How do Physicians Decide to Refer Their Patients for Psychiatric Genetic Counseling? A Qualitative Study of Physicians’ Practice

Psychiatric genetic counseling (PGC) is an emerging specialty discipline within the genetic counseling profession. A specialist PGC service was founded in 2012 in Vancouver, Canada, and though patient benefits have been demonstrated, many physicians do not regularly refer patients to the service despite awareness of its availability. We conducted a qualitative study involving semi-structured telephone interviews with Vancouver-based physicians who were aware of the PGC service to explore this phenomenon. Interviews were audio-recorded, transcribed verbatim, coded, and analysed for emergent themes. Consistent with a grounded theory approach, constant comparison was employed throughout data collection and analysis. Analyses of interviews conducted with 12 physicians revealed that referral practices were informed by perceptions about the purpose of PGC and interpretation of patient cues. Physicians perceived PGC as an information-focused intervention, and considered referral when patients explicitly expressed desire for information about recurrence risk or etiology that they felt unable to adequately address themselves. Even when physicians identified psychotherapeutic benefits of PGC, patient needs of this nature were not perceived as cues prompting referral to PGC. These data suggest that further work is necessary to position PGC in physicians’ minds as a service that could potentially benefit most individuals with psychiatric disorders and their families, and that it encompasses more than information provision. It is important to increase physicians’ awareness of the complementary role that genetic counselors can play to that of the physician in providing psychotherapeutically oriented counselling about illness etiology.     

An Interdepartmental Self-Management Lab: A Self-Help Approach to Student Development

The authors describe a self-help information and referral center for students that provides pamphlets, files, books, audiocassettes, videotapes, and computer programs on more than 100 topics related to health, personal growth, and academic skills. The center is located in a university library and is jointly sponsored by three departments.     

Mastery or mystery? Therapeutic writing: A review of the literature

Recent developments in online support and counselling suggest that the users of chat rooms, for example, or the Samaritans' e-mail 'listening' service, have already discovered the power of writing as a self-help vehicle. Developments in computer-mediated counselling and therapy are essentially text-based and client-driven. The therapeutic use of expressive and reflective writing is not widely recognised in British counselling and therapy circles. The empirical foundations for the therapeutic uses of the literary arts are, however, well established. This review aims to map the use of 'writing therapy' by drawing together cross-disciplinary research and practitioner reports which might support the place of writing as a creative therapy in its own right, whether as an adjunct to face-to-face counselling or as a self-help tool.     

A randomised controlled trial to assess the effectiveness of providing self-help information to people with symptoms of acute stress disorder following a traumatic injury

BACKGROUND: Patients attending accident and emergency (A&E) may develop long-term psychological difficulties. Psycho-education has been suggested to reduce the risk of post-injury disorders. AIMS: We tested the efficacy of providing self-help information to a high-risk sample. METHODS: A&E attenders were screened for acute stress disorder and randomised to two groups: patients (n=116) receiving a self-help booklet and those who did not (n=111). A sample of 'low' scorers was also included (n=120); they did not receive a booklet. Psychological assessments were completed at baseline (within 1 month post-injury) and 3 and 6 months post-injury. RESULTS: Post-traumatic stress disorder (PTSD), anxiety and depression decreased (p<0.001) across time but there were no group differences in these measures or quality of life. However, subjective ratings of the usefulness of the self-help booklet were very high. CONCLUSIONS: This trial failed to support the efficacy of providing self-help information, as a preventative strategy to ameliorate PTSD.     

Benefits and Changes for Family to Family Graduates

Family members of people with serious mental illnesses (SMI) need information and support to cope with the considerable stresses they experience. The Family to Family Education Program (FtF) is a structured, peer-led, 12-week information and support self-help class for such individuals. Previous research by Dixon et al. (2004) shows reduced subjective burden and increased empowerment among graduates. The present study sought to understand what processes take place during FtF participation that might lead to these benefits, as a first step in building a conceptual model of how FtF causes its effects, using semi-structured interviews with 31 FtF graduates. Qualitative data analysis suggested that new factual and emotional information from FtF shifts interviewees' understanding of their situation and that skills acquired through FtF then allow participants to incorporate these new perspectives into more adaptive behaviors. These changes led to both proximal and distal benefits for the FtF participants interviewed. The results are discussed in the context of self-help, stress-and-coping, and trauma recovery theories.     

