Counselling in General Practice

Roslyn Corney, Rachel Jenkins, Roslyn Corney, Rachel Jenkins

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134929498
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Many GPs now employ counsellors to help them with the psychological and emotional problems of their patients. The contributors to this book have wide experience of counsellor attachments and have been involved in developing and promoting GP counselling on a nation-wide scale. They explore the counsellor's role in general practice and investigate the issues involved, giving practical guidance which will be invaluable to those wishing to set up a counselling service.

Chapter 1
Counselling in general practice today

Roslyn Corney and Rachel Jenkins

Approximately one-third of all patients who consult their GP are likely to be seeking help for the emotional distress associated with a physical illness, or for what can be termed a ‘life problem’. Patients with emotional problems have been shown to attend their GP more frequently and show an increased demand for other medical services. In addition, studies have shown that patients with psychosocial problems are more likely to turn to a GP rather than the psychiatric or social services. In consequence, the majority of emotional problems experienced by patients are treated by GPs or by another member of the primary care team without referral to the mental health services. These details are documented in greater detail in Chapter 2.

A range of other professionals support and help GPs with these patients. These include other members of the primary care team, health visitors, district nurses and practice nurses as well as attachments of other professionals in the mental health field, such as psychologists, community psychiatric nurses and psychiatrists. More recently, counsellor attachments have also been set up specifically for this purpose.

THE DEVELOPMENT OF THE PRIMARY HEALTH CARE TEAM

Following the Family Doctor Charter of 1966, GPs were encouraged to form group practices and the number of singlehanded doctors began to fall. This has proceeded steadily until the present day when most young doctors entering general practice join a group practice. The Department of Health has also encouraged the building of group practice centres by offering favourable loans and rent schemes and by the provision of local authority-owned health centres. Approximately 25 per cent of general practitioners now work in such health centres.

In parallel with the development of premises came the attachment of District Health Authority nursing staff, to group practices and health centres in the 1960s (health visitors, district nurses and midwives). Ancillary staff, including receptionists, secretaries and administrators, had 70 per cent of their salaries paid by the local Family Practitioner Committee (FPC), and each doctor was able to have one or two staff members funded in this way.

In 1975, Marsh first reported on the work of a counsellor in general practice and, since then, a number of attachments have been described in the literature. However, the funding of these attachments has always been a problem. Originally many counsellors gave their services free or charged the client directly (usually on a scale according to the client’s financial circumstances). In a few instances, the GPs paid the counsellors while other counsellors claimed their fees from the patient’s private health insurance (if referred via a psychiatrist). More recently, however, some FPCs have been willing to fund counsellor attachments using the ancillary staff scheme described above. In July 1989, the British Association for Counselling asked all 94 FPCs if they were employing counsellors in general practice. Of the 52 who responded, 52 per cent were currently using counsellors and 42 per cent had agreed to reimburse GPs from the ancillary staff scheme.

A new contract for GPs came into operation in April 1990 and brought about a number of changes, some of which have made it easier for GPs to fund counsellors in general practice. Since the new GP contract, the range of staff eligible for reimbursement has been extended so that staff (including counsellors) who have a wider range of skills and training also qualify. However, the new contract does not guarantee that practices will continue to receive 70 per cent reimbursement of staff salaries through the ancillary scheme (except those staff in post prior to April 1990). Other GPs, however, have been using the money received through their health promotion clinics to pay counsellors. In this event, the counsellors have organised their counselling sessions as health promotion clinics—promoting mental health and preventing mental illness/ breakdown—and are therefore eligible to claim money specifically set aside for this purpose.

The FPCs have been taken over by the Family Health Service Authorities (FHSAs). These FHSAs have new powers and are entitled to vet any counsellors employed by GPs to ensure that they are suitably trained and experienced.

THE ROLE OF THE GP AS COUNSELLOR

McLeod (1992) stated that the ‘work of the GPs has always included counselling whether this is seen as the application of counselling skills in the consultation or the informed use of the counselling process with selected patients’; but the majority of doctors enter general practice with little training in counselling. This lack of preparation for counselling ‘together with the very real constraints of time, has limited the capacity of many GPs to adequately recognise patients’ needs and to respond effectively to these needs’ (McLeod,1992).

