Counselling in Primary Care

The British Association of Counselling and Psychotherapy's definition of counselling: The skilled use of the relationship (between the counsellor and patient) to help the patient develop self-knowledge, self-esteem and the ability to take control of his or her own life.¹

Several small studies have indicated that a primary care based counselling service can address the needs of a substantial group of patients for whom psychiatric care is inappropriate.² However, counselling in primary care remains controversial and other studies have found counselling is no more clinically effective (but also no more expensive) than GP care over a nine month period.³

Counselling may be concerned with addressing and resolving specific problems, making decisions, coping with crises, working through conflict, or improving relationships with others.⁴

The work of most counsellors in primary care is generalist and is not necessarily linked to any diagnostic categories. In generic counselling, a broad range of techniques is used to help the patient. In specific counselling, a specific model such as psychodynamic counselling or bereavement counselling is used.⁴

• Counselling is often recommended for a wide range of common mental health problems, including crisis intervention, mild to moderate depression, anxiety and panic disorder, relationship problems, post-traumatic stress disorder and obsessive-compulsive disorder.⁵
• It might also have a role in treating some psychosomatic conditions and some aspects of physical illness which can be difficult to treat, such as chronic pain, chronic fatigue, gastrointestinal disorders such as irritable bowel, and some gynaecological syndromes such as premenstrual syndrome and chronic pelvic pain.
• Counselling can also play an important role in health promotion for some patients, including smoking cessation and also coming to terms with chronic or terminal disease.

Counsellors focus on client choices in their life circumstances as a basis for their work. Counselling can involve a variety of different methods and techniques, including psychodynamic counselling and cognitive behavioural counselling. However, most are influenced by humanistic, process-experiential and psychodynamic principles. Examples of therapeutic approaches include4:

• Non-directive counselling:
  • Encourages the patient to share his or her problems with the counsellor.
  • Through listening, the counsellor affirms the patient's worth and allows him or her to take the time to express his or her thoughts.
• Problem-solving therapy:
  • Systematically teaches generic skills in active problem-solving, helping individuals to clarify and formulate their life difficulties and apply principles of problem solving to reduce stress and enhance self-efficacy.
• Cognitive techniques (such as challenging negative automatic thoughts) and behavioural techniques (such as activity scheduling and behavioural experiments):
  • Are used to relieve symptoms by changing maladaptive thoughts and beliefs.
• Behavioural therapy:
  • Seeks to solve problems and relieve symptoms by changing behaviour and the environmental factors which control behaviour.
  • Graded exposure to feared situations is one of the commonest behavioural treatment methods and is used in a range of anxiety disorders.
• Cognitive behavioural therapy:
  • Is a combination of the two techniques of cognitive and behavioural therapy.
  • It looks at how a person's self-perception can influence his or her behaviour.
  • It addresses some of the underlying issues and how these can give rise to destructive or damaging behaviour.
  • Can be useful in treating depression, anxiety and substance abuse.
• Interpersonal therapy:
  • Structured, supportive therapy linking recent interpersonal events to mood or other problems, paying systematic attention to current personal relationships, life transitions, role conflicts and losses.
• Psychodynamic counselling:
  • Based on the view that past and unresolved conflicts and events result in current emotional distress, a variety of methods are used to help the client make sense of repressed or forgotten experiences and help make sense of them, allowing the client to move forward and resolve the conflict or troubling behaviour.

• Current evidence suggests that counselling can be useful in the treatment of mild to moderate mental health problems in the short-term (up to 6 months).⁶
• Counselling is associated with modest improvement in short-term outcome compared to usual care, but provides no additional advantages in the long-term. Patients are satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs.^7,8
• Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly.⁹ There is insufficient evidence to recommend that generic counselling should be used alone in the treatment of patients with major depression.¹⁰
• There is limited evidence to suggest that the total costs incurred when patients are treated by counsellors are similar to patients receiving usual GP care.¹¹