Low-intensity CBT Skills and Interventions. Группа авторов
briefer support sessions is typically received with LICBT (Bennett-Levy et al., 2010), thereby making better use of scarce resources (van Straten et al., 2015). Using NICE guidelines (National Collaborating Centre for Mental Health, 2018) to inform delivery of different doses of CBT, LICBT represents a way to achieve high-volume working that helps to improve access and democratise CBT (Bennett-Levy et al., 2010). Although treatment dose directly provided by the practitioner is lower in LICBT, it is likely that patients themselves spend similar amounts of time engaging with the interventions as with HICBT (van Straten et al., 2015). This possibility arises as a result of the increased emphasis on patients to engage with self-help interventions between sessions; engagement with HICBT is often limited to completing homework set.
Here and Now v. Longitudinal Cognitive Behavioural Formulation
During an LICBT assessment, the practitioner employs a range of common factor and questioning skills (Chapter 5; Richards and Whyte, 2011) to gain an understanding of features associated with the patient presentation in the here and now (Chapter 2). This informs the cognitive-behavioural model shared with the patient and informs selection of the appropriate CBT self-help intervention (Chapter 4). Within HICBT, however, a greater range of questioning skills, such as the downward arrow technique (Beck, 1995) is employed to inform a longitudinal cognitive-behavioural formulation that extends beyond the here and now (Figure 1.1).
Figure 1.1 High- and low-intensity CBT formulation
A longitudinal formulation seeks to appreciate the influence of enduring cognitive distortions, such as intermediate – rules, attitudes, assumptions – and core beliefs, on the cognitive model that accounts for the way the presenting problem is impacting on the patient in the here and now (Beck, 1995).
Specific Factor Skills Employed When Questioning
As determined by the longitudinal formulation, HICBT assessment requires several specific factor skills (Chapter 5) to be employed to gain an understanding of the influence that intermediate and core beliefs have on the presenting problem. These include techniques such as continuum methods to evaluate negative schemas (Padesky, 1994). However, beyond skills such as funnelling (Chapters 2 and 6) adopted at both high- and low-intensity CBT, the focus of an LICBT assessment on the here and now requires a narrower range of questioning and specific factor skills.
Single-Strand v. Multi-Strand Interventions
LICBT represents a single-strand approach (Turpin et al., 2010) whereby following assessment a clinical decision is reached (Chapters 3 and 4) to adopt a specific CBT self-help intervention from the LICBT toolkit (Part II). The practitioner then supports the patient to engage with the single-strand intervention. This contrasts with HICBT where evidence-based protocols specify the delivery of several different interventions as part of a multi-strand approach. For example, in the treatment of generalised anxiety disorder (GAD), a treatment protocol (Dugas and Robichaud, 2007) informing NICE (2011a) guidelines specifies adopting cognitive restructuring to identify and challenge worry beliefs, problem-solving and exposure to uncertainty. The movement towards an even more elaborated multi-strand approach is now gaining momentum given further developments in third wave HICBT (Hayes and Hoffmann, 2017).
Workforce
Representing movement away from sole reliance on a Step 3 high-intensity CBT therapist workforce, the development and implementation of a Step 2 psychological practitioner role – psychological wellbeing practitioner (PWP) – denotes a core feature of the IAPT programme. Whilst both workforces share generic and basic CBT competences, the CBT and problem-specific competencies associated with assessment and treatment differ (Roth and Pilling, 2007a,b). Within the high-intensity therapist workforce, specific multi-strand CBT interventions are delivered to the patient. This contrasts to competencies held by the Step 2 LICBT psychological therapy practitioner workforce that empowers patients to manage their own recovery by providing them with ongoing support to engage with CBT self-help interventions (Chapter 6). Consequently, different competencies have implications for responsibilities placed on each workforce, making training and supervision of the Step 2 and 3 workforces fundamental to the IAPT programme (Roth and Pilling, 2008).
Responsibilities
Similar to debates within healthcare surrounding responsibilities of assistant practitioners (Wakefield et al., 2010), there has been little clarity regarding how the LICBT psychological therapy practitioner role fits within the wider mental health workforce. However, this is beginning to be addressed through the recent establishment of the Psychological Professions Network (Psychological Professions Network, 2018). Whilst currently non-registered practitioners, professional bodies are now in discussion to establish accreditation criteria to recognise LICBT psychological practitioners as a competency-based and autonomous mental health workforce that make their own treatment decisions. With assistant practitioners or paraprofessionals (Farrand et al., 2009) there is vertical substitution of roles delegated by a professional role higher up the occupational ladder (Nancarrow and Borthwick, 2005). Within the IAPT programme, however, PWPs neither undertake delegated roles nor assist HICBT therapists. The PWP psychological therapy practitioner level role therefore has equal status with that of the HICBT therapist within the stepped care model, with outcomes mutually dependent on both workforces.
Training and Supervision
Within the IAPT stepped care model, significant focus is placed upon ensuring that the Step 2 LICBT and Step 3 psychological therapy workforce have received high-quality competency-based training. Training is informed by a nationally specified HICBT (Liness and Muston, 2011) and LICBT training curriculum (University College London, 2015), itself informed by a CBT competence model (Roth and Pilling, 2007a). LICBT Psychological Therapy Practitioner training is supplemented by educator and student materials (Richards and Whyte, 2011) that have informed several features of this training manual. Ensuring accreditation of trainers and training programmes also helps to enhance fidelity to treatment delivery of LICBT interventions (Hides et al., 2010). Furthermore, separate curricula to inform training for the high- and low-intensity CBT workforce potentially reduces the likelihood of therapeutic drift, helping to maintain evidence-based practice (Waller, 2009). Differences between HICBT and LICBT also exist with respect to the types of supervision received (Chapter 9).
Challenges Encountered
Following the implementation of the IAPT programme, a number of challenges associated with LICBT have been identified. In addition to accounting for an emerging evidence base, overcoming such challenges may serve to enhance an understanding of LICBT and assist in determining a suitable definition (Bennett-Levy et al., 2010).
Clinical Heterogeneity
Whilst based on a CBT model, significant variation exists with respect to the content and delivery of CBT self-help interventions (Lewis et al., 2012). In addition to differences in the content of interventions included within CBT self-help for the treatment of specific common mental health difficulties, variations are also evident regarding the CBT self-help format. Such variation extends beyond differences between the modality to deliver self-help interventions, but also arises with respect to types of written CBT self-help approach. These can vary: intervention specific stand-alone worksheets, intervention specific CBT self-help booklets (e.g. Farrand et al., 2019a), CBT self-help booklets (e.g. Farrand et al., 2019b) and books (e.g. Gilbert, 2009) that target a specific common mental health difficulty and include psychoeducation in addition to worksheets.
Lack of Consensus Regarding Single-Strand Interventions
Although LICBT represents a single-strand approach (Turpin et al., 2010), there is little consensus between researchers, LICBT psychological therapy practitioners and HICBT therapists regarding the composition of single-strand interventions. For