Brief psychological intervention, often referred to as ‘low intensity interventions’, are based on the principle of helping the patient to develop skills in self-help approaches. As the evidence base continues to develop, the strongest models for brief ‘low intensity’ psychological interventions are for those based on cognitive-behavioural principles. These interventions focus on the ‘here and now’ of the patient’s problems to gain an understanding of the triggers for, and maintenance of, the anxiety or depression in terms of thoughts, physiology and behaviours; this is sometimes referred to as the A (autonomic), B (behavioural), C (cognitive) model of emotional disorder (Figure 10.1).

This understanding provides both the practitioner and patient with a shared understanding of the ‘vicious cycles’ of anxiety and depression, and offers a ‘map’ that can be used to guide decision-making about the best place to intervene to break the cycle, and the choice of intervention to achieve this. It can also be used subsequently to understand and manage stumbling blocks along the course of recovery.

Facing the challenge of balancing the principles of self-help whilst actively working to counter the inertia of depression or avoidance behaviour of anxiety, the practitioner works in a structured and active way alongside the patient to promote engagement and stimulate motivation. Using a combination of clinical skill and genuine ‘empathic curiosity’ the practitioner works to help the patient translate problems into achievable goals. To encourage self-efficacy between sessions, ‘tasks’ or ‘homework’ such as activity schedules or thought diaries are often used.

What types of problems are suited to brief intervention?

Patients seen before their difficulties have become entrenched, or before significant secondary psychosocial damage has occurred, are best placed to respond to brief psychological interventions. In reality, most patients are unlikely to attend primary care for help with mood problems until they are significantly affecting their daily lives and function, such as their ability to work, or where physical symptoms, such as fatigue or palpitations due to anxiety, are causing them concern. Sometimes the reason for asking for help is initiated not by the patient but at the insistence of a family member or partner who can see the effects of the problems more clearly. Even then, because of stigma, patients may be reluctant to admit to being depressed or anxious and may not talk about their mood problems unless directly asked. Because of this it is very important that the practitioner has the skills to ask directly and sensitively about mood, is able to respond with an explanation that is supportive, and helps the patient develop an understanding based on a normalizing rationale that instils hope.

Whilst brief interventions are ideally suited to early-onset, time-limited difficulties, it is also possible to use the focus that brief interventions bring to complex or multiple problems. In particular the opportunity to gain early momentum around specific problems, by turning them into achievable goals, instils hope. This can prove to be a helpful measure in itself; by breaking the cycle of immediate distress and enabling the patient to draw upon pre-existing coping and problem-solving abilities, the brief interventions can provide the ground work for future psychotherapy for more pervasive difficulties. By using a stepped care approach (Chapter 3), low-intensity interventions can provide a basis on which to improve the ‘here-and-now’ situation, which will increase self-efficacy and in turn prepare the ground for psychological therapy to address the longer-standing issues if required .

Not all patients attending primary care will be obviously anxious or depressed. The case study concerning John describes a primary care patient, who is typically reluctant to ask for help with emotional distress but presents with somatic symptoms that they can more easily talk about. Importantly, unlike the scenario above, this patient does not have the observable indicators of vulnerability that would be more easily recognised. However, in reality, they are just as vulnerable, but more at risk of being overlooked.

John is interesting as, whilst there are clear environmental and life stage factors to account for his emotional state, it requires a degree of ‘psychological mindedness’ to manage this transitional process. John, although intellectually and practically able, does not necessarily have the skills to look after his mental health.

This is not uncommon, and the practitioner who encounters John in primary care will most likely be presented with the physical manifestation of his emotional distress, namely palpitations, insomnia and fatigue. This type of patient can appear to respond initially to reassurance about their health. However, as the underlying maintenance factors of inertia, avoidance behaviours and faulty thinking have not been examined the problem will be maintained and they will inevitably re-present or deteriorate further without support.

As illustrated in the case of John, not all patients will present with obvious outward distress, and empathic curiosity is required to elicit how they are feeling. A simple empathic and curious enquiry such as that in Box 10.2 provides a useful normalising bridge from discussion about physical health or social concerns to the impact on the patient’s mental health and emotional wellbeing.