Student mental health: how can psychiatrists better support the work of university medical centres and university counselling services?

Student psychiatric morbidity is rising. Whilst the influence of university counselling services is widely reported, NHS involvement by psychiatrists and general practitioners is not so well described. Counselling and mental health service providers for students at the University of Leeds were approached for numerical data and a university Group on Student Mental Health discussed the findings. The Student Counselling Centre, the University Medical Practice and a dedicated student psychiatric clinic have all seen a rise in referral rates. The University Medical Practice has also seen a rise in the prescribing of psychoactive medication. Collaborative links at the University of Leeds are explored and options for the future discussed. These include self-help over the internet, a research project to assess student mental health needs and the provision of a dedicated NHS psychiatric team for the university.     

Audit and family systems consultation: evaluation of practice at a child and family centre

This audit of practice at a child and family centre included a 16-month case note review covering 319 cases, a postal survey of 45 families and an interview survey of ten GPs who typically referred cases to the centre. The audit furnished information from three different perspectives on the referral process, the consultation process, and outcome for clients attending the centre. The referral rate was about one new case per day and peak referral times were the beginning of the autumn and winter school terms. Almost half the referrals came from GPs; the remainder were largely from Paediatrics, Education and Social Services. Most clients were seen within two months. Half of the families referred had serious psychosocial difficulties including multiple problem members, multi-problem children, multi-agency involvement, psycho-educational difficulties, child protection problems or child placement difficulties. The majority of cases received six hours of consultation. Families where child abuse had occurred or families containing a multi-problem adolescent received a more intensive service. Between a half and three-quarters of cases had positive outcomes as rated by staff and parents. The service was viewed by GPs to be highly satisfactory. On the negative side, many parents felt ill-prepared for the consultation process and most children did not enjoy the experience.     

Maximizing Staff Resources in Meeting the Needs of Job Seekers in One-Stop Centers

The evolution of one-stop centers is examined in terms of the limitations of existing services and the one-stop response. Levels of support are discussed in relation to the needs of job seekers and options for matching needs with staff support (self-help, brief staff-assisted, and individual case-managed services) are reviewed. This article proposes 2 models for maximizing staff resources in one-stop centers. The first model deals with determining the support necessary for job seekers to make effective use of information and assessment resources. The second model deals with specific service delivery sequences for self-help, brief staff-assisted, and individual case-managed services.     

Anatomy of a campus crisis center

This article describes the organization and implementation of a crisis calling center for college students at Southern Colorado State College. The “Help Anonymous” telephone service was established in November of 1968 to make counseling help readily available to students in distress. Volunteers staffed the service after they had completed special training supervised by professional personnel. Calls received as of May 28, 1969, totalled 380. Problem areas mentioned most frequently by callers included dating, family, college classes, loneliness, and lack of information. Help Anonymous thus far has evolved three functions: a listening service, an information service, and a referral service. In addition, the program has revealed unusual potential for a variety of future applications within the college community.     

Private work in public places: Confidentiality and role tensions in a university counselling service

This paper aims to explore issues of confidentiality relating to working with undergraduate and postgraduate students in a university counselling service. The context of a counselling service within our institute of higher education has to be understood in its relationship to academic, administrative and managerial staff, to medical and psychiatric services personnel and to the wide range of other student support and welfare services in the organization whether run by university staff or the students' union. Some reflection will be given to the need for clarity in the range of roles counsellors have to play within the different functions of the university. The client-counselling relationship cannot be seen as a dyad but as a triad or an even more complex constellation of relationships when regarded in an institutional context. The central premise is based on understanding the conscious and unconscious dynamics in the institution and how these impinge on the relationship between client and counsellor in challenging or assuming the confidentiality held by the service. Such boundary issues are identified in consultation and referral, breaking confidentiality, referral of disruptive students, calls for help and holding confidentiality. The case material drawn on to illustrate these five areas is also described in terms of anxieties raised and how these are projected, introjected and contained.

