The somatic symptoms of depression and anxiety present the most significant barrier to recognition because patients who somatise their symptoms will often lead their physician to think there is a physical reason for the symptoms. This preoccupation with physical illness often delays or prevents diagnosis.  Care models focus on recognizing depression by initially assessing patient mood and interest, suggesting psychotherapy and counselling for patients who have mild depression, and pharmacologic and psychotherapy or counselling for patients who have moderate-to-severe depression.

Barriers to psychotherapy & counselling - physicians feel that barriers arise most frequently from factors centred with the patients, their psychosocial circumstances, and their attitudes and beliefs about depression and its care, and about pop-psychology attitudes to what psychotherapy & counselling are. Motivation for psychotherapy or counselling is seen as a major factor for the success of psychotherapy. Examination of this motivation process requires procedures which recognize motivation for psychotherapy prior to initiation of therapy. Although still debated, there are protocols such as the Psychotherapy Motivation Questionnaire.

For successful referral over to psychotherapy & counselling, confirmative factor analysis affirms "initiative" and "knowledge" as two separate factors. Patients with somatoform disorders and "unexplained physical symptoms" as the reason for referral show less motivation for counselling and psychotherapy than other patients, and may need more ‘push’ from the referring GP.  Patients with previous experience with psychotherapy or counselling show higher motivation.

Most primary care patients in London who experience depression state that they would prefer psychotherapy over antidepressant medications. However, when referrals for psychotherapy are made, only 20% ever follow up, and of these, half drop out of counselling treatment. This suggests that there are substantial barriers to accessing psychotherapy.

When surveyed, London patients report one or more perceived barriers that would interfere with or prevent initiation or regular attendance of psychotherapy. Perceived barriers were more common among depressed than non-depressed patients making depression both an indicator for psychotherapy or counselling and a barrier to receiving it. London Gp’s can be helpful in the referral process by talking through the patient’s concerns about psychotherapy. A particular concern with patients accessing private psychotherapy in London is the cost. The London Association for Counselling & Psychotherapy has a sliding fee scale of £6.00 to £80.00 determined by income & circumstances. Our psychotherapy and counselling fee policy is clear, explicit and published – and we believe that this can allay some reservations about accessing private counselling & psychotherapy services in London. A further de-motivating factor is often the perception that access to counselling & psychotherapy services in London is time-consuming, difficult and may require substantial waiting time. At The London Association for Counselling & Psychotherapy access is by online submission and application, psychotherapy assessment appointments can be made the next day, and referrals onto the appropriate psychotherapist or counselling practitioner in our London practice are usually made within days of that psychotherapy assessment

Studies show the increased probability of referring to a counselling or psychotherapy service for physicians who devote more time to nonclinical activities, perceive psychotherapy consultation in London to be more readily available, have less confidence in their ability to manage antidepressants, and have personal life experience with psychotherapy or counselling. The idea that physicians with academic or administrative responsibilities refer onto psychotherapy differently than full-time clinicians is consistent with the work of Borowsky et al. who found that psychotherapy referrals are extremely common in academic generalist practices. Of course; the association between availability of counselling & psychotherapy services in London availability and utilization is a time-honoured theme in health services research.

Psychiatrists are rarely consulted, perhaps reflecting the “occupational transformation of the mental health system.” Surprisingly, only a minority of patients are given meaningful assistance with making psychotherapy or counselling appointments. Most patients are just told to call a London counselling & psychotherapy service number, utilise BUPA, or use the phone book. We suggest that although you can refer onto our London counselling & psychotherapy services by giving out contact details alone, the more substantial, informed and consolidated the ‘push over’ is made during the referral process, the more successful the referral outcome. The counselling service will benefit from the position and respect that you have with the patient. This is also why, in the brief letter above, we are keen to dialogue with our referring GP practices in London, so that they can have a greater awareness and confidence in our counselling & psychotherapy service.

Indications for Psychotherapy & Counselling:

“What treatment, by whom, is most effective for this individual, with that specific problem, and under which set of circumstances?” Put simply, the assessor seeks to determine which type of psychotherapeutic intervention is likely to be most appropriate and at what level. This calls for

• expertise in a thorough psychiatric evaluation beyond just making a psychiatric diagnosis;

• knowledge about the different forms of psychotherapy and counselling and the general indications for each; and

• how to initiate the necessary referrals to psychotherapy & counselling services or individual psychotherapists.

Evaluation of Psychotherapy & Counselling

Very often the referring doctor fails to follow up with patients they have referred for psychotherapy and counselling. This is unwise from various points of view. Firstly, In London many patients do not even turn up for the first counselling session and some patients drop out of psychotherapy and counselling even under the best hands. Secondly, psychotherapists need to be accountable to the referring doctor to a certain extent. Patients referred for psychotherapy and counselling in London may be vulnerable and may be exploited by unethical psychotherapists since there is no regulatory government body for this profession at present. Thirdly, referring doctors can learn much by following up on the progress of patients undergoing psychotherapy & counselling, including insights into patients’ problems, and appreciating psychotherapeutic techniques.

The London Association for Counselling and Psychotherapy is a group practice with over 35 psychotherapists and counsellors.  We will assess referrals into practice, and determine the most suitable treatment intervention. Psychotherapies at the London Association for Counselling & Psychotherapy include most of the major psychotherapy and counselling orientations, CBT, REM, couples and group psychotherapy and full psychoanalysis.