SERENITY PROGRAMME TRAINING - · PDF fileDisadvantages • What [s the model? ... • Asking patients to complete the appointment card rather than the ... people declared 10% more

Serenity Day 1 Presentation 31/10/2015

Steve Cottrell 1

SERENITY PROGRAMME TRAINING

Helper TrainingDay one – updated 31-10-15

1 2

Guided Online Self-Help

(GOSH) for Generalised

Anxiety Disorder, Phobias and

Panic Disorder

3

Contents

• Client selection

• CCBT – the wider context

• E-therapy – not just CCBT

• Programme contents

• Change

• Phone support

• CCBT effectiveness

4

Day 2 - Contents

• The ‘4P’ model

• Communication types

• The relationship

• Cues and dynamics

• Intervention priority sequencing

• Telephone support

• Single-session therapy

5

6

Contacts

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

SERENE.ME.UK/HELPERS

http://creativecommons.org/licenses/by-nc-sa/3.0/

http://serene.me.uk/helpers/


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CCBT - Pros and Cons

Pros Cons

7

Advantages

• Accessibility & convenience - no waiting (maybe …)

• Users have more ownership

• Egalitarian

• Transcript record

• Increased choice

• Advantages for practitioners & the service

• Stepped care approach

• Mastery and agency

• Cost benefits

8

Disadvantages

• What’s the model?

– Bibliotherapy?

– Psychoeducation?

– CBT?

– Something else?

• How does the therapy ‘test’ the client?

• Are there boundaries in the traditional sense?

• What about acting out?

• Disinhibition (+ / -)

• Cue reduction

• Differences in information processing

• Ethics - who is the client?

• How can you assess?

• How can you formulate?

• How can you plan?

• Do you need to?

9

CLIENTSELECTION

10

Who?

• Social phobia

• Shame / fear of humiliation / stigma

• Fear of judgement (race, sexuality, socio-economics)

• A way to avoid authority / dependence

• Disability

• Life patterns (work routines, mobility)

• Rural issues

• Desire for anonymity

• Choice and curiosity!

11

CCBT – Client Selection (1 of 2)

Criteria for a Successful Psychological Approach

1 Desire for a psychological approach

2 Positive experience / expectation of talking therapy

3 Psychological mindedness

4 Introspective ability

5 Ability to form a trusting relationship

Table 1

12


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CCBT – Client Selection (2 of 2)

Criteria for a Successful CCBT Approach

1 Familiarity with computers

2 Desire to work with CCBT

3 Desire and ability to work independently

4 Symptoms make F2F distressing or unfeasible

5 Pressing need (isolation, mobility or access issues)

Table 2

13Factors Mitigating Against Effective CCBT Treatment

1 Severely reduced concentration or other cognitive impairment

2 Hearing loss making telephone work impractical

3 Dangerously impulsive or risky behaviour

4 Therapy-interfering behaviour e.g. low participation or motivation

5 Severe or intrusive symptoms affecting functioning (low mood / mania)

6 Active, intrusive psychotic symptoms

7 Suicidal intent (especially in the presence of plans to act)

8 Severe depression with incapacitating symptoms

9 Intrusive current or repeated ongoing crises

10 Pessimism or skepticism which inhibits productive working

11 Inability to speak or read English (unless interpreter available)

12 Primary problem is neither anxiety nor depression

13 No accessible problem thoughts (‘hot cognitions’) or behaviours

14 Severe personality problems

15 Lack of access to either computer or telephoneTable 3

14

Decision Making

A score of 15 in the PHQ-9 signifies a depression score in the ‘moderately severe’ range, a score of 15

or above signifies symptoms in the ‘severe anxiety’ range of the GAD-7. For the Hospital Anxiety and

Depression Scale (HADS), a score of 16 or above is in the ‘severe’ range for either anxiety or

depression symptoms.

