5.2Meeting Patients – Basic Psycho-Medical Care

Crijnen, AAM, & Kraan, HF (1982). Meeting Patients & Providing Basic Psycho-Medical Care. In AAM Crijnen & HF Kraan (Eds.), Theoretical Guide Psycho-Medical Education (pp. 1–39). Maastricht University Press, Maastricht, the Netherlands.

Meeting patients

Basic Psycho-Medical Care is the physician’s answer to the patient’s request for help with Mental Health Problems. When the patient decides to call in expert help for their complaints, a lot has already happened to them which determines the kind of help the patient is looking for.

Basic Psycho-Medical Care is the framework of the problem-solving process used by physicians when meeting a patient with Mental Health Problems

In the first part of this guide:

• We examine how the patient presents their problems to a care provider – in particular to the General Practitioner;
• We provide information about the occurrence of Mental Health Problems:
  • In the general population,
  • In the practice of the general practitioner,
  • And the Mental Health Services;
• We then discuss the theoretical framework of the problem-solving process used by doctors when confronted with a patient with Mental Health Problems.

Providing Basic Psycho-Medical Care

• When a patient with mental health problems makes a visit to his GP, we expect from the physician that they are able to recognize the Mental Health Problem.
• When recognized, the patient’s problem must be clarified through adequate information acquisition:
  • The physician wants to gain clarity about the patient’s request for help,
  • The meaning of the problem for the patient,
  • And about possible causes of the problem.
• The physician generates and evaluates explanatory hypotheses about this mental health problem.
• They formulate a diagnosis and make action-hypotheses by which they hope to be able to influence the Mental Health Problem.
• The physician draws up a treatment plan that is based on these action-hypotheses and subsequently carried out. 

We have called this process Basic Psycho-Medical Care.

In the second part of this guide:

• We will go deeper into the practice of Basic Psycho-Medical Care and will describe commonly-used communication skills and treatment methods.
• We will indicate which information can best be collected about the patient’s problem, how it can be collected and in what order.
• In addition, we will discuss some of the most common mental health problems and the significance of psychopathological symptoms for psychiatric research.

Mental Health Problems In Society

In recent years, a lot of research has been done into the occurrence of Mental Health Problems in society (Goldberg, 1980). The research tools that were used in the past ranged from putting a cross on a questionnaire to extensive psychiatric interviews. No dividing line was drawn between severe forms of psychopathology, mild forms of Mental Health Problem and the normal part of the population.

The results of these studies were very different. Some studies indicated that only a small percentage of the population had Mental Health Problems. In contrast, other studies have found that 60% of the population has mental health problems.

Patients with Mental Health Problems have many symptoms in common: anxiety, depression, fatigue, irritation and sleep disturbances

With the advent of standardized research interviews, which were linked to clearly defined diagnostic criteria, it became possible to obtain a picture of the number of patients with – serious – Mental Health Problems. It became clear that, with a few exceptions, most patients with Mental Health Problems had a number of symptoms in common, in particular anxiety, depression, fatigue, irritation and sleep disturbances.

In addition to the General Health Questionnaire, all kinds of other questionnaires were developed, such as the Amsterdam Biographical Questionnaire and the Delft Questionnaire, etc. Al these questionnaires appear to measure neuroticism.

However, Goldberg (1980) enabled us to obtain an impression of the number of patients with a Mental Health Problem using the General Health Questionnaire. Goldberg managed to discover the people with Mental Health Problems that had not yet sought professional help for their problems. Then, he could determine how many people with Mental Health Problems ended up in any treatment channel.

Soon, it became apparent that there is much less variation in the number of people with Mental Health Problems than previously assumed. Second, it became clear that the majority of people with Mental Health Problems are not treated by the Mental Health Care Services.

The majority of patients with Mental Health Problems are treated outside of Mental Health and Psychiatric Services

He was also able to examine which factors influence the treatment demand behavior. Goldberg (1980) summarized many population studies. Below is a brief overview of the patient’s journey through the medical services. We focus on the most important factors influencing patient’s decision whether or not to seek help.

Patient’s Journey In Mental Health

Out of a population of 1,000, 250 people appear to suffer from mental health disturbances at least once in the course of a year. Of these 250 people, 230 will visit their GP, but not specifically for this mental health problem. The decision whether or not to see a doctor is determined by the severity and nature of the symptoms, the psychosocial stress and the learned patterns of illness behavior.

Then it is the turn of the doctor. They will recognize in only 140 of their patients that Mental Health Problems are involved.

• Of 1.000 people, 250 will suffer from a Mental Health Problem;
• Of these 250, 230 will visit their General Practitioner;
• Of these 230, only 140 people will be recognized with a Minor Psychiatric Disorder by their GP;
• Of these 140 people, only 17 will be referred to a psychiatrist or other mental health facility, and only 6 to a psychiatric institution.

In the detection of Mental Health Problems by the General Practitioner, interview techniques, personality factors, training and attitude of the GP play a major role. When referring or not, the GP’s confidence in his own abilities, the availability of mental health care facilities and the attitude towards these facilities appear to be important.

Training, attitude and personality of the General Practitioner play a major role in the detection of Minor Psychiatric Disorder

Ultimately, of the 17 referred patients, 6 were admitted to a psychiatric institution. At least this is the situation in England.

In the Netherlands, the same number (17) of patients will turn to a facility of mental health care, but fewer patients are admitted to a psychiatric institution (2.6; communication Mental Health Case Register, Maastricht.) The availability of beds and the presence of outpatient facilities and mental health care (such as Ambulatory Mental Health Services and psychiatric outpatient clinics) will influence the decision. In addition to, of course, the presence of symptoms, the risk for the patient or others, and especially the attitude of the patient and family towards whether or not to include them in the decision, play a role in further referral.

Attitudes of patient and family, whether to include them in the process, play a mayor role in the decision to diagnose and treat a patient for Mental Health Problems

Not everyone will be funneled through the medical channel equally quickly:

• Someone with an acute psychosis will quickly end up with the psychiatrist.
• Depressed patients with suicidal thoughts, who are under severe psychosocial pressure, are also more often and more quickly sent to mental health care.
• However, anxious patients and especially patients with phobias or obsessive thoughts / actions are much less often sent to a mental health facility (Binder, 1981).

Patients can also be brought directly to the emergency room of a psychiatric facility. The filters in the medical channel do not always have to be taken all.

The Journey From Person To Patient

Most patients with Mental Health Problems consult their doctor, but you have to understand that a lot has happened before patients see their doctor. Philipsen (1969) described the relationship between four different phenomena that can be brought together under the concept of assuming the sick-role. The four phenomena have the character of successive phases of the same process: the course or journey of a disease case.

Assuming the sick- role

1. Being sick as the presence of a disease;
2. Sickness as a feeling of unwell-being related to a presumed condition;
3. Being sick is like seeking a cure;
4. Being sick as an acceptance of the sick role.

