withtwo of the agencies I had volunteeredfor, one a charity supporting parentsor relatives of those affected by drugsor alcohol, the other a leading socialcare organisation (working in thedrugs area).
Soon after starting in my new (non-counselling) role, I began to feel a greatsense of frustration and loss. I realised I did not want to stop counselling. But I am caught between the need to havean income and wishing to continuecounselling. Even though it is expensiveto continue due to supervision, personalinsurance and BACP membership, I stillwant to counsel.
In order to find work in counsellingI registered on the NHS website so thatsuitable jobs are flagged up on my email.This saves me trailing through vacancypages. There are difficulties: thevacancies coming up are asking for450 hours and either accreditation orworking towards accreditation. Bothof these are problematic for mebecause I am struggling even tovolunteer; I also need a part-time rolein counselling due to my young family.
Last summer, before completing mydiploma, I attended BACP’s studentconference and found the honesty ofthe speakers regarding finding workvery helpful. The whole day wasinteresting and informative, and Iapproached a member of the BACPHealthcare Executive with my idea thatthe NHS could offer apprenticeships forqualified counsellors; this would givethe opportunity to gain experience inhealthcare if you are newly qualified.
During the conference, a key speakertold us his story of how he foundwork in a prison offering counsellingto inmates. His message was ‘don’tgive up’, and he offered this quote byJoseph Campbell: ‘Follow your blissand don’t be afraid, doors will be openwhere you did not know they weregoing to be’1.
During training, I wrote in one ofmy assignments: ‘I am halfway throughthis journey that has changed my lifeso much, but I am very happy to beable to help people in a skilled way,unlike in the past, when I wanted tohelp but didn’t know what to do.’ Inhindsight, this still applies; counsellingis in my blood, and if I could, I wouldbe counselling tomorrow. Watch thisspace... �
Karen Barker qualified as a counsellor inJune 2010. She has previously volunteeredas a student counsellor at GASPED (GreaterAwareness and Support for ParentsEncountering Drugs) and the SunflowerChildren’s Centre, and since qualifying, hasvolunteered at Turning Point. She is currentlylooking for paid work as a counsellor.
Reference
1 Schwantes D. Ethics in a cocoon: how(not) to live well together. Indiana:AuthorHouse; 2007.
HCPJ July 2011 39
Just qualified…The journey towards a paid counselling job is a long road, but I’m not giving up,says Karen Barker
Reader responseHCPJ welcomes feedback on this article.
If you would like to contact Karen Barker, or HCPJ, please email
HEM
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A guide toassessment forpsychoanalyticpsychotherapistsJudy Cooper, Helen Alfillé
Karnac 2011
ISBN 978-1855755529 £9.99
In the preface to thisbook, Julian Lousadaexpresses concern at
the lack of attentionpaid to assessment in the training ofpsychoanalyticpsychotherapists.
I would certainly echo that. In defenceof training schemes, perhaps some solidexperience of work with patients isneeded before one can confidentlyapproach the sensitive and vital task ofassessment. Nevertheless, though it can become the most rewardingaspect of work as a psychoanalyticpsychotherapist, the task at first isdaunting and sometimes overwhelming.Perhaps, therefore, thought should begiven to the idea that ongoing trainingof psychotherapists could includecareful consideration of this crucialaspect of the work as therapists growinto their role.
This bijou book (fewer than 50 pages)would certainly be a valuablecompanion to anyone seeking to takestock of their work in assessment. It isnot detailed or systematic enough toserve as a comprehensive primer fortrainees new to the task. But for thosewho have been laying up experience inthe field of assessment and who wouldvalue a tool to help them pause, reflecton, and refine that experience, thebook is a delight. And trainees wouldcertainly get a taste of how central apart in a therapist’s working lifeassessment can become. The authorsclearly are experienced, sensitive, andwise therapists who are able to cast theirthoughts on the assessment process inneat but extremely helpful ways.
There are chapters giving an overviewof the whole process, consideration tothe question of diagnosis, the structure
and nature of the assessmentconsultation, the issues of transferenceand countertransference, andcontraindications for analytic work. Butthe book’s chief value is perhaps in itspeppering of clinical vignettes, oftenbrief, yet all illuminating and helpful. Inparticular, the final examples of workwith patients in their 60s, 70s and 80sare a most valuable counterweight tothe ageism with which even Freud wasso unfortunately prejudiced.
