Delivery Of Psychological Therapies Research Articles

Accessibility and efficiency of mental health services, United Kingdom of Great Britain and Northern Ireland.

ProblemMental ill health in the United Kingdom of Great Britain and Northern Ireland has been a major driver of labour market exclusion through sickness absence, reduced productivity and job loss.ApproachA government-supported programme for improving access to psychological therapies was launched in 2008 and expanded across England in 2010. The aim was to provide evidence-based treatments for people with common mental disorders through three principal strategies: (i) routine session-by-session outcome monitoring; (ii) integration with the wider care system; and (iii) delivery of psychological therapies as part of a stepped-care approach.Local settingAccess to effective psychological therapies was previously low in the United Kingdom. In 2010, only about 35% of people with moderately severe mental disorders were in specialist or non-specialist treatment.Relevant changesThe accessibility of quality mental health services has increased, as has the efficiency of the country’s mental health system. The numbers of people entering treatment have increased steadily from 0.43 million in 2012–2013 to 1.09 million in 2018–2019. The recovery rate of patients in treatment increased from 42.8% to 52.1% during 2012–2018. The number of people moved off sick pay and benefits rose from 3683 to 18 039 over the same period.Lessons learntA clinical guideline on psychological therapies is a prerequisite for increasing the accessibility and efficiency of mental health services. An integrated approach allows mental health services to have better reach. Routine collection of patient-level outcome data plays an important role in the value and function of the mental health care system.

A systematic review of the implementation of psychological therapies in acute mental health inpatient settings.

Research has demonstrated that psychological therapies are not routinely delivered in acute mental health inpatient settings despite being recommended by the National Institute for Health and Care Excellence (NICE) guidelines. This study aimed to identify the barriers and facilitators to implementing psychological therapies in acute mental health inpatient settings. A systematic review and narrative synthesis was undertaken. Primary studies were included if they examined the implementation of a NICE recommended psychological therapy in acute psychiatric inpatient settings and were of any study design. Four databases were searched for eligible studies (MEDLINE, CINAHL Plus, PsycINFO and Embase) and Google Scholar. A total of 16 studies (a mixture of both qualitative and quantitative methodologies) were included in the review, and the majority evaluated the implementation of Cognitive Behaviour Therapy. Overall, the literature was deemed to be of poor to moderate quality. The main barriers to the implementation of psychological therapy were the busy nature of the ward, multi-disciplinary professionals not being suitability trained and the acute nature of service users mental health difficulties. Facilitators to implementation included the adaptation of interventions to be specifically delivered in the acute inpatient setting, training of multi-disciplinary professionals, leadership support with the delivery of psychological therapies and prioritising the therapeutic relationship. There is a requirement for senior management to prioritise the implementation of psychological therapies and update clinical guidelines to describe modifications necessary to implement psychological therapies in acute inpatient settings. Future research should improve their methodological quality and continue to develop the evidence base of brief psychological therapies in acute inpatient settings.

Catastrophic cognitions about coronavirus: the Oxford psychological investigation of coronavirus questionnaire [TOPIC-Q

Cognitive therapies are developed on the principle that specific cognitive appraisals are key determinants in the development and maintenance of mental health disorders. It is likely that particular appraisals of the coronavirus pandemic will have explanatory power for subsequent mental health outcomes in the general public. To enable testing of this hypothesis we developed a questionnaire assessing coronavirus-related cognitions. 12 285 participants completed online a 46-item pool of cognitions about coronavirus and six measures of different mental health problems. The sample was randomly split into derivation and validation samples. Exploratory factor analyses determined the factor structure, selection of items, and model fit in the derivation sample. Confirmatory factor analysis (CFA) then tested this model in the validation sample. Associations of the questionnaire with mental health outcomes were examined. The 26-item, seven-factor, Oxford Psychological Investigation of Coronavirus Questionnaire [TOPIC-Q] was developed. CFA demonstrated a good model fit (χ2 = 2108.43, df = 278, p < 0.001, comparative fit index (CFI) = 0.950, Tucker-Lewis index (TLI) = 0.942, root mean square error of approximation (RMSEA) = 0.033, standardized root mean square residual (SRMR) = 0.038). The factors were: cognitions about (1) safety and vulnerability, (2) negative long-term impact, (3) having the virus, (4) spreading the virus, (5) social judgment, (6) negative self, and (7) being targeted. The questionnaire explained significant variance in depression (45.8%), social anxiety (37.3%), agoraphobia (23.2%), paranoia (27.3%), post-traumatic stress disorder (57.1%), and panic disorder (31.4%). Cognitions about negative long-term impact had the greatest explanatory power across disorders. TOPIC-Q provides a method to assess appraisals of the pandemic, which is likely to prove helpful both in longitudinal studies assessing mental health outcomes and in delivery of psychological therapy.