Assuming the psycho-role

De Smit’s (1963) thesis describes how the stages of this process take place in Mental Health Care:

1. Existence of abnormal or deviant behavior;
2. Recognition that this behavior is based on a psychiatric disorder;
3. Followed by the recognition that treatment is indicated;
4. Treatment by a mental health facility and the person becomes a patient / client.

We see that both models are very similar to each other. De Smit’s model is based on psychiatric problems, but is equally valid for other mental health problems, such as anxiety and mood disorders.  

Phase 1 — Well-being or chronic unwell-being

Disease occurs when there is a reduction in the balance between well-being and unwell-being. The nature and severity of illness influences the transition from well-being to unwell-being. Transient periods of general malaise and mood disturbances are common. If someone is not feeling well, they first of all wonder why they feel that way.

A person who feels unwell, wonders why they feel unwell and attributes meaning to complaints and symptoms 

Phase 2 — Giving meaning to symptoms

• I can’t feel well:
  • Because I drank too much the night before;
  • Because I have the flu;
  • Because my relationship has ended, etc.
• I may feel depressed:
  • Because of a virus infection;
  • After a stressful event;
  • Because I have had too little physical activity, etc.

— Gaining Insight: Attributions & Medical Students

In this connection it is illustrative to cite the following example. Many medical students experience body sensations during their studies that are attributed to pathological processes. Students are under internal or external stress, such as doubt, sadness, fear of exams, an excess of stimuli. They are emotionally stimulated and, like other people, often experience unwell-being, which usually passes.

Being unwell can be muscle pain, palpitations, forgetfulness, etc. However, as students’ knowledge of illness has increased, they have gained new ground to give meaning to bodily sensations, which are initially neglected and barely noticed. The symptoms can worsen under the influence of stress and students become more aware of their body. They notice physiological or psychological dysfunction in themselves. They see a connection – often erroneously – with a patient they have seen, a clinical anecdote or a family member who has been ill.

Symptoms previously considered normal are considered abnormal in the light of newly acquired knowledge (candidate disease). This phenomenon disappears over the course of medical school: students learn more about the disease and discover that the connections they have made between symptoms and a disease are not entirely correct. The attributions, i.e. the cognitive connections they make between their symptoms and factors responsible for the development of the symptoms, change (Mechanic, 1978).

The core of the message is that everyone makes connections between physical or psychological feelings of un-wellness and possible causes.

Core message is that every person connects feelings of non-wellbeing with possible causes

— Attribution Theory

Attribution theory (Kelley, 1980) provides insight into the way people explain cause and effect of human behavior. People assume that behavior does not just happen, but is the result of a number of causes. These causes can be within the person (e.g. character, fear) or outside the person (e.g. circumstances). If someone is well able to handle a situation, this is usually attributed to the person themselves. If they are unable to deal with the situation, this is usually attributed to the circumstances.

The consequences of attributions have also been investigated: when a person judges another person and attributes the causes of behavior to a cause that is within the person themself, the effect will be that positive attitudes and characteristics will be attributed to this person.

When a person attributes the causes of complaints within themselves, they feel more positive and more powerful – a physician can support this process by providing Insight

Attributions can result in the disease being denied, thereby delaying possible treatment. People can also exaggerate their disease, which may lead to treatment being instituted too soon. A person may not want to disturb others or be unwilling to resolve the disturbing implications of their symptoms.

The bottom line is:

• How does a person judge their feelings of being unwell?
• What meaning do they give to their feelings?
• To what causes do they attribute these feelings?

These attributions also influence the treatment a patient will demand.

Phase 3 — Consulting Significant Others

Before the decision is taken to consult the doctor, the complaints are told to significant others, especially family members or friends. The advice that these others give is often decisive whether someone takes the sick- or psycho-role or not.

Cultural influences, social norms, personality traits, interaction patterns, and medical knowledge about circumstances in which one may or must feel ill, play a role in the advice given and the patient’s reflections. The decision to seek professional help is often made at this stage.

Friends are more likely than family members to advise a person to seek professional help. This difference in counseling behavior probably arises, because friends do not want to be bothered with someone’s problems or know more about the availability of professional help. While family members fear the stigma of psychiatric treatment.

In general, men and women differ in how they handle their problems:

• Women are more willing to recognize psychological problems in themselves;
• They talk about them more easily with other people and seek treatment more quickly than men;
• Women have more social contacts and, as a result, their knowledge about options for solving psychological problems is greater.

• Men, on the other hand, isolate themselves more often;
• Receive no information about the existence of professional help;
• Their behavior then degenerates more easily to the point that it is serious or bizarre enough that others will seek help (Goldberg, 1980).

Phase 4 — Decisions to take on the disease- or psycho-role

If someone decides to be ill, he usually goes to the doctor in the hope of getting help and, sometimes, also to get professional recognition of the sick role. At present time, it is often impossible for the doctor to make a diagnosis. Yet what happens in this phase of the disease process is important for the course of the disease.

Research in Great Britain showed that at the time of consultation only half of the patients could be properly diagnosed (Royal College of General Practioners’ Research Committee, 1950). However, it is very difficult for doctors to say that someone is not ill, even if no diagnosis can be made. They say that someone is only temporarily ill and predict a return to normal functioning.

Physicians find it hard to say that a person isn’t ill

Many physicians, with some exceptions, will agree with the patient that they are unable to function and therefore do not need to work. This explanation and the prescription of medication enhances the patient’s illness behavior. Patients are confirmed in their faith that something is not right.

The doctor is not likely to tell the patient to behave differently or to try to change their circumstances if they want to feel better. The patient will pay more attention to bodily sensations and will begin to look anxiously at themself. To the extent that they become preoccupied with themself, they get fewer opportunities to interact with their environment and fewer contacts. This can lead to a drop in self-image, to less positive experiences and to a drop in their mood (Goldberg, 1980).

Single Patients

It is easy to see why single people should visit their doctor more often than others (Fink, 1969). They are unable to discuss their symptoms with others. The visit to the doctor can be seen as an attempt to confirm the likely meaning of symptoms, and as a form of human contact in response to their loneliness. Of course, the tendency to accept the sick role increases, because there are no family or friends to offer support in coping with the feeling of being unwell.

Psycho-Role vs Sick-Role — Important Differences

The above-described phases of the patient journey also apply to Mental Health Problems, but there are a number of obvious differences and consequences to be noted (see Table 1).

With Mental Health Problems, physicians should try to understand the goal, the meaning and the gains of the complaints

General Practitioner & Mental Health Problems 

Most patients with Mental Health Problems did not go to the doctor with psychological complaints. The patients usually interpret the symptoms in terms of a non-specific physical illness. They seek advice for the accompanying somatic symptoms. There are several reasons why patients do this.

Patients with Mental Health Problems often seek advice for the accompanying somatic symptoms

First, the patient thinks the doctor expects them to present physical symptoms and the patient wants to figure out the meaning of strange symptoms (Goldberg, 1980). In addition, the physical reactions to stress are perceived more strongly by the patient. The patient becomes more sensitive and perceives body sensations more intensely.

