Do GPs have a duty to be counsellors?

PRACTICE DILEMMA

A depressed patient wants her GP to be her sole counsellor, but he does not have the time. What should he do?

THE DILEMMA

Laura has moderate depression, which has responded to antidepressants.

However, she has many unresolved psychological conflicts and I have suggested counselling with the local voluntary service. She tells me that she does not want to see anybody else, as I understand her problems and I know about her family; she wants me to provide counselling. Unfortunately, I do not have the time, but I feel guilty about letting her down. What should I do?

A GP'S VIEW

Dr Peter Ilves, a GP in London

It is encouraging to hear that a patient trusts their GP to this extent; this is invaluable and is sometimes lost and threatened by all the initiatives that are driven through primary care.

In the distant past, counselling and support were a part of general practice.

However, the current reality is that a GP has only a fraction of the time available that is needed to offer this fully.

In this situation, two or three double appointments might address some of the issues. There are some simple techniques that may be utilised to potentiate her recovery.

In some cases simple guidance and/or positive visualisation through cognitive behavioural therapy (CBT) techniques or neuro-linguistic programming tools can be used. It might be that she simply needs some ongoing support while she finds her own way out of her situation.

However, if she appears to need formal counselling, it is unlikely that you will be able to offer this and, in truth, most of us do not truly have the specialised skills of a counsellor. It may also be that she needs a more dynamic input and CBT or a psychodynamic approach might be required.

If the doctor-patient relationship is as solid as this scenario implies, then the GP should be able to make the point that it is in her best interests that she take on expert help. However, the doctor should not leave the patient feeling that they have been abandoned.

If the response of the patient is negative they could be demonstrating a dependence on their GP.

This would make things more complex but it would be advisable not to heighten this by succumbing to setting up multiple appointments.

A MEDICO-LEGAL VIEW

Dr Marika Davies, medico-legal adviser, MPS

It is unfortunate that Laura does not wish to go elsewhere for counselling, but this does not mean you should be expected to provide this service.

You are unlikely to have the necessary training or time to be able to provide Laura with the counselling that she requires.

According to GMC guidance you must recognise and work within the limits of your professional competence and you must try to give priority to patients on the basis of clinical need.

Laura's needs must be weighed up against the needs of your other patients.

You will need to explain to Laura why it will be beneficial to her to have counselling, and that the local service has the experience and resources to provide her with this.

You should also reassure her that the counsellor will become sufficiently familiar with her past history and family situation, and that you will continue to take an interest in her care and that you will also review her progress regularly.

It is understandable that you might feel that you have let her down, but you are only able to act within the boundaries of your own clinical expertise, taking into account the many other demands on your time and your obligations to your other patients.

A PATIENT'S VIEW

Trevor Seemann, member, Patient Partnership Group

As Laura's depression is moderate she is not a risk to herself or anyone else, but she is in need of psychological support.

She could be encouraged to accept a counsellor by having an initial meeting in your surgery with you in attendance. This might possibly place her at ease with a counsellor and enable you to withdraw from the process.

Alternatively, she might accept meeting the counsellor with a member of her family accompanying her.

Ultimately, she needs to realise that it is not practicable for you to take on the role of counsellor.

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