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essay is based on a 15 minute simulated triage assessment conducted by a
trainee psychological wellbeing practitioner. It aims to provide a critical
formulation of a probable diagnosis, a critical risk management plan and
present the level of intervention required based on the stepped care model
(NICE, 2011) (appendix 1).


The client identified her
main problem as “feeling low all the time.” The trainee PWP gathered
information about the client’s current difficulties through the use of
Papworth’s (2013) ‘4 Ws’ – (What? When? Where? Who with?) – and Socratic
questioning (Padesky, 1993). The client’s symptoms were then applied to the
Five Areas model (Williams, 2015) (appendix 2). The client identified the onset
as being an organisational restructuring in work that she had found
overwhelming. Currently, the client’s symptoms are worse in the morning or when
she is in the house alone. She described her physical symptoms – feeling ‘worn
out,’ experiencing headaches and flu-like symptoms – in addition to
self-critical thoughts such as “I should be able to do things,” “Why aren’t I
getting things done?” She reported feeling “flat” in mood and some feelings of
guilt regarding her husband doing most of the housework, and behavioural wise a
reduction in social activity and avoiding seeing friends.

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The Diagnostic and
Statistical Manual of Mental Disorders 5th edition (American
Psychiatric Association, 2013) is the most
widely used tool for classifying mental disorders (Thomason, 2014). It has been criticised for being ‘too subjective’ as
it relies entirely on a client’s own self-report of their symptoms in order to
obtain a diagnosis (Morrison, 2014). However, as there is no ‘scientific’ way
to determine a psychiatric diagnosis, some level of subjectivity is unavoidable
(Paris, 2013).


The DSM-5 states that for a
client to meet the criteria for a ‘major depressive episode,’ they must have
experienced five or more symptoms including depressed mood (characterised as
feeling sad, down or hopeless) and lack of enjoyment or pleasure, within the
same two week period for longer than two weeks (APA, 2013, p.160). The client
reported experiencing consistently low mood for around 6 months, as well as a
number of symptoms classified within the DSM-5 (as previously discussed). This
is also the client’s first experience of mental illness, so this would be
classed as a single major depressive episode. The DSM-5 recommends exploring
whether the client’s symptoms can be attributed to another medical condition or
the use of substances in order to obtain a more accurate diagnosis. The client
reported not experiencing any other form of physical or mental health problem.


The client completed two questionnaires
– the Patient Health Questionnaire (PHQ-9) (Kroenke et al, 2001), which asks questions
related to symptoms of depression, and the Generalized Anxiety Disorder
Questionnaire (GAD-7) (Swinson, 2006) which asks questions regarding symptoms
of anxiety (appendices 3 & 4). Although the PHQ-9 and GAD-7 are useful
tools for supporting a probable diagnosis and monitoring changes in
symptomology, the scores alone cannot be relied on to identify this, and the
therapist must check that the sores correlate with the symptoms the client is
describing during clinical contact (Kroenke and Spitzer, 2002). The client
scored 4 on the GAD-7, which denotes a ‘sub-therapeutic’ level of anxiety, and 12
on the PHQ-9, which denotes a ‘moderate’ level of depression. The client’s
scores were congruent with the symptoms described during the assessment, and
both client and trainee PWP agreed this was an accurate rating.


PWPs must assess both current
and previous levels of risk in the following areas – harm to self/ risk of
suicide, harm to others from the client, harm to the client from others, substance
misuse and self-neglect (Morgan, 2000) (appendix 5). A comprehensive risk
management plan should be created in collaboration between client and
therapist, and would support the client to manage their potential risk
behaviours in order to keep themselves and others safe (DoH, 2007). The client presented
as being ‘low risk’ when assessed by the trainee PWP based on the above factors
as she denied any thoughts, plans or intentions to harm herself or others, she
did not feel at risk from anyone else, she was not misusing substances and was
managing to look after herself. The client also denied any historic risk.


Morgan (2004) states that mental
health services often take a ‘risk averse’ approach due to fear of negative
consequences as a result of ‘blame culture.’ However, empowering and effective
treatment is more likely to come from a positive risk-taking approach, which
involves, “Identifying the potential risks involved, and developing plans and
actions that reflect the positive potentials and stated priorities of the
service user,” (p.18). A positive risk management plan is based on the client’s
existing helpful coping strategies and protective factors (DoH, 2007) (appendix
6). The client identified talking to her husband as helpful and that if her
mental health deteriorated she would be able to turn to her husband, family and
friends for support.


