BSc (Hons) Community Health Care NURSING
(Health Visiting)
Mental Health and Helping Skills
Claire Margaret Ramsden
Submission Date – 6th June 2002
Word Count – 2,989
Contents
Page
- Introduction ……………………………………………… 1
- The development of a helping relationship ………. 2
- The Ante-Natal Visit ……………………………………….. 2
- The Birth Visit ……………………………………………….. 4
- The Second Post-Natal Home Visit ……………………… 5
- The Third Post-Natal Home Visit …………………….….. 6
- Developing the Care Plan …………………………………. 8
- The First Listening Visit …………………………………… 10
- Continuing Care …………………………………………….. 11
- Conclusion ………………………………………………… 13
- Appendices
Appendix 1 – The EPDS explained …………………….… 15
Appendix 2 – Edinburgh Post-natal Depression Scale (EPDS) 16
Appendix 3 – EPDS – Scoring …………………………….. 17
Appendix 4 – The Stages of Change Model ……………… 19
Appendix 5 – EPDS – 19/02/2002 ……………………….. 20
Appendix 6 – EPDS – 25/02/2002 ……………………….. 21
Appendix 7 – Post-natal series of events ………………… 22
- References ………………………………………………… 23
- Bibliography ………………………………………………. 29
- Introduction
“Mental health: is the emotional and spiritual resilience that
enables us to enjoy life and survive pain, suffering and
disappointment. It is a positive sense of well-being and
an underlying belief in our own worth and the
worth of others”. Holland (2000)
This assignment identifies a client I have been visiting as part of the BSc (Hons) Community Health Care Nursing – Health Visiting, within a large inner city area. The assignment describes how the client’s mental health needs were assessed and a negotiated plan of care was offered to support the client.
An outline of the Health Visiting role is addressed along with the role of others involved in the care. A critical reflection of the experience is addressed with its implications on the role of the specialist practitioner within the wider picture of mental health practice in primary health care.
The assignment is a reflective incident, it is therefore written in the first person singular.
- The development of a helping relationship
To ensure anonymity and confidentiality of the client and family, names have been changed. The mother’s name has been changed to Joanne, aged thirty. The father is Gavin, aged thirty-two. Their eldest son is Oliver, aged two years and newborn girl named Kelsie. Informed consent was obtained from Joanne.
The problem that became a mental health issue began in the period, prior to the birth of Kelsie. During the monthly meeting between the Health Visitor and Community Midwife, issues were raised regarding Joanne’s low mood. She had refused treatment for anxiety, stress, and/or depression as she felt she was coping. Following the meeting, I had a lengthy discussion with my CPT – it was concluded that Joanne presented a suitable case for me to visit professionally, both ante-natally and post-natally.
- The Ante-Natal Visit
Joanne was contacted and an ante-natal visit arranged. The ante-natal visit is designed to establish a relationship, introduce the perspective of Health Visiting and hopefully, identify any factors creating vulnerability in the family (Robotham and Sheldrake, 2000). I discussed with Joanne the role of the Health Visitor, explaining that I would visit her and the baby post-natally in their home for as long as she needed and thereafter at the clinic. Support services within the practice area were portrayed and I explained that I would ask her to complete the Edinburgh Post-natal Depression Scale (EPDS) questionnaire between the sixth and eighth post-natal weeks (Cox, Holden, Sagovsky, 1987). This would be undertaken in order to determine her mental status over the previous week (See Appendix 1,2,and 3).
Joanne described her pregnancy as difficult. She suffered nausea and vomiting, and had been a hospital in-patient at 9 weeks of pregnancy, being prescribed anti-emetics and an intra-venous infusion for 5 weeks. She also stated that she felt that she was not a good mother to Oliver. When asked about this she felt that being a working mother was hindering Oliver’s development (Oliver’s developmental checks had been undertaken and everything appeared to be normal). Gavin had been unable to help, as he had been working extra shifts. Harvey (1999) describes a symptom of depression as feeling that you are not a good mother or you are not taking care of the baby.
Joanne and Gavin have few friends and no family in the area. Joanne’s mother lives in Liverpool, visiting Joanne and family fortnightly. Joanne has no contact with her father. They appeared to have minimal support from friends and family. These factors contributed to Joanne’s bio-psychosocial needs. With all this information I completed the health needs assessment of the family.
