Low-intensity CBT Skills and Interventions. Группа авторов
a strong evidence-base for the treatment of common mental health problems, alongside several severe and enduring mental health problems such as psychosis and schizophrenia (NICE, 2014a). However, without unsustainable increases in the levels of funding (Layard et al., 2007) it is unlikely to radically improve access to evidence-based psychological therapy when only available within a traditional high-intensity CBT (HICBT) format. Revolution not evolution in the delivery of CBT was therefore required, leading to the implementation of CBT in the form of supported low-intensity CBT (LICBT) self-help interventions. Whilst LICBT has been implemented within Stepped Care (Richards, 2010a) and alongside wider organisational systems such as case-management supervision (Chapter 9) within the IAPT programme, it represents a fundamental shift in the delivery of CBT in its own right and shares common characteristics.
Key Point
The core characteristics of LICBT are:
Use of CBT-informed self-help resources to deliver CBT techniques (Richards, 2004)
Delivery through a variety of CBT self-help mediums, primarily within written, computerised (cCBT) or internet-based (iCBT) formats (Chapter 7) with increasing research now focusing on other delivery formats such as video-mediated, e-mail and based around apps
CBT self-help interventions supported by an LICBT psychological practitioner workforce
A Step 2 LICBT psychological practitioner workforce competent in supporting patients to use CBT self-help interventions
Briefer session times required to support the patient to use LICBT techniques delivered through CBT self-help interventions
Adoption of CBT self-help interventions for the treatment of common mental health problems directly informed by the evidence base.
Continued developments in the evidence-base still make a single definition capturing the key characteristics of LICBT elusive (Bennett-Levy et al., 2010). However, with respect to the IAPT programme, consensus concerning core characteristics of LICBT is beginning to emerge.
Evidence Base
Consistent with HICBT, a large evidence base supports the implementation of LICBT in the form of guided written CBT, cCBT and iCBT self-help interventions. This has informed the clinical evidence base for LICBT treatment of common mental health problems determined by NICE (National Collaborating Centre for Mental Health, 2018). For a comprehensive review of the evidence base, see Bennett-Levy et al. (2010).
Interventions
There are over 30 systematic reviews and 50 controlled trials demonstrating the effectiveness of CBT self-help interventions for the treatment of common mental health problems (Delgadillo, 2018). Systematic reviews comparing guided CBT self-help with face-to-face psychological therapies have identified no significant differences in treatment effectiveness or drop-out up to one year post assessment (Cuijpers et al., 2010). However, variability in effect size across studies highlights the need for further research to recognise moderators that may be associated with effectiveness (Delgadillo, 2018). Research to date has identified clinical moderators to include mental health condition, support type and patients with existing depression rather than those at risk (Farrand and Woodford, 2013). Research moderators include unclear allocation concealment, observer-rated outcome measures and comparisons with waiting-list control groups (Gellatly et al., 2007). With respect to guided self-help, moderators associated with session length, delivery mode or therapist background were not related to effectiveness. Very few studies have examined the effectiveness of cCBT across conditions (Carlbring et al., 2018).
Delivery and Support
The evidence base regarding ways to improve access through the provision of choice regarding cCBT, iCBT (Ritterband et al., 2010), telephone-based (T-CBT; Mohr et al., 2012), video teleconferencing (Varger et al., 2019) or email to support LICBT (Hadjistavropoulos, 2018) is encouraging. A systematic review comparing face-to-face with iCBT demonstrated no difference in effectiveness (Carlbring et al., 2018). Additionally, no differences emerged regarding drop-out that has previously been identified to be a challenge for internet-based interventions (Christensen et al., 2009). Evidence has also demonstrated the utility of T-CBT (Bee et al., 2008). In a randomised controlled trial comparing high-intensity face-to-face with T-CBT there was little difference in effectiveness post treatment with lower attrition with T-CBT (Mohr et al., 2012). However, caution should be exercised given that treatment gains were better maintained with face-to-face CBT following the end of treatment.
Acceptability
Excluding a study examining a CBT self-help intervention based on behavioural activation for armed forces veterans (Chapter 20; Farrand et al., 2019a), little research has examined the acceptability of written CBT self-help interventions (Lewis et al., 2012). However, good levels of acceptability have been demonstrated regarding the delivery of therapy over the telephone (Lovell et al., 2006; Ludman et al., 2007) and patients’ experience of cCBT for depression (Rost et al., 2017). However, methodological challenges arising from qualitative research in this area have been associated with difficulties defining user acceptance and variations in measurement (Rost et al., 2017). Furthermore, whilst some patients have expressed a preference for cCBT, the majority are generally ambivalent (Knowles et al., 2015). A complex relationship is therefore likely to exist between patients’ preferences expressed towards delivery format and support type (Bee et al., 2010). This has reinforced requirements to promote choice of support type within a stepped care model (Bower and Gilbody, 2005).
Key Point
Evidence-based conclusions associated with LICBT:
Guided CBT self-help is as effective as face-to-face psychological therapies for the treatment of common mental health difficulties, excluding post-traumatic stress disorder (PTSD) and social anxiety.
More research is needed to recognise other moderators that may be associated with greater effectiveness.
Use of cCBT, ICBT and T-CBT offers the opportunity to improve access without reducing effectiveness.
Good levels of acceptability are associated with T-CBT and cCBT, although methodological limitations should currently limit conclusions from being generalised.
Differences between HICBT and LICBT
Whilst both are grounded within a CBT model and directly informed by the evidence base, significant differences exist between HICBT and LICBT beyond time taken to deliver the intervention. Awareness of wider differences related to the clinical method and workforce is especially important if confusion between LICBT and Brief CBT is to be avoided. Brief CBT is a variation of HICBT with delivery of techniques condensed as a result of greater specificity and flexibility afforded to the therapist following treatment protocols (Hazlett-Stevens and Craske, 2004).
Clinical Method
With both low- and high-intensity CBT based on a CBT model, the most obvious (often only!) difference identified by many is related to the dose of therapy (National Collaborating Centre for Mental Health, 2018) received by the patient. However, whilst a CBT model informs the clinical model within both high- and low-intensity CBT, several additional clinical features differentiate them (Table 1.1).
Table 1.1
Therapeutic Dose
Within HICBT the optimal dose of therapy is typically in excess of ten weekly 60-minute treatment sessions recommended by NICE for the appropriate common mental health problem. However, following an assessment in the region of 40 minutes, an average of five