The ABCD of Ease; psychological therapies in Grampian.
Introduction
In recent years a number of documents have been published by the Scottish Government. ((2000, 2006) see appendix 1 for references) and the Dept of Health (2004, 2007) stressing the importance of psychological therapies and their effective delivery. These have been influential in promoting the development of local NHS groupings to consider the issues.
The purpose of this document is to present the work and consultations of a multi disciplinary group in considering the shaping and delivery of psychological therapies in NHS Grampian. The group needed to consider the Scottish Governments recommendations, the practicalities of delivering psychological therapies and most importantly the therapeutic needs of the patient population.
In Grampian we started with the Psychological therapies review, culminating in a stakeholder’s day in March 2006 (see stakeholders day summary) which recommended the developmentof Psychological therapies Steering Group with specific aims.
Psychological therapies Steering Group (PTSG)
A. 1. Definition of Psychological Therapies
“Refers to a range of skills, competencies and interventions based on identified psychological concepts and theory, which have been acquired through training and maintained through supervision".
Framework for Mental Health Services in Scotland,
Section 2. Core Service Elements
2. Range of therapies supported by NHS Grampian (PTSG)
This list is not exhaustive and will be regularly reviewed by the group.
- CBT and behavioural therapies
- Schema focussed therapy
- Psychodynamic therapies Individual
Group (including therapeutic community)
- Counselling
- Art psychotherapy
- Psychodrama psychotherapy
- IPT
- THORN approach
- Solution focussed therapy
- Family therapy ( not available currently in Grampian)
- Music therapy ( not available in Grampian)
3. Psychological literacy endorsed by NHS Grampian(PTSG)
This most basic level of psychological intervention requires the understanding of the complexity of communications and sensitivity to the difficulties of working with people with mental health issues. All staff in contact with patients should have an understanding of the importance of their contribution to the therapeutic relationship and to the patients' experience of treatment regardless of their professional role in the team or where this is delivered.
Grampian Psychological Therapies Steering Group
B. Role/Remit
1. Influence, interpret and develop a strategic response for psychological therapies on behalf of NHS and present this to the CMB for endorsement and ongoing support
2. Develop a cross agency tiered model of stepped care for psychological interventions within Grampian.
3. Devise supervision networks with a view to all NHS staff offering psychological therapies receiving adequate supervision and all qualified therapists working towards accreditation
4. Consider means of evaluating services on offer.
5. Identify gaps and assist in devising structure for increased psychological therapeutic skill base within all clinical areas (including inpatient areas).
6. Consider training programmes on offer nationally and develop local provision as far as possible.
7. Continue work on the psychological therapy skills analysis compiling a database of staff, skills and supervision.
C. Constitution of Grampian PTSG
Mix by professional background and theoretical modality.
Professional groupings
Nursing
Allied Health professionals
Management
Psychiatry,
Psychotherapy
Psychology
Teams
CMHT
Inpatient and day patient services
Eating disorder
Substance misuse
Elderly
Specialist psychotherapy
Specialist psychology
Forensic
Rehab
Geographical
Aberdeen
Aberdeenshire
Moray
D. Local reviews
Each of these groupings was asked to comment on delivery and provision of psychological therapies in their area
Summary of Aims and Objectives for Grampian Psychological Therapies
The requirements for psychological therapies across an organisation as diverse as NHS Grampian are extremely complex. The Grampian PTSG has a remit to undertake this in a systematic fashion.
1. Define the problems, the treatment settings and the psychological therapies
2. Referral pathway
3. Practitioners require Education, Accreditation, Supervision and Evaluation
1.Define the problems,the treatment settings and the psychological therapies
It has become widely accepted that a tiered model of service delivery (offering either stepped care or matched care) represents the most cost-effective way of organising the delivery of psychological treatments for mental health problems
a.Problems
Tier 1 Relatively common transient or mild mental health problems
characterised by distress but with limited effect on functioning
Tier 2 Moderate mental health difficulties which are not likely to improve
without specific intervention, but which do not prevent most day-to-
day coping
Tier 3 Complex mental health problems, most likely long standing and
recurrent, significantly impairing quality of life and daily functioning
Tier 4 Severe mental health problems with significant impairment of
Functioning
b.Treatment settings
(Whilst recognising that patients may be supported in more than one setting for the purposes of this document we are describing the setting or location of staff of the psychological therapy)
setting O selfhelp,not for profit organisations, mental health promotion.
setting 1 primary care
setting 2 secondary care CMHT, psychiatric inpatient
setting 3 Specialist services area wide, e.g eating disorders, therapeutic community
Overall picture for psychological therapies delivery settings and problem levels in Grampian
Advantages
- Smaller specialist teams with specialist therapy trained staff dealing with most complex group.
