IAPT Improving Access to Psychological Therapies Who are

IAPT Improving Access to Psychological Therapies

Who are we? …. . What do we do? �Barbara Fulton, Lorraine Parker & Yvonne Drew �Psychological Therapists: Open Mind Service �Part of the wider NHS IAPT programme which implements guidelines for people suffering with depression and anxiety disorders �We offer realistic and routine first-line psychological treatment �Based at Cobden Street: our aim is to reduce barriers to accessing psychological treatment (that offenders may come across)

Stepped care model �Step 1: Recognition �Step 2: Mild/Moderate common mental health problems �Step 3: Moderate/Severe common mental health problems �Step 4: Treatment resistant, Atypical and psychotic depression, psychotic illnesses, those at significant risk, Personality disorder �Step 5: Risk to life, severe self-neglect

Barriers • Blocking of Treatment (many offender service users have repeated experiences of refusal and exclusion from services) • Problems dismissed • Not registered with a GP

Psychological Therapies A variety of therapies have been reviewed for their effectiveness (Nice Guidelines) � CBT – depression & all anxiety disorders �IPT, BCT, Counselling, BDT- depression (varying indications) �CBT, EMDR- post traumatic stress disorder

Cognitive Behavioural Therapy EMDR Barbara Fulton & Yvonne Drew �Depression: Moderate to Severe �Depression: Mild to Moderate �Panic Disorder �Generalised Anxiety Disorder �Social Phobia �OCD (Obsessive Compulsive Disorder) �PTSD (Post Traumatic Stress Disorder) �Hypochondriasis (Somatoform disorder) �Specific Phobias

Integrative Therapy Lorraine Parker �Blends elements of a range of therapies - Gestalt - Object relations - Cognitive behavioural approaches - Attachment - Psychodynamic �Personality disorder or characterlogical issues underlie depression and/or anxiety.

Consider a referral if…. . �Depressed mood lasting for more than two weeks �Anxious mood lasting for more than 2 weeks �Has already been diagnosed with depression or an anxiety disorder � Problem behaviour: which appears to be associated with anxiety or depression �Sufficient time remaining: sentence/licence

Not Offender Rehabilitation �We specifically target depression & anxiety and not offending history � We work within psychological models formulating the offender’s problems from their point of view �Not about prosocial modelling, reinforcement and reward of prosocial behaviour �Offending history is only focused on if identified as significant to their psychological problem and formulation �Risk assessment and risk management throughout treatment

Not offender Rehabilitation: case study �Male, aged 45 �Offence history: sexual relationship with a minor (15 yrs), downloading & distributing images of children �Unrepentant (makes this clear at initial meeting) �Diagnosis: agoraphobia (since release from prison) �Fear: “I could be chased, have to fight for my survival, do damage to my attackers and then end up back in prison” �Problems identified: Isolated and depressed �Therapy: Cognitive and behavioural interventions targeting avoidance of situations perceived as difficult to escape from

Referral Process �Provide the service user with information about IAPT �Advise that therapy is not compulsory �Complete referral documentation �Questionnaire: this needs to be the service users interpretation of their mood and situation �Service user needs to sign 2 consent forms (inc) �Return the completed referral pack & book an available appointment slot �IAPT staff are happy to guide you

Referral Process � 1 st appointment: Initial assessment �Assess for service suitability �Assess for therapy suitability (CBT, EMDR or Integrative) �Agree an initial treatment plan � If not suitable: signposting/referral �If not suitable: OM guidance

Assessing for CBT Suitability why is this important? �Service users with unfocused, multiple or very chronic problems are least likely to benefit from short term CBT � Demoralisation �CBT is not a one size fits all

How OM’s can help with assessing suitability for CBT �Is there potential for acceptance of the CBT model? “what are your beliefs about what’s causing your difficulties” �Those with an insistence that their problem is due to a chemical imbalance or caused by other people are unlikely to be suitable

How OM’s can help with assessing suitability for CBT �Are the able to identify thoughts, feelings, behaviours and body sensations? Thought Body sensation Emotion behaviour

How OM’s can help with assessing suitability for CBT �Are they able to access their own emotions in relation to situations ? “how did you feel when that happened……” (look for a one word answer) �Are they able to comment on their thoughts in relation to situations ? “what ran through your mind when that happened…. ”

How OM’s can help with assessing suitability for CBT �Are they goal orientated? …do they have the ability to work on one specific problem at a time? …. be aware of vagueness, rambling, frequent topic changes, desire to work on all problems at once

How OM’s can help with assessing suitability for CBT �Do they have alliance potential? - Note: eye contact, posture and general ‘feel’ - Poor rapport, idealising or blaming

How OM’s can help with assessing suitability for CBT �Are they able to accept personal responsibility in therapeutic process? “what would you like to get out of therapy? . . what might your role be in that” “you’d be expected to work on your problems in between cbt sessions…. what’s your thoughts about that? ” �Active v Passive?

Are they Anxious/Depressed……but struggling to meet the CBT checklist? ? ? �Seek IAPT guidance…. . “It’s good to talk!” �May be more suited for Integrative Therapy �CBT checklist: the assumptions can be difficult to meet (those who have PD or other characterlogical issues) �Transference

Countertransference �A redirection of feelings towards the service user �Emotional entanglement with a service user �Heart sink feeling…. or hot potato Look out for: Service user reminds you of someone you have strong negative feelings towards Feeling parental towards them Overly identify with them Difficult to supervise/relationship breaking down

Countertransference Is the service user wanting help with their anxiety or negative mood? . . if not: �Could the difficulties encountered be better dealt with in supervision with your manager �Reflective and reflexive practice is key �Be aware that countertransference is normal �Be consistent with boundaries

Co- existing Drug and Alcohol Use � 70 -80% of clients in drug and alcohol services have anxiety disorders, depression, trauma (Weaver, 2003) �IAPT services should be working inclusively alongside substance misuse services to improve outcomes (IAPT Positive Practice Guidelines) �CBT: Co-existing anxiety/depression (NICE guidelines (2007) Dug misuse: psychosocial Interventions)

Co-existing Drug and Alcohol Use High Intensity � Formal therapies delivered by IAPT therapist � CBT for depression or specific anxiety disorder �Low Intensity � Delivered by IAPT therapist � Guided self-help & Behavioural Activation for anxiety disorders and depression �Low Intensity � Delivered by Probation Key Worker � Motivational Interviewing & Contingency Management

Co-existing Drug and Alcohol Use � No evidence that using substances makes usual psychological interventions ineffective Problem solving Time management Decision making Goal directed behaviour if an executive function deficit exists: CBT can be adapted Analytical thinking Executive Organisational ability

Co-existing Drug and Alcohol Use �Accepted: experimental, recreational as well as stable drug and alcohol use �IAPT staff will determine stability �Not accepted: unstable drug and alcohol use �Instability across drug and alcohol use can lead to therapy disruption

Multiple Competing Needs inc personality disorder, learning disability, drug dependence, alcohol dependence, homelessness, domestic violence etc. . . • May lead to non attendance/disrupted therapy sessions /poor homework compliance • May compete with motivation for therapy and treatment engagement • Offender service users with multiple and competing needs may be misunderstood as being a ‘time wasters’

Thank You Any questions ………its good to talk!