Exploring service users' experiences of psychological interventions in primary care: thematic synthesis of the evidence and an empirical study using Interpretative Phenomenological Analysis

Abstract

The global burden of mental disorders is significant and Primary Mental Health Care services (PMHCS) play a crucial role in public mental health by providing local, accessible and efficient psychological interventions that meet individuals’ needs. Improving access to, and provision of psychological interventions in PMHCS is considered a public health priority. Qualitative research focused on patients’ experiences can inform development of accessible, high-quality and person-centred mental health services. This thesis portfolio explores qualitative approaches to service users’ experiences of PMHCS.

The first paper is a qualitative meta-synthesis which collates and syntheses the available qualitative literature focusing on service users experience of psychological interventions in PMHCS. The second paper is an empirical study exploring service users’ experience of psychological interventions during Covid-19 pandemic in a Primary Mental Health Care service in Northern Scotland.

The qualitative meta-synthesis involved a systematic search of multiple databases. Twenty-two articles met the inclusion criteria, with data then extracted and coded on NVIVO using thematic synthesis. The Critical Appraisal Skills Programme (CASP) tool was chosen to assess study quality. In the qualitative empirical study, nine semi-structured interviews from Primary Care Mental Health users in Northern Scotland were audio-recorded, transcribed and analysed using Interpretative Phenomenological Analysis (IPA).

The qualitative meta-synthesis identified four analytical themes and ten subthemes. The themes were: (1) Access and Acceptability: facilitators and barriers, (2) Structural aspects (3) Therapeutic process, and (4) Outcomes. A model of interrelationships between themes is proposed to integrate these findings. The qualitative meta-synthesis findings suggested several ‘essential ingredients’ across psychological interventions, modalities, formats and settings. The crucial role of relational factors, the importance of assessing how individuals perceive treatment features and of tailoring the intervention to individuals’ needs were emphasised.

Results also suggested involving more service users in discussions and decisions about psychological interventions offered might enhance access, acceptability and engagement.

From the empirical paper analysis of the semi-structured interviews revealed twelve subthemes and four superordinate themes. The superordinate themes were: (1) Orientating to treatment, (2) Interventions features, (2) Change enablers, and (4) Impact. The participants’ accounts revealed both facilitators and barriers associated with access and psychological change as well as narratives around Cognitive Behavioural Therapy (CBT) acceptability, outcomes and remote delivery. The role of General Practitioners (GPs) emerged as a key determinant of access to psychological interventions in primary care. The therapeutic relationship contributed to person-centred care provision, idiosyncratic change processes and self-empowerment. A personal commitment to engage with homework was described as a change enabler.

Both studies results are discussed in relation to existing literature, and implications for future research and practice. In terms of implications, the systematic review strongly suggests that clinicians and staff should be more willing to involve service users in discussions about psychological intervention, and in particular to explore their feelings, expectations and needs about intervention. This is especially true when service users present with specific needs or diversity issues. Furthermore, assessing individuals’ preferences and perception of treatment features may help identify the ‘right fit’ between individual characteristics and structural aspects of interventions; whilst also trying to minimize adverse effects of intervention.

Importance should also be given to relational factors in order to facilitate person-centred care and address service users’ challenges experienced across therapy modalities and formats.

The implications of the empirical study concerned primary care services, GPs and clinicians, specifically in a Scottish context, but with generalizability to other settings. Firstly, Primary Care services should seek to improve communication to service users about the accessibility and availability of psychological interventions. For example, providing information about benefits, challenges and level of commitment associated with CBT interventions to help service users make an informed choice and adjust inaccurate expectations that they might hold about psychological interventions. Also, PMHCS should keep offering psychological interventions remotely, remaining mindful of the challenges associated with.

Secondly, results suggested the need for GPs to receive further specialised training in assessing mental health needs. GPs might also provide information about psychological treatment available alongside medications.

Finally, clinicians in PMHCS should remain mindful of the key role of the therapeutic relationship in tailoring the material and intervention to meet service users’ needs.