David QuarmbyPrincipal adult psychotherapist,Lancashire Care NHS Foundation Trust
Managing socialanxiety: a cognitivebehavioral therapyapproach 2nd ed– therapist guide – workbookDebra A Hope, Richard GHeimberg, Cynthia L Turk
Oxford University Press 2010
ISBN therapist guide: 978-0195336689 £27.50
ISBN workbook: 978-0195336696 £17.99
From a therapistperspective, thesebooks should be
seen as a pair ratherthan as single books.They are part of theTreatments That Work(TTW) series and peoplefamiliar with the styleof the series will findthe structure andformat reassuringlyfamiliar. Readersunfamiliar with theseries can check outthe books and
resources at: www.oup.com/us/ttwThese books form one of the problem-
specific treatment protocols whichunderpin much of the Improving Accessto Psychological Therapies (IAPT) model.As such, they are essential reading fortherapists and supervisors providingcognitive behavioural therapy (CBT)
interventions within psychologicaltherapy services.
The books have been significantlyupdated from the first edition(published in 2000), both in relation tothe evidence base but also in relationto elements of the treatmenttechniques. There is a very strongclinical narrative throughout and thechanges demonstrate that the authorshave used their clinical experience toshape the content while grounding thebook in a very solid research base.
The clinically collaborativeunderpinnings of these books areevident from the first chapter of theclient workbook which is entitled, ‘Aninvitation: are you ready to begin thejourney to overcome social anxiety?’This acknowledgement that there arepros and cons to addressing socialanxiety and the incorporation of adecisional balance exercise as part ofthe planning process with the clientshow that the authors are as focusedon the collaborative relationship as onthe clinical techniques.
The psycho-education and assessmentsections are very strong, as are thebackground chapters at the beginningof the Therapist Guide. This will providetherapists with a strong theoreticalbasis which provides the framework onwhich the therapy for social anxiety isdelivered.
Therapists who are newer to workingwith social anxiety will find the session-by-session structure helpful in layingout a treatment path with clients. Moreexperienced therapists can use thestructure to review their currentpractice and ask the ‘why don’t I do itthis way?’ question.
These books will provide therapistswith a sound theoretical underpinning,guidance on how to structure anddeliver social anxiety treatment inconjunction with clients, and aperspective on troubleshooting problemsthat arise in the course of treatment.
Kieran DohertyIAPT lead/senior practitioner, InclusionMatters primary care psychologicalservice, Liverpool
40 HCPJ July 2011
Reviews
In, against andbeyond therapy:critical essaystowards a post-professional eraRichard House
PCCS Books 2010
ISBN 978-1906254322 £22.00
This book hasbeen publishedat a crucial time
when the teaching andpractice of counsellingand psychotherapy arebeing questioned notonly by practitioners
but also by the Government and, morewidely, the State. As such, RichardHouse’s critical essays on what a‘post-professional’ era really meansdirectly conflict with the current drivetowards qualification, research andtheory to support evidence-basedpractice. This book challenges the verybasis upon which the ImprovingAccess to Psychological Therapies(IAPT) programme and Layard’s
Depression Report1 are founded.In, against and beyond therapy
skilfully critically analyses literature thatspans over two decades, focusing onpostmodern themes that question thevery foundations of psychotherapeuticpractice. House highlights the tensionsbetween rigid systems founded on post-enlightenment scientific ‘truths’ thathave emerged from positivistic theoryconstruction versus a postmoderndeconstruction that leads topsychotherapy based on the paradoxof ‘knowing the unknowing’. He presentsliterature that emerges beyond the ageof scientific Cartesian dualism,questioning psychiatric diagnosis toconsider how acceptance ofunexplainable subjective experienceinforms spirituality. Interestingly, Housealso discusses ideas of the developmentof spiritualised cognitive therapy.
House analyses the literature ofleading postmodernist writers to developa stance in relation to psychotherapeuticethics, professionalisation, training, andproposes a way forward in a transmodernpost-therapy era. He challenges thereader to think beyond the post-
enlightenment and modernist paradigmto consider postmodernist thinking inthe context of the professionalisationof psychotherapy.
This book is an interesting read forpractitioners and trainers alike and posessome very difficult questions relating towhat exactly is taking place within thecounselling room. Once the power andknowledge is deconstructed, the basicpremise is that power, knowledge andevidence-based practices are constrictedregurgitations of power bases that missthe essence of humans’ ‘being’. Houseconcludes by offering an alternativeview of what counselling in a trans-modern era might look like.