The potential of the consultation in general practice was explored by Michael Balint and his followers. Balint groups have been established where small groups of doctors develop effective ways of using short consultations. The skills and techniques of counselling are an important and necessary part of the work of all GPs, as they are constantly involved in their patients’ grief after a bereavement, their relationship difficulties, children’s problems after a marital breakup, or those learning to cope with a chronic or serious illness. ‘Listening sensitively to the patient and helping to make sense of his distress, the use of explanation, guidance and informed reassurance are all “tools of the trade”’ (McLeod, 1992).

Counsellors and others argue that although counselling skills help the GPs in their consultations, the focus of the doctor’s work is different from that of the counsellor (Rowland et al., 1989). In general, the aim and function of a counsellor is to help the clients to help themselves, to clarify difficulties and attempt to resolve them. Rather than giving advice, reassurance or medication, the counsellor systematically attempts to avoid long-term dependency. The GP’s role is sometimes different; the GP can be viewed as the expert, whose job is to listen to the patient, attempt to diagnose any disorder and prescribe treatment to ease or to cure. Even those GPs who have trained as counsellors do not always find it easy to enter into this sort of counselling relationship or to have the time or emotional resources to do so. There may also be problems for which they have to revert to a ‘doctoring’ role at a later stage (Rowland et al., 1989).

SHOULD COUNSELLING BE OFFERED IN PRIMARY CARE?

Advantages

A number of favourable accounts of counselling attachments that have been published in the general practice and counselling literature are reviewed in Chapter 4. The lack of unfavourable accounts (published or unpublished) may indicate that they are rare occurrences or that they have not been documented formally (or a combination of the two).

Reports of successful attachment and employment schemes of other professionals (Clare and Corney, 1982; Strathdee, 1988) have shown that these schemes generally facilitate better collaboration and communication and the development of trust between different professionals. Doctors feel happier at referring distressed patients to someone whom they know and trust. The doctor might also receive direct feedback from referred patients.

Counsellor attachments may also benefit the counsellor who might gain satisfaction from being part of a team rather than working in isolation in addition to the medical support and backup provided (Corney, 1987).

As shall be discussed in Chapter 3, a counsellor in the practice may also offer support to other members of the team. This may enable team members to undertake some of the counselling work. Sharing the care of patients with long-term intractable problems may help reduce the stress imposed by these patients.

Many GPs consider that one advantage of employing counsellors is that clients can see a counsellor in a familiar environment. The fact that the doctor has suggested counselling may overcome the client’s initial scepticism of the value of counselling. Being referred to an ‘in-house counsellor’ might not attract the same stigma as a psychiatric referral. In addition, one of the problems of referring patients to psychiatrists is that many patients fail to turn up for the first appointment (Illman, 1983).

Disadvantages

One of the main disadvantages is that of cost. The costs of employing a qualified counsellor are not inconsiderable and we have little evidence (as yet) to indicate whether clients benefit greatly from professional counselling in comparison to other forms of ‘talking’ help. Would a harassed and depressed young mother receive as much benefit from talking to a health visitor (with limited counselling training) as talking to a counsellor? Would the support and befriending from another young mother with slightly older children be as helpful?

Counsellors are limited in the number of clients that can be seen each week and it is important that each referral is considered carefully. Other options such as group counselling or making more use of the counsellor’s role in supporting and advising other members of the primary care team should also be considered to limit excessive costs.

The question of client choice has also to be considered. Attaching counsellors to primary care may limit client choice. Some clients may regard that being referred to a counsellor in a general practice ‘may not provide sufficient anonymity and privacy’ (McLeod, 1988). It is important that other options are available for clients who wish to seek alternative help that is not linked to medical care. Many doctors would argue that employing counsellors has far-reaching consequences as it legitimises general practice as the place to go with social and emotional problems. Will the widespread adoption of counsellors employed in general practice increase the medicalisation of these social and emotional problems? Or will patients feel that they do not have to adopt a sick role (and accompanying illness behaviours) to visit their GP with these problems before being referred to more appropriate help?