Then there is also the stigma of psychosocial illness and, as a result of which, patients prefer to present somatic suffering to the GP rather than to bring forward psychological problems. It appears that more than half of the patients with a demonstrable psychiatric disorder show significant somatic symptom formation in addition to the psychological disorders. Not only does this occur in our Western culture, but this phenomenon has also been demonstrated in African cultures (Giel, 1969).

Be Alert to Psychopathological Symptoms

The close relationship between mental disorders and physical complaints already indicates that a physician must have the skills to recognize and deal with disorders in functioning that are not caused by physical illness, in addition to diagnosing physical illnesses. The doctor must be especially attentive to signals that indicate psychopathological symptoms. We will come back to this in more detail in a later section on the recognition of Mental Health Problems.

Critiques of the ‘Medical Method‘

Before a patient visits his doctor, a lot has happened to him. The patient has experienced feelings of dissatisfaction, given them meaning, and talked about them with important others in their immediate environment. They made the decision to visit the General Practitioner. At that moment the doctor knows nothing about complaints and causes. They must first get a picture of what is going on and then deal with the patient’s complaints in a meaningful way.

This is not easy: a large number of patient – doctor consultations are not satisfactory, at least for the patients.

In his article ‘Working Methodically’ (1978), Van Aalderen discusses the method that general practitioners learn during their clinically-oriented training. This method: ‘history-taking – examination – differential diagnosis – prognosis – therapy and follow-up’, which he refers to as the medical method, is based on a number of presuppositions:

• The expression of a physical complaint means that there is a problem with a physical dimension so that the patient asks for medical help;
• There are objective solutions for an – individual – problem if it resembles a general problem of which the solutions are known;
• If the problem cannot be resolved immediately, further investigation or treatment is better than no investigation or treatment.

Van Aalderen comments on these assumptions are as follows:

Re. 1. This assumption implies, among other things, that a complaint indicates the direction of a request for help. This is not necessarily valid for treatment in which it is not yet sufficiently established what the request for help is. Such unclear and complicated situations are common in general practice. In such cases, the application of the medical method can easily lead to improper or insufficient assistance, i.e. assistance that the patient does not need or that is insufficient.

Re. 1. and 2. These two assumptions make certain objectifications valid: complaints can be regarded as symptoms of a problem that can be tackled by objective means – independent of the patient. One consequence of this is that patients are being treated, but this is not possible with psychological and social problems (whether or not related to somatic problems). Therefore, solutions must be sought in every situation that are acceptable to this patient. Instead of working on the patient, we have to work with the patient.

Re. 3. This assumption doesn’t do justice to a serious consideration of the advantages and disadvantages of treatment: If it doesn’t benefit, it shouldn’t harm. This can also violate the patient’s self-responsibility: after all, something must always be done.

The medical approach isn’t very helpful when active involvement of the patient is required – such as in Mental Health

Van Aalderen thus declares the medical method unsuitable for turning the provision of care into a joint venture that requires the active involvement of the patient.

Basic Psycho-Medical Care

• Basic care
• For clients with problems in their Mental Health
• At the level of Primary Health Care or General Medicine.

Basic Psycho-Medical Care is summarized in Table 3.

The term basic care carries two meanings:

1. This care for persons with Mental Health Problems must be limited to the level of primary care or general practice. The interventions will have to be relatively simple and limited, but also fast and efficient;
2. The methods used by the physician must be clear, insightful, easy to learn and evaluate.

This basic care will have to be especially suitable for the nature and frequency of occurrence of Mental Health Problems as they occur in primary care or general medicine.

Methods used by physicians in general medicine must be clear, insightful, easy-to-learn and -evaluate, and they should be effective

The limitations of the medical method in the doctor-patient consultations, which we discussed in the previous sections, occur especially in Mental Health Problems. For these problems we introduce a systematic method, which partly shows similarities with the way in which somatic problems are dealt with, but partly there are also clear differences, which have to do with the nature of the Mental Health Problem and the role of the patient in a Mental Health Problem.

Summary of 5 Phases in BPMC & Self-evaluation

We have called this method Basic Psycho-Medical Care which objectives are summarized as:

1. Recognition Of a Complaint Pattern as a Mental Health Problem

Recognition of a complaint pattern as a Mental Health Problem: in the previous paragraphs we pointed out the difficulties that can arise when a patient presents a Mental Health Problem through or together with many physical complaints. This is especially important in the mood disorders often presented in primary health care or general medicine. 

Furthermore, Mental Health Problems often occur as:

• Psychosomatic complaint patterns (easily degenerating into somatic fixation);
• Anxiety neurotic or anxiety-equivalent symptoms (including phobias);
• Psychological exhaustion states;
• Behavioral and relationship problems on a neurotic basis.

Psychotic decompensations, although relatively rare, are of such a nature that they must be carefully diagnosed and referred in a timely manner – properly supervised by the General Practitioner.

Lighter or Serious — Hard To Tell

The transition from lighter psychological complaint patterns to serious psychiatric disorders is always a gradual one. Incidentally, the notions of lighter and serious come about in a complicated way. Mixed with it are the notion of the severity by which the psychological phenomena control the personality, the possibilities for and changeability of complaints and situations, and last but not least the subjective experience of suffering.

In Mental Health Problems, physicians should always examine accompanying problems in life

In any form, however, one should always highlight the life-problems that are the cause and/or effect thereof.

Recognition means: receiving signals that indicate a possibility of a Mental Health Problem and elaborating these signals further in the next step.

2. Clarifying A Possible Mental Health Problem Through Adequate Acquisition Of Information

The result of this step can be:

• An impression of the patient’s request for help and expectations with regard to any help;
• The patient’s view of the Mental Health Problem where the patient remains the expert about his own problem:
  • How did this happen?
  • Why didn’t the complaints go away?
  • What could be done about them?

We make use of a number of communication interventions which are known from social skills training. These are: asking questions, reflecting on emotions, summarizing and ordering, observing, concretizing and confronting.

This clarification of the request for help doesn’t have to be limited to an individual patient, but can also be extended to a relational or family system. 

3. Formulation of the main problem in a diagnostic classification-system

Then, the doctor puts his expertise in the spotlight, and translates and names the problem in a scientific language. Classifying the problem in a diagnostic system can be according to the CHAM system or the DSM-5.

Labeling is, however, not the most important goal of classification

The emphasis in diagnostics should be:

• On generating and evaluating a number of hypotheses with which the Mental Health Problem – in principle – can become understandable, explainable and influencable.
• On estimating subjective aspects of the Mental Health Problem, such as the experienced severity and the amount of suffering.

In addition to a diagnosis, physicians should search for factors and conditions that play a role in the origin of the Mental Health Problem

4. Formulation of a patient management plan

Without immediately taking action or even treating the complaints, a plan will have to be formulated first. Epidemiological research has shown that many of the Mental Health Problems in Primary Care ‘solve themselves.’ Own problem solving, sudden occurrences in situations, changes in the social relations, no longer wanting to complain, etc. are the reason for this.

