Low-intensity CBT Skills and Interventions. Группа авторов
evidence-based intervention to patients in the first instance (see Clinical Decisions 1, 2 & 3 sections of this chapter).
Ensure clinical decision-making supports self-correction within the stepped care model, including stepping a patient up, down or discharging them (see Clinical Decision 4 section of this chapter).
Risk is managed effectively and with the immediacy required as informed by risk management decision-making protocols during assessment and guided self-help (GSH) sessions (Chapters 2 and 3).
Alongside clinicians, patients and policymakers, within the IAPT programme the case management supervisor also plays a fundamental role in clinical decision-making (Chapter 9; Turpin and Wheeler, 2011). Clinical skills supervision provides an additional space where LICBT practitioners can bring questions regarding clinical decision-making. This further enhances fidelity (Waller, 2009) to appropriate guidance informing service delivery (NCCMH, 2018).
Decision-Making Protocols within Low-Intensity CBT
Working at Step 2 within a stepped care service delivery model (NICE, 2011b; Chapter 1), LICBT practitioners follow service protocols to ensure efficient, effective, safe and acceptable mental health service delivery. It is recommended that these are consulted throughout all decision-making processes (NCCMH, 2018).
Clinical Practice
Common Clinical Decisions within the IAPT Programme and Factors to Consider
Clinical decision 1: Is a Step 2 or 3 treatment suitable for the patient? Consider:Service inclusion and exclusion criteriaProvisional diagnosisSeverityRiskAlcohol and drug use.
Clinical decision 2: Which Step 2 intervention do I offer? Consider:Provisional diagnosisCo-morbidityThe role of signposting.
Clinical decision 3: How should the intervention be delivered?
Clinical decision 4: Should I discharge or step the patient up?
Decision 1: Is Step 2 or 3 Treatment Suitable for the Patient?
The suitability of a mental health service refers to its capacity to meet the needs of a patient, with need defined as ‘the ability to benefit in some way from healthcare’ (Stevens and Gabbay, 1991: 20). At referral, suitability of the service to meet patient need must be decided on with initial reference to IAPT inclusion and exclusion criteria (Chapter 1).
Clinical Practice
IAPT Inclusion and Exclusion Criteria
Inclusion criteria:Common mental health difficulty such as depression and/or anxietyDifficulty of mild-moderate (Step 2) to moderate-severe (Step 3) level of severity as determined by standardised, routine outcome measures (ROMs).
Exclusion criteria:Failing to meet at least mild severity on ROMsHigh level of risk – likelihood of harm to self or othersSevere, complex and enduring mental health problems (e.g. very severe depression, bipolar, psychosis or personality disorder). These will be considered for stepping up to Step 4 secondary care mental health services unless specific IAPT-SMI pathways are in place (Johns et al., 2019).
Following assessment (Chapter 2), the majority of people deemed suitable for IAPT services (Steps 2 and 3) are likely to enter LICBT treatment (Step 2). In some cases, immediate allocation to Step 3 will be indicated; namely by the evidence base, the LICBT practitioner's knowledge of the patient's provisional diagnosis and the availability of treatments at Steps 2 and 3 as outlined in clinical guidelines (see Chapter 3).
Clinical Practice
To Determine the Suitability of Step 2 and 3 Treatments consider:
Presenting problem/provisional diagnosis: identified through structured interviewing techniques and Routine Outcome Measures (ROM's; Chapter 2).
Diagnostic criteria: outlined in classification systems, Diagnostic and Statistical Manual of Mental Disorder-V (DSM; APA, 2013); International Classification of Disease-11 (ICD-11; WHO, 2018).
Step 2 and Step 3 intervention selection criteria outlined in clinical guidelines (NICE, 2011b).
Whilst decision-making may be protocol-driven, it remains important to consider patient-specific factors to maintain a patient-centred approach. If unacknowledged, these factors may result in LICBT treatment being unhelpful or potentially even harmful (Papworth et al., 2015). Maintaining patient-centredness may include adapting practice to accommodate sensory or intellectual disabilities, language, intervention acceptability (Farrand et al., 2019) and existence of co-morbid conditions and/or symptoms.
Provisional Diagnosis
With the exception of post-traumatic stress disorder (NICE, 2018b) and social anxiety disorder (NICE, 2013), all common mental health difficulties of mild-moderate severity should be initially considered for treatment with LICBT (Table 4.1).
Table 4.1
Recommendations are subject to change as the evidence base develops. For example, NICE guidance regarding obsessive-compulsive disorder (OCD; NICE, 2005) was previously only recommended for HICBT treatment at Step 3. However, recent evidence demonstrates that LICBT may confer some benefits for treating OCD including fewer patients needing to be stepped up subsequent to a LICBT intervention (Chapter 14; Lovell et al., 2017).
Severity
Severity generally refers to the number and intensity of symptoms as captured by ROMs. Whilst high baseline/pre-treatment symptom severity may predict limited recovery following an LICBT intervention (Gyani et al., 2013), it does not imply there will be no treatment response (Delgadillo et al., 2017a). For example, for the treatment of depression, research has demonstrated that LICBT interventions such as behavioural activation (Chapter 11) can yield clinical effects comparable to components of HICBT interventions (Lorenzo-Luaces and Dobson, 2019). Basing clinical decisions regarding Step allocation on ROM severity alone may therefore not provide a full picture. Rather, adopting a patient-centred approach that considers ROM severity alongside other information may better inform the decision as to step allocation.
Clinical Practice
Wider Information to Consider Alongside ROM Severity (NICE, 2011b, para. 1.4.1)
Chronicity, history and duration of disorder:Has the patient experienced these symptoms for a long time, or have they presented recently?Is this the patient's first episode or have they had more than one episode in the past?
Functional impairment and impact: are the symptoms having a substantial impact on patient functioning – for example, in work, school, social, interpersonal domains?
Treatment history: has the patient been treated for these symptoms before? What was the effectiveness of the treatment received?
Relevant social or personal factors.
Co-morbid mental and/or chronic physical health disorders.
For example, following assessment, immediate allocation to Step 3 may be recommended where a condition has been previously treated with LICBT to minimal effect (treatment history) and the patient expresses a preference for another treatment approach (NICE, 2011b).
Risk
Level of risk will impact the decision as to whether LICBT or HICBT is suitable to meet patient need (NICE, 2011b), with risk subsequently assessed at every patient contact and decisions made accordingly