Peoples’ understandings of a primary care-based mental health self-help clinic

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Abstract

Self-help programmes are increasingly advocated as a means of managing mental health problems. This qualitative study explored patients’ understandings of the use of a UK primary care-based self-help clinic (facilitated by a nurse). As part of a wider evaluation of the clinic, in-depth interviews were conducted with a purposive sub-sample of clinic users. Data indicate that people understand their problem as one of having lost an ability to cope, and that the ethos underlying the clinic is well matched to restore a sense of coping, by motivating patients to re-establish and retain control over their everyday lives. However, some patients experienced a sense of dissonance between prior expectations and actual use of the self-help clinic. Without prior familiarity with self-help, engaging the patient as the mechanism of change may be difficult. Some patients expected formal counselling and were influenced in this by their previous experience of services and discussions with the GP at the point of referral. It takes time and active engagement with self-help materials before patients become aware that they are a crucial mechanism of change. Patients may benefit from information and a referral process, which emphasises the centrality of self-efficacy and the patient as ‘change agent’ prior to referral.

Introduction

Mental health problems are highly prevalent in primary care, and psychological therapies such as cognitive-behavioural therapy (CBT) are popular with patients [1] and effective [2]. However, access to such therapies is problematic because of the low availability of trained therapists. CBT can however, be provided as a self-help intervention (i.e. through written manuals), and this is increasingly seen as a means of making effective psychological therapy more widely available [3]. There is growing evidence that such self-help is effective [4]. Although self-help sometimes involves provision of written information alone, another model is facilitated self-help, where the patient receives brief assistance from a therapist to help in implementing programmes and activities in the manuals [5], [6].

Although the potential for self-help in mental health is significant, key issues concerning these treatments remain. For example, how does self-help in mental health [7] achieve its effects (i.e. what are the ‘mechanisms of change’)? and how should self-help interventions be organised and provided in primary care [4] so as to maximise those effects?

Work has examined the technology of self-help (i.e. the handbooks and other materials used) and considered how materials should be designed to maximise effectiveness [8]. Although the technology is important, qualitative work conducted in self-help in other chronic diseases as part of the Chronic Disease Management Programme [9], [10] has indicated that benefits of self-help are often mediated through changes in self-efficacy [11], [12]. Self-efficacy is a psychological construct that refers to the strength of a person’s belief in his/her capability to do a specific task or achieve a certain result (i.e. manage symptoms or engage in self-help) [13], [14] and is a key predictor of a range of health behaviours and outcomes [15]. Self-efficacy can be enhanced through a number of mechanisms, but the most effective is performance attainment (i.e. actual experience of the success of actions). However, depression and anxiety may impair both self-efficacy beliefs, and the ability to engage in those behaviours that might increase self-efficacy [16]. The development of self-efficacy in self-help interventions in mental health therefore requires investigation.

In addition, psychological therapy research has highlighted the importance of the therapeutic alliance between patient and therapist in facilitating patient change [17]. Although there is no consensus as to the exact meaning of the term, concepts of relevance include the patient’s evaluation of the potency of the interventions offered, agreement over the goals of therapy, and the ability to forge a strong personal bond with the therapist [18], [19]. However, little is known about the influence of such mechanisms in facilitated self-help, where therapist–patient contact is reduced and the self-help material is more the focus of the intervention than the therapist–patient relationship.

Despite the effectiveness of self-help, there is evidence of ambivalence and limited uptake by patients of self-help guidelines in primary care for other conditions such as asthma [20]. One of the reasons for this might be that self-help is a relatively innovative approach to management in medicine, which has traditionally been characterised by professional paternalism and relatively passive patients [21]. Given that patients’ use of services is dependent to an extent on previous experience with those services and the expectations that those experiences engender [22], effective implementation of innovative self-help services might be hindered by expectations as to the nature of mental health treatment [1] and self-help, as well as the actual information received about the new service. Qualitative research has significant potential to illuminate such complex processes [22].

The implementation of an innovative self-help clinic in primary care provided an opportunity to examine issues concerning:

  • (a)

    the mechanisms of change, and the role of self-efficacy in self-help interventions in primary care mental health;

  • (b)

    patient expectations concerning self-help in mental health, and ways in which the clinic could be designed to engage more fully with patients’ perceptions of its role and function.

The clinic operated from 10:00 a.m. to 4:00 p.m. one day a week through an informal referral system where patients made an appointment at the reception desk following advice to do so from GPs or other health professionals, or through seeing poster adverts in the practice. Patients with depression and anxiety (e.g. post-traumatic stress disorder, obsessive-compulsive disorder, phobias, etc.) were encouraged to attend the clinic. Patients were given an initial 30 min patient-centred assessment focusing on problem identification, followed by 15 min follow-up sessions usually two weekly thereafter. There were no minimum or maximum number of sessions and the clinic saw four new patients weekly with 10–15 follow-ups per clinic. Therapeutic intervention focused on simple health technologies such as self-help manuals, handouts and leaflets, videos and audio-tapes coupled with advice on lifestyle changes (exercises, diet, time management). A large proportion of the interventions in the self-help clinic were based on CBT principles with an emphasis on the simpler behavioural mechanisms. The behavioural techniques were designed to alleviate symptoms of depression and anxiety by increasing the number of pleasurable activities, reducing patients’ responses to feared situations and reducing exposure to stimuli that cause depressive symptoms. Cognitive techniques were designed to reduce particular thought processes that increase depressive and anxiety symptoms, e.g. automatic negative thoughts, distortions [23]. The clinic was run by an experienced nurse behaviour therapist who sought to ‘facilitate’ use of the self-help materials, increasing patients’ feelings of confidence in using self-help as opposed to providing a specific psychotherapeutic intervention.

Section snippets

Method

The evaluation of the self-help clinic consisted of a quantitative and qualitative component. The findings of the former, which indicated that the clinic provided support with self-help material was feasible, acceptable to patients and efficient component are reported elsewhere [24]. The qualitative component, reported here was designed to illuminate peoples’ experience of the clinic and the processes underlying referral and utilisation. Semi-structured interviews were conducted with a

Patient formulation of problems

The perceived problems for which people sought help were related to a perceived inability to carry out everyday functions, accompanied by feelings of loss of control.

My father died … last year and, its sort of been building up for some time before that. I didn’t have any time off work, … several normal things happened really, just normal day-to-day events, but eventually, my daughter was mugged just outside the house and just that following week … I couldn’t go back to work. I just couldn’t

Discussion and conclusion

In this study, expectations of respondents about the self-help clinic were influenced by their own sense of vulnerability and resilience, and the loss of routine ways of managing problems and maintaining control. The data showed considerable congruence between the findings described earlier concerning the importance of self-efficacy in self-help interventions, and patients’ perceptions concerning the nature of their problems, and what they had attained through attendance at the self-help clinic

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