The insidious point is that the 25% of Mental Health Problems that require treatment and – if not – easily become chronic, are difficult to distinguish beforehand (Goldberg, 1980). On the other hand, indiscriminate treatment of all these Mental Health Problems would entail unnecessary medicalization or psychiatrization.

This treatment strategy is more about a decision-making process, in which the following steps are followed:

• Whether or not a form of treatment within the Primary Care setting:
  • Is reassurance and information about the problem sufficient?
  • Should the doctor help solve the Mental Health Problem?
• If treatment is required, if so which treatment plan?
• To what extent does this match the patient’s expectations and request for help?
• Can I, as a doctor:
  • Do this myself, or do I have to refer?
  • In the latter case, where to?
• Is consultation necessary for these decisions?

5. Performing a simple treatment plan, including consultation

The following forms of treatment are considered important in Basic Psycho-Medical Care:

• Psycho-education, counseling, motivational interviewing, including a reference to Mental Health Services;
• Counseling;
• Supportive & structuring care;
• Crisis-intervention;
• Psychopharmacological interventions.

6. Evaluation of one’s own performance in the above five steps.

These objectives are quite obvious, but practical implementation encounters more problems.

Since there is a multitude of approaches available within mental health care, a choice will have to be made, and, while choosing, connection has to be sought as closely as possible with the objectives of treatment for patient and physician.

In the following, we will further elaborate the concept of Basic Psycho-Medical Care in the sense of the required knowledge, skills and attitude aspects. First, we will inform you about the theoretical background; subsequently, the 6 objectives for practice will be elaborated on.

Theoretical Background

The provision of Basic Psycho-Medical Care can be seen as a problem-solving process for doctor and patient. The physician is confronted with a Mental Health Problem presented to them by the person seeking help, in which case they are expected to be able to offer help in solving it.

This help can take very varied forms:

• Advice to some kind of therapeutic regimen,
• The elimination of troublesome symptoms,
• A process of gradual insight,
• Changes in the social situation,
• Raising awareness of certain emotions,
• Motivating to a different lifestyle,
• Psycho-education and knowledge about more preventive mental health care, etc.

These interventions are intended to support the patient’s own responsibility for their own mental health, in the sense that Mental Health Problem will ultimately be solved by themselves as well as possible.

Many interventions in Mental Health Care intend to support patients’ responsibility for their own mental health

Two conditions are important for the realization of Basic Psycho-Medical Care:

• High-quality interventions – as necessary as well as sufficient conditions;
• A suitable doctor-patient relationship – as a necessary condition.

A problem-solving process is the basis for making high-quality interventions, in which two strongly related components can be distinguished:

A medical problem-solving process regarding diagnostics …

In this process, all kinds of hypotheses about the relevant Mental Health Problem are generated and tested against reality. It involves understanding and explaining these problems by the doctor. In behavioral science theory, the distinction between understanding (Verstehen) and explaining (Erklären) has been given a lot of weight. 

Verstehen

By understanding  we mean an interpersonal feeling, a ‘common-sense-like’ insight into what is going on with the other. If someone suddenly loses a loved one, one can imagine the emptiness, the lack, the confusion about it, etc. This understanding arises from common, comparable experiences that have been passed through with common and similar circumstances. It will be clear that all kinds of common feelings, attitudes and prejudices play an important role in it.

Physicians develop hypotheses based on understanding and explaining their patient and their complaints 

Erklären

By explain is meant a theoretically founded understanding. In keeping with our example, the behavioral and experience reactions after the loss of a loved one can – on the basis of theory and empiricism of grieving processes – be explained retrospectively and even predicted to a certain extent (See also the article by E. Lindemann: Symptomatology and management of acute grievance).

When confronted with a Mental Health Problem, every person, including the doctor, first forms a number of understanding hypotheses. Some of these take on a more ‘explanatory’ character, because the theoretical knowledge is used to arrive at further, more scientific explanations.

For example, the Understanding Hypothesis: If someone loses his partner, then his depression is obvious can become an Explanatory Hypothesis: If someone loses his partner, depression can develop, if he directs the anger about it on himself, an example from psychodynamic theory.

Obviously, generating explanatory hypotheses requires theoretical knowledge about Mental Health Problems and their treatment. In view of the wide variety of theoretical approaches, a selection must be made from these theories with regard to Basic Psycho-Medical Care: psychodynamic theories, learning theory, biological psychiatric theories, and system and communication theory have been chosen.

As a problem solver, the doctor quickly appears to form a number of understanding and – depending on his skills – explanatory hypotheses. These appear to give further direction to the interview. By obtaining further information, for example with the help of the psychosocial history, they try to find confirmation – or refutation – of these hypotheses in the material provided by the patient.

In this problem-solving process, diagnostic classification plays the role of an ordering principle with which a number of phenomena and thus a number of hypotheses can be brought together under one heading.

Diagnostic classification organizes information obtained from the patient with hypotheses about origin and treatment

For example, if one knows the symptoms of a vital depressive syndrome, it is possible to put a number of complaints, such as insomnia, lack of appetite, sadness, apathy, excessive guilt, weight loss, under an ‘explanatory heading’. 

Followed By Intervening In The Patient’s Problems …

Closely related to this is the other aspect of problem solving in which the doctor takes action, that is, intervenes in the patient’s problems.

In principle, the physician thus always goes through an empirical cycle. Understanding and explaining is not the only important thing, however; in addition, the doctor also wants to come up with an intervention that answers the patient’s request for help. It is expected that so-called action hypotheses will also be derived from this understanding and explanation, on which change-oriented interventions can be based.

Through Action Hypotheses

However, action hypotheses do not necessarily have to arise from explanatory hypotheses; due to the multitude of possible approaches, action hypotheses often rely on a different theoretical framework than explanatory hypotheses. This is especially the case with psychodynamic theory, which can have great explanatory power, but offers few possibilities for action hypotheses.

Action hypotheses are central to this, but are strongly interwoven with the manner of implementation in the communication with the patient. The treatment skills necessary for Basic Psycho-medical Care are of great importance, such as structuring or counseling therapy.

These action hypotheses are thus expressed through interaction with the patient and can be confirmed (they catch on) or disproved (they do not work). Access to knowledge plays an important role in both forms of problem solving. Both for generating explanatory hypotheses about the origin, survival and influence of the Mental Health Problem, as well as for the application of communication skills and more specific forms of treatment. The latter skills are also important in problem solving themselves.

Communication Skills

The so-called communication skills, that is to say the ability to apply the basic operations of the interview, such as open questioning, open-to-closed cones, summarizing, reflections of emotions, etc., act as building blocks for the more specific forms of treatment in Basic Psycho-Medical Care, such as counseling, advisory / motivational / educational forms of conversation, supportive and structuring talk therapy.

Attitude

Attitude aspects greatly influence this problem solving process. Apart from their significance for the climate of the doctor-patient relationship, discussed below, they are important in generating understanding hypotheses, in which intuition, feelings and prejudice are important components. The hypothesis-testing process also appears to be influenced by the attitudes of the physician; e.g. the tenacity with which the physician wants to see certain hypotheses confirmed or disproved.