Acceptance and Commitment Therapy for perinatal mood and anxiety disorders: A feasibility and proof of concept study.

The aim of the current study was to assess the feasibility, safety, and effectiveness of a newly developed Acceptance and Commitment Therapy (ACT) intervention developed specifically to address the unique context of pregnancy and parenthood. The intervention was delivered to women accessing a specialist Perinatal Community Mental Health Service (PCMHS). An open-label pilot study was conducted of an 8-week, group-delivered ACT intervention targeting women with moderate-to-severe mood and/or anxiety disorders during pregnancy and/or postpartum. Outcomes included session attendance rates, dropout rates, crisis/inpatient service use, and standardized symptom scales. Participant's responses to open-ended questions contained in an end of therapy questionnaire were analysed using thematic analysis. Seventy-four women were referred to the intervention with 65 (88%) completing treatment. The median number of sessions attended was 7. No women required input from crisis/inpatient services. All reported finding the intervention helpful. The implementation of ACT in daily life, therapist support, and group processes were cited as helpful aspects of the intervention. At post-treatment, there was a significant reduction in global distress (d=0.99) and depressive symptoms (d=1.05), and an increase in psychological flexibility (d=0.93). On the secondary outcome of global distress, 38% of women were classified as recovered, 31% had reliably improved, 27% remained the same, and 4% had reliably deteriorated. The delivery of ACT in a routine practice setting is feasible, safe, and effective. A randomized control trial (RCT) is needed to establish the efficacy and cost-effectiveness of this group-delivered ACT intervention. Group-delivered Acceptance and Commitment Therapy (ACT) is acceptable for women with moderate-to-severe perinatal mood and/or anxiety disorders and can be feasibly delivered in a routine practice setting. The trans-diagnostic nature of ACT enables the concurrent treatment of depressive and anxiety symptoms within the same intervention which is particularly helpful in the perinatal context given the comorbidity of mood and anxiety disorders. With training and supervision, mental health practitioners without extensive education in the delivery of psychological therapies can facilitate the ACT group programme. As this was a feasibility study, there was no control group, adherence to the manual was not assessed, and the absence of a follow-up period limits our knowledge of the longer-term benefits of the ACT group programme.

Business as usual? Psychological support at a distance.

The impact of COVID-19 has challenged the long accepted ‘norm’ in delivery of psychological therapy. Public policies designed to reduce transmission have made it extremely difficult to meet with service-users safely in the traditional face-to-face context. E-therapies have existed in theory and practice since technological progress has made them possible. They can offer a host of advantages over face-to-face equivalents, including improved access, greater flexibility for service-users and professionals, and cost savings. However, despite the emerging evidence and anticipated positive value, implementation has been slower than anticipated. Concerns have been raised by service-users, clinicians, and public health organisations, identifying significant barriers to the wide spread use of e-therapies. In the current climate, many clinicians are offering e-therapies for the first time, without prior arrangement or training, as the only viable option to continue to support their clients. This paper offers a clinically relevant review of the e-therapies literature, including effectiveness and acceptability dilemmas and challenges that need to be addressed to support the safe use and growth of e-therapies in psychology services. Further research is needed to better understand what might be lost and what gained in comparison to face-to-face therapy, and for which client groups and settings it might be most effective.

Contending with the minimum data set: Subjectivity, linearity and dividualising experiences in Improving Access to Psychological Therapies.

Improving Access to Psychological Therapies has lead to a huge increase in the delivery of psychological therapy within the United Kingdom over the past 10 years. Central to the culture of Improving Access to Psychological Therapies is outcome monitoring, brought into every therapeutic encounter through the compulsory collection of the minimum data set in each session. This article explores the role of compulsory outcome monitoring in service users' experiences of using Improving Access to Psychological Therapies, with a focus on how these forms are folded into distress, therapy and recovery. Data from a small-scale qualitative study are drawn upon. Thematic analysis was conducted on multimodal interviews with current service users. The article explores the ways in which the minimum data set acted as a 'quasi object', exploring three main roles of the minimum data set: as an authorising mediator, an alienating adversary and a deferring gatekeeper. Pictures of therapeutic progress, as presented via outcome measures, often ran counter to users' reported experience of distress. We conclude that far from being a neutral and objective assessment tool, the minimum data set functions as a living actant in the therapeutic encounter.

