Referrals for bereavement counselling in primary care: a qualitative study

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Abstract

The growth in the provision of counselling services in British primary care offers an opportunity for general practitioners (GPs) to refer patients to counsellors following bereavement. This study explores the factors that influence GPs referral decisions. Qualitative interviews were conducted with 50 GPs from two cities in southern UK. The study found that GPs draw on notions of abnormal bereavement in making referral decisions. Indicators of bereavement problems related to: the nature of the death; level of social support; and reaction to the death. GPs views about the types of patients likely to benefit from counselling were further criteria employed in referral decisions. The study indicated that consideration of these factors may discriminate against certain types of patients being referred. Further education in the range of psychological theories of bereavement may assist GPs in understanding their bereaved patients’ experiences and in developing their skills in recognising abnormal reactions and making appropriate referrals.

Introduction

There remains some ambivalence as to the role of general practitioners (GPs) in providing support to bereaved patients. The increased rates of mortality and morbidity following bereavement have led some to advocate a role for the primary health care team [1], [2], while others have questioned the advisability of this and have highlighted the dangers of medicalising a normal process of life transition [3]. However, patients are increasingly expecting to be offered support post-bereavement [4] and the continuing secularisation of society may mean that people expect to be able to turn to GPs, rather than religious advisers, for support following a death [5]. There is evidence that GPs may not have the appropriate skills to offer bereavement support [6], with a survey indicating that only 30% had received any educational in-put about bereavement support and just 9% believing their training to be sufficient [7]. Additionally, at a time when GPs are experiencing increasing workloads it is likely that many will feel that they do not have the time to engage in prolonged supportive interventions [8].

Over the last decade, there has been a rapid growth in the provision of counselling services based in or associated with primary medical care [9]. This growth has arisen from various policy initiatives and a recognition that the many patients who consult with psychosocial problems may be better served by those with counselling skills. A national survey carried out in 1993 found that 31% of practices had counsellors and a further 62% would have welcomed such a service [10]. By 1999, 51% of practices had counselling provision [9]. There is some evidence that dealing with loss and bereavement forms a substantial proportion of counsellors’ case-loads, suggesting that GPs view bereavement as a problem which responds to the type of help counsellors can provide [10].

Research on bereavement has conceptualised normal and abnormal bereavement reactions [11], [12]. Normal bereavement reactions are identified as the process whereby an individual moves through stages of sadness and grief to a state of acceptance and adaptation. Abnormal bereavement reactions have been identified as those where individuals develop mental health problems such as depression and anxiety or specific bereavement disorders where grief is absent, delayed or chronic. Risk factors that predict poor bereavement outcome have been identified as relating to individual factors, relationship with the deceased, type of death and circumstances after death. GPs are viewed as having a role to play in preventing and treating abnormal bereavement reactions [11], [12] and bereavement counsellors are one of the resources that GPs can use to manage this group of patients. However, little research has been conducted examining the use GPs make of practice-based counselling for bereavement and how they decide what patients to refer to such services.

The study reported on here was conducted to explore the factors that GPs take into consideration in making decisions about the referral of bereaved people to counsellors in primary care and the strategies used by counsellors in counselling bereaved clients. The strategies used by counsellors have been reported elsewhere [13]. This paper draws on the data collected to describe the factors that inform GPs referral decisions to practice-based counsellors.

Section snippets

Study design

This study comprises a qualitative design in which the aim was to explore the range of issues that GPs take into account in making decisions about the referral of patients to practice-based counsellors. It was not the intention to conduct a survey to identify the numbers of patients GPs refer to counsellors or the relative significance of specific factors in referral decisions. Rather than seeking to make generalisations about GPs’ referral decisions, this study uses established qualitative

Results

The referral of bereaved patients to practice-based counsellors was not considered a routine pathway by any of the GPs because it was felt that most patients dealt and recovered from their bereavement in their own way and that this normal life process should not be medicalised. Additionally, counselling was identified as an important but limited resource and GPs wanted to ensure that they referred only those patients who needed, and were most likely to benefit from, such a service. Many of the

Discussion and conclusion

The size of the study and mixed methods of data collection place some limitations on the conclusions that can be drawn from our findings. We sampled from two areas of southern UK covering both urban and rural settings, a diversity of socioeconomic environments and different sized practices with the aim of maximising the range of the sample. However, recruitment of GPs was difficult, as anticipated. It may be that those participating were more knowledgeable about bereavement risk and more

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