Intuition, feelings and prejudice are important attitudinal components for establishing – or hindering – a climate of trust and acceptance

Doctor-patient Relationship Defined By Climate Factors

In addition to the realization of high-quality interventions, establishing a good doctor-patient relationship is also a necessary condition for Basic Psycho-Medical Care.

Attitude aspects are of great importance in this:

• To what extent is the patient allowed room to express expectations;
• To give a vision of their own problem;
• To formulate their own request for help?

In this way, the doctor underlines the basic attitude in which they participate in problem solving, but leave the ultimate responsibility with the patient.

The physician participates in problem-solving, but leaves the ultimate responsibility with the patient

After Rogers (1972) theorized about climate factors, their significance has been shown in empirical research:

• Empathy – understanding the world of experience from within;
• Congruence and transparency – the fact that they remain a doctor and do not show themself unnecessarily defensive or vulnerable;
• Positive disposition and unconditionality – the credibility of the doctor’s efforts and the steadfastness in accepting the patient;
• Non-directivity – the doctor connects as much as possible to the frame of reference, and to emotional and behavioral patterns of the patient in a non-authoritarian way.

Although these dimensions are trainable, longer experience of the physician is required to remove the artificiality and stiffness that entails uncomfortable application. Nor should these dimensions of the doctor-patient relationship be understood as absolute à priory. It turns out that on the one hand non-directivity and on the other hand congruence and transparency easily become at odds. The non-directivity requires following the patient’s frame of reference, while congruence emphasizes the input of the physician’s individuality. In the dependency which characterizes the doctor-patient relationship, the latter dimension easily obtains preponderance. This can also be very functional, such as with advisory or supportive / structuring talk therapy.

In Practice Basic Psycho-Medical Care

In the previous section we explained what the objectives of Basic Psycho-Medical Care are. We then discussed the theoretical background of this type of care. In order to be able to work in the practice of primary care, we must have knowledge of the presentation of Mental Health Problems and know how we as care providers should deal with them.

We will further elaborate the various objectives of Basic Psycho-Medical Care, while focusing on practice.

1. Recognizing A Symptom Pattern As Mental Health Problem

Goldberg (1980) showed on the basis of empirical research that many (30-50%) of the Mental Health Problems presented in Primary Health Care are not recognized and that doctors and GPs differ greatly in their competence to recognize these problems. These hard-to-recognize problems appear to be especially the common mood disorders in primary care – whether or not combined with anxiety symptoms and psychosomatic complaint patterns. An important characteristic is the interwovenness with somatic complaints – whether or not with an organic substrate – which we have already discussed.

After first examining the relatively easier-to-recognize Mental Health Problems with pronounced psychopathological symptoms, we will pay attention to this more difficult to recognize group of Mental Health Problems.

In the consultation , the doctor must be open to all kinds of signals that may indicate the presence of a Mental Health Problem.

Patient’s presentation

The doctor must pay attention to:

• The general appearance of the patient;
• Manner of contact, including an impression of the degree of consciousness, the attention and the concentration;
• Facial expression;
• Eye contact;
• Manner of dressing and grooming, etc.
• General psychomotor activity (movement pattern when walking, tension, restlessness, gesticulation, grimaces, tics, catatone phenomena.

The speech takes a special place: attention is paid to:

• Form characteristics, such as speed, loudness, intonation, accents and possibly more specific speech disorders (word finding and articulation problems; stuttering);
• Substantive characteristics are of course important for the recognition of all kinds of disorders in thinking (for example, incoherence, delusions) and also give an impression of the perception of reality.

We limit ourselves here to signals; these should, if necessary, give rise to a more extensive psychiatric examination.

Patient’s complaints

We now turn to the Mental Health Problems which occur often in Primary Care, but are easily ignored. Research by Goldberg (1980) showed that mood disorders and anxiety symptoms are involved in 80% of Mental Health Problems.

For your orientation, we formulate an overview of complaints and problems that are common in Primary Care (See Table 4.)

The method of interviewing has proved to be decisive for detecting Mental Health Disorder. We will therefore discuss this in concrete terms.

Open questions and an open mind are decisive for detecting Mental Health Problems

If the opening of the conversation is handled properly, patients with Mental Health Problems will give clues about the nature of their disorder.

Common mistakes

The most common mistake is that the doctor does not give the patient a chance to present the complaint in his own way. The doctor often starts with a closed question, such as: How is your diabetes?; or he poses an open question: How are you today?, when the patient enters the room. The patient will then take this as a courtesy on the part of the doctor and will not go into it too deeply.

If the patient had been seated in a chair and there had been eye contact, the same question could have produced a very different response.

Another common mistake is that the doctor is buried in their papers: at the beginning of the conversation to read the last notes, at the end to write down the findings of this consultation. Doctors who behave like this, miss a lot of verbal and nonverbal clues of mental health disorders.

What guidelines can we give?

The actual interview does not start until the doctor and patient sit down.

• The interview opens with an open-ended question, such as: What brings you  here today? The doctor must stimulate the patient to present his complaint as completely as possible. In doing so, he observes the patient carefully. The patient’s attitudes and mannerisms may suggest tension or depression, and the patient may say things that need clarification later. For example: I felt a bit down last week and the headache started on Saturday.
• The patient then continues to talk about his headache. The doctor will return to the depressed feeling later. We have heard and responded to the patient’s complaint, usually a somatic complaint.
• When we suspect that there is a Mental Health Problem, we bring the conversation to healthy areas of functioning, which are often affected by problems in mental health.
• Only then do we start talking about the patient’s fears and anxiety-related problems (Goldberg, 1980).

General Psychological Functioning

It can help to ask the patient if his somatic symptoms get worse when he is worried or if they arise under certain circumstances. Headache is such a common symptom of emotional disturbance that it makes sense to ask about it directly in response to the questions about other symptoms.

The following topics are covered:

• Appetite,
• Weight and sleep, in addition to fatigue,
• Irritation,
• Loss of concentration;
• Loss of libido.

Most patients with significant mood disturbances will report symptoms in a number of these areas.

Fears and worries

It is now natural to ask about tension and worries.

The doctor should ask the patient whether they think at night about their concerns, so they can not sleep and their body does not get the chance to relax and recover.

Always ask whether the patient is very concerned about their current health and is concerned that the symptoms are related to a serious illness. If the patient reports stress and fears, ask how severe they are. It may be useful for the patient to discuss hypochondriac symptoms and fears with the doctor.

Depression

It often happens that doctors diagnose the depression, simply because the patient has said during the interview that they feel depressed or have shed a few tears while describing a painful event.

A gloomy mood can indeed be the result of a painful event.

However, the diagnosis ‘depression’ is a syndrome diagnosis and must include some other characteristic phenomena in addition to the depressive mood disorder.

It can help to convince you that the following phenomena are present:

• The intensity of the mood disorder,
• The presence of physical symptoms (inhibition) associated with depression,
• And phenomena associated with a changed self-concept (especially negative self-image).

