Low-intensity CBT Skills and Interventions. Группа авторов
are reduced. This is recommended in acknowledgement of an observed increased likelihood of relapse where there are residual symptoms at the end of treatment (Ali et al., 2017).
The patient moves below the threshold for caseness with few residual symptoms – discharge them from the service.
Whilst recommendations exist in relation to stepping up, the LICBT practitioner should always work collaboratively with the patient to determine the wider reasons that may have impeded improvement before reaching the decision to step up. This is especially important as these reasons may act to impede engagement with a Step 3 intervention if unchecked. The COM-B model (Chapter 8) is likely to be helpful to explore difficulties for a patient engaging or using the LICBT intervention. In some cases, contextual (e.g. demand and service capacity) and subjective (e.g. therapist and patient characteristics) factors may influence practitioners to hold patients on their caseload instead of discharging or stepping up, for example due to long waiting lists (Delgadillo et al., 2015), contravening available guidelines. Presenting the patient during case-management supervision (Chapter 9) is therefore of fundamental importance in ensuring that clinical decisions to continue treatment are evidence based.
Summary
This chapter has outlined the importance of decision-making for LICBT practitioners working in a stepped care mental health service delivery model. Decision making as to whether Step 2 or Step 3 of a stepped care model are more suitable to meet patient needs have been outlined with respect to exclusion and inclusion criteria and linked to research evidence (NICE, 2011b) and clinical guidelines such as the DSM (APA, 2013) and ICD-11 (WHO, 2018). Finally, the key self-correcting mechanism of stepped care has been highlighted, alongside emerging research on the possible number of sessions and level of patient improvement to inform decision making for stepping up and/or ending treatment.
Assessing Your Understanding
Assessment is based on the case study.
Saoirse is a 53-year-old single parent to Fleur (aged 13) and has also recently become a full-time carer to her mother who has dementia. Since giving up her job as a biomedical researcher she has been feeling down and exhausted, is sleeping poorly and experiencing frequent headaches and back pain. She feels anxious about her future and her own health. She worries about spending money so does not socialise or do things with her daughter and has become isolated from her friends. All her time seems to be spent on household chores, but she struggles to get these done. To relax she sits in front of the TV but struggles to take anything in as she feels overwhelmed and worries about how she will continue to cope. Her thoughts also drift off to what her life used to be like, and whether things can ever change. Although Saoirse's friends invite her out, she often turns them down thinking, ‘What do I have to say anyway? All I am is a carer now. What do they understand?’ Over time, people have stopped calling her. Saoirse's scores on the PHQ-9 and GAD-7 are 22 and 11 respectively. Saoirse has never had previous treatment. She wants to feel better and get back to how she used to be but can't see how things will change with her mother's poor health.
Declarative
Multiple Choice Questions
1 What would you need to consider when deciding what treatment is indicated and at which step for Saoirse? [Select all that apply](a) Provisional diagnosis(b) Practitioner feels confident they can support this patient(c) ROM scores(d) Service waiting lists for treatment with high-intensity CBT(e) The patient requesting a high-intensity intervention
2 Which evidence-based treatment(s) would be most appropriate for Saoirse? [Select all that apply](a) Worry management(b) Signposting to community organisations and resources relevant to the patient(c) Behavioural activation and worry management combined(d) Problem-solving(e) Behavioural activation
Procedural
Saoirse has attended four LICBT treatment sessions and noted some improvement in her mood and an increase in her Routine and Necessary activity levels. Her scores are 18 on the PHQ-9 and 10 on the GAD-7. She still reports feeling down and frequently experiences negative thoughts about herself and her future. Saoirse has reported finding it difficult to complete homework tasks (scheduling Pleasurable activities) recently. She'd like to continue seeing you for sessions as she feels you understand her. Taking this information into account, along with the previous information, write down the information you would take to supervision to help decide next steps.
Answers to Assessing Your Understanding questions can be found in the appendix on p. 334.
Reflection Point
When considering next steps for Saoirse, what beliefs come to mind?
How might these impact on your decision-making process?
Further Reading and Resources
Bennett-Levy, J., Richards, D.A., Farrand, P., Christensen, H., Griffiths, K.M., Kavanagh, D.J. et al. (eds), ( 2010) Oxford Guide to Low Intensity CBT Interventions. Oxford: Oxford University Press.
National Collaborating Centre for Mental Health (NCCMH) ( 2018) The Improving Access to Psychological Therapies Manual. Available at www.england.nhs.uk/publication/the-improving-access-to-psychological-therapies-manual (accessed 6 October 2019).
National Institute for Health and Care Excellence (NICE) ( 2011) Common Mental Health Disorders: Identification and Pathways to Care (CG123). Available at www.nice.org.uk/guidance/cg123 (accessed 9 October 2019).
To access the online resources accompanying this chapter, please visit: https://study.sagepub.com/farrand
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