Alarge practice in Dulwich, south London, has been running a counselling service in patients' homes since February 1997.
Paxton Green group practice - with a 30-strong primary healthcare team of GPs, nurses, health visitors, counsellors and psychologists - had already introduced counselling and nurse practitioner posts, nurse prescribing and welfare rights surgeries.
But team discussions identified an inequity because housebound patients were unable to benefit from the counselling service. This affected the work of other team members visiting patients in their homes. Staff felt that often they had to contain and deal with complex psychological and emotional problems without the support and expertise required.
The primary healthcare team decided that one of the counsellors would offer home assessment and, if appropriate, treatment to these patients. The service would be regularly audited and evaluated.
However, serious thought needed to be given to how counselling in a domiciliary setting could be conducted appropriately and effectively. Counselling and psychotherapy training rightly stress the importance of 'boundary', 'frame' and 'contract' issues in creating the best framework for therapy. But, arguably, at times not enough attention is paid to the specific contexts in which counsellors and therapists find themselves working.
A statement was drawn up for each patient, outlining the conditions before their initial assessment. This states: 'It is important that the situation at home is as close as possible to that of the counsellor's room in the practice.
This means that you will need a room available for the session which is quiet, where there are no other people, and no distractions, ie no television, radio or telephone, so that the counselling will not be interrupted. It is not necessary to offer the counsellor food or drink: this could get in the way of the counselling and take up precious time.'
The domiciliary service was incorporated into the current appointment system of 50-minute sessions, with 10-minute gaps between them, allowing the counsellor to travel between the patient's home and the practice.
Results In the first year, 6 per cent of all counselling referrals to the service were for domiciliary work (10/152). Domiciliary appointments represented on average 1.5 a week (out of a total of 18).
Feedback was positive. The nurses reported that patients were helped to cope more effectively and that this benefited their overall health. Patients were reassured to know that help was available from a skilled practitioner.
Early results suggest that receiving counselling reduces patients' use of other practice services. In the two months before the first session this group of patients used the primary healthcare team 59 times; in the two months after it, they used the team 45 times, including counselling sessions.
More work needs to be done to further substantiate this finding.
Referred patients' problems Eight of the 10 patients felt depressed in relation to a recent life event (reactive depression). Again, bearing in mind the study size, this is a far higher level than can be found in referrals to the practice-based counselling service, where the annual total is 25 per cent. It may point to a feeling of powerlessness and passivity engendered by becoming housebound.
The nurse practitioner referred one 86-year-old patient to the counsellor because he was having difficulty coming to terms with a loss of cognitive and motor ability after a stroke. He felt depressed, and had a history of endogenous depression, as well as a long history of illness. He was seen six times.
In the first session, he said he felt confused about being alive, as he had been certain he was going to die as a result of his recent illness. He was also upset by his wife, who had apparently said, 'Don't think I'm going to look after you.' His mood brightened during the sessions.
The counsellor encouraged him to link past with present to make sense of his situation. This made him feel more complete. The client also reported it was important that the counsellor did not interrupt him. Before, he felt people did not have the patience to listen to him.
The domiciliary counselling service at Paxton Green has so far been a success, and has ensured that housebound people do not lose out. Practices where this facility is not on offer should consider developing it.
But in doing so, counselling and psychotherapy training may need to pay greater attention to the specific contexts in which counsellors and therapists work.
Paul Gurney is practice counsellor at Paxton Green group practice, south London.