You can assess the intensity of the depressed mood by asking the patient to describe their mood. Inquire about feelings: as if time stood still, as if the patient is no longer enjoying anything, as if a large cloud is hanging over their head.

You have to go along with the experience of these feelings. You also need to be aware of any plans to commit suicide.

Depression is characterized by early awakenings, daytime fluctuations, loss of libido, slowing of thoughts and actions, in addition to weight loss and loss of appetite.

Many doctors do not ask about depressive thoughts and a changed self-concept. Still, the answers in this area are important because of the significance they have for prescribing or not prescribing antidepressants, as well as the presence of physical symptoms.

The best approach to this topic is to ask the patient what he thinks about when he feels depressed:

• Are there thoughts that keep coming up in him that don’t leave his mind?
• Does he blame himself for being like that?
• The patient feels that he is not as good as other people or that he feels he has done wrong
• Here too, there is a hierarchy of questions: questions about feeling worthless can be followed by questions about nihilistic ideas. 

This framework gives the GP guidance when approaching most patients with a Mental Health Problem. If major psychiatric disorders are suspected, additional information must be obtained – of course. Examples are: organic brain syndromes, schizophrenia, anorexia nervosa, etc.

2. Clarifying A Mental Health Problem Through Acquisition Of Information

In the previous section, we indicated which areas of life we ​​want to talk about if we suspect that the patient presents a Mental Health Problem.

In this section we mainly want to discuss:

• The formulation of the request for help;
• The technique of the question-clarifying communication;
• Why to stimulate the expression of the request for help;
• And the accompanying emotions of the doctor.

Request for help: Why does this patient come to me with this complaint at this moment?

Having the request for help formulated is an important goal in the consultation. We want to answer the following question:

Why does this patient come to me with this complaint at this moment?

It is not enough to know what is wrong with this patient; you also need to know why he is coming to you as a doctor and what he wants from you:

• Have you already thought in a certain direction?
• How much trouble do you experience because of your complaints?

The patient may have certain intentions in presenting this complaint: they can make clear: Look how I suffer, or want confirm their self-definition: I am sick, etc. It is good to conclude the clarification by formulating the request for help. Then you list all aspects that can play a role in the perception of the complaint. The patient can then tell you whether you understood what he wanted to say.

Open your consultation with an open-question and ask your patient to describe their request for help in their own words

In order to get the question to the fore as clearly as possible, you should ask the patient if they want to describe their experiences in their own words. Doctors are accustomed to assume that they have understood the nature of the complaint before the complaint has been clearly stated.

Often, doctors are impatient and assume too soon that they have understood the complaint

Patients stimulate this by talking about themselves in vague, impersonal sentences, such as ‘trouble with the nerves’. The patient feels relieved when it appears that the doctor has understood the nature of the complaint and proceeds with an impersonal analysis of the symptoms: When did they start?

The remedy for this problem is to encourage the patient to describe their experiences in their own words. The doctor can help by asking about the nature of the pain, the abnormal experiences or behaviors and trying to get the clearest possible picture of the complaints.

For example: Can you describe the pain for me?, instead of: Is it a cutting or a dull pain? Or: You talk about nerves, what do you mean by that? 

If the patient is sufficiently supported to clarify the nature of his complaint, the doctor can ask for more information about the origin of the symptom, in which situations it occurs, and also what the consequences of the symptom are for themself and their family. When parents talk about sick children, it is important to get an exact description of the behaviors that cause concern.

Note-taking

If it is necessary to look up something in the patient’s files during the first minutes of the interview, it is important that the patient does not continue to tell his story while the doctor is reading. Although the doctor thinks they are listening, in reality, they will forget much of what they hear.

Physicians can’t multitask: they can’t listen to the patient and read the files or fill out any forms simultaneously

The clarification of the reason for help-phase is so important, because the patient is given the opportunity to formulate his request for help.

When the physician is in charge, the patient will volunteer less information

In the foregoing it has already been explained how doctors’ thought process proceeds. The danger of formulating hypotheses at an early stage is that the doctor will no longer listen openly, but selectively picks up what they like from the patient’s story. Moreover, they would like to test their hypotheses which they mainly do by asking closed questions.

The patient, who at the start of the consultation was inclined to present their subjective perception in addition to their physical complaints, will contribute less and less, if the doctor is in charge of the conversation and collects information about the physical complaints through closed questions. There is a great risk that the patient will stop telling, but will answer the questions. The patient has then gotten the idea that you can only answer what the doctor asks you in the consultation room.

You could say that, in this way you cause the patient to crawl into his shell. Balint (1955) constantly insists: ‘experience shows that you always get an answer to questions, but nothing more’. As a result, the doctor receives in fact less and less information and has less and less opportunity to adjust their own thinking process.

Physicians should make sure to notice starting points for an exploration of Mental Health Problems

Ultimately, a diagnosis / hypothesis emerges that neither the doctor nor the patient is satisfied with. Because the doctor has not noticed indications for the existence of a Mental Health Problems, they also have no starting points to go into this. 

Request For Help-clarifying Communication

Almost all basic social skills are discussed in the question-clarifying communication. Nevertheless, we would like to discuss a number of techniques of the question-clarifying communication separately here, because they are especially important in this type of communication.

In this regard, it is not our intention to discuss basic skills in detail. For those, you will find special video tapes in the Skills Laboratory reflecting the relevant basic skills. Here, we just want to touch on what is meant by these techniques.

Stimulate Your Patient To Express the Request For Help

Centralizing the request for help, implicitly means letting go the medical model. With Mental Health Problems, we let the patient contribute more regarding responsibility and expertise than with purely somatic problems. We assume that the doctor plays a subordinate role in decisions about life problems.

In decisions about life-problems, the patient is the expert and should assume their responsibility

In the case of requests for help in psychiatry and psychotherapy, the aim is also for a more equal input from patient and practitioner, in the sense that the patient should determine for himself as much as possible how he shapes his life and that the therapist indicates what role he can play in this.

The patient is an expert and it is the doctor’s task to find out what the patient’s complaints are and how those complaints are experienced. We pointed out earlier that the patient’s own attributions, in other words, the patient’s own judgment about the origin, scope and influence of their Mental Health Problem, is of great importance for the treatment plan and for the ‘compliance’ with the treatment initiated.

The task of the doctor may be to interpret the symptoms from his expert, more objective vision and to stimulate the patient to formulate a request for help.

Physician’s Emotions & Their Professional Functioning

In Mental Health Care, attitude and other emotional aspects often have a profound effect on the interview situation:

• Severe symptomatic behavior (intense fear, aggression, suicidal behavior), as well as a strongly appealing interaction, will arouse emotions of fear, powerlessness, aversion, etc. in various interviewers.
• It will be clear that the – symptomatic – behavior of the client – in combination with the responses of an interviewer – can result in a very difficult interview situation.
• Often one has to add to these stressful situations, thinking-, perception-, and memory-disorders of the client.
• Also, due to an unfavorable match of the personalities of doctor and patient, there can be a lack of empathy in the side of the care-provider.

