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Information

Editors

LeenaJaakkola
TuulaArvonen

Psychotherapy in General Practice

Essentials

  • Each general practitioner consultation offers many opportunities to establish a good rapport with the patient. The doctor may choose to take full responsibility for the care or share it with other team members.
  • A psychotherapeutic understanding and approach towards the patient are important. If pressed for time, it is easy to miss the actual, psychological cause of the patient's ill health as it can be masked by the physical symptoms.
  • The doctor should be sensitive to reading ”between the lines” and have the courage to broach issues not immediately introduced by the patient. In a telemedicine setting this is particularly challenging and requires an active and bold approach by the doctor. When the essential issues are quickly established, many unnecessary visits and investigations are avoided. Continuity of the therapeutic relationship supports the feeling of security in the patient and helps in telling about the real worries.

Psychotherapeutic approach during an appointment

  • The role of the doctor is such that it will always offer an opportunity to give the patient a feeling of a good, respectful interaction between two individuals. A meeting of this kind may have a surprisingly large significance to the patient's mental well being.
  • Even at a busy appointment setting, providing the patient with time and trying to understand his/her situation may often “pay itself back”, when repeating visits for various reasons are reduced.
  • Familiarise yourself with the patient's life situation and how he/she experiences it. Moreover, ask what the patient has done so far to obtain help and from where has he/she received support. What has helped?
  • Physical diseases, particularly if chronic, often deplete mental resources. The patient's feelings of insecurity can be alleviated with a calm approach and by giving a sufficient amount of easily understood information.
  • Involving the family should be considered on a case-by-case basis. Even a single appointment with the family or the couple may provide essential information on the development of the situation and the factors affecting it, which the patient may not alway recognize him/herself. Support from the family may be first-rate important at the time of crisis and when the patient is self-destructive. In such situations, it is advisable to agree with the patient on what kind of contact the physician may have with the family.
  • Family, work community, health visitors and peer groups as well as social workers, substance abuse workers, psychologists and psychiatric nurses, among others, should be considered as potential co-operation partners with whom to share the responsibility for treatment.

Patients with psychosomatic symptoms

  • The problems of 5-20% of patients receiving long-term care from a general practitioner are psychosomatic in character.
    • These patients can be divided into different groups.
      • Psychosomatic symptoms are temporary and caused by a transient increase in anxiety.
      • Psychosomatic symptoms are continuous, target organs change and the patient is very worried about the symptoms.
      • Psychosomatic symptoms are associated with detectable changes in the target organ(s) or general health.
      • The somatic symptom is conversion-based.
  • There may have been repeated traumatic events in the person's early life. The patient does not possess words to express emotions and starts to express himself/herself through the body. The interaction between the mind and body is known to have mechanisms that lead to physical symptoms.
  • If the doctor's impression of the illness differs from that of the patient, the doctor may perceive the situation as frustrating. A confrontation between the doctor and patient does not advance the situation so even then the only way forward is to gain the patient's trust aiming at
    • creating a feeling of safety and avoiding confrontation
    • advocating the proper investigation of symptoms and the reality as well as calmly searching for connections between the patient's everyday life and the symptom emergence
    • referring the patient, if indicated, for a psychiatric assessment so that the background for the symptoms can be better identified.

Patients with psychiatric symptoms

  • A sign or symptom as such reveals neither the severity of the condition nor the problems it may mask.
  • Questionnaires can be used as additional tools, but each patient warrants individual assessment.
  • Psychiatric problems may be transient, they may have reached a crisis point or be chronic and, in some cases, very disabling.
  • Patients who are likely to require long term help should be referred to psychiatric care. The process should be discussed with the patient and the transition made as smooth as possible; this may make it easier for the patient to accept treatment, and the feeling of safety will prevail during the transition.
  • The depletion of mental resources due to a physical disease may manifest itself as psychiatric symptoms Depression, Drugs and Somatic Diseases.
  • The patient may also have substance abuse problems or other problems with dependencies and is not able to appreciate how these can cancel out any treatment efforts Recognition of Alcohol and Drug Abuse.
  • Any transfer of patients from the psychiatric sector to the follow-up care by a general practitioner should be accompanied by a clear plan including the following: how therapy is to be implemented, an overall view of treatment and consultation contacts.
  • Patients with personality disorders may tax the doctor with frequent, demanding consultations. The doctor will often feel uncomfortable and find it difficult to give his/her full attention and keep to his/her resolutions. The doctor will often recognise feelings of anger and is at risk of losing his/her professional approach. Within the professional work team, these patients often cause conflict situations. The usual empathetic approach is ineffectual in these cases. Balint groups and other forms of clinical supervision are beneficial.

