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

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

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

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

asked to carry out a clinical assessment of a patient presenting with symptoms of

depression. The entire process was filmed and graded by a member of staff who was

playing the role of the patient. A brief definition of reflection will be given, with the

emphasis on improving the practice of mental health.

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

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

plan for future experiences (Kemmis, 1985). This essay will refer to John’s reflective

model as a framework for reflection, focussing on the issues that can affect patient-

centred assessment interviews.

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

and uses that patients own knowledge and experience of distress to guide the

assessment, Richards & Whyte, (2008). Research dictates that this form of interview

practice is correlated with patient satisfaction and improvement (Lovell & Richards,

2000).

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

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

and having difficulty concentrating. The aim of the interview was to gather

information about the patient’s current problems and provide them with accurate,

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

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

depression and anxiety, (Lovell, Bee, Richards & Kendal, 2006). My interview was
structured around Richards & Whyte’s (2008) assessment criteria, therefore was

patient-centred. I began by introducing myself and confirming the patient’s name. I

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

Following the introduction I explained confidentiality and asked them to fill in a

PHQ-9 (Kroenke, Spitzer &Williams, 2001) and GAD-7 ( Spitzer, Kroenke, Williams

& Lows, 2006) questionnaire. The patient did not seem affected by the issue of

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

hard work. Once these were finished I asked if she could say in her own words why

she was here and to identify the main problems.

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

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

technique referred to as “funnelling” which is advocated by Richards & Whyte

(2008). I began by asking open ended questions such as “what is the problem” and

then asking increasingly specific questions such as “how is your sleep” so that the

patients account was placed at the centre of the interview. However, the issues around

being assessed and the presence of a time limit were always at the back of my mind. I

felt nervous that I would fail the assessment or run out of time. This made my

questioning style much more regimented than it should have been. As a consequence

of this, I feel it pulled away from the patient centeredness of the interview and that

she may have felt a little rushed. Furthermore, my worries around running out of time

meant that I did not always explore her answers to my questions to the degree that I

would have in a real life situation. In future practice I will try to use the funnelling

technique more effectively and spend more time following up the patients answers.

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

which she replied that she was tired. From this, I asked about her current sleep
patterns and the quality of her sleep. She revealed that she was going to bed much

later (3-4 am) and as a result getting up later in the afternoon. I began to ask more

specific questions about things which would affect the patient’s sleep such as the

amount of tea and alcohol she was drinking. The patient replied that she drank

between 6 and 7 cups of tea a day and switched to wine in the evening. At this point I

began to educate her about the influence of caffeine and alcohol on sleep and that she

should try and cut down. Unfortunately, on telling the patient this, her body language

became much more sunken and closed off as though she was being told off and her

answers to questions also become less detailed. At the time I felt pressurised to

educate the patient on the influences of caffeine and alcohol so that they could make

an informed decision and also so that I could show the assessors that I was aware of

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

the patient and that it would have been better for me to ask the patient more questions

about the influence the alcohol and caffeine had on their sleep thus letting her come to

her own conclusions. This conclusion is supported by research conducted by Stewart

(2000) who found that patient’s health improved when their therapy was

collaborative.

Once I had obtained a good understanding of the patient’s problem and she
had agreed with my summary, I continued to follow Richards & Whyte’s (2008)
guidelines and attempted to provide her with some information on depression and
Cognitive Behavioural therapy. I wanted to ensure that the patient fully understood
the cycle of depression and the type of therapy that I could provide. I felt that the best
way to do this was by using William’s (2009) Five Factor Model. To begin with the
patient seemed to recognise that our cognitive, emotional, behavioural and physical
factors were linked and that by changing one we can change the rest. However, as I
continued to explain the different types of therapy I tended to use complicated
terminology such as positive reinforcement and behavioural activation which the
patient did not seem to understand. She began to put her hands on her head and her
facial expressions suggested that she was confused despite saying that she understood.
I began to feel frustrated with myself for not being able to explain the models
properly and as a consequence gave her much more written information on depression
to compensate. I neglected to notice that in her PHQ-9 and GAD 7 forms she had
mentioned that she was having trouble concentrating. In this circumstance my
approach was inappropriate for this patient. Once again I believe that my nerves got
the better of me and my tendency to rush meant that I missed this important piece of
information. I should have used more simplistic and specific examples during my
explanations that allowed her to interact and remain focussed. Therefore, my actions
were incongruent with Richards & Whyte’s (2008) theory and my own beliefs that the
information given to patients should match their needs. Effective clinician-
patient communication has been linked to patient comprehension,
recall, satisfaction, and improved health outcomes. Castro, Wilson,
Wang & Schillinger (2007).
I feel that overall my assessment strategies went well, the patient mentioned

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

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

psycho-education and allow the patient to come to their own conclusions regarding

changes in their life style patterns. In short collaborative. This reflective essay has

been extremely challenging but I feel it has helped me to identify some key issues in

my practice. I will certainly be more aware of these in future and change my

behaviour as a consequence of this.

References

Kemmis, S. (1985). Action research and the politics of reflection. In D. Boud & R.
Keogh & D. Walker (Eds.),Reflection: Turning experience into learning (pp. 139-
163). London: Kogan Page.
Kroenke, K., Spitzer, R. & Williams, J.(2001) The PHQ-9 validity of a brief
depression severity measure. Journal of General Internal Medicine. Vol 16, pp. 606-
613.

Lovell, K., Bee, PE., Richards, DA., & Kendal, S. (2006) Self-help for common
mental health problems: evaluating service provision in an urban primary care setting.
Primary Health Care Research & Development. Vo1 l7. pp. 211-220.

Lovell, K. & Richards, D. (2000) Multiple Access Points and Levels of Entry
(MAPLE): Ensuring Choice, Accessibility and Equity for CBT Services.
Behavioural and Cognitive Psychotherapy, vol. 28, pp. 379–391.

Richards, D. & Whyte, M. (2008) Stepped care for common mental health problems:
a handbook for low-intensity workers. Oxford, Wiley.

Spitzer, R., Kroenke, K., Williams, J. & Lowe. (2006) The GAD 7. A brief measure
for assessing generalised anxiety disorder. Archives Internal Medicine. Vol 166.
pp.1092-1097.
Stewart, M. (2001)Towards a global definition of patient-centred care. British
Medical Journal. Vol. 322, pp. 444-445.

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

Castro, C. M., Wilson, C., Wang, F. Schillinger D. (2007). Babel Babble:


Physicians' Use of Unclarified Medical Jargon with Patients, MD. American
Journal of Health Behaviour. 31, pp 85-95.