In 2001, Deaves suggested that prevention of post-natal depression (PND) should begin in the ante-natal period, primarily identifying predisposing factors. These include social and psychological i.e. previous PND. Social factors include bereavement, difficulties with relationships – particularly supportive relationships, and inadequate social support. Green and Murray (1994) surveyed literature assessing the extent of depression during pregnancy, concluding that prevalence rates of depression during pregnancy were equal to those after delivery. Following on from this they used the EPDS (See Appendix 1, 2 and 3) to record scores during the ante-natal period, comparing them with post-natal scores, they found a close link between the two periods.
Through personal reflection and discussion with the Community Practice Teacher (CPT), the situation was critically analysed, concluding that Joanne would benefit from extra support. However, on being approached Joanne declined extra support stating that she would be happy to see me following the birth of the baby.
- The Birth Visit
The following week my CPT received notification of Joanne’s delivery and I arranged a birth visit; a visit designed to discuss the positives and negatives of the birth experience. Describing the birth experience as being positive, Joanne however, felt that the labour was too quick; 1¼ hours from the 1st contraction to delivery of the placenta, with no time for any pain relief.
During this visit, it became evident that meaningful communication between Joanne and Gavin was lacking, both verbally and non-verbally. Research shows that women can experience feelings of being alone and without support from about 3½ weeks post-natally (Eastwood, 1995). Rickitt (1987) states that women in unsupportive relationships are more likely to experience feelings of isolation, and, a woman without a close, confiding relationship is nineteen times more likely to develop post-natal depression. With this research in mind and Joanne’s previous history, I felt it necessary to meet Joanne to discuss ways of relieving any possible anxieties/stress. Accordingly a home appointment was made to see Joanne by herself.
- The Second Post-Natal Home Visit
On arrival for the visit Joanne was extremely cheerful and appeared very organised. The house was exceptionally clean and tidy and Oliver was sitting quietly watching television. However, the atmosphere felt very tense and Joanne appeared not to want to talk. The visit quickly came to an abrupt end by Joanne stating she had to go out.
Through further reflection and discussion with my CPT It was agreed that by involving her G.P. a multi-disciplinary approach to Joanne’s care would be created. In practice, this would result in professional collaboration of meetings and ultimately joined up working (Fatchett, 1998).
As a specialist practitioner, there is a need to develop skills of effective listening, in order that help can be provided by allowing clients to talk and identify their health needs (Ewles and Simnett, 1995). Rollnick, Mason and Butler (2000), state that the acquisition of listening skills requires practice and self-awareness of what is being achieved and how the patient responds, they also state that it is easy to allow the attention to wander, either by thinking about similar experiences or interrupting and agreeing or disagreeing.
Beginning with the aforementioned visit and continuing with the following visits, praise was seen as being a successful tool. Praise and encouragement would, hopefully, enable Joanne to look at her lifestyle more globally.
2.4 The Third Post-Natal Home Visit
On arrival for the visit, the greeting was unwelcoming, involving minimal eye contact. Joanne stated that she was unable to cope with the present situation. She explained that she had not wanted any health professional, her husband, or her mother to know her true feelings, and that she felt she was not caring for the children. I discussed the EPDS questionnaire with Joanne, suggesting that it be completed, Joanne agreed. I explained that this was a guide to identify how she had been feeling over the past seven days, not just during this visit. Crafter (1997) explains that there is no single cause for PND. However, women often experience a series of events post-natally, which can compound their depression. It was felt that Joanne had experienced a series of events that could have compounded her depression (See Appendix 7).
Cullinan (1991) explains that most women complete the questionnaire in less than five minutes. Â Joanne took less than three minutes, scoring 21 out of a possible 30 (See Appendix 5). Â On reflection I was satisfied that my skills and ability had recognised the PND, but more importantly that a plan of care needed to be negotiated. Â Leeds mental health guidelines (2002) state that if a woman scores above 12, the EPDS should be repeated after 7 – 14 days, if still above 12, offer 4 listening visits and inform the G.P. Â I decided that a number of areas needed to be covered, these included â
- Informing the G.P.
- Informing my CPT
- Discuss with Joanne, the issues highlighted in the questionnaire.
