Low-intensity CBT Skills and Interventions

a practitioner′s manual

Paul Farrand, Paul Farrand

• Publisher: SAGE Publications Ltd
• Year: 2020
• ISBN:
  9781529737608
• Edition: 1
• Topic: Psicologia
• Subtopic: Terapia cognitivo-comportamentale

This book takes you step-by-step through the Low-intensity CBTinterventions and clinical procedures. With an Online Resource site of accompanying workbooks and worksheets, it provides a comprehensive manual fortrainee and qualified Psychological Wellbeing Practitioners.

1 Low-Intensity Cognitive Behavioural Therapy: Revolution Not Evolution

Paul Farrand

Learning Objectives

By the end of this chapter you should be able to:

• Appreciate the context justifying the emergence of low-intensity CBT
• Critically evaluate the fundamental characteristics of low-intensity CBT
• Demonstrate a critical awareness of the evidence base supporting low-intensity CBT and methodological limitations
• Critically appraise differences between low- and high-intensity CBT
• Demonstrate an awareness of key challenges associated with low-intensity CBT

Background

On a worldwide scale, mental health service delivery is associated with under-investment, excessive waiting times, lack of choice, significant demands on patients, large workforce variation and poorly informed by the evidence base (Ngui et al., 2010). This has resulted in increased demands for parity of esteem between mental and physical healthcare to improve access to evidence-based treatment, meet patient aspirations, provide high-quality care and give equal status to training and practice (Royal College of Psychiatrists, 2013). Across England, efforts to achieve parity of esteem resulted in the publication of the No Health without Mental Health (Department of Health, 2011) mental health strategy. This strategy identifies long-term ambitions to transform mental healthcare with Closing the Gap: Priorities for Essential Change in Mental Health (Department of Health, 2014) translating these ambitions into short-term action. To achieve these ambitions, however, it was recognised that a new mental health programme would be required for implementation across England.

The IAPT Programme

The IAPT programme represents the first national implementation of a mental health programme to make evidence-based psychological therapies available to every adult needing them for the treatment of common mental health problems ‘at the right time and in the right place’ (Seward and Clark, 2010: 480).

Key Point

The main drivers justifying development and implementation of the IAPT programme for the treatment of common mental health problems (Seward and Clark, 2010) have been:

• Justice-based care arising from the personal impact of mental health problems on patients (Layard and Clark, 2015)
• A strong clinical evidence-base determined by the National Institute for Health and Clinical Excellence (NICE) informing mental health treatment
• A powerful economic case to address societal and lost productivity costs associated with mental health problems calculated to be in the region of £7–10 billion (Centre for Economic Performance, 2006)
• Recognition that solely focusing on increasing the availability of the high-intensity mental health workforce was no longer a viable option (Bennett-Levy et al., 2010).

These drivers created a strong ‘constellation of rationale and evidence’ providing the initial momentum to justify and establish the IAPT programme (Seward and Clark, 2010: 480). The IAPT programme is now informing similar service developments on a worldwide scale in countries such as the USA (Chapter 20), Hong Kong and Sweden.

Stepped Care

Prior to development of the IAPT programme it became apparent that achieving long-term ambitions to transform mental healthcare and meet epidemic level demands for treatment would require a fundamental change in the organisation of mental health treatment (Richards, 2010a). The change was to develop a mental health stepped care delivery model enabling service delivery to be least restrictive (Bower and Gilbody, 2005; van Straten et al., 2015). Lower demands would be placed on patients in terms of costs and personal inconvenience and on service providers through the utilisation of a different workforce at Steps 2 and 3 of the stepped care model (Richards, 2010a). Rather than relying solely on high-intensity Step 3 face-to-face psychological therapists, the revolution in service delivery spearheaded the evolution of a new Step 2 LICBT psychological therapies practitioner workforce.

Key Point

The core characteristics associated with stepped care implemented within the IAPT programme (Richards, 2010a) are:

• The mental health psychological practitioner workforce supporting evidence-based low-intensity CBT at Step 2 and therapies workforce delivering evidence-based high-intensity psychological therapies at Step 3
• Assessment is undertaken at Step 2 unless knowledge of the mental health difficulty at referral suggests it is unlikely to be consistent with NICE Guidelines for Step 2 treatment
• The pivotal role of NICE guidelines to inform evidence-based clinical decision-making regarding selection of the appropriate step for the treatment of common mental health problems
• As determined by NICE, patients receive the least restrictive evidence-based psychological therapy to promote recovery
• Outcome measures are systematically taken at every session to inform ongoing treatment decisions and support self-correction whereby patients not responding adequately will be supported to step up to a NICE evidence-based high-intensity treatment
• Stepped care models should accommodate stepping down where a less intensive treatment becomes appropriate.

What is Low-Intensity CBT?

CBT is an evidence-based psychological therapy with 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 ...