CCBT recommended CCBT with extra support CCBT not applicable

>= ⅗ from table 1 and

>= ⅗ from table 2

< ⅗ from table 1 or

< ⅗ from table 2

One or more from table 3

(exclusion criteria)

PHQ-9 & GAD-7 < 15 & GAF > 50 PHQ-9 or GAD-7 > 15 GAF <50 or other impairment

15

CCBT – THE WIDERCONTEXT

16

Mental Health Problems

• Worldwide 151 million people suffer from depression at

any one time and 844,000 people die by suicide every

year (Funk et al, 2010)

• One in four UK adults experiences at least one

diagnosable mental health problem in any one year (ONS,

2001)

17

Why? (1 of 2)

• About 13% of population of Britain suffer anxiety or depression or both at any one time (more than 7 million people)

(Meltzer et al, 1995)

18

18


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Why? (2 of 2)

• Of the 7 million people who may benefit from counselling or psychotherapy for anxiety or depression, 70,000 do so - about 1 in 100

(Meltzer et al, 1995)

19

19

Drivers 1 of 2

• The drive to develop cheaper, better treatments

• Evidence-based practice

• The development of self-help books & guided self-help

• The growth of the Internet

• Clinical trials of internet-based CBT and self-help manuals

• Increasing interest in high volume, lower intensity manualised approaches to CBT

20

Drivers 2 of 2

• Salutogenesis, health promotion and public health

• Changes to delivery systems (e.g. stepped, collaborative

care)

• The move towards consumerism in the NHS

• The McDonaldisation of healthcare

• Increasingly well-informed patients

• The ascendancy of science and technology

• Recognition of the economics of mental health issues

21

Tiered Service Structure

Low and medium secure, specialist inpatient servicesspecialist community teams

Assertive outreach, acute inpatient services, community mental healthsupported accommodation, early intervention & gateway

crisis resolution and home treatment

Primary health & care team, third sector counselling & support, primary mental health support mainstream leisure, education & recreation, low-level support &

mainstream accommodation

Self-help, mental health promotion and education

High secure & residentialhighly specialist inpatient

4

3

2

1

Foundation Tier

22

Contribution of Factors to Disorders

0

2

0

4

0

6

0

8

0

1

00

Predisposing factors Precipitating factors Perpetuating factors

Pre-morbid Acute Early Chronic

Diagnostic threshold

Seve

rity

23

Predisposing Factors

• Predisposing factors: social class, genetic

vulnerability, inequity, parental health & wellbeing,

cultural mores, economic factors

• Requires social & political interventions, policy level

24


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Precipitating Factors

• Precipitating factors: Stress, loss, social isolation,

relationship conflict, acute health crisis, personal

catastrophe

• Require workplace interventions, crisis intervention,

individual and community focus

25

Perpetuating Factors

• Perpetuating factors: Negative cognitions, habits of

mind, entrenched behaviour patterns, gaps in

knowledge, untested assumptions, unrecognised

deficits, diet, exercise, social isolation, relationship

conflict, stigma

• Requires personal therapeutic focus: interpersonal

level

26

Protective Factors

• What are some mental health protective factors

• How might CCBT contribute to these?

27

E-THERAPYNOT JUST CCBT

28

Web basedStandalone

Multi-mode

Synchronous Asynchronous

Messaging

EmailMessageboard

CD-ROMNetwork

Video, SkypeFacetime

Journal / Blog

Web, CDPaper etc.

TelephonyVOIP

MMORPG, VR, AR,Virtual Worlds

29

Learning in a Virtual World

• J. Med. Internet Res. 2010;12(1)

• Event took place on June 15, 2009

• On a private island owned by Boston University and WHO

• Dr. Elliot Sternthal, Boston Medical Center

30

http://www.jmir.org/2010/1/e1/

http://www.jmir.org/2010/1/e1/


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31

32Kylie Coulter’s consulting room in Second Life

33 34

35

Virtual Iraq / Afghanistan36


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37 38

Video next

39 40

Differences in engagement

Differences in engagement

• Instead of spending one hour a week with a therapist,

Talkspace lets users send unlimited messages to their

therapist for $25/week

• Therapists can have more flexibility and serve a broader

range of clients

• As of May 2015, Talkspace

said it has more than 250

therapists online

41

A hierarchy of engagement...

• Specific software e.g. Fear Fighter, Beating the Blues, LLTTF Moodgym, Blues Begone etc.