Margaret E SmithSenior lecturer and programme leader forMSc Integrative Counselling andPsychotherapy, University of Derby;integrative psychotherapist
Reference
1 The Centre for Economic Performance’sMental Health Policy Group. The depressionreport. A new deal for depression andanxiety disorders. London: LSE; 2006.
HCPJ July 2011 41
reviews
www.aspergerfoundation.org.ukWebsite of the Asperger’s SyndromeFoundation, a small charity committedto promoting awareness. Includesinformation sheets and details oftraining for parents and professionals.
www.autismni.orgNorthern Ireland’s autism charitywebsite has a downloadable bookletfor mental health professionals. Wakingup to Asperger’s syndrome aims to raiseawareness of AS as a mental healthissue, and provides basic informationon diagnosis and treatment options.
www.autism.org.ukThe National AutisticSociety’s usefulwebsite includes anintroduction to ASand details of services,news and events.
www.mencap.org.ukFeatures a downloadable factsheet onAS and an excellent professionals’ areawith information on aspects affectingpeople with a learning disability.
www.ninds.nih.govAS information page prepared by theNational Institute of NeurologicalDisorders and Stroke (NINDS).
www.scottishautism.orgPublications on autism, includinghelpful reading suggestions.
www.talkaboutautism.org.ukOnline community for parents andcarers of children with any form ofautism; helpful site with clearinstructions on how to join in.
www.users.dircon.co.uk/~cnsPlain but informative site for
university studentswith autism and AS; includesbooks/articles, study skills, andsurviving the university environment.
www.wrongplanet.netWrong Planet is a web communitydesigned for individuals (and parents/professionals of those) with autism,AS, ADHD etc, where memberscommunicate with each other. There’san article section with how-to guides,a blogging feature, anda chat room for real-time communication.
Please note that AS is commonly referredto interchangeably as either Asperger’ssyndrome or Asperger syndrome.
Web resources……Asperger syndrome
42 HCPJ July 2011
The summer has finally arrived –even in Scotland! In stark contrastto my last update, the snow
on the hills has been replaced by awonderful covering of purple heather.I reminded myself recently how oftenI take these beautiful scenes for granted,because they are always there, yetconstantly changing.
In the world of therapy, change iswhat we are about and yet we do soin the context of holding consistenttherapeutic boundaries with ourclients. It can sometimes be too easyto take things for granted, includingthe constancy and safety of thetherapeutic relationship and thetremendous courage and resilience we meet every day in our clients.
A couple of months ago, while drivingsouth along the M1 and passing theexit for Bretton Hall, I was remindedof travelling to my own counselling
training at the University of Leeds.Those journeys (which I am sure willresonate with others!) held manyemotions but the overriding one wasof excitement, reflecting an enthusiasmfor all that learning and a deep desireto want to be a good therapist. I amprivileged to be reminded of that eachday when I see the enthusiasm andexcitement in our students on traineeplacements. It is that enthusiasm whichreminds me that there is much to lookforward to, even when as a professionwe travel through uncertain times.
Come and meet usAs an executive, we have been busypursuing our decision to have a FourNations approach and do our best tomeet with members. It is importantthat we hear directly about the issuesaffecting you as therapists in 2011. Sofar we have managed to arrangeinformal gatherings with memberswhen we attended ‘Making Connections’events in both Belfast and Edinburgh.It was good to meet with so many
members, and we look forward tomeeting more at future events.
Can I draw your attention to the‘Making Connections’ section of theBACP website (www.bacp.co.uk/makingconnections/) where you can register forthese free events. They offer an excellentmix of networking opportunities andinformation gathering, and alwayshave an interesting keynote speaker.
Upcoming BACP HealthcareeventsIn the autumn, BACP Healthcare willhost a seminar in York on the subject of‘Healthcare in transition: strengtheningour professional identity’. The one-dayevent aims to bring you up to date onrelevant developments and reforms inhealthcare. You’ll find further detailsabout how to register interest on page 4.
Later in the year, we plan to hold aconference in Scotland which will offera particularly northern perspective…more information to follow.
As always, do get in touch! Pleaseemail me at [email protected]
BACP Healthcare updateChair’s report
Development update
Healthcare reforms and GP commissioningI write this update after the coalitionGovernment has announced a ‘naturalbreak in the passage’ of the Health andSocial Care Bill (affecting NHS England)to enable further consultation1. Thisnews has been broadly welcomed andaffords us all some time to reflect onthe proposed reforms and prepare forchanges ahead.