Following the use of the EPDS questionnaire, it was apparent that Joanne was suffering from post-natal depression. Â Having explained my role to Joanne and how I would support her, I explained that I needed to inform her G.P, my CPT and discuss the situation with the counsellor, based at the clinic, Joanne then asked about anti-depressants. Â I explained that her G.P would decide if these were appropriate. Â I asked if she would agree to see her G.P, she stated that she had an appointment the following day for her post-natal check. Â We agreed that Joanne would keep the appointment and I would contact the G.P that day to explain my findings and discuss her care from a Health Visiting perspective. Â We arranged for a repeat EPDS to be completed during the following weeks visit.
I discussed the visit with her G.P, we discussed the possibility of a course of anti-depressants, the G.P stated that these were a possibility and she would assess Joanne the following day.
2.5Â Â Â Â Â Â Â Â Developing the Care Plan
Through further reflection with my CPT and Joanneâs G.P, I was able to critically analyse the situation. Â It was agreed that Joanne would benefit from extra support and listening visits could provide her with a method of moving forward. Â Joanne agreed and fortnightly listening visits were arranged.
The âStages of Change Modelâ, (Prochaska and Diclemente, 1982) was chosen to structure the visits. Â This provided a framework, which allowed the need to change behaviour, to be worked through. Â The third post-natal visit appeared to promote Joanneâs attitude to change, from the pre-contemplation stage to the contemplation stage; âthe individual thinks seriously about changing their behaviourâ (Prochaska and Diclemente, 1982). Â Having previously used, this model it seemed a suitable way to structure the visits and plan her care. Â Egan (1990) describes a model of counselling. Â However, not having undertaken any counselling I felt that this model was inappropriate for my use. Â Orem (1991), describes a Self Care model, but I decided not to use this model, as Joanne did not perceive that she had a problem, therefore I decided that we could not have worked through her problem with ease, using this model. Â
I felt that using the Stages of Change Model (Prochaska and Diclemente, 1982), would allow Joanne to work through her problem of low self-esteem in order to make specific changes to her pattern of behaviour. Â Joanne ultimately became empowered understanding her role as a mother and accepting her individual limits. Â The Stages of Change model was chosen as at the initial ante-natal visit Joanne was placed at the pre-contemplation stage; this stage is seen as when the individual is not considering changing their behaviour; Joanne had expressed that she was coping and declined extra support. Â Rollnick, Mason and Butler (2000), state that the Stages of Change Model attempts to describe readiness and the way in which individuals move towards making decisions and behavioural changes in their everyday lives.
Mental health problems are a common occurrence in primary health care. Â Hannigan (1998) states that non-mental health specialist practitioners are increasingly becoming involved in identification, assessment, and care of people with mental health problems. Â It is noted by Eastwood (1998), that Health Visitors have an important role to play in individual counselling, but states that it has its limitations. Â With these thoughts in mind, several interventions were put into place to support Joanne; the rationale for these interventions will be discussed.
To meet Joanneâs individual needs and to develop a helping relationship, recognition of the links between my specialist practice setting and the wider mental health picture was identified. Â The National Service Framework for mental health (2000) identifies the promotion of mental health for all, explaining that â
âMental health promotion is essentially concerned with how individuals,
families, organisations and communities feel, the factors which influence
how they feel and the impact that this has on
overall health and well-beingâ. Â Â Â Â Â Â (D.O.H, 2000, p 14)
In discussion with my CPT I expressed concern for Joanne and her score on the EPDS questionnaire. Â We agreed that an important role of the Health Visitor was early detection of post-natal depression where use of listening visits usually had a successful outcome (Mead, Bower and Gask, 1997). Â Trebble and Greenhill (1992) discuss the management of post-natal depression, concluding that the Health Visitor is in an ideal situation to offer non-directive counselling through listening visits.
The plan of care was discussed with Joanne who agreed to partake. Â Both the plan of care and Joanneâs agreement was documented in the Health Visiting notes.
