The clinical psychologist in primary care

Soc. Sci. & Med.. Vol. 13A, pp. 707 to 713 Pergamon Press Ltd 1979. Printed in Great Britain

THE CLINICAL P S Y C H O L O G I S T IN PRIMARY CARE D, F. CLARK Consultant Clinical Psychologist, Ladysbridge Hospital, Banff, Scotland Abstract--This paper presents some aspects of the potential contribution of clinical psychologists to the work of general practitioners and reviews the recent reporting on this. It further surveys 42 consecutive referrals to a clinical psychologist by a number of general practitioners in the North of Scotland which are thought to be representative of a general trend throughout the UK as a whole, both in terms of the nature of the referrals and of the clinical psychological services given in response to these. The lack of overlap of these services with others, such as psychiatric, paediatric, and educational psychological is noted. The interaction between primary care and clinical psychological services here reported is one which has implications for other social agencies like social work and community health services, and is perhaps setting a pattern for longer term developments nationally. Some of the implications of such a development are discussed.

INTRODUCTION

As clinical psychology has developed from a preoccupation with psychometrics and has more and more developed behavioural analysis and techniques of treatment a n d rehabilitation, so also an increasing number of clinical psychologists have found themselves operating not only in psychiatric hospitals, but also in district general hospitals and other units where they will collaborate with medical specialties other than psychiatric. For example, a brief scrutiny of journals such as the Journal of Psychosomatic Research or of Psychosomatic Medicine will clearly show the relevance of psychological techniques and researches to the advice, care, treatment and rehabilita[ion given to individuals with surgical and post traumatic damage, to cardiovascular cripples, disturbed young mothers with intransigent babies and children, and increasingly to the elderly and the psycho-geriatric. It is hardly surprising therefore, that in recent years a number of general practitioners have become increasingly aware of the potential contribution of clinical psychology to their day to day work. Researchers quoted in a recent paper [1] indicate that it is widely accepted that in any year between 10 and 15~o of the population will consult their general practitioner with a complaint which is largely or entirely psychological in nature [2, 3]. For any given practice the psychiatric consultation rate depends on the.predilections and working style of the doctor in question [4], on the characteristics of the patients in the practice (women presenting twice as frequently as men) [2] and on other environmental features [5]. A recent paper has reported on a typical year's work of a clinical psychologist in a Health Centre [6]. In the same way, the possible contributions of the clinical psychologist to other areas of medical endeavour have been well illustrated by Rachman & Philips in an easily read but relevant volume [7]. Some of the issues which are dealt with there include the response of patients to doctors' orders, the problems of pain experience, a psychological approach to headaches, sleep disorders, psychological impact of admission to 707

hospital, the role of placebo medication, the self control of bodily functions and similar topical issues. For a number of years now, many clinical psychologists by dint of their work with psychiatric patients and the mentally handicapped, have been very well aware of how many of their techniques of assessment, treatment, training and rehabilitation could be applied in the primary care context. Those who have opportunities to test their expertise in this setting are rapidly finding that their contribution is increasingly being sought mostly in areas where the general practitioner is presented with problems which are on the borderline of normality, of psychiatry, of marital counselling or of general experimental psychology. Surprisingly seldom is there any question of problems being referred which more properly ought to go to the paediatrician, the psychiatrist or the neurologist. This bears witness as much to the high standards of general practitioner education in the area in question as to the fact that there is a section of the general practitioners' clientele which has particular needs outside these specialties. As Kat [8] has indicated, collaboration between clinical psychologists and general practitioners has moved rapidly from discussions about what might be done to early reports on what is being done and, of course, the report of the Trethowan Committee recognises the potential of primary health care as a specialism for psychologists in an Area Department. Kat's main concern in his paper is that clinical psychologists working in primary health care will be collaborating with and interacting with a variety of other professions and personnel and that their involvement in this functioning team will vary with the task they are undertaking and the expectations of their co-professionals as well as the illness behaviour of the population served. Broadhurst [9] has recently attempted to assess how much work is, in fact, being done "by clinical psychologists in the NHS for, or in collaboration with, general practiti0n~rs. She concluded that while much of this work may be patchy and sporadic, probably one in" seven clinical psychologists in the U K