It also seems to me that the ‘natural
break’ allows more time for the GPconsortia that are ploughing aheadwith local reform to work through thepitfalls and offer central governmentsome of the solutions. I think thesepioneering GP consortia will be in astrong position to influence the finerdetail of reforms and theirimplementation.
In this evolutionary context, BACP is leading a research project that aimsto inform how we engage with GPcommissioning in order to supportimprovements in counsellingprovision. As I write, the researchproject is in process, and includesinterviews, focus groups and surveysof GPs, commissioners, practicemanagers, BACP members and keyindividuals from other interested
organisations. To all those who arereading this and have taken part –thank you!
I intend to deliver a workshop onGP commissioning, which will beinformed by our current research, atthe divisional conference (for moreinformation, please see the back cover).I am planning an interactive sessionand look forward to working withdelegates on the day to develop ourjoint understanding and capability to engage and influence GPcommissioning.
I am keeping an open mind on thefindings of the research but I anticipatethat the success of BACP’s futurework to influence improvements inthe provision of NHS counsellingacross the UK will be enhanced by
Tina Campbell outlines thenews from the division’sExecutive
A new research project on GPcommissioning is among theinitatives taking place at BACP,writes Louise Robinson,Healthcare developmentmanager
HCPJ July 2011 43
the engagement of BACP members aslocal ambassadors. I am keen to hearfrom any members interested in thework we are doing and in workingtogether to influence change. Emailme at [email protected] or tel 01455 883311.
Counselling for depressionIn follow-up to the article IAPT andcounselling – the story so far inApril’s issue of HCPJ, I thought it may interest HCPJ readers to knowthat BACP has completed the firstwave of post-qualification training in Counselling for Depression (CfD) to 72 trainees. The training takes amanualised approach to helping clientsaddress the emotional problemsunderlying their depression and isdelivered through 10 half-day teachingmodules which include: genericinduction to IAPT, theoretical principlesand values, humanistic conceptualisationof depression, application of coreconditions in the context of IAPT,working with emotional process, andworking briefly. The modules aredesigned to ensure the training iscompliant with recommendations inthe National Institute for Health andClinical Excellence (NICE) guideline for depression.
The training to date has been fundedby the Department of Health; BACPplans to deliver another wave of CfDand CfD Supervisor training incollaboration with higher educationinstitutions in the academic year 2012.BACP is also considering how to widenaccess to the training for counsellorswho are not funded by IAPT but who areinterested in gaining this qualification.Entry requirements for the training are:� Diploma in humanistic/person-centred counselling or psychotherapy� Minimum two years post-qualificationexperience (healthcare setting)� BACP accreditation or equivalent.
BACP-accredited counsellors whosuccessfully complete the training andsubsequent 80-hour practice periodcan apply for a Senior Accreditationaward. Non-accredited BACP memberscan count the training towards theirBACP accreditation training andpractice hours.
More information will follow infuture updates; in the meantime, ifyou have a query about the trainingplease email [email protected]
Reference
1 Watt N, Wintour P. NHS reforms: Lansley agrees to change health bill.http//www.guardian.co.uk; 4 April 2011.
Reader responseResponse to Isabel Gibbard
I read Isabel Gibbard’s Opinion page(HCPJ April 2011) with interest andwould like to add my own commentsto the debate on Counselling forDepression (CfD). Firstly, I think BACPis to be commended on its efforts toinitiate person-centred therapy intothe Improving Access to PsychologicalTherapies (IAPT) programme. Introducinga specifically designed person-centred/emotion-focused therapy (EFT) focusfor working with depression is awelcome challenge to the prevailingand relatively unquestioned trend forcognitive behavioural therapy (CBT) andI feel BACP is to be further applauded
for its commitment to developing arandomised controlled trial (RCT) ofcounselling for depression1.
Though I agree with Isabel in that I too understood that counselling is a generic term and the title thereforeis somewhat misleading, riskingobscuring the person-centredmodality, I understand that BACPinformants have emphasised that theuse of the term ‘counselling’ in thisway is purely pragmatic, but wouldencourage speed in moving towardsthe proposed use of ‘person-centredexperiential counselling for depression’for this intervention1.