The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evidence from the 2nd UK National Audit of psychological therapies

BackgroundCognitive Behaviour Therapy (CBT) is the front-line psychological intervention for step 3 within UK psychological therapy services. Counselling is recommended only when other interventions have failed and its effectiveness has been questioned.MethodA secondary data analysis was conducted of data collected from 33,243 patients across 103 Improving Access to Psychological Therapies (IAPT) services as part of the second round of the National Audit of Psychological Therapies (NAPT). Initial analysis considered levels of pre-post therapy effect sizes (ESs) and reliable improvement (RI) and reliable and clinically significant improvement (RCSI). Multilevel modelling was used to model predictors of outcome, namely patient pre-post change on PHQ-9 scores at last therapy session.ResultsCounselling received more referrals from patients experiencing moderate to severe depression than CBT. For patients scoring above the clinical cut-off on the PHQ-9 at intake, the pre-post ES (95% CI) for CBT was 1.59 (1.58, 1.62) with 46.6% making RCSI criteria and for counselling the pre-post ES was 1.55 (1.52, 1.59) with 44.3% of patients meeting RCSI criteria. Multilevel modelling revealed a significant site effect of 1.8%, while therapy type was not a predictor of outcome. A significant interaction was found between the number of sessions attended and therapy type, with patients attending fewer sessions on average for counselling [M = 7.5 (5.54) sessions and a median (IQR) of 6 (3–10)] than CBT [M = 8.9 (6.34) sessions and a median (IQR) of 7 (4–12)]. Only where patients had 18 or 20 sessions was CBT significantly more effective than counselling, with recovery rates (95% CIs) of 62.2% (57.1, 66.9) and 62.4% (56.5, 68.0) respectively, compared with 44.4% (32.7, 56.6) and 42.6% (30.0, 55.9) for counselling. Counselling was significantly more effective at two sessions with a recovery rate of 34.9% (31.9, 37.9) compared with 22.2% (20.5, 24.0) for CBT.ConclusionsOutcomes for counselling and CBT in the treatment of depression were comparable. Research efforts should focus on factors other than therapy type that may influence outcomes, namely the inherent variability between services, and adopt multilevel modelling as the given analytic approach in order to capture the naturally nested nature of the implementation and delivery of psychological therapies. It is of concern that half of all patients, regardless of type of intervention, did not show reliable improvement.

An overview of the effectiveness of psychological therapy for depression and stepped care service delivery models

Depression is one of the most prevalent health disorders globally and causes significant distress and cost to the sufferer and society. Psychological therapy for depression has been recommended over a number of decades; however, access to these treatments remains limited. Cognitive behaviour therapy, behavioural activation, self-help approaches, interpersonal therapy and non-directive therapy all demonstrate moderate to large effect sizes when compared to treatment as usual. Differences between psychological interventions however are small and unstable when reviewed in meta-analyses suggesting that for most people adding complexity to treatment does not result in improved outcomes. Stepped care is one system used to organise delivery of psychological therapy that stratifies interventions across several levels of symptom severity. There is debate regarding the ideal design and operation of this complex system resulting in considerable variability in its use in clinical settings. Further research is needed to identify the most cost effective approach to the delivery of psychological therapies for depression as we need to continue to reduce the gap between demand and access to therapy.

Recovering an emerging self: Exploring reflective function in recovery from adolescent‐onset psychosis

This paper investigates (1) the processes involved in how young people with adolescent-onset psychosis adapt to psychosis and (2) how processes of reflective function (RF) influence the adaptation process. This study used a qualitative design to inductively construct hypotheses about processes of adaptation and to deductively explore the influence of RF on adaptation. Eight young people (aged 18-21) who had experienced clinically significant psychosis and attended a Child and Adolescent Mental Health Services (CAMHS) first-episode psychosis service participated in two interviews: (1) grounded theory open interview; (2) Adult Attachment Interview (AAI). Grounded theory methodology was used to investigate young people's experiences of adaptation to psychosis. Fonagy's manual of RF was used to identify passages with different levels of RF in the adaptation narratives and to assign an overall rating of RF with regard to attachment states of mind to AAI transcripts. Links between adaptation themes and RF were examined qualitatively across participants. Two main themes relating to adaptation and adolescent individuation emerged. Moderate RF was linked to primarily positive adjustment and successful individuation following psychosis. Impaired RF was associated with unresolved adaptation and blocked individuation post-psychosis. Level of RF appeared to moderate adaptation and individuation processes post-psychosis and should be considered in the delivery of psychological therapies.

Does therapists' competence matter in delivering psychological therapy?