The therapist should explore
protective factors with the client, which can be defined as, “Strengths or
assets that help people to maintain mental wellbeing and be resilient,” (Mind
Matters, date unknown). The client described her husband as being a protective
factor, and also showed a hopeful and motivated attitude towards engaging in therapy.
It is also good practice for the practitioner to provide the numbers for the
Crisis Team, Samaritans and NHS 111, and advise the client to make an emergency
appointment with her GP or present at A&E if at immediate risk. However, the
therapist should be mindful not to over-estimate the client’s level of risk as
this can result in the client being offered treatment that is more restrictive
than necessary and more time consuming and costly for the service (Bryan and
Rudd, 2006, p.185).


Risk can never be eliminated
completely and the risk that the client presents with can fluctuate depending
on environmental, situational and personal factors (Health Service Executive,
2009, p.5-13). Therefore, it is important for the practitioner to reassess the
client’s risk during each clinical contact, as well as at planned intervals
while they are on the waiting list for treatment through the use of ‘check in


Improving Access to
Psychological Therapies (IAPT) is a nationwide initiative introduced in 2008 to make treatment more
accessible for people with common mental health problems (NHS, 2007). The
stepped care model was implemented within IAPT to enable access to the most
effective, least restrictive level of intervention required (NICE, 2011).


The PWP role involves
assessing and treating people with common mental health problems using CBT (Cognitive
Behavioural Therapy) based interventions, and sits at step 2 within the stepped
care model (DoH, 2015). A range of treatments can be offered at step 2,
including 1:1 sessions, psycho-educational groups and computerised CBT (NHS and
DoH, 2010, p.32). It would be good practice for the practitioner to explain the
different forms of treatment available for the client during the full
assessment and give them the choice of preferred treatment in order for the
client ownership over their therapy and to continue to build a positive
therapeutic alliance (We Need to Talk Coalition, 2010, p.11).


The CBT approach has proven
to be effective in treating a number of common mental health problems by empowering
clients to identify and challenge extreme thinking and unhelpful behaviours. It
is used by many mental health services as it is a short term, cost effective
intervention and client progress is easy to measure (BABCP, 2012). However, it
is acknowledged that it is less effective in treating ‘deep-rooted’ problems
that develop from early life experiences, and has been criticised for its lack
of emphasis on the relationship between client and therapist in comparison to
other therapeutic approaches (McLeod, 2013). However, in more recent years the
CBT approach has acknowledged the correlation between a positive therapeutic
relationship and the overall effectiveness of therapy in treating the client’s
symptoms (BABCP, 2012).


As discussed earlier in this
essay, the client is presenting with symptoms of a moderate major depressive
episode according the criteria defined within the DSM-5 (2013), which is
congruent with the scoring on her PHQ-9 (Kroenke, Spitzer and Williams, 2001).
The NICE Guidelines (2011) state that individuals experiencing mild-moderate
depression can be treated at step 2. Based on the presentation of the client
during the assessment – low risk, first episode of mental illness and no
co-morbidity factors – a step 2 level intervention would be appropriate. According
to the COM-B model (Michie et al, 2011), the client presented as having the
capability to engage in treatment as she did not identify any barriers to accessing
treatment, and she already has a basic knowledge of the CBT approach. The
client described lacking motivation to carry out tasks that she used to enjoy,
eg, spending time with friends, however seemed motivated to engage in therapy.


If necessary, the client
could be stepped up to a higher intensity treatment at step 3. This would be
appropriate if the client’s symptoms did not improve in response to step 2
interventions (Durham, 2007) or if their level of risk increased significantly.
An advantage of the stepped care model is that it is easier for the client’s
care to be ‘stepped up’ to a higher intensity treatment, however it is argued
that there is subjectivity around what level the client would sit within the
model from practitioner to practitioner (Bennett- Levy et al, 2010). This
highlights the importance of practitioners engaging in regular supervision in
order to reflect on each client case to ensure the most appropriate options for
treatment are being offered to them.

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