CONCLUSION

A number of questions will be raised in the following chapters. However, it is vital that future counselling placements are properly and systematically evaluated so that firmer evidence is obtained on the benefits and costs of providing counsellors in this setting.

REFERENCES

Clare, A.W. and Corney, R.H. (1982) Social Work and Primary Health Care, London: Academic Press.

Corney, R. (1987) ‘Marriage guidance counselling in general practice in London’, British Journal of Guidance and Counselling 15:50–8.

Illman, J. (1983) ‘Is psychiatric referral good value for money?’, BMA New Review 9:41–2.

McLeod, J (1988) The Work of Counsellors in General Practice, Occasional Paper 37, London: Royal College of General Practitioners.

McLeod, J. (1992) ‘Counselling in primary health care, the GP’s perspective’, in M.Sheldon (ed.), Royal College of General Practitioners Clinical Series on Counselling in General Practice, London: RCGP Enterprises.

Marsh, G.N. and Barr, J. (1975) ‘Marriage guidance counselling in a group practice’, Journal of the Royal College of General Practitioners 25: 73–5.

Rowland, N., Irving, J. and Maynard, A.K.(1989) ‘Can GPs counsel?’, Journal of the Royal College of General Practitioners 39:118–20.

Strathdee, G. (1988) ‘Psychiatrists in primary care: the general practitioner viewpoint’, Family Practice 5:111–15.

Chapter 2
The need for counselling The extent of psychiatric and psychosocial disorders in primary care—a review of the epidemiological research findings

Anthony Mann

Psychiatric and psychosocial disorders seen and managed within primary care settings can easily be belittled; the critics adopting several arguments, including:

Compared to many common physical diseases, psychiatric disorders and psychosocial problems seen in primary care do not constitute a major health issue.

They are not ‘real’ mental illnesses.

Nothing much is known and anyway most of these disorders recover spontaneously.

The purpose of this chapter is to respond to such observations. The evidence quoted is largely drawn from work carried out over the last two decades within the former General Practice Research Unit, under the direction of Professor Michael Shepherd, at the Institute of Psychiatry.

ARE THEY A PUBLIC HEALTH ISSUE?

Epidemiological studies, both here and in the United States, suggest that the rate of mental illness in the population is in the range 10–15 per cent at any point in time. These figures can be enlarged or reduced, depending on the extent and duration of symptoms counted and whether those disorders associated with physical illnesses are included. All such community surveys show that the non-psychotic disorders—anxiety and depression —are the most prevalent. The important and relevant item is that the primary care service in the United Kingdom is the main point of contact for people with psychiatric disorders.

Over double the number of contacts occur for psychiatric disorder in primary care compared to other forms of psychiatric contact. National Morbidity Statistics show that, at 9 per cent, psychiatric disorders rank as the third most common cause of

Table 2.1 Comparative rates of attendance for different levels of psychiatric care (rates per 100,000 general population, all ages and sexes combined in 1981)

Table 2.2 Psychiatric disorder in an average general practice population of 2,500

consultation in primary care following those to do wi...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Tables
• Contributors
• Preface
• Acknowledgements
• Chapter 1 Counselling in general practice today
• Chapter 2 The need for counselling The extent of psychiatric and psychosocial disorders in primary care—a review of the epidemiological research findings
• Chapter 3 What is counselling?
• Chapter 4 Studies of the effectiveness of counselling in general practice
• Chapter 5 The ethics of counselling
• Chapter 6 Practical and Training Issues
• Chapter 7 The counsellor as part of the general practice team
• Chapter 8 Setting up a counsellor in primary care The evolution and experience in one general practice
• Chapter 9 Evaluating counsellor placements
• Chapter 10 The future of counselling in primary care
• Appendix Referral forms and counselling questionnaire