Within the service client and counsellor contract to work together. It is made clear that counselling is a professional relationship with agreed boundaries and a commitment to confidentiality. This is crucial to the working relationship and is a means of providing the client with both safety and privacy. Any limitation on the degree of confidentiality offered may reduce the usefulness of counselling. Bound by his or her professional code of ethics the counsellor will reach an agreement with the client at the outset about the extent of confidentiality they are offering, take care not to disclose information given in confidence and, when possible, be able to negotiate any change in agreement with the client.

Exceptional circumstances which may occur and give rise to the counsellor's decision to break the confidentiality formerly agreed between him or herself and the client are those which give grounds for believing the client will cause serious harm to others or themselves or have harm caused to them. Reference will be made to the role of consultant supervision in such situations and how any breaking of confidentiality can best be minimized. Attention will be given to the relevant ethical codes to which counsellors adhere and the issues of confidentiality within the legal process as well as whether the requirements of providing counselling services for students in higher education impel us, logically and practically, towards certain policies in regard to boundaries.     

Development of a Substance Abuse Consultation and Referral Service in an Academic Medical Center: Challenges, Achievements and Dissemination

Approximately 25% of US hospital beds are occupied by individuals with active substance use disorders (SUD). Acute medical hospitalization provides an opportunity to address SUDs and provide patient-centered intervention and referral for treatment. Nationally, some hospitals have developed substance abuse consultation departments to improve the care of hospitalized substance users. In this paper we describe the Addiction Psychiatry Service (APS) in a large urban hospital which provides bed-side SUD consultation, screening, intervention and referral to treatment. APS utilizes the multiple disciplines of psychology, social work and medicine to integrate substance abuse services throughout the hospital and educate future generations of medical and psychology trainees. We conclude with how the APS service is informing the development of similar programs in other academic departments within our hospital and best practice recommendations to further disseminate this service model.     

Factors contributing to the survival of self-help groups

Despite the growing utilization of self-help groups, there have been only a handful of studies that have examined the factors that contribute to their survival. The purpose of this study was to explore the factors that contribute to self-help group survival by examining their relationship with external sources (i.e., national and local self-help organizations, professionals) and group organizational characteristics (i.e., leadership diversification, recruitment, attendance at group meetings). Representatives from 245 active and 94 recently disbanded self-help groups were included in the analysis. Results indicated that the primary factors that discriminated between active and disbanded groups were the number of new people to attend a meeting, average group meeting attendance, length of existence, leadership diversification, outreach to potential group members, and support from national and local organizations. Results are discussed in terms of what national self-help organizations, self-help clearinghouses, and others who interact with self-help groups can do to empower and support them.     

Outcome predictors in guided and unguided self-help for social anxiety disorder

Internet-based self-help with therapist guidance has shown promise as an effective treatment and may increase access to evidence-based psychological treatment for social anxiety disorder (SAD). Although unguided self-help has been suggested primarily as a population-based preventive intervention, some studies indicate that patients with SAD may profit from unguided self-help. Gaining knowledge about predictors of outcome in guided and unguided self-help for SAD is important to ensure that these interventions can be offered to those who are most likely to respond. Utilizing a sample of 245 patients who received either guided or unguided self-help for SAD, the present study examined pre-treatment symptoms and program factors as predictors of treatment adherence and outcome. The results were in line with previous findings from the face-to-face treatment literature: namely, the intensity of baseline SAD symptoms, but not depressive symptoms, predicted treatment outcomes in both unguided and guided self-help groups. Outcomes were unrelated to whether a participant has generalized versus specific SAD. Furthermore, for the unguided self-help group, higher credibility ratings of the treatment program were associated with increased treatment adherence. The findings suggest that guided and unguided self-help may increase access to SAD treatment in a population that is more heterogeneous than previously assumed.     

