Low-intensity CBT Skills and Interventions - Группа авторов

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6). Where a patient presents at assessment with high risk of suicide, significant self-neglect and/or self-harm or potential to cause harm to others, risk should be managed immediately following the service's risk protocol (Chapter 4). This may result in onward referral to specialist mental health services such as crisis or emergency services.

      Alcohol and Drug Use

      The NICE guideline for alcohol use disorders (NICE, 2011c) and the IAPT Drug and Alcohol Positive Practice Guide (National Treatment Agency for Substance Misuse, 2012) recommend routine assessment of drugs and alcohol with practitioners who are competent to identify harmful drinking. As problematic drinking may not be associated with poorer treatment outcomes such as non-recovery or drop-out (Buckman et al., 2018), it should not be treated as an automatic exclusion criterion from working at Step 2 or Step 3 of a stepped care model (National Treatment Agency for Substance Misuse, 2012). Clinical decision-making during assessment should determine patient ability to attend and engage with LICBT treatment alongside the extent of the impact alcohol/drug use is having on their general level of functioning. Appropriate screening tools with cut-offs such as the AUDIT-C (Bush et al., 1998) should be used as part of decision-making to offer treatment to patients using drugs and/or alcohol. In some cases, alcohol and drug use may require the suitability of Step 2 and Step 3 treatment to be reconsidered.

      Clinical Practice

      Indicators of Unsuitability of Step 2/3 Treatment for Patients Using Alcohol or Drugs

       Meet diagnostic criteria for dual diagnosis, where a substance-use disorder is co-morbid with a mental health difficulty, and there may be complex needs.

       Alcohol and/or drug use identified as the primary condition and/or associated with functional impairment which would impact engagement with treatment.

      In both instances, recommend treatment for alcohol/drug misuse from specialist services and support referral (NICE, 2011c).

      Decision 2: Which LICBT Intervention Do I Offer?

      In the first instance, intervention choice will be determined by the provisional diagnosis where the LICBT practitioner will ‘match’ the patient's presenting problem with the NICE recommended intervention (NICE, 2011b).

      Clinical Practice

      NICE (2011b) Recommended LICBT Interventions

       Medication management (Chapter 10)

       Behavioural activation (Chapter 11)

       Graded exposure (Chapters 13 and 14)

       Worry management (Chapter 15)

       Problem-solving (Chapter 16)

       Structured exercise (strenuous physical activity) programmes (Chapter 20).

      Treatment planning will be further guided by consideration of specific factors associated with the patient's experience, goals and presentation.

      Co-morbidity

      Co-morbidity occurs when a patient meets criteria (using the DSM-V or ICD-11) for a diagnosis of two or more mental disorders simultaneously (Clark et al., 2017). It is common in mental health populations, with over 70 per cent entering the IAPT programme experiencing two or more mental health difficulties (Hepgul et al., 2016). Where co-morbidity is identified during assessment, the LICBT practitioner is required to use guidelines (e.g. NICE, 2011b) and consult service protocols to determine the main provisional diagnosis before reaching a clinical decision regarding treatment to offer (Table 4.2).

      Signposting

      For patients experiencing practical and social problems (including housing, debt, and legal issues, lack of social support and/or employment difficulties), signposting to statutory and/or third sector organisations may be an alternative to initiating treatment at Step 2/3. Signposting will also be an essential component of an effective Step 2 LI intervention where involvement of additional support and advocacy services is considered to facilitate and enhance engagement with treatment and its effects (e.g. see Beck et al. 2019). Unemployment has been frequently linked to poorer outcomes in therapy (e.g. see Delgadillo et al., 2016); and within the IAPT programme recognition of the relationship between employment and mental wellbeing has led to the development of employment advisors to support patients seek meaningful employment whilst engaging with their LICBT intervention (Hogarth et al., 2013).

      Decision 3: How Should the Intervention Be Delivered?

      To improve access and acceptability (Richards, 2010a), LICBT intervention delivery can be supported across a number of different formats (Chapter 7). New technologies, including phone-based apps, are also rapidly developing and being implemented in Step 2/3 settings to augment and support treatment (Bennion et al., 2017). However, more research is needed to determine efficacy prior to full implementation (Leigh and Flatt, 2015).

      Despite the potential of telephone- and computerised-CBT to improve access and promote choice for patients, LICBT practitioners may be ambivalent about such formats compared to face-to-face delivery (Meisel et al., 2018). This may be rooted in perceptions that telephone and computerised delivery will have a negative impact on the therapeutic relationship, treatment outcomes and patient levels of satisfaction and perceived acceptability (Turner et al., 2018). However, the evidence base highlights these modalities to be equivalent with respect to dropout and acceptability (Boyden and Dobel-Ober, 2016; Tutty et al., 2010). In some cases, LICBT interventions supported over the telephone have been reported to demonstrate greater effectiveness than face-to-face support (Farrand and Woodford, 2013). Similar findings have been reported for computerised-CBT compared to control conditions with respect to outcomes and acceptability (Andrews et al., 2018). Acceptability of computerised-CBT may be enhanced for those with concerns over confidentiality (Vallury et al., 2015). Given the range of interventions and delivery methods available, a collaborative decision should therefore be reached regarding the most suitable option. The COM-B model (Michie et al., 2011) may aid decision-making, specifically to determine if any factors related to Capability, Opportunity and/or Motivation are evident that may affect engagement with a specific modality or format (Chapter 8).

      Decision 4: Should I Discharge or Step up?

      The fundamental role of the self-correcting mechanism within stepped care ensures that minimal response to LICBT treatment results in the patient stepping up to an intervention of greater intensity (Bower and Gilbody, 2005). Monitoring early response to treatment may help determine if a Step 2 intervention is likely to lead to recovery (Delgadillo et al., 2014).

      Clinical Practice

      Clinical Decision-Making Informed by Number of Treatment Sessions

       Patients demonstrating reliable improvement by their fourth LICBT treatment session have been found to be twice as likely to achieve recovery compared to those who have not (Delgadillo et al., 2014). Therefore providing a minimum of four treatment sessions before reaching a clinical decision as to whether to step up or discharge is supported (except in the case of significant early deterioration).

       As such, where reliable improvement or recovery has not been achieved by the fourth session or there has been little improvement – or worsening of symptoms – by the sixth support session, consider stepping up.

       Providing more than six support sessions has not been found to lead to better outcomes (Delgadillo et al., 2014) therefore prolonging LICBT treatment on the basis of poor treatment response is not recommended except

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