• No visual / auditory information - asynchronous (e.g. email)

• No visual / auditory information - synchronous (e.g. ‘chat’)

• Auditory information only (e.g. ‘phone)

• Visual and auditory at a distance (e.g. Skype)

• Blended methods e.g. Serenity Programme

• Immediacy, contextual richness and sense of presence increase with each step

42


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A Continuum, not ‘either - or’

• The blend can be adjusted to suit the client ...

Practitioner contact time

Computer use

43

Asay and Lambert (2002)

Percentage Improvement as a Function of Therapeutic Factors

44

45

‘MINDSPACE’ The ‘Nuffield Ladder’

46

Behavioural Insights Team

47

Consciousness Raising (1 of 2)

• Organ donation - defaulting ‘in’ - will double the

percentage of people joining the organ donation

register

• Healthier food - salt in pre-prepared food to be reduced

(by 1 gram per person per day compared with 2007

levels) estimated to save around 4,500 lives a year

48


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Consciousness Raising (2 of 2)

• Tax - changing letters to say that most people in the

area had already paid their taxes boosts repayment by

15% - could generate £30 million of extra revenue

annually

• Environment - redesigned Energy Performance

Certificates (EPCs) will tell people how costly it will be to

heat a home they are buying

49

Cheers!

• Heineken are removing 100 million units of alcohol by

lowering the strength of one of its major brands, the

equivalent of reducing total UK alcohol intake by 0.3%

• The introduction of ‘schooners’ (2/3 pint glasses) as an

option in pubs from October 2011

• Change4life - increasing the social desirability of certain

behaviours

50

http://www.bbc.co.uk/news/uk-12113880

51

• Prompting patients to repeat the time and date of their appointment to staff (reduced DNAs by about 11%)

• Asking patients to complete the appointment card rather than the nurse (active commitment - reduced DNAs by about 18%)

• Using a poster that indicated the number of patients who usually turned up promptly to their appointments (reduced DNAs by about 2%)

(Highlighting positive or negative behaviour normalises them and increases that type of behaviour; Schultz et al. 2007) - total reduction in DNAs about 30%

Bedford NHS - Reducing DNAs

52

• Signatures are more effective if placed at the beginning of a form than at the end - an experiment showed that people declared 10% more miles on their car insurance application when signing upfront (resulting in them paying higher premiums)

• ‘Active nil returns’ - people lie less if they have to do so actively rather than passively (e.g. by omitting relevant information) - application forms for some benefits will have fields which require an applicant to write ‘Nil’ or ‘Nothing to declare’ rather than a blank response

Honesty

53

Verbal Commitments

• Restaurateur Gorden Sinclair added two words that his receptionists used when taking customer bookings over the telephone. Instead of the usual ‘Please call us if you need to change or cancel your booking’ before hanging up, Sinclair asked staff to say ‘Will you please call us if you need to change or cancel your booking?’ and then pause, prompting the customer to make a verbal commitment by answering ‘Yes’ - this verbal commitment led to a reduction in no-shows of 20%

54

http://www.bbc.co.uk/news/uk-12113880


Steve Cottrell 10

Influence

Liking

Reciprocity

Social proof

Scarcity

Authority

Consistency

Cialdini’s 6 Principles of Persuasion

55

Influence

Liking

Reciprocity

Social proof

Scarcity

Authority

Consistency

People align

with commitments

People like

people who like them

People

repay in kind

People

follow similar

others

People

want what is scarce

People

defer to experts

56

Influence

People like


People

repay in kind

People

follow similar

othersPeople

want what is scarce

People

defer to experts

People align

with commitments

57

Influence

People like


People

repay in kind

People

follow similar

othersPeople

want what is scarce

People

defer to experts

People align

with commitments

Give genuine

praise and recognition

Highlight unique

benefits

Recognise and use

‘peer power’

Give what you want to

receive

Expose your

expertise

Make commitments

active, public and voluntary

58

Praise Effort, Not Ability

No

• You’re so clever

• You’re a natural

• Another great result

• That’s exactly what we wanted

Yes

• You worked really hard

• You planned it really well

• That wasn’t easy and you didn’t give up!

• Tell me how you did that …

59

PROGRAMME CONTENTS

60


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61

What is it?

