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the patient is finding any such intervention and how they view its role within the context of their potential work with you.

      Alcohol Consumption and Drug Use

      Misuse of alcohol or substances can have a significant negative impact on a patient's functioning and adversely impact their ability to engage with treatment. It is therefore worthwhile to ask about any substances the patient is currently taking and the way they believe these may impact on their ability to engage with LICBT. It is important to remember that caffeine is a strong, long-lasting and highly consumed stimulant so should also be specifically asked about, funnelling down to enquire about a potential impact on the patient's ability to sleep (Chapter 17). Arguably, it is unlikely that on first meeting, a person will divulge illicit drug use or overuse of alcohol but it is still worth enquiring about and checking in subsequent sessions.

      Administration of Routine Outcome Measures

      To ensure the effectiveness and efficiency of the stepped care model of mental health service delivery (Chapter 1) standardised Routine Outcome Measures (ROMs) are systematically taken at every session, informing the IAPT programme Minimum Data Set (MDS; Table 2.2).

Table 2.2

      Whilst initially developed to assess the severity of symptoms associated with Generalised Anxiety Disorder (GAD), the GAD-7 (Spitzer et al., 2006) is adopted as the default measure to address severity across the range of anxiety disorders within the IAPT programme. However, when being used for all anxiety disorders, the measure fails to address the key symptoms to target for specific anxiety disorders. This information can inform clinical decision-making (Chapter 4) to target the most distressing symptoms for the patient. Anxiety-related disorder specific ROMs have therefore been recommended to accompany the MDS within the IAPT programme (Table 2.3; NCCMH, 2018).

Table 2.3

      Collecting ROMs enables the LICBT practitioner to monitor treatment progress and inform ongoing treatment decisions, supporting ‘self-correction’ within the stepped care model when necessary (Bower and Gilbody, 2005). Furthermore, their use can be effective in enhancing patient outcomes (Shimokawa, et al., 2010) that can be helpful to highlight to patients when introducing ROMs. Within the IAPT programme, analysis of the ROMs also enables services to be monitored centrally to inform programme and organisational efficiency (Richards, 2010a).

      Clinical Example

      Introducing Routine Outcome Measures

      Monitoring symptoms using a number of tried and tested questionnaires is useful for checking progress and seeing whether what we are doing is helping you with your difficulties. It is useful to start with a baseline so I shall explain each of the measures and then give you feedback on what the scores indicate. Each session I shall ask you to complete the measures and discuss how things are going with your treatment. Many people find it helpful to track their progress and there is research that shows that people receiving feedback on session-by-session measures tend to do better in treatment.

      Risk Assessment

      It is essential that the patient's level of risk is determined at assessment and given that risk is not static, monitored at every support session (Chapter 6). Novice LICBT practitioners may worry about asking risk-related questions.

      Reflection Point

      Think about who you would ask for support from if you found yourself worrying a lot about undertaking a risk assessment or enquiring about risk.

      However, it has been highlighted that enquiring about suicide could reduce, rather than increase, suicidal ideation (Dazzi et al., 2014). The LICBT practitioner should not be apologetic or embarrassed asking about risk and instead, should introduce it in a positive way.

      Clinical Example

      Introducing Risk Assessment

      I would like to ask you some very specific questions now about your safety. It might be that some areas do not affect you and that's fine, but it's important I ask you anyway. Going forward, I shall ask similar questions to these each session to check whether there have been any changes.

      Where appropriate, each area addressed in a full risk assessment should be asked in relation to the present and the past (Table 2.4). Knowing if a patient has made a serious attempt on their life previously is useful to know to inform clinical decision-making around risk in the present.

Table 2.4

      In the event of serious concerns about risk it is imperative that follow-up questions are asked to work down the funnel and ascertain the current level of risk. Immediate risk issues should be addressed directly, the service risk protocol should be enacted, and the situation raised during the next case management supervision session (Chapter 9).

      Information-Gathering: Problem Formulation

      A useful way to get a fuller understanding of a patient's presenting difficulty is to ask questions about a recent time the problem happened (e.g. ‘Can you tell me about the last time you felt really low?'; ‘Can we go through the panic attack you had yesterday so we can see what happened?'). These questions should enable the presenting difficulty to be translated into a LICBT here and now problem formulation (Chapter 1). Depending on the LICBT problem formulation model adopted, this will involve targeting questions to address the presenting problem in terms of the main arising symptoms.

      Clinical Example

      Questions to Elicit Symptoms of the Presenting Problem

       PhysicalDo you notice any sensations in your body when you have a panic attack?When you're feeling low, do you notice anything is going on in your body?

       BehaviouralIs there anything you do when you notice yourself getting worried?What do you do when you are feeling particularly low?

       CognitiveHave you noticed any words or images go through your mind when you are feeling worried?When you're particularly low, have you noticed any thoughts or pictures that come to mind?

       EmotionalWhen you notice being tired, your legs are heavy and you are off your food, how do you feel emotionally?When you're lying awake, unable to get to sleep, how does that make you feel?

      Symptoms explored will vary according to the problem formulation model adopted, between a specific focus on physical (Autonomic), Behavioural, Cognitive and Emotional symptoms and description of the wider context within the Five Parts (Padesky and Mooney, 1990) or Five Areas (Williams and Garland, 2002) approaches. Capturing symptoms in this manner can be a useful way to orientate patients to a CBT-informed approach (Figure 2.2).

      Figure 2.2 Symptoms of presenting problem represented within the Five Parts Model (5-part model adapted with permission of the author, copyright 1986 by the Center for Cognitive Therapy; www.padesky.com)

      Information Giving and Shared Decision-Making

      Having collaboratively captured the main symptoms that are affecting the patient the

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