708

D.F. CLARK

are involved in it. Although this particular paper may reflect what is happening in the largely rural Scottish scene, its detailed contents when matched against the very few available reports on similar work elsewhere in the U K show that, in spite of expectation, the content and nature of the work is of more general applicability. For example, two papers report similar types of referral, procedure and outcome for an urban Scottish environment and for a mixed urban and rural English environment [6, 8]. Broadhurst [9] further reports that the enthusiasm, both of general practitioners and clinical psychologists who have collaborated in this way, is high and that it seems likely that there will be more intensive involvement in primary care problems as time goes by. Such involvement has, of course, been adumbrated by the Trethowan Report on the Role of Clinical Psychologists in the National Health Service [113] and it seems highly likely therefore that in spite of the paucity of reports of this kind in the literature so far, more detailed and extensive studies will emerge very soon. It is important to note that a good deal of the work undertaken by clinical psychologists in this context consists not only of individual casework, but also of training general practitioners in the principles of psychological management. So far the research roles so commonly assumed by clinical psychologists in the specialist hospitals have not been given full rein, but have taken second place to psychological skills and techniques in patient treatment and management. There was no doubt from Broadhurst's survey that over 90% of all the psychologist respondents in her survey were keen to see psychologists have a permanent and continuing attachment to health centres. The general scene then in the U K is probably fairly well reflected by the information reported in this paper. Other recent studies have also looked at the kind of primary care activities in which clinical psychologists might engage, and at the proportion of cases that GPs come across that might involve clinical psychologists [11, 12]. So far as the latter is concerned, the GPs themselves came to the conclusion that psychological problems were highly relevant in 11% of cases, qmte relevant in 7% and slightly relevant in 19%; the equivalent percentage assessments by the psychologists themselves sitting in with GPs in four general practices were 8, 4 and 28%. In the study by Davidson [11] around half the respondents, consisting of 76 Croydon general practitioners, felt that there was a need for clinical psychologists to carry out ability and other assessments but a rather higher percentage of GPs sought treatment /rod counselling facilities, with sexual and marital problems accounting for three-quarters of the treatment load and more than half consisting of such miscellaneous problems as phobic disorders, addictive problems, obesity, obsessional difficulties, relaxation training, family therapy, training in social skills and so on. Rather over half the respondents felt they could benefit from additional teaching in clinical psychology and the behavioural sciences. There seems little doubt from both of these surveys that general practitioners who have had experience of direct access to clinical psychological services as distinct from psychiatric services, find them highly relevant to their day to day work and that patients too can be significantly helped when

facilities are available. None of the work reported so far suggests that these services are in any way intruding upon or adversely affecting present working relationships and services given by psychiatrists. In the experience of the writer, there is surprisingly seldom any question of problems being referred which more properly ought to go to the paediatrician, the psychiatrist or the neurologist, nor has any such difficulty been indicated in the published literature. It would indeed be the primary professional concern of a clinical psychologist working in such a context to ensure that relevant onward referrals or referrals back to the general practitioners of cases which were outside his professional competence, occurred promptly. Over the past year or so the writer has accumulated some experience of general practitioner referrals in a context rather different from those reported from Birmingham, Croydon, Livingstone New Town and so forth. Since there is as yet, and in spite of the fact that clinical psychologists the length and breadth of the U K are more and more working directly with general practitioners, a dearth of reported information about the nature and results of such work, this paper is presented as a further indication of what general trends are apparent in the work. Many general practitioners will as yet have no direct access to Area Departments of Clinical Psychology and therefore they may need further information about the scope and characteristics of clinical psychological work. For this reason, the following cases are reported and a few implications of these referrals are examined. Clearly, no selective principle other than the awareness of the nature of the case on the part of each referring general practitioner has operated. The writer simply reports data on 42 consecutive referrals to his Department by a number of local general practitioners. In other words, the paper reports 42 consecutive patient problems which the referring general practitioners saw as being relevant to the skills and competence of a clinical psychologist as distinct from a psychiatrist or other medical specialist. No attempt has been made to assess the outcome of cases advised or treated with the outcome of similar but untreated cases. Such a procedure, would, of course, have involved major ethical considerations which at this early stage of the art did not seem justified. The paper is therefore designed merely to give some impressions to psychiatrists, clinical psychologists and general practitioners of the sort of referrals that might be appropriate and some idea of the minimum caseload which.might be expected from a rural catchment area involving approximately eleven different general practices and a rather larger number of practitioners. It seems not unlikely that social workers might also be interested both to be aware of the facility which clinical psychologists offer and of the problems which might be tackled. SUBJECTS

Table 1 shows the reason for referral of 42 consecutive patients to the Department of Clinical Psychology by sex. Because of the low cell values it is clearly not appropriate to calculate X2 in this table. Nevertheless. it is apparent, unlike previous data reported [21, that there seems to be no difference