Human Contact

Interactive Programme

Self Assessment

Telephone Support

A theoretically integrative

blended learning approach to

treatment of anxiety

Human contact, interactive

Internet programme and

telephone support

62

What’s in the Programme?

• A series of assessment measures

• A series of information pages

• A resource page for helpers

• A brief self-help programme, open to anyone

• A series of interactive workbooks

• Microsites

63

http://serene.me.uk

Free Programme

Helpers Resources

Members Area

Information Pages

Cwm Taf MindWelsh

Information

Tests and Assessments

Health Information

Local Resources

Microsites

Site Structure

64

Assessment meeting

Modules 1 and 2

Support call

Module 3Goal setting

meetingModule 4

Support call Module 5 Support call

Module 6 Module 7

Module 8

Module 9

Support call

Support call Support call

Final meeting

The Programme

65Referral received Contact client & arrange to meet

Client keeps appointment?

Meet with client – baseline measures, login given, ask to read Modules 1 & 2, make appointment to ‘phone in 2 weeks

Helper telephones client at agreed time

Ask client to read Module 3 - make appointment for 2 – 4 weeks to meet face-to-face

Face-to-face session – goal setting using Module 3 - make appointment to ‘phone in 2 - 4 weeks


Module 4 - make appointment to ‘phone in 2 - 4 weeks





Client wants to continue?






Module 9 - arrange follow up meeting if required, post-measures

Discharge or re-assess and refer to step-up service if required

Two more contact attempts, discharge if no further contact

Follow-up meeting (if required)

Serenity Programme Helper’s Guide v.1.2

NoYes

Yes

No

66


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CHANGE

67

The ‘Hype Cycle’

68

5 Cautions from Ferlie & Fitzgerald

Finding one

• There is no strong relationship between the strength of

the evidence and the rate of adoption of change

69

Finding two

• Scientific evidence is in part a social construction as well

as ‘objective data’

Implication

• There is no such entity as ‘the body of evidence’ but

rather ‘competing bodies of evidence’


70

Finding three

• There are different forms of evidence differentially

accepted by different individuals and different groups

Implication

• Different groups must come together in a learning

environment outside of the daily routine


71

Finding four

• Specific organisational and social factors influence the

path and outcome of change

Implication

• The most effective implementation strategies combine

top-down pressure and bottom-up energy


72


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Finding five

• The upper tiers of NHS management, purchasers and

R&D play a marginal role only in change processes

Implication

• There is a need to acknowledge that change is

embedded within the professions themselves


73

Prerequisites for Successful Change...and Effects When One is Missing!

1 2

3 4

1. Pressure for change2. Capacity for change3. A clear shared vision4. Actionable first steps

21

3

2

3 4

1

3 4

21

4

Bottom of ‘In-tray’ Anxiety & frustration Fast startfizzles out

Haphazard efforts& false starts

74

PHONE SUPPORT

75 76

77

Telephone ‘Baggage’

• Telephones mean different things to different people

• May bring good news, bad news, a lifeline or a curse, may bring only work!

• What meaning does the telephone hold for you?

• Take 5 - 10 minutes to discuss with a partner, using counselling skills to help your partner explore ...

• Can we leave this baggage behind when making a call to a client?

78


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Controversies

• If people can fall in love in chat rooms, by letter or email, then the medium can sustain a relationship and allow therapeutic, affective work

• If you cant see the client, can you still work effectively (ask a visually impaired counsellor!)

• We emote ‘as if’ in virtual worlds - ‘telepresence’ and our suspension of disbelief

• Telepresence entering social consciousness – Tron, The Lawnmower Man, Matrix, The Cell, Gamer, Surrogates, Avatar, Inception, Vanilla Sky, Total Recall etc.

79

Interpersonal support - it’s important to CCBT

• Andersson G, Cuijpers P. (2009) Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cognitive Behaviour Therapy.38(4) p196-205

• Included 12 studies found effect size of 0.61 for supported and 0.2 for unsupported CCBT (0.8=large; 0.5=moderate; 0.2=small)

• Attrition is high without interpersonal support

• This is ‘support’ in the broadest sense - interpersonal support and encouragement - a containing relationship

• It’s not counselling, though counselling skills are key ...