- Clarifies training needs for psychological therapies in the teams
Disadvantages
- Gives clarity to referral pattern but does not reflect that teams are often carrying complex cases on long term supportive basis
- Leaves unmet need in primary care.
c. SpecificAvailability of psychological therapies
Psychological therapies have an important place amongst the range of treatments available as part of comprehensive, user-centred mental health services. As the evidence base for their effectiveness has grown, so has their
popularity with service users and carers.
In 2001 the Department of Health published a review entitled “Treatment Choice in Psychological Therapies and Counselling – Evidence Based Clinical Practice Guidelines”. The purpose of the document was to summarise evidence on the efficacy of psychological treatments for a range of mental health problems. Cognitive-behavioral therapy and psychodynamic psychotherapy are the most frequently applied methods of psychotherapy in clinical practice. Although there is substantial evidence for the efficacy of cognitive-behavioral therapy and some evidence for the efficacy of psychodynamic psychotherapy, further studies are required to improve the positive outcome rates of treatment responders in specific mental disorders. For psychodynamic psychotherapy further studies of specific forms of treatment in specific mental disorders are required to corroborate the available results.
Practice based research is vital. We lack information about the effect of treatment setting on the outcome of therapy because such research is difficult to design. Psychotherapy research focuses on standardized interventions of “pure” types of therapy (e.g., cognitive, behavioural, or psychoanalytic). There is little evidence about the most effective ways to deliver therapy or which factors influence access to therapy in the real world. This work can be undertaken locally to a limited extent by evaluating pre and post treatment on all psychological therapies.
GPTSG decided against prescribing the specific therapeutic modalities required in various treatment settings. It is intended that each clinical area (with the help of the group if requested) develops its own therapeutic interventions consistent with their client groups’ requirements and with the psychological therapies endorsed by GPTSG.
2. Referral pathway ( see appendix 4)
The CMHT should be the first stop for all referrals in to the psychiatric service. This allows the teams to ration the referrals to specialist services and have ownership of any waiting lists that ensue. Patients should not be referred directly for psychological therapies by primary care who do not have the opportunity to see the whole picture of psychological therapy availability in the way that a team would.
The specialisms will be clear on their referral criteria to facilitate patients receiving the best intervention at the time. Patients referred to the psychiatric service have increasingly complex needs which are best managed with a team approach. Patients first attending the CMHT may need social work input and medication before they could be considered amenable to a psychological therapeutic approach. The CMHT can offer psychological therapies within the team and if this is not sufficient and it is felt the patient might benefit form other input the referral can be made to the tertiary specialist service. The team may elect in consultation with the specialist team to retain contact with the patient or to “hold” the case without action.
This does not mean that the CMHT has to assess all the patients referred as it can be evident from G.P. letters that the patient requires other interventions.
Advantages
- Teams develop a repertoire of interventions designed to fit their population
- Regardless of professional background clinicians can develop their therapeutic skills
- Users have access to a bigger broader psychologically skilled base and more opportunity to engage in psychological therapy.
Disadvantages
- Less time to devote to other core activity of the team
- Time required for supervision
3. Practitioners require Education, Accreditation, Supervision and Evaluation
1. Education
Training needs to be available in the psychological therapies outlined above. It would be helpful to increase availability of trainings locally –
Analytic group introductory course
THORN training
CBT diploma
Family therapy
2.Accreditation
All staff with psychological therapy training should be working towards accreditation appropriate to the modality.
When staff are offered training it comes with the understanding that there will be an expectation to use those skills and to engage in supervision to become an accredited practitioner integral to the psychological workforce.
3. Supervision
All staff offering psychological therapies should be receiving appropriate supervision. Supervision networks for each therapeutic modality are required with a designated responsible coordinator.
4. Evaluation
All psychological interventions should be evaluated pre and post therapy.
What's next?
- To develop and coordinate the delivery of psychological therapies in secondary care requires the continuing cooperation of a multi disciplinary group such as exists in the steering group.
This group would be involved in establishing
a. Supervision networks for each modality
b. Evaluation processes
c. Accreditation process
d. Developing local training
e.Liaising with specific groups and considering their needs around psychological therapies e.g progressing 3Rs, in patient settings, CMHT, implementation of ICPs, eating disorders.
Developments
1.NES has offered funding to each health board for 2 yearsof 0.5 wte grade 8B to promote the development of psychological therapies as per delivery plan, 3Rs etc.
GPTSG discussed this and propose that the job should be further divided to cover the 2 main modalities of CBT and psychodynamic psychotherapy.
