LITMIR.BIZ

Скачать книгу

will be an electronic patient record of each session.

       Outcome measures may become part of an anonymised national database.

       You will regularly discuss patient progress with your supervisor.

       With patient consent, explain that clinical recordings of sessions will be used to inform supervision, giving details about how they will be used.

       Indicate the conditions under which confidentiality will be broken in respect of risk to self or others.

      When risk is addressed, it is important that the practitioner is open and transparent with the patient, specifying the conditions under which risk concerns would be disclosed to others.

      Clinical Example

      Breaking Confidentiality

      I will only break confidentiality if there are concerns about immediate or serious risk to, or from others, or to yourself. I would talk to you before taking action so we can come up with a plan of how best to do it. But it is important that you know that there are times when I would be legally bound to break confidentiality.

      Having completed introductions, orientating the patient to the session and explaining confidentiality, provide the patient with the opportunity to ask questions and say if they would like to add anything to the agenda for the session.

      Information-Gathering: General Presentation

      To establish relevant information about the presenting problem, a patient-centred interviewing style is recommended (Richards and Whyte, 2011).

      Key Point

      Features of a patient-centred approach:

       Treating the patient with dignity and respect

       Acknowledging them as experts by experience

       Being informed by the evidence base and using collaborative decision-making to decide the most acceptable intervention for the presenting problem (Chapter 4).

      Triggers

      It is important to identify triggers to specific events associated with the presenting problem in the here and now (Chapter 1). For example, ‘What sorts of things trigger the panic attacks you are experiencing on a daily basis?'; ‘Have you noticed anything that is more likely to lead to a bad night's sleep?'; ‘Have you noticed any triggers to your low mood?'.

      Onset and Progress

      A general understanding regarding events or impacts that may have contributed to the problem in the here and now should be obtained. The presenting problem may have started suddenly (e.g. the end of a significant relationship, redundancy, a panic attack when stuck on a ride) or had a gradual onset (e.g. becoming progressively anxious and worried about things). The progress of the problem may indicate that it has remained the same since it started. The patient may have had periods when the problem was significantly better or worse, or it may have been getting gradually worse over time. It is important to ensure that questioning around onset and progress is used to understand the context associated with the presenting problem only. This is different to finding out what factors may have initially contributed to the onset of the problem that forms part of the assessment to derive a longitudinal cognitive-behavioural formulation undertaken within HICBT (Chapter 1).

      Medication

      Given the impact medications may have on successful engagement with LICBT interventions, or potential difficulties that may require monitoring, such as those related to risk or withdrawal effects, it is important that the assessment explores medication use for mental and physical health difficulties (Chapter 10).

      Clinical Example

      Questions Exploring Medication Use

       What medications are being taken?

       What are medications taken for?

       Are medications being taken as prescribed?If not, explore attitudes towards medication taking.

       How long have medications been taken for?

       Have any side-effects been experienced?If evident, explore impact.Has the GP been informed?

       What are the potential benefits of the medication?

      If medication is not being taken as prescribed, or side-effects are being experienced and/or difficulties taking them are expressed, the LICBT practitioner should funnel to enquire about the patient's attitude towards medication taking. On these occasions the patient should be encouraged to raise any issues with their GP or other person involved in their care and followed up (Chapter 10).

      Impact

      The practitioner should try to establish the wider impact of the problem on the patient's life using open questions towards the top of the funnel such as ‘How does the problem impact your life?’ and then move down the funnel to gain more specific information – ‘You say it impacts your sleep. Tell me a bit more about how it does that'. The practitioner should be aware of any impact that has potentially significant consequences if not addressed. If any are identified the patient should be supported to address these. At times this may involve signposting or liaising with other health and social care, charitable or community organisations (Chapter 1). Failure to resolve any impact with potential consequences may serve to maintain the presenting problem and impair treatment (NCCMH, 2018).

      Modifying and Maintaining Factors

      Factors that make the presenting problem better or worse should be explored. At times these may be desirable and inform subsequent treatment, for example a patient with low mood experiencing relief when they have been walking through the park. Not all factors giving temporary relief to a problem are helpful, however, and many play a role in maintaining the problem – for instance, a patient reporting their anxiety as significantly lower if they only walk the dogs during the evening (avoidance) or carrying a bottle of water in case they feel faint (safety behaviour).

      Employment Status

      People with mental or physical health difficulties experience higher risks of unemployment, absenteeism and lower levels of productivity at work (NICE, 2009a). Being in a ‘good’ job can help maintain or facilitate recovery from mental or physical illness (Modini et al., 2016) – for example, providing opportunities to establish life-routines (Chapter 11), achieve a sense of self-worth or value and income. Questions to address current employment status and attitudes to work may therefore help identify if supporting employment opportunities may be helpful alongside LICBT interventions to further facilitate recovery from mental health difficulties and enhance mental wellbeing. Within the IAPT programme this approach is enhanced through the Psychological Wellbeing Practitioner working collaboratively with an employment advisor (NCCMH, 2018).

      Previous Treatments

      It is useful to know whether the patient has received previous treatments for the same or similar problems and whether they found particular treatments helpful in any way or they had a negative experience. This can be particularly helpful in recognising any previous challenges the patient may have experienced with LICBT interventions. This may help to inform potential adaptations that could be made (Chapters 18 and 19) or choice of other evidence-based psychological therapies.

      Other Current Treatments

      The patient may be seeing another mental health professional or a complementary therapy practitioner who is providing homeopathic remedies or interventions. It is useful to find

Скачать книгу