With strong and frequently occurring transference and countertransference feelings (respectively patient and doctor transfer feelings, wishes, old conflicts and fears – which were originally aimed at a figure in the past – often unconsciously into the doctor-patient relationship), the process of the clarification of the request for help becomes impeded, complicated or even impossible due to a lack of objectivity.

In medical practice, however, it often involves minor transference phenomena. These become clear when the doctor always has difficulties with one particular theme in the handling and treatment of patients.

The treatment of patients may bring up minor intra-psychic conflicts in the physician, who therefore cannot resolve the problem properly. Obviously, problem clarification around these ‘difficult’ themes for the doctor may be insufficient. In this – fortunately infrequent situation – further exploration and problem-clarification may be indicated for the practitioner.

Transference-phenomena in the physician-patient communication may hamper the medical competence of the physician

The nature of psychosocial and psychiatric problems on the one hand and the uncertainty with regard to problems (for which the doctor would not be primarily trained) on the other, make attitudinal aspects very important.

The following situations may occur e.g:

• Strong moral disapproval and powerlessness towards addiction problems;
• Strong ethical and moral disapproval of incest and pedophilia;
• Fear and defense in some psychotic symptoms;
• Therapeutic pessimism and powerlessness in dementia processes, etc.

The situation can be problematic if the doctor’s attitude has a disruptive effect on his problem-solving ability. Skewed analyzes of the problem situation, incorrect valuations, neglect, etc., can lower his medical competence to below an acceptable minimum.

3. Formulation of the main problem in a classification-system

While the doctor and patient are talking to each other, the doctor develops a number of hypotheses that make the Mental Health Problem understandable, explainable and influenceable.

Physicians’ hypotheses should make a problem understandable, explainable and influencable

The doctor would like to see these hypotheses confirmed or rejected, so that he can gain more insight into the problem. The meaning of the different models used in Mental Health Care becomes clear here.

Somatic Medicine

In somatic medicine, a model of the human organism can be built on the basis of biochemical and physiological theories. From here we can largely explain and even predict the development of somatic diseases.

Mental Health

There are also various theories in Mental Health Care that can explain the behavior or feelings of patients. There is a multitude of theories, sometimes providing competing explanations, sometimes each making sense of part of the patient’s problem. As a doctor or psychotherapist, based on knowledge of one or more of those theories and your experience with patients, you form a framework with which you try to gain insight into the problem or behavior of the patient.

The aim of the models is to place the information provided by the patient in an explanatory framework. They are in fact a simplification of reality, but also give meaningful meaning to the observed phenomena. All models provide an explanation of the observed behavior as well as a consideration of the most appropriate interventions. In some models, the emphasis can be mainly on the first, in others on the second.

An explanatory framework should provide an explanation of the observed behavior as well as a consideration about appropriate interventions

A clear example is the psychodynamic model that makes the connection between the emotional development of the child and any behavioral abnormalities of the adult. The development of Mental Health Problems is explained herein. The family interaction model, on the other hand, is very suitable for formulating therapeutic interventions. In practice, more than one model can be used simultaneously or consecutively.

Systems Theory

Systems theory (Romme, 1981) indicates an ordering of levels at which we can look at human functioning.

1. Organ level: what physical changes are there;
2. Level of the individual: emotional complaints and statements of the individual about his complaints;
3. Level of the group: what problems are there in dealing with emotionally significant others?
4. Level of the organization of groups: structure of work, marriage, professional norms and values, etc.

The diagnostic classification means that the problem is ordered and summarized in a diagnostic label. Use is made of an existing diagnostic system, such as the DSM-III/5 or the CHAM system. Elsewhere in the Theoretical Guide the strengths and weaknesses of this diagnosis are discussed.

In addition to a Diagnostic Classification, the physician should have an understanding of the severity of the situation and amount of suffering

The subjective aspects of Mental Health Problem are also important for the physician to estimate the severity of the situation and the patient’s suffering. They are decisive for the urgency with which treatment or referral must be initiated, or even – in very serious cases – to take measures regarding Legal Actions.

In general, when referring to a mental health facility, the physician should also have an impression of the patient’s disability to function socially due to his problems and of the patient’s response to treatment already initiated (Goldberg, 1980).

We have already indicated that a doctor, based on his knowledge, his personal vision of man and his own experience, forms a framework within which he tries to gain insight into the problem or behavior of the patient. An intuitive sense of where the bottlenecks are is an important source of hypothesis formation. Of course this has consequences. It means that the physician must know himself well and that his views and behavior do not hinder adequate problem solving. As in the clarification of request phase, attitudinal aspects also play a major role in the diagnostic phase.

Physicians should translate Mental Health Problems back into manageable life problems

In summary, this diagnostic phase should provide a number of data: such as, diagnosis, understanding- and explanatory-hypotheses, and an estimation of the experienced suffering. The background is always to translate the Mental Health Problem back into manageable life problems. If the doctor does not succeed in this, two dangers threaten to occur, namely the individualization of social problems and the risk for somatic fixation. This should always be taken into account when designing a treatment strategy. We will discuss these pitfalls in more detail in the next section.

4. Formulation of a patient management plan

When drawing up a treatment strategy, a number of decisions must be made one after the other:

1. Is a form of treatment in Primary Care appropriate or not?
   • Is reassurance or psychoeducation about the problem sufficient;
   • Or should the physician help solve the problem?
2. If treatment is required, which treatment plan?
3. Does the plan connect with the expectations and the patient’s request for help?
4. Can I do this myself as a physician or do I have to refer? Where should I refer?
5. Is further consultation necessary for these decisions?

In the next section we will discuss a few forms of treatment. Here, we will discuss two mechanisms that we must be aware of because they may influence the decisions we make.

These two mechanisms may prevent us from adequately solving Mental Health Problem.

Individualization Perspective

Our society can respond to social problems in a certain way. Social problems, which occur on a macro or meso level, are reduced to a problem of the individual. This is called the individualization perspective (Nijhof, 1978). Social problems are ‘medicalized’, whereby the treatment does provide some relief or sedation, but the core social problems remain unaffected.

An example is the closure of mines in Limburg, the Netherlands, where many former miners have – unjustly – ended up under the WAO. In the light of the individualization perspective, individual change-oriented therapy for people with Mental Health Problem is essentially an improper activity.

Somatic Fixation

A second mechanism that often occurs is somatic fixation. By this we mean the phenomenon that people receive or demand exclusive medical-somatic attention for problems that are not primarily or that are only partially determined somatically, whereby important psychosocial aspects are pushed into the background, so that they become inaccessible and unsolvable (Huygen, 1978 ).

In Somatic Fixation important psychosocial factors are pushed in the background and become inaccessible and unsolvable

People get stuck and become dependent on the medical system. That is not only their own fault, because the process of somatic fixation can also be triggered by one-sided somatic attention from the general practitioner or by unnecessary medical treatment.

Prevention

In the context of the prevention of somatic fixation, it is especially important that the GP ensures that the patient does not become dependent on his judgment more than necessary. As equal partners, the general practitioner and patient must bear their own share of responsibility.

