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       There is additional potential to enhance practitioner resiliency (Skovholt and Rønnestad, 2001) and further opportunities for reflection in LICBT with the provision of case management alongside clinical skills supervision (Farrand et al., 2016).

       Reflective questions are used throughout each chapter to stimulate personal reflection on salient, and at times, challenging points.

      Closing the Gap between the DPR systems

      Self-practice/self-reflection (SP/SR; Bennett-Levy et al., 2001) offers effective ways to close the gap between the three systems associated with the DPR model. The focus of SP/SR, including reflection on the personal self, enables trainees to learn from the application of procedural skills whilst reflecting on any personal impact that skills application may have on them. This enables trainees to more effectively put themselves in the patients’ shoes, facilitating competency development by enabling them to anticipate challenges when directly experiencing specific factors associated with the LICBT clinical method. Tools such as blogs to support written reflections following self-practice have been used to enable trainers to address commonly occurring themes or share reflections as the basis of classroom discussion (Farrand et al., 2010). This approach can be particularly helpful when the delivery of training includes university-directed or self-directed learning components.

      Assessing Your Understanding

      An ‘Assessing Your Understanding’ section is included at the end of each chapter to help you appreciate your understanding of declarative knowledge and continue to develop procedural competency. Multiple-choice, extended-matching or essay questions and case studies are included at the end of each chapter to enable you to assess your declarative knowledge. These are supplemented by SP/SR activities to help you continue to develop clinical competency during, or following, training, to stimulate continuing professional development and facilitate the transition from novice to expert (Bennett-Levy et al., 2009). Reflection points included within each chapter are included to stimulate reflection on key areas.

      1 Low-Intensity Cognitive Behavioural Therapy: Revolution Not Evolution

      Paul Farrand

      Learning Objectives

      By the end of this chapter you should be able to:

       Appreciate the context justifying the emergence of low-intensity CBT

       Critically evaluate the fundamental characteristics of low-intensity CBT

       Demonstrate a critical awareness of the evidence base supporting low-intensity CBT and methodological limitations

       Critically appraise differences between low- and high-intensity CBT

       Demonstrate an awareness of key challenges associated with low-intensity CBT

      Background

      On a worldwide scale, mental health service delivery is associated with under-investment, excessive waiting times, lack of choice, significant demands on patients, large workforce variation and poorly informed by the evidence base (Ngui et al., 2010). This has resulted in increased demands for parity of esteem between mental and physical healthcare to improve access to evidence-based treatment, meet patient aspirations, provide high-quality care and give equal status to training and practice (Royal College of Psychiatrists, 2013). Across England, efforts to achieve parity of esteem resulted in the publication of the No Health without Mental Health (Department of Health, 2011) mental health strategy. This strategy identifies long-term ambitions to transform mental healthcare with Closing the Gap: Priorities for Essential Change in Mental Health (Department of Health, 2014) translating these ambitions into short-term action. To achieve these ambitions, however, it was recognised that a new mental health programme would be required for implementation across England.

      The IAPT Programme

      The IAPT programme represents the first national implementation of a mental health programme to make evidence-based psychological therapies available to every adult needing them for the treatment of common mental health problems ‘at the right time and in the right place’ (Seward and Clark, 2010: 480).

      Key Point

      The main drivers justifying development and implementation of the IAPT programme for the treatment of common mental health problems (Seward and Clark, 2010) have been:

       Justice-based care arising from the personal impact of mental health problems on patients (Layard and Clark, 2015)

       A strong clinical evidence-base determined by the National Institute for Health and Clinical Excellence (NICE) informing mental health treatment

       A powerful economic case to address societal and lost productivity costs associated with mental health problems calculated to be in the region of £7–10 billion (Centre for Economic Performance, 2006)

       Recognition that solely focusing on increasing the availability of the high-intensity mental health workforce was no longer a viable option (Bennett-Levy et al., 2010).

      These drivers created a strong ‘constellation of rationale and evidence’ providing the initial momentum to justify and establish the IAPT programme (Seward and Clark, 2010: 480). The IAPT programme is now informing similar service developments on a worldwide scale in countries such as the USA (Chapter 20), Hong Kong and Sweden.

      Stepped Care

      Prior to development of the IAPT programme it became apparent that achieving long-term ambitions to transform mental healthcare and meet epidemic level demands for treatment would require a fundamental change in the organisation of mental health treatment (Richards, 2010a). The change was to develop a mental health stepped care delivery model enabling service delivery to be least restrictive (Bower and Gilbody, 2005; van Straten et al., 2015). Lower demands would be placed on patients in terms of costs and personal inconvenience and on service providers through the utilisation of a different workforce at Steps 2 and 3 of the stepped care model (Richards, 2010a). Rather than relying solely on high-intensity Step 3 face-to-face psychological therapists, the revolution in service delivery spearheaded the evolution of a new Step 2 LICBT psychological therapies practitioner workforce.

      Key Point

      The core characteristics associated with stepped care implemented within the IAPT programme (Richards, 2010a) are:

       The mental health psychological practitioner workforce supporting evidence-based low-intensity CBT at Step 2 and therapies workforce delivering evidence-based high-intensity psychological therapies at Step 3

       Assessment is undertaken at Step 2 unless knowledge of the mental health difficulty at referral suggests it is unlikely to be consistent with NICE Guidelines for Step 2 treatment

       The pivotal role of NICE guidelines to inform evidence-based clinical decision-making regarding selection of the appropriate step for the treatment of common mental health problems

       As determined by NICE, patients receive the least restrictive evidence-based psychological therapy to promote recovery

       Outcome measures are systematically taken at every session to inform ongoing treatment decisions and support self-correction whereby patients not responding adequately will be supported to step up to a NICE evidence-based high-intensity treatment

       Stepped care models should accommodate stepping down where a less intensive treatment becomes appropriate.

      What is Low-Intensity CBT?

      CBT is an evidence-based psychological

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