2.6Â Â Â Â Â Â Â Â The First Listening Visit
The first organised listening visit aimed to reduce Joanneâs feelings of low self-esteem and inability to cope with her present situation. Â The visit was structured and time managed allowing Joanne to talk at length. Â Joanne explained that she had seen a female G.P. and the appointment had been useful. Â Joanne had been prescribed a monthâs course of anti-depressants, and felt that these were beginning to take effect. Â Within the visit, feelings were discussed. Â She expressed feelings of joy at the birth of Kelsie and was able to discuss her home life and relationships in more detail. Â The visit concluded by discussing Joanneâs progress, she felt that significant progress would be achieved with the help of the listening visits and the anti-depressants. Â This visit proved to be successful, with the unexpected outcome of Joanne wishing to take Oliver to a playgroup. Â I gave Joanne a list of playgroups in the area and agreed that this would be beneficial for herself and Oliver. Â
During this visit, Joanne was able to express her feelings in more detail, I felt that Joanne was prepared to take further action; this indicated that she had moved to the preparation stage of the model (Prochaska and Diclemente, 1982). Â The visit concluded by Joanne repeating the EPDS. Â Her score was 14 out of a possible 30 (See Appendix 6). Â I was pleased that, Joanne had moved forward in a positive direction and, thought that I had played a small part in her progress.
Unfortunately, until this visit it had not become clear to Joanne that there was an identified health need and a reason to change. Â Joanne described her mood as very low, recognised that she was obsessed by housework, and expressed concerns of not being a âgood motherâ. Â
On reflection, this visit provided a structured framework for future visits helping Joanne build up her confidence and resolve issues linked with low self-esteem and disempowerment.
2.7Â Â Â Â Â Â Â Â Continuing Care
The listening visits are on-going, both Joanne and I feel that she is moving forward in a positive direction. Â The stage of âreadiness of actionâ is appearing. Â However, it should be noted that it is possible for individuals to relapse as well as progress, it is felt that Joanneâs acknowledgement of progress is a turning point. Â Issues were also raised about the listening visits that were both negative and positive. Â On the positive side I feel that Joanne might benefit from a post-natal group setting with other mothers experiencing the same feelings, however, negatively there are no groups of this nature in my area. Â Eastwood (1995) describes how promoting peer group support with post-natally depressed women can have a successful outcome, stating that the groupâs self-esteem increased as the group members respected each others feelings and the confiding relationship counteracted their feelings of isolation.
- Conclusion.
I found the listening visits a very exhausting, draining, and strenuous experience having never trained in this field of practice. Â I received excellent clinical support from my CPT, which helped my reflexivity and development of better active listening skills (Rollnick, Mason and Butler, 1999). Â I feel also that a support group would be a positive move for future practice, especially if other Health Professionals were incorporated into the group i.e. Midwife, Counsellor, and Mental Health Practitioners. Â I personally would benefit from a formal basic counselling course.
Mead, Bower and Gask (1997), raised the question of concern between the boundaries of primary and specialist mental health practitioners. Â Evidence presented within this analysis suggests that care was taken to offer Joanne the best support and intervention at primary level, although closer communication between the community mental health team and me may have offered an enhanced approach to Joanneâs care.
10% – 15% of women experience PND, about 50% of these remain undetected by health professionals (Murray, 1997). Â May (1995) suggests that this is a transition period for all members of the family, often producing social, mental, and physical health distress.
This assignment has discussed the helping relationship and rationale for the plan of care to support my client with PND. Â It is apparent that symptoms of PND are compounded by a poor relationship with partners. Â This experience has been a useful learning experience and it is satisfying to know that Joanne has gained support from the listening visits and was able to discuss her feelings with me. Â For my part, I was encouraged by the feedback I received from the G.P and CPT who were supportive of the care I had provided for Joanne.
I found sharing my concerns with other health care professionals to be of great help – I felt that I had been able to adopt a multidisciplinary approach to mental health care, thus promoting Joanneâs mental health. Â Cox (1986), states that although primary health care workers regularly visit mothers in the puerperium, rarely is post-natal depression recognised. Â It is argued that primary health care professionals with appropriate training do recognise post-natal depression and share information regarding clientâs mental health problems.
The EPDS was a helpful tool in assessing Joanneâs PND providing a baseline for treatment and a framework for the listening visits. Â However, it should be noted that it is only a tool and clinical judgement should be used at all times. Â May (1995), states that a good relationship between Health Visitors and mothers may help them confide their true feelings. Â Although it can be argued that without building a rapport, and having some basic counselling skills, the therapeutic value to a professional relationship may be significantly reduced. Â
- Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Appendices
Appendix 1.