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Table 3. Study of GP referrals to clinical psychologist. Sex by times seen Times seen

.1

2

3

4

5

6

9

Total

Female Male

7 10

3 7

3 0

2 1

1 1

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Total

17

10

3

3

2

3

4

42

between the number of males and females referred. Probably the cells most worthy of comment are those indicating the very strong preponderance of female subjects who have phobic or anxiety states. Indeed this has been confirmed by subsequent referrals since the data reported here were collected. Table 2 breaks down all subjects by age and reason for referral. Perhaps one of the more surprising results here is the number of older patients who were submitted as assessment problems as is also the fact that no less than 15 subjects were of school age in an area where, although markedly overworked, there is a good educational psychologist service. These were all cases where the problem was taken by the parents of the child to the general practitioner for advice and guidance because there was disturbed behaviour in the home. Some of the parents seem to find it difficult to relate their understanding of this to the functions of an educational psychologist, especially if there was no parallel disturbed behaviour in the school. The second point of interest in this table is that eight of the nine assessment problems were mature adults. These cases often involved issues related to physical illness or suspected early dementia or necessitated intellectual assessment following cardiov~tscular accident. In a few cases, there was the question of possible deterioration of a somewhat unusual personality into psychosis and in one case there was a need for specific assessment of the depth of depression in a man who was progressively going blind. It is interesting to note that eventually a n onward referral to a psychiatrist was suggested in five (11.9~o) cases. One of the most important, features indicated by Table 2 is that the breakdown of problems presented by these referrals indicates relatively little overlap either with general medicine or with psychiatry. So far as children were concerned, there is obviously a much greater overlap with teaching and educational psychology and it is of the greatest value that good liaison currently exists in the Grampian Region between educational and clinical psychologists, both academically and professionally. Many of the difficulties at home and school, most of the marital and sexual difficulties and the one case of vocational guidance, all involve behaviour patterns which could not

be described as demonstrating any particular psychiatric syndrome so much as failure of appropriate learning of social skills, or of inter- and intra-personal conflicts representing a disturbance of normal functioning somewhere below the level of disorder which would clearly necessitate psychiatric intervention. The cost effectiveness of clinical psychological intervention in these cases appears to be relatively good. Table 3 shows that although there might be a slight trend for female patients to require a larger number of sessions, nevertheless, 64.370 of cases were dealt with in either one or two sessions and the vast majority of sessions lasted between 30 and 60 minutes. Those cases requiring six or more sessions were all subjects involved in behaviour modification schemes where extensive hierarchies of conditioned stimuli had to be worked through, usually in desensitization-type programmes. OUTCOME OF REFERRALS Table 4 classifies the results rather coarsely and separates out those subjects where only assessment was required. The measurement of improvement as reported in Table 4 is, of course, notoriously complex but was carried out on the basis of two important assumptions. First, that it would be improvement reported' both by the clinical psychologist with his view of the client and by the client himself/herself. Where both agreed that the patient was free of symptoms and personal difficulty, they were classified as having greatly improved but where one did not agree with tile other about the extent of improvement, they were classified as slightly improved. The same applied to the no improvement category. The second important assumption was that there were no parallel treatments, e.g. pharmacotherapy, occurring simultaneously with the psychologist's treatment other than those which had been initiated some considerable time before referral and were simply being maintained, often for reasons irrelevant to the difficulties being tackled. All patients reported as greatly improved were considered by themselves and by the clinical psychologist as symptom-free at the end of treatment or to have entirely resolved the particular problem they came with. Those reported as having slightly improved were those who now found the problem to be less acute and could live with it or alternatively had a reduction in symptoms which allowed them to return to work or to normal living, although not entirely symptom-free. It might well be suggested that greater attention should have been paid to those subjects who were given advice only, but that was complicated by the fact that in some instances other treatment agencies