- This would offer approximately 1 day a week to address the themes as described above for CBT based therapies ( schema focused, IPT, mindfulness) and psychodynamic based therapies ( family therapy, group therapy, mentalisation).
- They would be members of the steering group and would work with the steering group to establish
a. Supervision networks for each modality
Establish the supervisor capacity and gather information on potential supervisees. They would not expect to be sole provider of supervision.
b. Evaluation processes
Consider means of evaluating therapies available either with specific measures pertinent to treatment approaches or more generic outcome measures.
c. Accreditation process
Be aware of the accreditation requirements of the different modalities and able to advise staff that have trained and are working towards accreditation.
d. Developing local training
Facilitate the development of local trainings where practicable.
- The aim would be to set up an infrastructure that could be maintained after the funding ceases.
- They would work with the different clinical areas to engage staff in supervision networks
- They would be expected to liaise with nursing colleagues to advance psychological literacy on the wards
- Working with primary care and vol. orgs to consider, coordinate and integrate services as available in keeping with model and principles outlined above.
Developments
1. Linda Treliving as chair of the steering group will attend the Joint Local Committee and Mental Health Partnerships in the first instance with a view to further involvement of representatives from primary care and vol. orgs to attend the psychological therapies delivery group.
2. One day stakeholders meeting in September 2008 to which representatives from voluntary organisations, primary care, local authority and users will be invited to contribute.
Appendix 1
References
“Organising and Delivering Psychological Therapies”. 2004. Department of Health
“Treatment Choice in Psychological Therapies and Counselling: Evidence Based Clinical Practice Guideline”, 2007, Department of Health.
“A Framework for Mental Health Services in Scotland”. Section 2; core service elements, Scottish Executive, 2000.
"Delivering for Mental Health", 2006, Scottish Government.
“Evidence based psychotherapy: special case or special pleading?” G. Parry. Evid. Based Ment. Health 2000; 3; 35-37
“ Cognitive-Behavioral Therapy and Psychodynamic Psychotherapy: Techniques, Efficacy, and Indications”F. Leichsenring,W Hiller, M Weissberg, E Leibing. American Journal of psychoth.2006:60:3.
Appendix 2.
Responses.
Directorate/Service / DetailsOld Age Psychiatry / Constellation of interventions listed.
Suggested priority.
Qualifications.
OAP Therapeutic Activities Group.
Timescales.
Accreditation.
Training figures.
Adult Mental Health / Disposition and types of current qualifications and staff aspirations.
Team statements re referrals, staffing, effectiveness, future delivery/clinical networking, clinical supervision.
Specialisms (incl L.Dis) / Paper showing disposition and types of current qualifications and staff aspirations.
Moray – Integrated Mental Health Service / Paper received indicating Core, Extended and Overarching Skills required
Allied Health Professionals / Paper received with projected training needs.
Eating Disorders – / Small Multi-disciplinary Team with cognitive behavioural skills, but always have to train new staff. Other therapies desired and therefore support this initiative. Suggests staffing required by EDS..
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8 / Rowan CMHT / .
Nursing perspective / Summary of aims of 3Rs consistent with development of psychological therapies.
Description of Patients journey
20 year old female factory worker attends GP with mild anxiety problems interfering with everyday working that seem to relate back to experience of early trauma.
History of poor relationships and couple of presentations at casualty with self harm and overdosing in response to crisis.
Family history of depression and alcohol problems.
Contact with CAMHs. “Out of control” as child
Interventions at this point.
Voluntary organisations
Practice counsellor/ mental health worker
Returns to GP.
Now off work , relationships deteriorating and depressive symptomatology which has failed to respond to GP prescriptions is increasing.
Refers to CMHT.
Patient assessed and treated by team with CBT and antidepressants
Patient well and discharged back to GP.
Returns 2 years later following perpetrators death.
Describing depressive symptoms, preoccupied with csa, nightmares,
20 sessions CBT in team and antidepressants helps.
However self harm incidents start increasing in number.
Demanding of therapist. Asking for more input.
Conceives a child with boyfriend who feels unable to manage patients “moods”
Continues in treatment with CMHT but demanding of more time.
Child protection issue.
CMHT involved with social worker/ cmhn.
Admissions with clear parameters.
Child taken into care.
Patient deteriorates further.
Repeated admissions.
Referred to psychotherapy.
Assessed but not able to cooperate with contact more intensive than once weekly individual therapy with continuing support from CMHT and inpatient services as necessary.
1 year of individual therapy and then introduced into 3 day model of Therapeutic community by attending individual work and one day programme.
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