The Edinburgh Post-natal Depression Scale (EPDS)
explained.      (Cox, Holden, Sagovsky, 1987)
The EPDS (See appendix 2) (Cox, Holden, Sagovsky, 1987) is a ten-item self-rating questionnaire which, when used 6 â 8 weeks after delivery, is a highly specific and sensitive in the detection of post-natal depression. Â
The scale consists of ten statements relating to symptoms of depression and women are asked to indicate on a four-point scale how closely each statement reflects their mood during the last seven days. Â It is important to discuss the possibility of depression at the ante-natal visit and explain the role of the Health Visitor and the EPDS.
If the woman scores over 12, the EPDS should be repeated in one week, this allows for the woman having a âbadâ week.  At all times clinical judgement should be used.  If the Health Visitor is concerned then referral to an appropriate person should be undertaken, with the womanâs consent.  If the woman scores over 12 the following week, then listening visits should be undertaken and a plan of care discussed with the woman.  Any woman scoring on question ten (see Appendix 2) should be referred to the G.P. immediately.
Appendix 2.
Edinburgh Post-Natal Depression Scale.
(Cox, Holden, Sagovsky, 1987)
How are you feeling?
As you have recently had a baby, we would like to know how you are feeling. Â Please tick the answer which comes closest to how you have felt in the past 7 days, not just how you feel today.
In the past seven days –
- I have been able to laugh and see
the funny side of things:
As much as I always could                â¡
Not quite so much now                â¡
Definitely no so much now                â¡
Not at all                                â¡Â                                               Â
- I have looked forward with
enjoyment to things:
As much as I ever did                        â¡
Rather less than I used to                â¡
Definitely less than I used to                â¡
Hardly at all                                â¡Â                                               Â
- I have blamed myself unnecessarily when things went wrong:
Yes, most of the time                        â¡
Yes, some of the time                        â¡
Not very often                                â¡
No, never                                â¡
                                       Â
- I have felt worried and anxious for no very good reason:
No, not at all                                â¡
Hardly ever                                â¡
Yes, sometimes                        â¡
Yes, very often                        â¡Â       Â
- I have felt scared or panicky for no very good reason:
Yes, quite a lot                        â¡
Yes, sometimes                        â¡
No, not much                                â¡Â       Â
No, not at all                                â¡Â       Â
       Â
- Things have been getting on top of
me:
Yes, most of the time I havenât been able
to cope at all                            â¡
Yes, sometimes I havenât been coping as
well as usual                            â¡
No, most of the time I have coped
quite well                               â¡
No, I have been coping as well as ever            â¡
               Â
- I have been so unhappy that I have
difficulty sleeping:
Yes, most of the time                        â¡Â       Â
Yes, sometime                                â¡
Not very often                                â¡
No, not at all                                â¡
                                       Â
- I have felt sad or miserable:
Yes, most of the time                        â¡
Yes, quite often                        â¡
Not very often                                â¡Â       Â
No, not at all                                â¡
                                       Â
- I have been so unhappy that I have
been crying:
Yes, most of the time                        â¡
Yes, quite often                        â¡
Only occasionally                        â¡
No, never                                â¡Â       Â
- The thought of harming myself has
occurred to me:
Yes, quite often                        â¡
Sometimes                                â¡
Hardly ever                                â¡
Never                                        â¡
Appendix 3
Edinburgh Post-Natal Depression Scale â Scoring.
(Cox, Holden, Sagovsky, 1987)
- I have been able to laugh and see the funny side of things:
As much as I always could                                                0
Not quite so much now                                                        1
Definitely no so much now                                                2
Not at all                                                                        3
- I have looked forward with enjoyment to things:
         As much as I ever did                                                        0
Rather less than I used to                                                1
Definitely less than I used to                                                2
Hardly at all                                                                3
- I have blamed myself unnecessarily when things went wrong:
Yes, most of the time                                                        3
Yes, some of the time                                                        2
Not very often                                                                1
No, never                                                                        0
- I have felt worried and anxious for no very good reason:
No, not at all                                                                0
Hardly ever                                                                        1
Yes, sometimes                                                                2
Yes, very often                                                                3
- I have felt scared or panicky for no very good reason:
Yes, quite a lot                                                                3
Yes, sometimes                                                                2
No, not much                                                                1
No, not at all                                                                0
(Continued over)
- Things have been getting on top of me:
Yes, most of the time I havenât been able to cope at all        3
Yes, sometimes I havenât been coping as well as usual        2
No, most of the time I have coped quite well                        1
No, I have been coping as well as ever                                0
- I have been so unhappy that I have difficulty sleeping:
Yes, most of the time                                                        3
Yes, sometime                                                                2
Not very often                                                                1
No, not at all                                                                0
- I have felt sad or miserable:
Yes, most of the time                                                        3
Yes, quite often                                                                2
Not very often                                                                1
No, not at all                                                                0
- I have been so unhappy that I have been crying:
Yes, most of the time                                                        3
Yes, quite often                                                                2
Only occasionally                                                                1
No, never                                                                        0
- The thought of harming myself has occurred to me:
Yes, quite often                                                                3
Sometimes                                                                        2
Hardly ever                                                                        1
Never                                                                                0
Appendix 4
The Transtheoretical Model/Stages of Change Model.