Patients should not become dependent of the physician and bear their own share of responsibility

In the book ‘General Practitioner and Somatic Fixation (Huisarts en somatic fixation)’ (Grol, 1981) the processes underlying somatic fixation are discussed in detail and how the GP should proceed to minimize the risk of somatic fixation.

5. Performing A Simple Treatment Plan, Including Consultation

We want to implement a treatment plan that we have drawn up.

The PMO-MPS staff indicated the following treatment types as relevant for Basic Psycho-Medical Care:

Psychoeducation, advisory and motivational forms of interviewing, as well as referral

Vrolijk et al. (1972) describe the theoretical foundation of this form of communication. In Primary Care, counseling is often required, advising the patient to make lifestyle changes. Many advices are not followed. We know from our own experience that we ourselves will only follow advice if we are convinced that the new way of life is better or more pleasant.

Referral is a special form of advice. According to Goldberg (1980), the General Practitioner appears to play a decisive role in the entry of patients into mental health facilities.

Counseling and referral play an important role in preventing somatic fixation and directing the client to the help indicated for them.

A referral must be based on an estimate of the clinical severity of the Mental Health Problem, i.e. the patient’s perceived distress and the extent to which the patient is no longer able to function socially (Kessel, 1965). The patient’s response to previous treatment is also taken into account in the decision to refer. Of course, a doctor must have sufficient knowledge of the social situation to be able to refer to the correct services.

If a physician decides not to refer, but to treat the Mental Health Problem themselves, they must have sufficient insight into their own expertise.

Counseling

The starting point of the counseling communication is that the patient must solve his existential problems and help himself. The patient, by the way, decides about their own life. The care provider can contribute to this by helping the patient to achieve maximum exploration of their feelings and motives. This can result in solving the problems, in being more open and free regarding their own feelings, or in being able to make decisions. Ultimately, the patient must become independent and self-proficient, so that further treatment with the care provider is no longer necessary. The theory behind counseling is based on Rogers’ ideas about client-centered therapy (Rogers, 1972).

The book by Vrolijk (1972) examines the necessary requirements regarding the therapist’s interventions and further explains Rogers’s ideas.

Counseling can be of great help in referring problems with which the patient comes to the doctor back to the patient themselves, as it were, in order to prevent unnecessary medicalization / psychiatrization. The difference with the above forms of communication is small in these cases, in which the doctor closes off the medical channel of treatment.

Supportive-structuring Communication

This communication often starts the consultation between care provider and client. Before the counselor can analyze the problem, the client must feel supported enough to tell the counselor about his problem. Often this form of treatment gradually changes to a different form (for example counseling or advice). In Mental Health Problems of a chronic nature and in people with limited problem-solving capacity, this form of treatment is often continued for a long time.

It is a method in which, in addition to a selection from psychotherapeutic interventions, also treatment strategies that change the social situation can be applied (Romme, 1981). The goal is to reduce stress and improve order, because a lot of smaller or larger problems have a chaotic effect on the patient, who has lost the overview and is no longer able to create order himself. The interventions can target all kinds of factors, such as lability in personality structure, stressors in the social situation, deficiencies in problem-solving skills, communication disorders with significant others, etc.

Crisis Interventions

Crisis-intervention is a term that is used both for acute care aimed at dealing with psychosocial problems, and for acute care for people with extreme behavior.

We can describe a crisis as a state that arises when an individual is faced with an obstacle to an important life purpose, which state is insurmountable for some time as long as they use their usual method of problem solving. In What Is Social Psychiatry?, Romme et al. (1981) describe the phases of a crisis situation and discuss the methodology of the crisis intervention.

Medication

Prescribing psychotropic drugs as a sole treatment plan is rarely an adequate approach in the treatment of Mental Health Problems

Psychopharmaceuticals are frequently used in Primary Care. They are an important asset for the treatment of patients with anxiety, mood disorders and psychotic experiences. However, to be able to work adequately with these medications, you must have sufficient knowledge about their indications, dosage and possible side effects. Prescribing psychotropic drugs alone is rarely an adequate approach. In general practice, these drugs are often prescribed lightly, without a careful indication. The Theoretical Guide contains an introduction to psychotropic drugs.

Consultation

Consultation with advice and and taking questions takes place between two professional care providers, where one care provider tries to assist the other in solving a Mental Health Problem within the framework of his own professional functioning. An additional goal of consultation is that in the future the consultant will be better able to solve similar problems independently (Gersons, 1977).

In the consultation questions, the care provider wants to be supported in his own attempts to deal with the problems. It may also be possible to have some of the problems solved by another professional, or to collaborate and look at the problems together and look for a solution.

So much for a brief introduction to the different forms of treatment that are supposed to be available to the General Practitioner. A literature reference has been given for each description, so that it is possible to delve deeper into the subject matter on your own. Extensive references can also be found in the commented bibliography in this Guide.

6. Evaluation of one’s own performance in the above 5 steps

We have come to the end of this introduction to meeting with patients. You will understand that we expected a lot of the care-provider. We expect physicians to:

• Have knowledge about Mental Health Problems and therapeutic skills (the Erklärende aspect);
• Make contact and to empathize with the patient’s problems (the Verstehende aspect).

This may result in a care provider becoming aware of a conflict between his own ideas and values ​​and those of the patient, or that he may discover that he lacks certain competences to help adequately help solve the problems. Social interaction results in self-awareness, and everyday events constantly refine a person’s image of himself.

Interaction results in self-awareness and refines a person’s image of themselves

Based on his self-image, a person will in turn perceive others (the patient) and interact with them (Wegner, 1980). We have already touched on this process in the discussion of formulating hypotheses about the origin and resolution of Mental Health Problems.

An important aspect of self-perception is self-evaluation. Feedback from dealing with others and the result of comparing with others gives your ‘self’ information about your own performance.

You can also stimulate this process of self-perception and self-evaluation, which always takes place in our dealings with others.

In Mental Health Care it is needless to say that every care provider regularly talks with other professionals about how they interact with patients. We call this intervision and supervision.

The GPs have formed Balint groups and group practices to discuss, among other things, each other’s experiences and functioning.

Basis of self-evaluation is your willingness to reflect on one’s own performance

However, this has not yet become common practice in somatic medicine. In the future, the (self-) evaluation of health care professionals will be increasingly introduced. The basic condition for effective (self-) evaluation is the willingness to reflect on one’s own performance. During the (self-) evaluation, attention can be paid to strengths, limitations and weaknesses, motivation and possibilities to correct deficiencies, own emotions, etc.

During this psycho-medical internship you will have the opportunity to gain experience in dealing with patients with mental health problems. After a consultation you will often have questions about your own performance and need the opinion of a professional. Most mental health professional are happy to talk with you about your functioning.

So much for this introduction. You now have some guidance to have the first consultations with patients. Meeting with patients will again raise many questions for you. In this Theoretical Guide, a number of topics are further elaborated and you will find literature references, so that you can dive into the literature on your own.