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A Reflective Essay on a DVD Assessment of the Practice of Mental Health

The following essay describes a critical reflection on events that arose during a DVD

assessment of a student psychological wellbeing practitioner. As part of their training

towards a PG Certificate in the Practice of Primary Mental Health, the student was asked

to carry out a clinical assessment of a patient presenting with symptoms of depression.

The entire process was filmed and graded by a member of staff who was playing the role

of the patient. Brief definitions of reflection, patient-centred interviewing and the

therapeutic alliance will be given, with the emphasis on improving the practice of mental

health.

Reflection is a positive active process that reviews, analyses and evaluates

experiences, draws on theoretical concepts and previous learning to provide an action

plan for future experiences (Kemmis, 1985 cited in Boud, Keogh & Walker, 1985). This

essay will refer to John’s reflective model (1995) as a framework for reflection, focussing

on the issues that can affect patient-centred assessment interviews.

The therapeutic alliance is the means by which a mental health professional

engages with and effects change in a patient. The clinical outcome of any psychotherapy

is significantly affected by the strength of such an alliance, (Krupnick et al., 1996).

Patient-centred interviewing accepts that a patient is an expert by experience and

uses the patients own knowledge and experience of distress to guide the assessment,

Richards & Whyte, (2008).

The lecturer was playing a patient who was depressed. Her symptoms included

low mood, trouble sleeping, drinking alcohol and smoking cannabis more than usual, and

having difficulty concentrating. The aim of the assessment interview was to gather
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information about the patient’s current problems and provide them with accurate,

evidence-based information which they could utilise to help combat these problems.

Research shows that this form of facilitated self help is successful in the treatment of

depression and anxiety, (Lovell, Bee, Richards & Kendal, 2006). Throughout the

assessment I attempted to use an interview structure that was centred around the patient.

This structure provided me with a good understanding of how the patient both perceived

and felt about the problem. According to research presented by Lovell & Richards,

(2000) this form of patient-centred interviewing promotes patient satisfaction with the

therapy. If a patient feels that the therapist fully understands their problem and how they

feel then they are more likely to collaborate with the therapist about possible treatments,

this leads to understanding and consequently the patient is more likely to improve.

I began by introducing myself and confirming the patient’s name. I tried to

appear warm and welcoming by smiling and using open body language. According to

Richards & Whyte, (2008) this approach puts the patient at ease and creates a strong

therapeutic alliance. Following the introduction I explained confidentiality and asked

them to fill in a PHQ-9 (Kroenke, Spitzer &Williams, 2001) and GAD-7 (Spitzer,

Kroenke, Williams & Lows, 2006) questionnaire. Psychometric questionnaires are used

as assessment tools designed to track the patient’s progress throughout the therapy and

ensure that the patient is improving. The patient did not seem affected by the issue of

confidentiality but sighed a lot during the psychometric measures as though they were

hard work. This is of course an assumption, however on further reflection the patient did

identify that she was having trouble concentrating therefore was likely to have struggled

with this task. I will go on to discuss this oversight later on in the essay. Once the
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questionnaires were finished I asked the patient if she could say in her own words why

she was here and to identify the main problems.

In order to achieve a firm understanding of the patient’s problem and to provide

some structure around these difficulties I attempted to use a questioning technique

referred to as “funnelling” which is advocated by Richards & Whyte (2008). I began by

asking open ended questions such as “what is the problem” and then asking increasingly

specific questions such as “how is your sleep” so that the patients account was placed at

the centre of the interview. However, the issues around being assessed and the presence

of a time limit were always at the back of my mind. I felt nervous that I would fail the

assessment or run out of time. This made my questioning style much more regimented

than it should have been. Furthermore, my worries around running out of time meant that

I did not always explore her answers to the degree that I would have done in a real

assessment. As a consequence of this, I feel it pulled away from the patient centeredness

of the interview and disrupted the therapeutic alliance. According to Dozier, Hicks,

Cornille & Peterson, (1998), the types of questions used in therapy are critical to the

quality of the therapeutic relationship. Research suggests that circular questions such as

“how is it that we find ourselves together today?” contribute more to the early therapeutic

alliance and appear to elicit feelings of freedom and acceptance within the patient.

Questions that appear more lineal and regimental on the other hand, such as “how come

you're not willing to try harder?” produce feelings of judgement and restriction. In future,

I will try to use the funnelling technique more effectively and spend more time following

up the patient’s answers in my practice.

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As part of the assessment I asked the patient about her current relationships with

family and friends, in particular how her depression was affecting her relationship with

her partner. She replied that they were happy, however at times she felt that she was

becoming overly irritable with him and that she was upset about this. I felt like I should

reassure her as her mood had significantly dropped on talking about this, her body

language appeared more sunken and her voice shaky. I reassured her that it was perfectly

normal for people to feel irritable when they are feeling stressed and low in mood, that

she was only human and not to ‘beat herself up’ over this. She smiled and seemed to open

up a bit in her body language following this. Looking back I feel that I should have

continued with this and highlighted how good it was that she was now seeking help for

her depression. However, I will continue to use this reassurance in future sessions with

my patients. Research suggests that using a normalising formwork in this way can

facilitate therapeutic work and help patients gain perspective of their symptoms (Warman

& Beck, 2003).