(Prochaska and DiClemente, 1982)
PRECONTEMPLATION
CONTEMPLATION
PREPARATION
ACTION
MAINTENANCE
Appendix 5.
Edinburgh Post-Natal Depression Scale.
(Cox, Holden, Sagovsky, 1987)
How are you feeling?
As you have recently had a baby, we would like to know how you are feeling. Â Please tick the answer which comes closest to how you have felt in the past 7 days, not just how you feel today.
In the past seven days –
- I have been able to laugh and see the funny side of things:
As much as I always could                â¡
Not quite so much now                â¡
Definitely no so much now                â¡
Not at all                                â¡Â                                       Â
- I have looked forward with
enjoyment to things:
As much as I ever did                        â¡
Rather less than I used to                â¡
Definitely less than I used to                â¡
Hardly at all                                â¡Â                                       Â
- I have blamed myself unnecessarily when things went wrong:
Yes, most of the time                        â¡
Yes, some of the time                        â¡
Not very often                                â¡
No, never                                â¡
- I have felt worried and anxious for no very good reason:
No, not at all                                â¡
Hardly ever                                â¡
Yes, sometimes                        â¡
Yes, very often                        â¡Â       Â
- I have felt scared or panicky for no very good reason:
Yes, quite a lot                        â¡
Yes, sometimes                        â¡
No, not much                                â¡
No, not at all                                â¡
- Things have been getting on top of me:
Yes, most of the time I havenât been able
to cope at all                                â¡Â                  Â
Yes, sometimes I havenât been coping as
well as usual                                â¡Â                    Â
No, most of the time I have coped
quite well                                â¡Â              Â
No, I have been coping as well as ever        â¡Â   Â
- I have been so unhappy that I have difficulty sleeping:
Yes, most of the time                        â¡
Yes, sometime                                â¡
Not very often                                â¡
No, not at all                                â¡
- I have felt sad or miserable:
Yes, most of the time                        â¡
Yes, quite often                        â¡
Not very often                                â¡
No, not at all                                â¡
- I have been so unhappy that I have been crying:
Yes, most of the time                        â¡
Yes, quite often                        â¡
Only occasionally                        â¡
No, never                                â¡Â       Â
- The thought of harming myself has occurred to me:
Yes, quite often                        â¡
Sometimes                                â¡
Hardly ever                                â¡
Never                                        â¡
Appendix 6.
Edinburgh Post-Natal Depression Scale.
(Cox, Holden, Sagovsky, 1987)
How are you feeling?
As you have recently had a baby, we would like to know how you are feeling. Â Please tick the answer which comes closest to how you have felt in the past 7 days, not just how you feel today.
In the past seven days –
- I have been able to laugh and see the funny side of things:
As much as I always could                â¡
Not quite so much now                â¡
Definitely no so much now                â¡
Not at all                                â¡Â                                       Â
- I have looked forward with
enjoyment to things:
As much as I ever did                        â¡
Rather less than I used to                â¡
Definitely less than I used to                â¡
Hardly at all                                â¡Â                                       Â
- I have blamed myself unnecessarily when things went wrong:
Yes, most of the time                        â¡
Yes, some of the time                        â¡
Not very often                                â¡
No, never                                â¡
- I have felt worried and anxious for no very good reason:
No, not at all                                â¡
Hardly ever                                â¡
Yes, sometimes                        â¡
Yes, very often                        â¡Â       Â
- I have felt scared or panicky for no very good reason:
Yes, quite a lot                        â¡
Yes, sometimes                        â¡
No, not much                                â¡
No, not at all                                â¡
- Things have been getting on top of me:
Yes, most of the time I havenât been able
to cope at all                   Â