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CHAPTER THREE. Pre-specialist opinion

Caparrotta, Luigi; Ghaffari, Kamran Karnac Books ePub

There is strong empirical evidence for the potential benefit of psychological treatments to individuals with a wide range of mental health problems (DoH, 2001), hence, psychological therapies should always be considered as an option when assessing such individuals.

The commencement of the assessment process sometimes predates the referral letter, because most patients referred to specialist local psychological therapy services will already have undergone a preliminary screening. That is to say, the referrer, whether in primary or secondary care, in making the referral is expressing the opinion that the patient may be helped psychothera-peutically This preliminary phase, involving the formation of a “pre-specialist opinion” on the part of the referrer, as opposed to a “specialist assessment” conducted by psychological therapy specialists, is an important but little studied component of an overall assessment for psychological therapies. The referrer, in formulating an opinion, may already be asking any, or all, of the questions posed below.

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CHAPTER NINE. Concluding remarks

Caparrotta, Luigi; Ghaffari, Kamran Karnac Books ePub

The aim of this work is to highlight the role of assessment within psychological therapies with a special reference to the psychodynamic approach.

We have explored how the various nuances of the first encounter may shape attitudes and expectations in both the patient and the assessor/doctor. This initial encounter is a joint enterprise where unrealistic expectations are challenged and concerns are empathically listened to and addressed with sensitivity without undermining the patient’s capacity to make decisions. Mutual thinking about the difficulties, reaching an understanding, and imparting information allows the patient to reflect and make appropriate choices.

We have attempted to examine the subtle interaction between two “strangers” by paying attention to verbal and non-verbal communication cues. With the help of clinical vignettes we examined in detail how the patient’s presentation and narrative may assist the assessor gradually to arrive at a provisional diagnosis and a psychodynamic formulation.

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CHAPTER EIGHT. Post-assessment routes

Caparrotta, Luigi; Ghaffari, Kamran Karnac Books ePub

In the previous chapters we concentrated on the referral process and the various stages of assessment that led to a comprehensive psychodynamic formulation. The formulation helps to sketch an articulated picture of the unique world of the patient and guides the patient and the assessor to a mutual, appropriate, and agreed plan of action.

In certain circumstances, however, the assessment might provide helpful and important insight into issues that the patient may be able to deal with without further need for psychotherapy. Recommendations for no psychological treatment are just as important as recommendations for treatment.

What treatment modality, where and by whom can the patient best be helped?

Post-assessment options

The assessor, in his/her formulation, needs to reach a decision regarding the most suitable form of management. A number of patients may not benefit from a psychological intervention not just because of their lack of motivation and unwillingness to commit to a working relationship, but also because of florid psychotic episodes, continuous substance-related disorders, and organic mental conditions. The assessor should then discuss and explain the reasons why psychological therapy is not appropriate. He/she should also discuss alternatives that might be more appropriate and helpful. These may include, for example, referral to a psychiatrist, day hospital, CMHTs, specialist services.

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CHAPTER FIVE. Suitability for psychological therapy

Caparrotta, Luigi; Ghaffari, Kamran Karnac Books ePub

In this chapter we will continue with our structured plan by exploring, thinking, developing, and testing hypotheses with the patient, in order to arrive at an answer to a question raised in the previous chapter.

Is psychological intervention a suitable form of treatment for this particular patient?

Appropriate selection of patients for psychological therapy and, in particular, for psychodynamic psychotherapy, is essential. Poor selection may have deleterious effects on patients, and can also lead to a considerable waste of limited resources. Truant (1998) states that on average some 25% of patients will drop out of therapy prematurely, and about 50% of these do so within the first four weeks.

Two well-known generic suitability factors, which in our opinion underpin any form of talking therapy, will now be considered. These are:

(i) motivation to change;

(ii) capacity to form a working (therapeutic) relationship.

It is important to carry out a detailed and careful assessment of these two factors. Our own clinical experience confirms the general view that lack of motivation and poor therapeutic relationship probably account for the vast majority of drop-out cases.

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CHAPTER TWO. The referral process

Caparrotta, Luigi; Ghaffari, Kamran Karnac Books ePub

Pre-referral stage

We consider it pertinent to highlight this “pre-referral stage”, for we believe that it may have an impact on the patient’s decision regarding whether or not to attend a psychotherapy consultation.

The referral process evolves from the interaction between patient and referrer. The decision to initiate the referral process may be taken by the referrer, the patient, or both. Experienced referrers tend to discuss the process and merits of “talking therapy” with the patient, which may help them to reach a decision. On the other hand, referrers with a very limited knowledge of psychotherapy may set the process in motion by prescribing “psychotherapy”, without giving an adequate explanation of the reasons for this decision or of the benefits the patient may derive from such an intervention. Increasingly, patients tend to request a psychotherapy referral.

Having mutually decided that “talking therapy” would be helpful, the referrer needs to choose the most appropriate setting; e.g. in-house counselling, specialist hospital based services, private referral. For example, in the Primary Care setting, the majority of cases in which problems are mild and stress-related could be dealt with by the in-house counsellor, particularly if the patient prefers not to be referred to a hospital-based specialist service. However, the ability to make such a decision is determined by the availability of properly trained and supervised counsellors within the practice.

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