80

Samaritans

• Have been providing email support since 1994, numbers roughly double each year

• Samaritans receive about 500 emails a day, respond in less than 24 hours

• More males email than ‘phone

• People are 3 times more likely to mention suicide in email than by ‘phone

• In 2011 Samaritans received over 206,000 emails

2-minute movie

81

82

Telephone Support - is it Second Best? (1 of 6)

• There are benefits to the client

• To the provider

• Possibly to the wider environment too ...


• What are these benefits?

• Who might benefit most?

• Who and why might choose telephone-support over other approaches?

83


• Benefits to the client

– Convenience

– Access for disadvantaged groups

– Cheaper - less travel required

– Anonymity

84


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• Benefits to the provider

– Less physical space required

– Reception and appointment administration

– Personal safety

– Practitioner anonymity

– Cost effectiveness

85


• Who might benefit most (1 of 2)

– Young men - less likely to disclose in relationship

– Single parents, people with childcare problems

– Older or more physically vulnerable people

– People in remote or rural areas (access of confidentiality issues)

– People with caring responsibilities

86


• Who might benefit most (2 of 2)

– People who find movement or transport difficult

– People with restricted freedom - children or people in abusive relationships

– People on very low incomes

– Certain diagnoses - social anxiety, agoraphobia, shame-based pathology, issues with authority or dependence, impulse control issues

87


• There are of course, disadvantages ...

– Reduced visual cues

– Caller can terminate the call easily - esp. If dealing with sensitive subjects

– Assessment issues

– Potential distractions and interruptions

– Can’t ensure client’s privacy - potential recording, others ‘listening in’

– Cant absolutely identify the client!

88

Telephone Support - Remember ...

• Leaving messages with people? Consent to leave messages

• Block caller ID with ‘141’

• Who may answer the ‘phone? Non-committal introductions

• Call recording

89

Telephone Support - Remember ...

• Others listening in on extensions

• Procedure in the event of repeated ‘no answer’

• ‘Last number redial’ breaching clients confidentiality

• Procedure for contingencies - drunk / abusive / deteriorating / suicidal clients

90


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Telephone Support - Privacy

• Telling a client their call is confidential, then they hear background voices

• Client becomes hesitant, distracted or monosyllabic - ‘It sounds as though someone has walked in - if they have, just say yes’

• Calls ideally take place behind closed doors - like face-to-face therapy

• Trivialising ‘phone calls - interruptions are thought to be permissible ‘would you like a coffee?’

91

Telephone Support - Reasons for Referral

• Because of you ...– Your personal limits

– Your professional limits

– The limits of your competence / training

• Because of the client ...– The client needs broader / deeper / more enduring

intervention

• Because of your agency ...– Time limits

– Restrictions on type of service offered

– Organisational policies

92

Hard-learned Lessons

• Three missed appointments = discharge

• Whoever cancels the session, rearranges it

• Helpers (nearly) always initiate

• Permission to leave messages

• Single-session time frame

• Strengths and solution focus

• Goal setting is often the hardest part

93

Safeguarding and Governance

• What do you think a provider needs to have in place to provide a high-quality telephone support service?


• Consider:

• Safety

• Effectiveness

• Acceptability

• Equity

• Efficiency

94

But Does it Work?

95


Steve Cottrell 17

Does CCBT Work?

• Meta-review results broadly agree that, for depression

and anxiety disorders, CCBT has been found to be as

effective as therapist-led cognitive behaviour therapy

(Fouroushani et al, 2011)

• Telephone work no less effective that F2F for most

(Geoffrey C. Hammond Tim J. Croudace, Muralikrishnan Radhakrishnan, Louise

Lafortune, Alison Watson, Fiona McMillan-Shields, Peter B. Jones, [n= 39,227, Published

2012, cost saving of 36.2% over FTF])

97

Does CCBT Work?

98

‘Computerized treatments have been shown to be a less-intensive, cost- effective way to

deliver empirically validated treatments for a variety of psychological problems’

Does CCBT Work?

99

Stefan Leucht, Sandra Hierl, Werner Kissling, Markus Dold and John M. Davis (2012). Putting the efficacy of psychiatric and general medicine

medication into perspective: review of meta-analyses. British journal of Psychiatry 200:97-106.

