This essay is a critical reflection of my current skills as a Psychological Wellbeing Practitioner (PWP) that I undertook during the videotape recorded formal skills assessment, using reflective model (Driscoll’s, 2007, refer appendix-1). This model consists three simple questions: what happened, so what, and now what: further quick questions provide the critical reflection by stimulating in-depth enquiry leading to form action plans. Using this model, I elaborated purpose of a recorded patient-centred assessment (PCA) with comprehensive structured and content framework for Improving Access to Psychological Therapies (IAPT). Then critically analysed mixed interpersonal skills and the end section of PCA to explore learning, and ended the essay with highlighted learning needs with an action plan to develop my knowledge and skills for future practice. In my experience, reflection helps to perform PCA and identify discrepancies within the practice which can lead to continuous practice development. John, C (2000) explains the practitioner can focus self within the context of own lived experience that enables to confront, understand, and work towards resolving the contradictions within own reflective practice: between desirable and actual practice. Similarly, Driscoll (2007) describes reflection enhances professionalism rather than competes with the traditional form of knowledge, generate practice-based experience, learning, value professional’s work, shared practice, and service improvement. Inversely, he also explains that reflection might not fit with own learning style, passive resistance, e.g., too busy, incapability of time management and possibilities of exposing thoughts and ideas in public.
The IAPT programme was established in 2008 to enable people with common mental health problems to access evidence-based treatments deliver by PWP within “step 2 care” (refer appendix-2) recommended by National Institute for Health and Care Excellence (NICE) (IAPT, 2014). My rationales behind the assessment are: to identify patient’s eligibility, problem and impact, lifestyle issue, COM-B (refer appendix-3) and risk management etc. Now, based on gathered information, I act as a coach to support, motivate and encourage patients to help focus on self-management using low-intensity intervention such as guided self-help, behavioural activation, psychoeducation and other appropriate intervention or signposting (IAPT, 2014). IAPT (2015) helps to identify the purpose of PCA: person’s eligibility for service, the allocation urgency, degree of risk and management, provisional and possible secondary diagnosis, mental health cluster distribution, standardise measures, shared problem’s understanding, the shared decision as to agreed goal and type of and treatment.
Following the GP referral, I undertook the PCA of the allocated actor who pretended as a depressed patient reported feeling deficient and found difficult to cope with his life. NICE (2013) recommendation of patient centred care (PCC) is: a patient should provide with opportunities to make an informed decision about their care and treatment with regards to their needs and preferences, with the cooperation of their healthcare professional. Eventually, to further develop therapist skills (PCC), the term reflection started to make an appearance in the low-intensity curricula from 2000 (Bennett-levy, 2003 cited Bennett-Levy et al., 2009). Research indicates that PCC interview practice correlated with patient satisfaction and improvement (Lovell and Richard, 2000).
Assessment starts with an”Introductory session”. I begin PCA by adopted crib sheet which contains the “assessment structure and treatment” (Richard and Whyte, 2011) to enhance the performance of PWP assessment. Introduction section includes confirming patient details, PWP role, agenda, and length of assessment, risk and limitations of confidentiality, note taking, supervision and GP contact etc. Patient and I agreed on collaborative agenda setting increases consumer-centeredness, shared-decision and to provide effective care (Franklen, 2013).
To inform confidentiality limitations, I gained consent from the patient to share information if required such as risk. In some situation, statute or common law may require healthcare professionals to break confidentiality (Myles et al., 2007).
Next section of “Information Gathering” focuses on the problem by using questioning skills and collaboration etc. James et al., (2010) mentioned that within cognitive behaviour therapy (CBT), questions are used to explore the problem from different angles, create dissonance and facilitate revaluation beliefs, and to build adaptive thinking style. To identify patient’s difficulties, I collaboratively used 4’Ws’ (refer appendix-4) questions along with funnelling. Working together collaboratively benefits both the patient and the therapist in developing a robust therapeutic relationship (Dattilio and Michelle, 2012). I used funnelling technique include the open questions and encouraged the patient to talk in detail about their problem and patient also outlined a range of distressing symptoms and impact on ABC-E (refer appendix-5) which I covered alongside with the interpersonal skills, nonetheless use of closed questions to develop therapeutic alliance (Richard and Whyte, 2011).However, I repeatedly battled with time pacing skill throughout the assessment (reflected in next part of the model). Beck (2011) explains that actively collaborate, demonstrating empathy, caring and understanding, therapeutic style and alleviate stress throughout the assessment and elicit feedback at the end help to build the therapeutic alliance with the patient.
