Sibbald B, Addington-Hall J, Brenneman D, Obe P F
National Primary Care Research and Development Centre, University of Manchester.
Occas Pap R Coll Gen Pract. 1996 Nov(74):1-19.
Counselling services in general practice are now widespread but little is known about their nature or role. We therefore carried out in-depth telephone interviews with a representative sample of 72 general practitioners and 60 of their counsellors who had participated in a previous national survey of counselling services in England and Wales. Our aim was to gain greater insight into the functioning of these services in order to determine the most appropriate focus for future research and development. Interviews were semi-structured and focused on service initiation and duration; counsellors' background and training; working arrangements including sources of funding; types of clients; communication between general practitioners and counsellors; perceived advantages and disadvantages to general practitioners, counsellors, and clients; goals, barriers, and proposed changes. Approximately two thirds of counsellors were employed by district health authorities and attached to practices. One third were employed by the practice with the financial assistance of family health services authorities. Practice-employed counsellors appeared a relatively new service innovation whose growth was facilitated by the general practitioner contract of 1991. Practice-employed counsellors were preferred to practice-attached staff in that general practitioners had greater control over the selection of counsellors and their working arrangements. Problems with interprofessional communication were noted in relation to counsellors' wishes to maintain patient confidentiality by not exchanging information about patients with general practitioners. Counsellors received referrals principally from general practitioners and occasionally from other primary health care staff. Self-referral by patients was rare. The problems for which patients were most commonly referred were: stress/anxiety, relationship problems, depression, and bereavement. The principal therapeutic styles were Rogerian counselling, behavioural therapy, and psychodynamic psychotherapy. A quarter described their style as 'eclectic'. Individual, not group, therapy was the norm. Sessions were usually 50 minutes in duration. However, waiting list times, the frequency of sessions, and overall duration of therapy varied enormously. Overall 28% of counsellors held no formal qualification in counselling or in any of the psychotherapies. Counsellors and general practitioners were generally satisfied with the service and identified a wide range of benefits with few disadvantages. The principal problem was said to be that demand exceeded capacity and the principal change proposed was expansion of the service. The findings provide the most comprehensive account to date of the present state and likely future direction of counselling services in general practice and point to the need to: 1. Evaluate the cost-effectiveness of counselling in the management of common psychiatric disorders such as anxiety and depression 2. Establish a national policy for the training and accreditation of counsellors working in general practice settings 3. Educate general practitioners about the organization and role of counselling services with particular attention to interprofessional communication and the maintenance of patient confidentiality.
目前，全科医疗中的咨询服务已广泛开展，但人们对其性质和作用了解甚少。因此，我们对72名全科医生及其60名咨询师进行了深入的电话访谈，这些医生和咨询师参与了此前在英格兰和威尔士开展的全国咨询服务调查。我们的目的是更深入地了解这些服务的运作情况，以便确定未来研究和发展的最适当重点。访谈采用半结构化形式，重点关注服务的启动和持续时间；咨询师的背景和培训；工作安排，包括资金来源；客户类型；全科医生与咨询师之间的沟通；全科医生、咨询师和客户认为的优点和缺点；目标、障碍以及提议的变革。大约三分之二的咨询师受雇于地区卫生当局并派驻到各个诊所。三分之一的咨询师受雇于诊所，并得到家庭健康服务当局的资金援助。诊所雇佣的咨询师似乎是一项相对较新的服务创新举措，1991年的全科医生合同推动了其发展。与派驻诊所的工作人员相比，诊所雇佣的咨询师更受青睐，因为全科医生对咨询师的选拔及其工作安排有更大的控制权。在跨专业沟通方面存在问题，咨询师希望通过不与全科医生交换患者信息来维护患者的保密性。咨询师主要从全科医生那里获得转诊，偶尔也会从其他初级卫生保健人员那里获得转诊。患者自行转诊的情况很少见。患者最常因以下问题被转诊：压力/焦虑、人际关系问题、抑郁症和丧亲之痛。主要的治疗方式是罗杰斯咨询、行为疗法和心理动力心理治疗。四分之一的人将他们的治疗方式描述为“折衷主义”。通常采用个体治疗而非团体治疗。治疗时长通常为50分钟。然而，等候名单时间、治疗频率以及总体治疗时长差异很大。总体而言，28%的咨询师在咨询或任何心理治疗方面没有正式资质。咨询师和全科医生总体上对这项服务感到满意，并指出了广泛的益处，缺点很少。据说主要问题是需求超过了服务能力，提议的主要变革是扩大服务。这些研究结果提供了迄今为止对全科医疗中咨询服务现状和可能的未来方向最全面的描述，并指出有必要：1. 评估咨询在焦虑和抑郁等常见精神障碍管理中的成本效益；2. 制定一项针对在全科医疗环境中工作的咨询师的培训和认证国家政策；3. 让全科医生了解咨询服务的组织和作用，尤其要关注跨专业沟通和患者保密性的维护。