• The magnitude of Hedges’ g may be interpreted using Cohen's convention as small (0.2), medium (0.5), and large (0.8)

• Effect sizes:– Aspirin for prevention of first heart attack = 0.06

– Aspirin for secondary prevention of heart attack = 0.12

– Statin for prevention of heart attack = 0.15

– Prozac for MDD = 0.35

– Antihypertensives for high BP = 0.55

– Ritalin for ADHD = 0.78

Summary results of meta-analyses examining the effects of internet- and computerized CBT for depression and anxiety disorders

Andrews G, Cuijpers P, Craske MG, McEvoy P, et al. (2010) Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis. PLoS ONE 5(10): e13196. doi:10.1371/journal.pone.0013196http://www.plosone.org/article/info:doi/10.1371/journal.pone.0013196

100

Does CCBT Work?

101

64 articles, 92 studies reviewed, 9764 clients - Internet Interventions versus control conditions: Weighted Mean Effect Size = 0.53

Internet Interventions versus face-to-face: no significant difference

Andrews G, Cuijpers P, Craske MG, McEvoy P, et al. (2010) Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis. PLoS ONE 5(10): e13196. doi:10.1371/journal.pone.0013196

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0013196

Outcomes (3-month programme)

HADS (0-7 = normal, 8-10 = mild, 11-14 = moderate, 15-21 = severe) mean scores of first 12 participants

102




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Outcomes - Anxiety

103

Outcomes - Depression

104

User Feedback

• ‘It’s absolutely super, I’m really, really impressed with it, it’s a wonderful thing to have…’ (Service User)

• ‘I'm finding this a great way to work with people -everyone has been very positive about the programme. I feel that I have managed to make progress with 8 people today, usually I would see a maximum of 4 people in a day, what with travelling etc.’ (Occupational

Psychologist)

105

Recap (1 of 2)

• Pros and cons of CCBT

• CCBT in context

• Factors contributing to disorders

• Drivers for CCBT

• Different types of non-proximal therapy

• A hierarchy of engagement

• The contribution of the relationship

106

Recap (2 of 2)

• Influence and persuasion

• The programme - content and process

• The programme

• Change as a process - early and late adopters

• What drives change?

• Exercise - supporting CCBT dissemination

• CCBT effectiveness

107

Day 2 - Contents

• The ‘4P’ model

• Communication types

• The relationship

• Cues and dynamics

• Intervention priority sequencing

• Telephone support

• Single-session therapy

108


Steve Cottrell 19

References

Comparative Effectiveness of Cognitive Therapies Delivered Face-to-Face or over the Telephone: An Observational

Study Using Propensity Methods. Geoffrey C. Hammond, Tim J. Croudace, Muralikrishnan Radhakrishnan, Louise

Lafortune Alison Watson, Fiona McMillan-Shields, Peter B. Jones. PLoS ONE September 2012, Volume 7 Issue 9.

Available from: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0042916 accessed on 04-

06-13.

Andrews, G., Cuijpers, P., Craske, M.G., McEvoy, P., et al. (2010) Computer Therapy for the Anxiety and Depressive

Disorders is Effective, Acceptable and Practical Health Care: A Meta-Analysis. PLoS ONE October 2010, Volume 5

Issue 10. Available from:

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0013196 accessed on 04-06-13.

Radhakrishnan, M., Hammond, G., Jones, P.B., Watson, A., McMillan-Shields, F., Lafortune, L. Cost of Improving

Access to Psychological Therapies (IAPT) programme: An analysis of cost of session, treatment and recovery in

selected Pr

Lovell, K. et al. Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder:

randomised controlled non-inferiority trial; BMJ, doi:10.1136/bmj.38940.355602.80 Available from:

http://www.bmj.com/content/333/7574/883 accessed on 04-06-13.

109

Remember

If you don’t do something about this in the next 24 hours …

You probably won’t do anything about it!

110

Thanks for Listening!Questions?

111



http://www.bmj.com/content/333/7574/883

Documents

SERENITY PROGRAMME TRAINING - · PDF fileDisadvantages • What [s the model? ... • Asking patients to complete the appointment card rather than the ... people declared 10% more