Suicide can result from various factors, for example, psychiatric disorder, negative life events, psychological factors, alcohol and drug misuse, family history, physical illness, the suicidal behaviour of others, and access to self-harm which I thoughtfully included in PCA (Howton at el, 2012). Therefore, risk assessment (refer appendix-6) is a core component of PWP skills. Here, I followed a systematic approach to assess patient’s current risk and ensure to cover all areas of risk which improve the outcome of the patient: helping to keep them safe, peace of mind and confidence (Laura et al., 2012). In this section, I was unclear with impulsivity question, and mislead between suicidal thoughts and meaning of the thoughts on risk and this may due to my questioning style. Nonetheless, I establish the current risk of the patient is minimal.At present, suicide trend seems going down from 6,233, 6,122, 6,188 to 5,965 since 2013 to 2016, respectively (ONS, 2013–2016). However, Papworth (2013) state that the great challenge for the practitioner is predicting the risk of the severe event. DH (2009) provides the ‘Risk Management framework’ based on the principle that risk assessment should structure, evidence-based and consistent across the settings and services.
During the assessment, I also collected PHQ-9 and GAD-7 outcome-measures (OM, refer appendix-7) as a part of Minimum Dataset questionnaire which is also collected at every session (IAPT, 2011). Within the IAPT services, PWP also collects information on phobia scale, employment and work and social adjustment scales (W) which I covered in lifestyle questions. Then subsequently review the appropriateness and intensity of treatment, identify therapeutic targets, and manage the therapy process or therapist, is indicated (IAPT, 2011). Patient and I collaboratively analysed pre-completed PHQ-9: discussed primary diagnosis depression, cross-verified ABC-E, and patient’s expectations. Provided feedback on scores helped patient to understand about their condition as how it changes over time which can improve with support and develop the therapeutic relationship (IAPT, 2011). Consequently, if OM has not collected regularly may lead to services systematically over-estimating their effectiveness and risks missing information apparently crucial to improving the quality of the service in future (IAPT, 2011).
Alongside the social and psychological needs, PWP also required to consider co-morbidities. Mentally ill people are likely to have reduced physical health which may due to high health risk behaviours such as high caffeine intake, smoking, alcohol, and substance misuse (DH, 2011). I managed to cover these factors in the assessment and identified that patient’s caffeine intake increased, and alcohol intake is same, but the pattern of drinking had change (more frequent). I offered support with caffeine intake and sleep interference and also offered signposting to specialist alcohol service if the patient would want to work.
Next section of “Information giving”: With five areas model (refer appendix-8), I focused on summarising information from previous sections to consider treatment options (Papworth, 2013). Regrettably, I didn’t have enough time to explain five areas in detail; nevertheless, I saw patient the interconnected chain of five areas in their problem and maintenance of symptoms which can break if he acts on the behaviour such as taking a shower and dressing up more often and highlighted “Behaviour Activation intervention”. Williams et al., (2002) provide a seven-step approach to overcome problems by reintroducing activities, re-engage and reduce unhelpful behaviours.
Problem statement (PS) encompass the critical elements of problem-focused; shifts from fact-finding to collaboration; and provides a reference point for future contacts (Richards and Whyte, 2009). Collaboratively, I created PS includes triggers, symptoms, and impacts of the problem and an ultimate statement of the patient to priorities of problem which steers shared decision making, as treatment progress, therefore, it is also useful to monitor change (Papworth, 2009). The accuracy of PS needs to be check with the patient (Papworth, 2013) which I didn’t manage to include due to my inability cover in PS in allocated time and lost marks on this section.
Farrand and Woodford, (2013) describe new, realistic things and plans can achieve by goal setting which is evidence-based, and then progressively work towards them in a structured way that puts the patient in charge. I asked reasons for seeking help, motivation, barriers, avoidance and use COM-B to help patient identifying specific goals (Michie et al. 2014). Moreover, when working together on five areas, I explored on patient’s goals and future possibilities for patient rather than difficulties they exist in present (Papworth, 2013)
Finally, the assessment ends with “Shared Planning” and “Decision-Making Competencies” (reflected in next part of the model) which I did not able to cover.
Once the patient makes a choice, PWP takes an active role to ensure that the patient understands the appropriateness of the treatment by giving accurate information which is evidence-based and discussing the matter to arrive at an informed shared decision (Richards and Whyte, 2011). I failed on this section as my whole assessment became disaster due to the barriers to access time, constant building anxiety and lack of coordination with time management which left me grieving. Bennett-Levy et al., (2010) explain the length of the assessment should reflect the time limits imposed by PWP, rather than comprehensive evaluation.
Due to the words limit and focusing on to significant areas of learning, I reflected upon the mixed feeling of interpersonal skills (covered well and less well) along with time management, and overall impact on PCA including last section.