Psychotherapy in general practice

  • Every general practitioner will meet acutely anxious patients or those in a mental crisis and must possess skills to manage the situation. Regularly recurring education would be beneficial.
  • General practitioners vary as regards their natural competence and interest in a psychotherapeutic approach and management of these patients. Should the doctor find difficulties in recognising and treating mental problems, he/she should obtain relevant training and guidance. Discussions with a superior or colleagues about the possible problems may help to avoid conflicts with these patients.
  • If a general practitioner is interested in psychotherapeutic treatment, he/she can apply to do relevant courses and undergo clinical supervision, and consequently offer brief psychotherapy or crisis intervention psychotherapy to patients.
  • Moreover, a general practitioner who has been trained in psychotherapy or in clinical supervision may give advice to colleagues or act as a clinical supervisor. Training in family medicine strengthens the doctor's skills in taking constructively into account the patient's life situation.

Types of psychotherapy

  • Giving therapy sessions without appropriate training requires at least some clinical supervision.
    • A doctor who wishes to give brief psychotherapy sessions without being formally trained as a psychotherapist must regularly attend relevant clinical supervision.
  • A longer than normal appointment time must be reserved for a psychotherapy session; usually about 45 minutes.

Supportive psychotherapy

  • Listening and accepting the patient's concerns, offering reassurance and analysing the prevailing problem will all also treat the patient's mind.
  • All the aspects of the patient that function well should be reinforced and supported, and the patient is given assistance to handle difficult emotions in demanding and burdensome situations. Asking the patient about the matters that work well and what he/she still can do will help to illustrate the patient's existing resources.
  • Support of this kind may be given even if the appointments are fairly infrequent.

Crisis intervention psychotherapy

  • The way individuals react to external events may differ greatly and, therefore, an event which might appear small may sometimes lead to a crisis reaction that is both surprising and severe. In a crisis situation, the individual needs to talk about the event, sometimes over and over again. As the situation prolongs, a memory of an earlier traumatic event will often re-emerge into the consciousness and needs to be addressed. Knowing the patient's life situation and earlier traumatic events helps to understand and process the current situation.
  • The emphasis of crisis therapy is on brief and intensive intervention - preferably given once a week.
  • It is a good idea to find out about other local providers of psychosocial support, e.g. by actors of the voluntary/third sector (e.g. non-governmental nonprofit organizations).

Brief psychotherapy

  • The patient's ability to deal with emotional concepts must be assessed along with the severity of his/her problems. Provided the patient is motivated, brief psychotherapy may prove to be all that is needed to provide sufficient help.
  • The intervention should focus on a circumscribed problem area. A specific topic is agreed with the patient to be the central issue, i.e. the focus, of the therapy, and for which a solution is sought.
  • A termination date for the therapy should be set in advance.
  • The doctor's active interest, questions and observations will help the patient to better understand his/her situation. The way of working is chosen according to the patient. Some patients are analytical and consider causes and consequences whereas others strive to restore their emotional balance through active means. After a trusting relationship has been formed, the patient will be more ready to accept new thought patterns.

Referral to a psychotherapist

  • A suggestion of psychotherapy may be enough to kick-start the patient's mental work process. However, if incorrectly put forward, the suggestion may be considered insulting. In many cases, it is necessary to allow the matter to mature whilst continuing to encourage and work with the patient.

Internet-based therapies

  • Internet-based therapies and guidance on self-help may be useful, particularly in the early phases of symptoms.
  • The need for psychotherapy may, naturally, also appear during a teleconsultation. Providing actual psychotherapy over a video connection is more challenging than when working face-to-face, since it is more difficult to assess the patient's emotional state, level of anxiety, etc. A physician may, however, work using a psychotherapeutic approach also during teleconsultation, like during regular appointments. Clinical supervision is recommended.

Aids for a general practitioner

  • Clinical supervision
    • Consists of looking into and developing one's own work and one's professional self with the following aims: the improvement of the management and quality of work, professional development, ability to cope at work and the correct operation of the workplace. The clinical supervisor may be an experienced colleague, a general practitioner trained in psychotherapy or a psychiatrist.
  • Balint groups
    • Clearly structured guidance relating to patient care implemented in a group of doctors and facilitated by an experienced leader. This may help a doctor to better understand both the patient and himself/herself as well as the phenomena of the doctor/patient relationship and thus find new ways to work with the patient.
  • Ability to consult a psychiatric unit and a systematic division of responsibilities
  • A designated support person at the place of work, a mentor or tutor
  • Information on actual training in psychotherapies is available on the websites of universities and other academic institutions.
  • More information may be obtained, for example, from organisations that provide training in psychotherapy.