During the interview I asked the patient how she was feeling physically, to which

she replied that she was tired. From this, I asked about her current sleep patterns and the

quality of her sleep. She revealed that she was going to bed much later (3-4 am) and as a

result getting up later in the afternoon. I began to ask more specific questions about

things which would affect the patient’s sleep such as the amount of tea and alcohol she

was drinking. The patient replied that she drank between 6 and 7 cups of tea a day and

switched to wine in the evening. At this point I began to educate her about the influence

of caffeine and alcohol on sleep and that she should try to cut down. Unfortunately, on

telling the patient this, her body language became much more sunken and closed off as
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though she was being told off, and her answers to questions become less detailed. At the

time, I felt that I needed to educate the patient on the influences of caffeine and alcohol

so that they could make an informed decision. I also wanted to show my lecturer that I

was aware of this. However, on further reflection I can see that this was not in the best

interests of the patient. It would have been better for me to ask the patient more open

questions about the influence the alcohol and caffeine was having on their sleep, thus

letting her come to her own conclusions. This reflection is supported by research

conducted by Stewart (2000) who found that patient’s health improved when their

therapy was collaborative.

Once I had obtained a good understanding of the patient’s problem and

she had agreed with my summary, I attempted to provide her with some information on

depression and cognitive behavioural therapy. I wanted to ensure that the patient fully

understood the cycle of depression and the type of therapy that I could provide. I felt that

the best way to do this was by using William’s (2009) Five Factor Model. To begin with

the patient seemed to recognise that our cognitive, emotional, behavioural and physical

factors were linked and that by changing one we can change the rest. However, as I

continued to explain the different types of therapy I tended to use complicated

terminology such as “positive reinforcement” and “behavioural activation” which the

patient did not seem to understand. She began to put her hands on her head and her facial

expressions suggested that she was confused. According to Castro, Wilson, Wang &

Schillinger (2007) “the use of medical jargon can disrupt clinician-patient

communication
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and consequently the patient’s comprehension, recall, satisfaction and

most importantly health outcome.” I began to feel frustrated with myself for

not being able to explain the models properly and as a consequence gave her much more

written information on depression to compensate. However, to may dismay, this approach

led to a similar response from the patient. I neglected to notice that in her PHQ-9 and

GAD 7 forms she had mentioned that she was having trouble concentrating. In this

circumstance my approach was inappropriate for the patient. Once again I believe that my

nerves got the better of me and my tendency to rush meant that I missed this important

piece of information. According to Richards & Whyte (2008), I should have used

materials that matched the needs of the patient, therefore explained complicated jargon

and used specific examples such as “describe a situation where you have felt depressed?”

that would have allowed her to interact and remain focussed, as I was fully aware of this

prior to the interview, my actions were incongruent with my beliefs and I therefore feel

that I was influenced by the reality of being assessed. .

In conclusion, I feel that overall my assessment strategies went well, the patient

mentioned that they felt listened to and that I appeared to have a genuine need to help.

However, I feel I need to slow down my speech, try and be more specific when providing

information and allow the patient to come to their own conclusions regarding changes in

their life style patterns. This reflective essay has been extremely challenging but I feel it

has helped me to identify some key issues in my practice. I will certainly be more aware

of these issues in future and change my behaviour as a consequence of this.

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References

Boud, D., Keogh, R. & Walker, D. (1985) Reflection: Turning experience into learning
(pp. 139-163). London: Kogan Page.

Castro, C. M., Wilson, C., Wang, F. & Schillinger, D. (2007) Babel Babble: Physicians'
Use of Un-clarified Medical Jargon with Patients American Journal of Health
Behaviour. Vol. 31, pp. 85-95.

Dozier, R. M., Hicks, M. W., Cornille, T. & Eterson G. W.(1998) The Effect of Tomm's
Therapeutic Questioning Styles on Therapeutic Alliance: A Clinical Analogy Study
Family Proceedings Vol. 37, pp. 189-200.

John, C. (1995) Framing learning through reflection within Carper’s fundamental ways of
knowing in nursing Journal of advanced nursing Vol. 22, pp. 226-234.

Kroenke, K., Spitzer, R. & Williams, J. (2001) The PHQ-9 validity of a brief depression
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Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., Pilkonis, P.
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Lovell, K., Bee, P.E., Richards, D.A., & Kendal, S. (2006) Self-help for common mental
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Richards, D. & Whyte, M. (2008) Stepped care for common mental health problems: a
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Spitzer, R., Kroenke, K., Williams, J. & Lowe. (2006) The GAD 7 a brief measure for
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Stewart, M. (2001) Towards a global definition of patient-centred care British Medical

Journal Vol. 322, pp. 444-445.

Warman, D. M. & Beck, A. T. (2003) Cognitive behavioural therapy for schizophrenia:

An overview of treatment Cognitive and Behavioural Practice Vol.10, pp. 248-254.

Williams, C. (2009) Overcoming Depression and Low Mood: A five Areas Approach (3rd
edition) pp 23-26 Arnold: London.