Table 4. Study of GP referrals to clinical psychologist. Sex by result

Female Male Total

Great improvement

Slight improvement

8 4

5 4

12 28.6

9 21.4

No improvement

Assess only

Total

0 3

8 10

21 21

3 7.1

18 42.9

42 100.0

711

The clinical psychologist in primary care were invoked and it might be unfair to assess the value of the initial advice on the basis of the subsequent treatment. Nevertheless, it is clear that substantial improvement over 28~ of the referrals, and significant, although slight, improvement in a further 21~ (discounting "assessment only" cases) leaves only 7.1~ of the subjects who failed to respond favourably to the advice or treatment supplied. This was not always because the latter was totally ineffective, but in two cases because the subjects failed to return to continue treatment. No sex difference in response to treatment could be demonstrated in this small group. In the absence of a control group it is, of course, not possible to say whether many of these patients would have spontaneously remitted in symptomato'logy, but most had problems which were fairly longstanding and since there was no parallel treatment occurring at the time when they were seeing the clinical psychologist, other than as reported above (in some cases longstanding pharmacotherapy sometimes for other disorders) it is not unreasonable to assume that the relatively prompt improvement which occurred in most cases was related to the treatment/ advice given. So far as the content of treatment and counselling is concerned, Table 5 shows the action taken and shows that advice to the patient, the patient's parent and/or GP was given in fairly specific terms in just over 21~o of cases. This advice was, in the vast majority of instances, advice which went far beyond common sense guidance of the kind that subjects could have got from other informed agents such as their general practitioner, their lawyer, minister or friend, and in all instances involved detailed and specific psychological knowledge. For example, some subjects with identity difficulties or difficulties in grasping what were their fundamental attitudes were guided following the administration of role construct Repertory Grid techniques which enabled them to revaluate fundamental but not always consciously realised ways of looking at people and events which in turn led to advice being given to them on how to handle particular life situations. Obviously, in vocational guidance, advice could be given following detailed testing of intelligence, aptitudes and attitudes as well as relating this to past life history and present circumstances. An equal percentage of subjects responded to behaviour therapy, and a further 28~o were subjected to a combination of techniques. Trends in recent referrals suggest that there are increasing numbers of cases coming for marital/sexual guidance and counselling and specific techniques of marital therapy with couples are likely to be in increasing demand. For example, couples coming with a report of general marital disharmony coming near to paranoia in the case of one husband, were treated using a diversity of techniques from the "squeeze" technique to avoid ejaculaLio praecox to social skills training in which couples were advised how to maintain mutually interesting conversations, even how to sit with each other and in some instances how to deal with upsets on the part of their children. It also became, apparent as the work continued that there is an increasing need for behaviour regimes to be initiated which subjects can carry out on their own at home with adjuvant apparatus such as the bell and pad apparatus for

enuresis, or miniaturised bio-feedback apparatus or the help of family or friends. All of these techniques are likely to be economic in terms of professional time and there is little evidence that they are the less effective for being carried out outside the clinic room or office. Analysis of the source of referrals shows that they were referred from wide-ranging areas within the catchment area of the Department. Naturally, the majority came from a local general practice which is already heavily involved in the work of the hospital and from another general practitioner in a neighbouring town who has a particular interest in such cases. Nevertheless, 13 other cases were referred from 11 different centres within a 35 mile radius of the hospi* tal base of the Psychology Department. It is apparent that the referrals are partly a function of the awareness of certain general practitioners of particular capabilities of clinical psychologists as distinct from psychiatrists, and an awareness which has spread through personal contacts and word of mouth amongst practitioner colleagues. This emerges not only in the referral letters from the general practitioners but also in subsequent personal and telephonic conversations in which referring GPs show themselves to be relatively well-read, in both general psychiatry and psychology and in some instances to have published in these areas themselves. There has been no attempt on the part of the Department of Clinical Psychology to proselytize since its primary concern is with hospital services in mental deficiency in North East Scotland and it is therefore geared to undertaking only a small proportion of work within the primary care setting. Pressure of referrals continues, however, and clinical psychologist colleagues in a nearby urban setting report similar pressures. Perhaps if all referrals now being placed were to be taken on, there might be some increase in the variability of content of these referrals but at the moment it is fairly clear that both in urban and rural settings the kinds of cases referred do not differ greatly either between this area and other areas in the UK so far reported or between this area and urban areas. CONCLUSION As Broadhurst's paper indicated [9], a large number of clinical psychologists in the U K are now working in direct contact with general practitioners, either from a hospital out-patient clinic or health centre base. Very few have, however, reported the content of this work other than those quoted earlier in this paper. From the evidence of these and the present writer, however, there can be no doubt that this has made it increasingly clear that general practitioners both want and appreciate clinical psychological advice which is patently in a different category from psychiatric, educational psychological or paediatric interests, although there is evidence both of some overlap between these areas and confusion about which is the better agency to approach. In general the techniques available to clinical psychologists are fairly cost effective and can be brought to bear with minimum delay and in most instances, without what some people will see as the stigma attaching to a referral to a psychiatric out-patient clinic.

