IAPT Improving Access to Psychological Therapies

IAPTImproving Access to

Psychological Therapies

Who are we?…..What do we do?Barbara Fulton, Lorraine Parker & Yvonne Drew Psychological Therapists: Open Mind Service Part of the wider NHS IAPT programme which

implements guidelines for people suffering with depression and anxiety disorders

We offer realistic and routine first-line psychological treatment

Based at Cobden Street: our aim is to reduce barriers to accessing psychological treatment (that offenders may come across)

Stepped care modelStep 1: Recognition

Step 2: Mild/Moderate common mental health problems

Step 3: Moderate/Severe common mental health problems

Step 4: Treatment resistant, Atypical and psychotic depression, psychotic illnesses, those at significant risk, Personality disorder

Step 5: Risk to life, severe self-neglect

Barriers • Blocking of Treatment (many offender

service users have repeated experiences of refusal and exclusion from services)

• Problems dismissed

• Not registered with a GP

Psychological TherapiesA variety of therapies have been reviewed for their

effectiveness (Nice Guidelines)

CBT – depression & all anxiety disorders

IPT, BCT, Counselling, BDT- depression (varying indications)

CBT, EMDR- post traumatic stress disorder

Cognitive Behavioural TherapyEMDR Barbara Fulton & Yvonne Drew

Depression: Moderate to SevereDepression: Mild to ModeratePanic DisorderGeneralised Anxiety DisorderSocial PhobiaOCD (Obsessive Compulsive Disorder)PTSD (Post Traumatic Stress Disorder)Hypochondriasis (Somatoform disorder) Specific Phobias

Integrative TherapyLorraine Parker

Blends elements of a range of therapies- Gestalt- Object relations- Cognitive behavioural approaches - Attachment- PsychodynamicPersonality disorder or characterlogical issues

underlie depression and/or anxiety.

Consider a referral if….. Depressed mood lasting for more than two weeks

Anxious mood lasting for more than 2 weeks

Has already been diagnosed with depression or an anxiety disorder

Problem behaviour: which appears to be associated with anxiety or depression

Sufficient time remaining: sentence/licence

Not Offender Rehabilitation We specifically target depression & anxiety and

not offending history We work within psychological models formulating

the offender’s problems from their point of viewNot about prosocial modelling, reinforcement and

reward of prosocial behaviour Offending history is only focused on if identified as

significant to their psychological problem and formulation

Risk assessment and risk management throughout treatment

Not offender Rehabilitation: case study

Male, aged 45Offence history: sexual relationship with a minor

(15yrs), downloading & distributing images of childrenUnrepentant (makes this clear at initial meeting) Diagnosis: agoraphobia (since release from prison)Fear: “I could be chased, have to fight for my survival,

do damage to my attackers and then end up back in prison”

Problems identified: Isolated and depressedTherapy: Cognitive and behavioural interventions

targeting avoidance of situations perceived as difficult to escape from

Referral ProcessProvide the service user with information about

IAPTAdvise that therapy is not compulsory Complete referral documentationQuestionnaire: this needs to be the service

users interpretation of their mood and situationService user needs to sign 2 consent forms (inc)Return the completed referral pack & book an

available appointment slot IAPT staff are happy to guide you

Referral Process1st appointment: Initial assessment

Assess for service suitabilityAssess for therapy suitability

(CBT, EMDR or Integrative)Agree an initial treatment plan If not suitable: signposting/referral If not suitable: OM guidance

Assessing for CBT Suitabilitywhy is this important?

Service users with unfocused, multiple or very chronic problems are least likely to benefit from short term CBT

Demoralisation CBT is not a one size fits all

How OM’s can help with assessing suitability for CBT

Is there potential for acceptance of the CBT model?“what are your beliefs about what’s causing

your difficulties”

Those with an insistence that their problem is due to a chemical imbalance or caused by other people are unlikely to be suitable


Are the able to identify thoughts, feelings, behaviours and body sensations?

Emotion

Thought

Body sensatio

n

behaviour


Are they able to access their own emotions in relation to situations ?

“how did you feel when that happened……”(look for a one word answer)

Are they able to comment on their thoughts in relation to situations ?

“what ran through your mind when that happened….”


Are they goal orientated?

…do they have the ability to work on one specific problem at a time?

….be aware of vagueness, rambling, frequent topic changes, desire to work on all problems at once


Do they have alliance potential?

- Note: eye contact, posture and general ‘feel’

- Poor rapport, idealising or blaming


Are they able to accept personal responsibility in the therapeutic process?

“what would you like to get out of therapy?....what might your role be in that”

“you’d be expected to work on your problems in between cbt sessions….what’s your thoughts about that?”

Active v Passive?

Are they Anxious/Depressed……but struggling to meet the CBT checklist???

Seek IAPT guidance….. “It’s good to talk!”May be more suited for Integrative TherapyCBT checklist: the assumptions can be

difficult to meet (those who have PD or other characterlogical issues)

Transference

CountertransferenceA redirection of feelings towards the service

userEmotional entanglement with a service user Heart sink feeling….or hot potato Look out for:Service user reminds you of someone you have strong negative feelings towardsFeeling parental towards themOverly identify with themDifficult to supervise/relationship breaking down

CountertransferenceIs the service user wanting help with their anxiety or negative mood?....if not:

Could the difficulties encountered be better dealt with in supervision with your manager

Reflective and reflexive practice is keyBe aware that countertransference is normalBe consistent with boundaries

Co- existing Drug and Alcohol Use

70-80% of clients in drug and alcohol services have anxiety disorders, depression, trauma (Weaver, 2003)

IAPT services should be working inclusively alongside substance misuse services to improve outcomes (IAPT Positive Practice Guidelines)

CBT: Co-existing anxiety/depression (NICE guidelines (2007) Dug misuse: psychosocial Interventions)

Co-existing Drug and Alcohol Use High Intensity

Formal therapies delivered by IAPT therapist CBT for depression or specific anxiety disorder

Low Intensity Delivered by IAPT therapist

Guided self-help & Behavioural Activation for anxiety disorders and depression

Low Intensity Delivered by Probation Key Worker

Motivational Interviewing & Contingency Management

Co-existing Drug and Alcohol Use No evidence that using substances makes usual psychological interventions ineffective

Executive

Goal directed behaviou

r

Decision making

Problem solving

Time manageme

nt

Analytical thinking

Organisational ability

if an executive function deficit exists: CBT can be adapted

Co-existing Drug and Alcohol Use

Accepted: experimental, recreational as well as stable drug and alcohol use

IAPT staff will determine stability

Not accepted: unstable drug and alcohol useInstability across drug and alcohol use can

lead to therapy disruption

Multiple Competing Needsinc personality disorder, learning disability,

drug dependence, alcohol dependence, homelessness, domestic violence etc.............

• May lead to non attendance/disrupted therapy

sessions /poor homework compliance

• May compete with motivation for therapy and treatment engagement

• Offender service users with multiple and competing needs may be misunderstood as being a ‘time wasters’

Thank YouAny questions

………its good to talk!

Documents

IAPT Improving Access to Psychological Therapies