My main concern, however, is howthe extensive entry criteria to be
accepted onto the training for CfD,which clearly designates this trainingas post-qualifying training, will beperceived by the Department ofHealth, and consequently NHS staffand general practitioners. The currententry requirements are: a diploma inhumanistic/person-centred counselling
I anticipate that the success ofBACP’s future work to influenceimprovements in theprovision of NHScounselling acrossthe UK will beenhanced by theengagement ofBACP members aslocal ambassadors. I am keen to hearfrom any membersinterested in the workwe are doing and inworking together toinfluence change ‘
‘BACP Healthcare update
or psychotherapy, a minimum of twoyears’ post-qualification experience (in a healthcare setting), BACPaccreditation or equivalent, andexperience/qualification in supervision2.The training then requires anadditional 80 hours of supervisedpractice with fortnightly supervisionbefore a therapist (who it should be stated is already qualified andaccredited) is considered competentenough to work with depressionwithin the NHS and IAPT. Presentedwith this information, and comparingthis with CBT therapists, who are seenas qualified to work with depression as soon as they have completed theirtraining and without the need to beaccredited, I worry that most will draw the conclusion that qualifying as a person-centred practitioner is not sufficient enough to work in theNHS and with depression. I wait withbated breath to view any entry criteriafor humanistic practitioners to train to work with anxiety.
As a trainer on a BACP-accreditedpostgraduate diploma course incounselling and psychotherapy(person-centred), I would welcome the opportunity to include training forCfD on the course, enabling studentsto prove their competency to workwith depression in IAPT. However, theentry criteria dictate that therapistshave to be qualified, accredited andindeed supervising, before they can be considered sufficiently experiencedto train. This is especially frustratingas, by the end of the course, successfulstudents will have already met boththe general therapeutic competenciesand the metacompetencies for CfDand are familiar with EFT, which istaught on the programme. Includingtraining for CfD in established BACP-accredited person-centred programmeswould also rapidly increase the number
of therapists trained in CfD, whichwould help in offsetting the identifiedlow numbers of CfD practitioners inthe development of a RCT of CfD. I remain puzzled and concerned thatsuch a great opportunity for includinghumanistic therapy in IAPT has beenrestricted in this way.
Angela West (MBACP Snr Accredcounsellor and Accred supervisor) isprogramme leader for the PostgraduateDiploma in Counselling and Psychotherapyat Liverpool John Moores University.
References
1 Cooper M. Development of arandomised controlled trial for counsellingfor depression. BACP; 2011. See http://www.bacp.co.uk/admin/structure/files/pdf/7123_development%20of%20a%20rct%20of%20counselling%20for%20depression.pdf
2 Hill A. Curriculum for counselling fordepression: continuing professionaldevelopment for qualified therapistsdelivering high intensity interventions.IAPT; 2011. See: http://www.iapt.nhs.uk/silo/files/curriculum-for-counselling-for-depression.pdf
Current thinking on anxiety
I would like to thank HCPJ for thecluster of articles in the January 2011edition. I can’t remember the last time a series of articles sparked mythinking as much as these, particularlythe article on intensive short-termdynamic psychotherapy (ISTDP) andthe piece on experiential psychotherapyand the vagus nerves. So muchinformation was packed into this seriesof articles but in a very digestibleform, helping me crystallise mythinking in such a massivelycomplicated and important area.
Reading about current thinking on the physiological basis of anxiety;anxiety and early attachment; andabout the technique of focusing, andreflecting on all the issues raised inthese articles, is already contributingto a shift in my practice. For example,working more explicitly than I didbefore with clients’ ‘felt sense’ ofproblems and being explicit with themabout why I am offering to work withthem in this way, seems to be payingdividends, judging by feedback I amgetting from my clients to date.
Congratulations HCPJ on such aninteresting and useful edition!
Cordelia Galgut, CPsychol, MBACP (Snr Accred); counsellor/psychotherapist in private practice
44 HCPJ July 2011
reader response
Reader response……we invite your views and experiences
HCPJ welcomes feedback about any article, column ornews item in this issue. If you’d like to contact any of the authors, or the editor, please email [email protected], or write to the address on the inside frontcover, marking it clearly for the attention of SarahHovington, Editor, HCPJ.
We also welcome ideas for articles relating tocounselling and psychotherapy within the healthcaresector. We are particularly interested in new perspectiveson current thinking, debate on practical or professionalissues, and sharing of knowledge, experience and practice.For information on how to submit an idea, please contactthe editor, details as above.