SummaryTherapists differ in their effectiveness in the delivery of psychological therapy. Can trainees who are exposed to similar training in psychological therapy achieve the same standard of competence regardless of professional background? This is a timely question given the planned expansion of psychological therapists to treat common mental disorders in England and Wales and the Scottish initiative to increase access to psychological therapies.

Psychological therapies provision: views from primary care

Aims and MethodRecent National Health Service (NHS) policy and guidelines support the increased provision of psychological therapies. As secondary care providers of psychological therapies, we carried out a questionnaire study of how our services were perceived by local general practitioners (GPs). All GPs in the borough of Southwark were included.ResultsGeneral practitioners value secondary care psychotherapeutic input across a spectrum of complex diagnostic groups and are interested in further training/education. They also consistently complain about long waiting times and confusion about accessing the various services.Clinical ImplicationsWith increasing interest in and willingness to fund the delivery of psychological therapies, there is the potential for working more effectively across the primary–secondary care divide. However, improved communication between primary and secondary care is essential if the increased commitment at government level is to be translated into a locally effective service.

As mental health nursing roles expand, is education expanding mental health nurses? an emotionally intelligent view towards preparation for psychological therapies and relatedness

Mental health nurses (MHN) in the UK currently occupy a challenging position. This positioning is one that offers a view of expanding roles and responsibilities in both mental health act legislation and the delivery of psychological therapies, while simultaneously generic pre-registration training is being considered. Clearly, the view from this position, although not without challenge and internal discipline dispute, can also offer growing professional prestige, influence and respect from other health disciplines, as well as the wider public. Conversely, if the training, education and strategic enactment for new MHN roles is formulated and delivered from predominantly non-MHN axiomatic and epistemological stances, MHN identity can be seriously and potentially permanently diminished. This paper offers the construct of emotional intelligence as a framework to respond to these future challenges through making individual MHN enablement a primacy. This enablement of MHNs through enhanced emotional intelligence competencies is argued as requiring priority over the standard approach of enhancing strategies alone.

Delivery of psychological therapies: clinical governance implications for trusts

PurposeThe purpose of this paper is to provide an overview of the clinical governance issues involved in the provision of psychological therapies within a context of massive demand and expansion underpinned by recent policy developments at the Department of Health. Raises awareness of the potential risks to Trusts involved in inadequate governance of therapy provision.Design/methodology/approachThe paper shows an informed review of the recent policies and influences affecting the development of psychological therapies and the clinical governance issues arising from them.FindingsThe paper compares the realities of service provision with the ideal model of service delivery recommended by the Department of Health. Raises concerns for all those Trusts providing psychological therapies about their governance and risk management arrangements.Originality/valueThe paper shows the key summary and opinion for all Trusts responsible for provision of psychological therapies.

Promoting Good Practice in Cognitive-Behavioural Psychotherapies

The National Institute of Clinical Excellence (NICE) guidelines for anxiety (Panic and Generalized Anxiety Disorder) and depression were finally launched in December 2004, after much delay (see www.nice.org.uk). Given that these were such important documents, it might seem surprising that the launch went almost entirely unnoticed. Why was it surprising? Because the recommendations were ground breaking. CBT was identified as the first line treatment pretty much across the board, with huge resource implications. It is not the business of NICE to comment on resources (or the lack of these). However, it was noted in the anxiety guidelines that CBT should be available promptly from appropriately trained and supervised therapists. In many (if not most) areas, this strongly implies a huge change in emphasis in the delivery of psychological therapies. The (implicit) implications are staggering. With the honourable exception of Interpersonal Therapy in depression, other psychological therapies were not advocated – at all. In anxiety, combination treatment (medication and CBT) was not recommended as a first or second line treatment. Some medication (antipsychotic) was ruled out. Guided self-help (based on CBT principles) was “third choice”. So the explicit recommendation is that good quality, empirically grounded psychotherapies (CBT, CBT and IPT in depression) should be widely and promptly available, whereas therapies without an empirical basis were not recommended.

Research into the organisation, training and effectiveness of counsellors who work for free

The activities of voluntary or ‘paraprofessional’ counsellors, who work for free, represent a highly significant component of the delivery of psychological therapy in Britain and other countries. However, in recent years there has been relatively little published research into issues associated with the provision of service by counsellors who work on a voluntary part‐time basis, and who typically receive limited training and supervision. This paper introduces a special theme section on counselling in the voluntary sector, which highlights some recent examples of research into the context, organisation, training and effectiveness of such counsellors. Some suggestions are made concerning the research agenda for counselling in the voluntary sector.