712

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The clinical psychologist in primary care Possibly because of the high level of general practitioner medical education in this area, there have been relatively few, if any, cases which have been improperly referred and where the receiving clinical psychologist has had to refer immediately to psychiatric, paediatric or general medicine. It transpired in fact that just over 1 in 10 patients had to be referred onward to other specialisms. Moreover, the analysis of reasons for referral in this study coheres fairly well with the expected kind of referrals that general practitioners in Davidson's study indicated [11]. On the whole, the referring general practitioners in this study got it right, in that they asked the clinical psychologist to see patients who were generally demonstrating exacerbations of problems on the borderline of norreality related to developmental growth, personal relationships, cognitive perceptual psychological problems and work or daily living difficulties, which were not attributable directly to flagrant psychosis or organic disorder. These are indeed the cases where the psychologist with his special knowledge of the developmental psychology of children, adolescents and adults, of mental measurement and assessment, of belaaviour modification techniques, vocational guidance and family, sexual and marital disturbance, is best fitted to help. What this study does not indicate is the additional number of cases where communication between the general practitioner and clinical psychologist has resulted in the latter's advising the former of techniques that the G P may use either in assessment or treatment, to carry out psychologically based work on his own or with the collaboration of the clinical psychologist, patients' relatives, social worker or nurse. There is considerable scope for expansion of this function along with the more deliberate expansion of clinical psychological services into health centre buildings so that, for example, an office or consulting r o o m would be available to them on a regular basis. At another level, policy within National Health Service Areas needs to be looked at so that clinical psychologist establishments are sufficient to cope with this growing further demand for services, The question of staffing such services from an Area Psychology Service will be best resolved when Boards have had time to assimilate the details of the Trethowan Report and the various professions to react to it [10]. From the clinical psychologist's point of view, many of these cases were particularly interesting and gratifying to deal with because of the high probability of success and the fact that processes of disturbance had in many cases not become chronic. One interesting feature about the nature of professionalism was pointed up by the process of helping these clients. In those cases where advice was given to parents and childl or spouse and patient, it was often a source of considerable satisfaction to use professional knowl-

S.S.M. 13/6A

I

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edge not only to effect techniques of treatment and care as in hypnotic relaxation induction or the measurement of aptitudes and interests, but also to deploy accumulated academic knowledge of certain psychological processes and developments to people to extend their knowledge of themselves and others. This educative role is one which is in the spirit of the times and which because it can be used constructively and can be purveyed to a wider audience, lays an obligation on the professional to be critical and yet up to date in his awareness of psychological knowledge in general. The GPs involved have also shown, in discussion of cases and by their continuing interest and referrals, that the facility is worth developing both for the benefit of patients and by way of extending and enriching the education of practitioner and clinical psychologist alike. Acknowledgements--The writer is greatly indebted to the many general practitioners in the area for their continuing interest in the theory and practice of psychology as applied in the primary care setting. REFERENCES

i. Corser C. M. and Philip A. E. Emotional disturbance in newly registered general practice patients. Br. d. Psychiat. 132, 172-176, 1978. 2. Shepherd M.0 Cooper B.~ Brown A. C. and Kalton G. Psychiatric Illness in General Practice. OUP, London, 1966. 3. Bain D. J. G. & Philip A. E. Going to the doctor-attendances by members of 100 families in their first year in a new town. dl R. Coll. Gen. Pract. 25, 821-827, 1975. 4. Walton H. J. Differences between physically-minded and psychologically-minded medical practitioners. Br. J. Psychiat. 112, 1097-1102, 1966. 5. Philip A. E. Urban environments and mental health. In Environmental Quality (Edited by Coppock J. T. and Wilson C. B.). Scottish Academic Press, Edinburgh, 1974. 6. McAllister E. A. and Philip A. E. The clinical psychologist in a health centre: one year's work. Br. Med. J. 4, 513-514, 1975. 7. Rachman S. J. and Philips C. Psychology and Medicine. Temple Smith, London, 1975. 8. Kat B. Primary Health Care: on finding one's place in the team. Bull. Br. Psychol. Soc. 31, 154-156, 1978. 9. Broadhurst A. What part does General Practice play in community clinical psychology? Bull. Br. Psychol. Soc. 30, 305-309, 1977. 10. D.HIS.S. The Role of Psychologists in the Health Services. H,M.S.O., 1977. 11. Davidson A. F. Clinical psychology in general practice: a preliminary enquiry. Bull. Br. Psychol. Soc. 30, 337-338, 1977. 12. McPherson 1. G. and Feldman M. P. A preliminary investigation of the role of the clinical psychologist in the primary care setting. Bull. Br. Psychol. Soc. 30, 342-346, 1977,