Reflecting on the recorded PCA saw my cognition of wanting to get through the comprehensive assessment rather than coordinating the assessment’s length within the given a time frame, is crucial to note. When gathering information, I felt the patient is not giving precise knowledge of problem and impact of being off sick and low mood. Therefore, I used the in-depth funnelling technique for eliciting information in patient-centred manner and practitioner should use it often throughout the interview (Richard, and Whyte, 2011). Contrarily, James and Barton, (2004) argue the trainee PWP may ask too many questions at the “theory building” and get “stuck in the assessment and re-conceptualisation loop” generating more examples of negative thoughts and beliefs, without making an intervention which may cause further depression. However, asking more open questions on 4’Ws’ and ABC-E, I identified patient’s COM-B and provided opportunities to express “common factors” throughout the assessment which produced therapeutic alliance. Lambart et al., (2001) describes common factors such as empathy, warmth, and therapeutic relationships correlate highly with patient outcome than specialised treatment interventions. I also received good feedbacks from assessor with the frequent use of empathy, warmth, non-verbal cues, and normalising patient’s experience with an attempt to carry out collaborative session. Papworth, (2013) explains “collaborative empiricism” in therapeutic relationship in CBT allows a PWP and patient to develop a shared understanding of their difficulties, and to make discoveries together to effect change in cognition and behaviour. National curriculum (IAPT, 2011) explains the importance of skills training further develop PWPs “common factors? expertise of active listening, questioning style, engagement, coherence building, patient-centred: information gathering, information giving and shared decision making.
Somehow with critics, I also felt continue asking too many prompt questions and questioning styles (information gathering section), repetitions for reassurance, I ended giving little time to the patient to reflect on their answer. As a result, I adopted deter behaviours which entangled me into the assessment along with poor time management skills. As an outcome, I received remarks a “NOVICE” competent of time-pacing. James et al., (2010) concludes that asking questions in therapy is a complex, under-thought skills and they provide frameworks to identify helpful and unhelpful questioning skills. As an issue, I would consider to work on this skills which explained in next section of the model.
However, I also would like to challenge critics rather than only accusing interpersonal skills. Trifoni and Shahini, (2011) report students are usually affected by test anxiety gives rise to physical and psychological distress can affect motivation and concentration. Here, I also strongly consider the environmental factors such as access to clock arrangement, the ergonomic skill (refer appendix-9) of the actor, allowed time for the student to deal with test anxiety before the exam etc. Trifoni and Shahini, (2011) said instructors’ attitudes are key factors in reducing test anxiety such as test techniques, specific orientation before the test and information.
On the other hand, ergonomics training enhances employees’ skills in the use of office-workplaces environments by rearranging their workspaces to support their tasks, job demands, minimise distraction and increase privacy, and ultimately produce individual support, sense of control, work collaboration and environment satisfaction (Hung et al., 2004).
In the middle of the session, I realised inability to coordinate time due to barriers to access clock and time pressure which generated further nervousness and I lost confidence in time management. Trifoni and Shahini, (2011) state factors which provoke anxiety such as time limitation and pressure, negative evaluation. Although, the IAPT programme, does place a lot of demands on time so this skill assessment could see in fact mirror real-life by me. Here, I also perceive the initial nervousness at the beginning of the PCA made me unable to assert myself beforehand, and I felt too weak and late to take any action in the middle of the running session, for example, move a clock. Giasvand et al., (2017) report it is essential to plan for improving time management skills in order reduce anxiety students and strengthen academic motivation among students. Finally, I also consider working on time management skills along with other elements of interpersonal skills such as questioning style and dealing with test anxiety etc.
Finally, time efforts started hiring me unfavourably from ‘information giving’ section and disapprove me to cover the last section of shared planning and decision making, and left with incomplete PCA. For this section; I already offered treatment (BA) when explained five areas earlier but unable to agree with plans and actions with the patient and ended session unprofessionally. Despite, knowing mental health disorders and the evidence-based therapeutic options available, I didn’t leave with any opportunities to communicate this philosophy to help patients to make informed treatment choices (IAPT, 2011).
If I reflect, these could increase patient’s vulnerability if it were a real-life situation due to the vague ending of therapy which increases the susceptibility of patient’s dropout. One in five patients will drop out of psychotherapy before completing treatment, according to 2012 studies (Swift, and Greenberg, 2012 cited in Chamberlin, 2015).According to research study, that novice practitioners are more bound to lose patients at early stage, with high dropout of 75 percent (Chamberlin, 2015)
On the whole, I couldn’t pass the skills assessment as I didn’t able meet the “National curriculum requirement for the education of PWPs during summative skills assessment” (IAPT, 2011) to work within time limits of 45mins.
From reflection on recorded evidence has solely feature that for me it is significant to understand my current incapacity of practice as a PWP, to become a safe practitioner. I have already put action plans in place and started working on every single element of interpersonal skills such as questioning style, funnelling skills; avoid repetition, and test anxiety-nervousness, time management skills.
To achieve these, I must practice focussing on building self-confidence, self-awareness, self-reflection, evidence-based learning, practising more role play, use an audio tape recorder, observe another practitioner, welcoming feedback from supervisor and experienced colleagues and reflective practice. Formal and informal learning (Manuti, 2015), mental well-being (NICE, 2009) and management practice (NICE, 2015) at the workplace are essential for improving my communication skills; offer invaluable support through which I can improve my skills and achieve competency requirement as PWP and overcome unproductive practice. Apart from these, I have also started using interventions learnt at universities such as problem-solving, dealing with worries, breathing technique to gain self-control in various challenging personal and professional life situations. Overall, with whole experience, I have learnt to prepare for improving and appearing successfully to pass the exam on the second attempt.