LITMIR.BIZ

Скачать книгу

Programme for Depression (Lovell and Richards, 2012), the cognitive restructuring intervention comprises a ‘thought diary’ to identify unhelpful thoughts and ‘evidence table’ to challenge them. However, ‘as long as the intention is cognitive or schematic change’ (Clark, 2013: 2), interventions such as behavioural experiments have also been associated with cognitive restructuring. This approach has been adopted within a cognitive restructuring intervention (Farrand et al., 2019a). However, when using this intervention, consideration needs to be given to ways of supporting the behavioural experiment when undertaken outside the session (Chapter 6). Unlike HICBT, where in-vivo experiments are encouraged (Rouf et al., 2015), supporting interventions outside of a support session are not commonly undertaken in LICBT.

      Therapeutic Drift during Support Sessions

      Although clear distinctions should be drawn between low- and high-intensity CBT, challenges can be encountered when an LICBT psychological therapy practitioner drifts between supporting single-strand CBT self-help interventions and delivering multi-strand interventions (Waller, 2009). When the practitioner drifts into HICBT, adopting techniques such as downward arrow (Beck, 1995) or continuum methods (Padesky, 1994), challenges to working outside of competencies developed during training (Roth and Pilling, 2007a) or working within constraints imposed by the therapeutic dose is encountered. They may be more likely to arise when the LICBT psychological therapy practitioner drifts into employing HICBT techniques to deliver specific stand-alone worksheets within sessions rather than supporting the patient to work through CBT self-help workbooks between sessions. However, LICBT psychological therapy practitioners losing confidence in the LICBT interventions when patients show little sign of recovery has also been recognised as a factor that can lead to therapeutic drift (Telford and Wilson, 2010).

      Therapeutic Drift within CBT Self-Help Interventions

      The genesis of self-help as a concept informing self-help books (Smiles, 1859) precedes the development of CBT self-help. Consequently, CBT has been adapted in many different ways to inform the content of the self-help interventions leading to significant heterogeneity. This has resulted in some CBT self-help interventions being more representative of HICBT by adopting multi-strand interventions, longitudinal formulations and techniques to address more enduring cognitive distortions (Beck, 1995). For example, a commonly adopted written CBT self-help book for depression, Overcoming Depression, (Gilbert, 2009) includes techniques such as cognitive restructuring but as part of a multi-strand approach including a compassion focus and addressing other difficulties that can be co-morbid with depression, such as anger. Additionally, multi-strand interventions have been adopted within iCBT programmes proposed to be LICBT with support provided by LICBT practitioners (Richards et al., 2018). For example, ‘Space from Depression’ includes techniques for depression such as behavioural activation, self-control desensitisation and cognitive restructuring alongside techniques used to challenge core beliefs. NICE guidelines for depression are cited as the justification for the approach taken. However, these guidelines highlight these techniques when used as part of a multi-strand approach within HICBT.

      LICBT self-help interventions adopting a multi-strand approach is therefore inconsistent with a single-strand approach associated with LICBT. They can drift away from the focus of the difficulties presented in the here and now and address a longitudinal formulation and require a psychological practitioner workforce to drift from the LICBT clinical method.

      Reflection Point

      What implications for practice when selecting LICBT interventions arise as a consequence of heterogeneity in the CBT clinical method included within self-help interventions?

      Whilst there is guidance informing the selection of CBT self-help interventions (Richards and Farrand, 2010; University College London, nd), the focus is largely upon criteria related to presentation, style and the evidence base but it largely fails to address characteristics differentiating low- from high-intensity CBT.

      Retention of the LICBT Psychological Therapy Practitioner Workforce

      A major challenge experienced by the IAPT programme has been attrition from the PWP, LICBT psychological therapy practitioner workforce (National Collaborating Centre for Mental Health, 2018). Soon after the end of training a significant number of the PWP workforce leave the role, with many seeking to undertake HICBT training to work at Step 3 of the Stepped Care model. High attrition has potential to destabilise services and challenge recovery rates with the workforce largely comprising novice practitioners that have failed to enhance and develop their competencies (Roth and Pilling, 2017). Experiencing a situation such as this with a workforce has the effect of threatening and fragmenting the quality of care (Imison, Castle-Clarke and Watson, 2016). Furthermore, failing to maintain the PWP challenges the economic case used as a justification behind the IAPT programme, threatening long term sustainability. However, development of the Psychological Professions Network, new vocational routes into training such as apprenticeships and developments in Assistant Practitioner roles represents the potential to reduce attrition by improving access to the workforce.

      Increased Demands Placed on LICBT Psychological Therapy Practitioners

      Working within a high volume LICBT mental health environment having higher patient caseloads alongside shorter contact durations compared with HICBT has the potential to place increased demands on the LICBT psychological therapy practitioner workforce (Richards, 2010b). To ensure safe and effective working with a high volume of patients ‘clinical case management’ supervision was developed for the LICBT practitioner working within the IAPT programme with clinical skills supervision focused on skills development (Chapter 9; Richards, 2010b). However, whilst both forms of supervision meet four of the purposes of supervision (Turpin and Wheeler, 2011), the fifth function associated with ‘Staff Support and the Prevention of Burn-Out’ may not be fully realised. Consequently, there may be a failure to support the practitioner to better maintain their own health and well-being or to address any emotional difficulties of their own unrelated to work.

      Key Point

      Challenges encountered with LICBT:

       Clinical heterogeneity regarding the content and delivery of CBT self-help interventions, self-help format and types of written CBT self-help interventions.

       Lack of consensus exists as to what constitutes single strand with respect to LICBT interventions.

       Therapeutic drift between low- and high-intensity CBT arising with respect to both clinical support sessions and within the CBT self-help interventions.

       High levels of attrition can be experienced with the LICBT psychological therapy practitioner workforce.

       High levels of demands are placed on the LICBT psychological therapy practitioner workforce potentially requiring higher levels of supervision capacity to support staff.

      Summary

      For many years, service delivery has evolved to meet large increases in demand for mental health treatment. However, simply evolving mental health services has resulted in excessive waiting times, lack of choice and poor connection to the evidence base. Revolution in mental health service delivery based on the implementation of LICBT within Step 2 of a stepped care model has provided a solution to these challenges. This chapter has highlighted that whilst based on a CBT model, key characteristics associated with the LICBT clinical method and workforce serve to distinguish low- from high-intensity CBT with these characteristics addressed more extensively in other chapters. As can be common with revolution however, several new challenges to be addressed have emerged.

      Assessing Your Understanding

      Declarative

      Essay Questions

       Critically evaluate differences between low- and high-intensity CBT for the assessment and treatment

Скачать книгу