Surveying the drug service users' perspective through self-help groups

Survey data is presented from a questionnaire designed and distributed through Victorian drug self-help groups. This survey yielded 203 returns representative of Melbourne metropolitan admissions to drug treatment services on the variables of sex and region. The survey is examined both from the perspective of its methodological potential for providing entry to this hard-to-access population and also on the basis of its findings. Questioning of this sample concerning the difficulties they had encountered when seeking help revealed that the most frequently listed difficulties were waiting periods for access to services. Respondents that had previously used particular services were asked how beneficial they had found these services: Respondents most frequently listed self-help groups, residential and methadone services as beneficial and least frequently listed medical (hospital casualty) and doctor services as beneficial. Stepwise logistical regression revealed six variables significantly predicting selfhelp treatment. Those reporting having sought self-help groups were predicted by more frequently listed problems with alcohol and ‘over the counter’ drugs, reports of having sought counselling services and more frequently reported difficulties due to a lack of information and admission restrictions when seeking services. Despite a number of methodological weaknesses identifiable in the survey, experience with this project suggested collaboration between researchers and those active in self-help networks as a useful model for future research into the drug service users perspective. Such collaboration should, however, begin at an earlier phase than occurred in the present study.     

An organizational typology for self-help groups

Conclusion Several continuing obstacles have hindered the compilation of a research-based body of literature on self-help groups. Among them are the diversity of the groups and the need for appropriate research methodology. The validated typology described above was designed to address some of these problems. It provides a means of recognizing the diversity of the groups and sorting them into broad types without stating that one is better or more productive than another. It supplies a framework for examining the organizational features of a group in order to facilitate comparison with other groups. It recognizes the potential effects of time, change, and leadership on the small local units of self-help organizations. It has implications for making research more compatible with self-help groups. The use of this typology might eliminate some of the ambiguity and conflicts currently found in the literature and thereby help people — professionals and self-helpers — to more clearly understand the nature and functioning of self-help groups.     

The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain

Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews: N = 11) and specialist chest pain nurse (focus group: N = 4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.     

A survey of mental health care provider's and managed care organization attitudes toward, familiarity with, and use of group interventions

Managed Care has had a significant impact on delivery systems for mental health services. Direct and indirect persuasion to provide more cost-effective treatments has been one consequence. The cost-saving qualities and the effectiveness of group interventions have produced clear expectations for an increased use of therapy groups. This study compared perceptions and uses of group treatments on a national sample of managed care organizations and mental health providers. Because group psychotherapy encompasses such a broad definition, five specific types of group interventions were defined: problem-focused homogenous, process-oriented heterogeneous, psycho-educational, self-help, and short-term groups. Implications of differences and similarities between directors of managed care organizations and treatment providers are examined and discussed across five response categories (familiarity/training, perceived effectiveness, likelihood of reimbursement/referral, daily use, and expectation for future use).     

A Systematic Review and Meta-Analysis on the Efficacy of Self-Help Interventions in Tinnitus

This study is a review and meta-analysis on the efficacy of cognitive-behavioural therapy (CBT) self-help interventions for tinnitus. Randomized controlled trials were identified by searching in databases (e.g. ISI Web of Knowledge, PubMed, Cochrane Library, and PSYNDEX) and by manual search. Ten studies with 1188 participants in total were included in the meta-analysis. Participants were 49.2 years old and had tinnitus for 5.2 years. Self-help interventions significantly reduced tinnitus distress (d = 0.48) and depressiveness (d = 0.25) when compared with a passive control (e.g. information only and discussion forums) at post-assessment. There was no difference to the face-to-face controls (group treatment). The presence of therapists and the methodological quality of the studies did not influence the results. Sensitivity analysis revealed that there might be a publication bias regarding the comparison to the face-to-face control. However, the results suggest that CBT self-help interventions are an effective treatment for tinnitus distress. Since few studies were identified, this conclusion must be supported by future meta-analyses.