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IAPTImproving Access to
Psychological Therapies
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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)
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Stepped care modelStep 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
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Barriers • Blocking of Treatment (many offender
service users have repeated experiences of refusal and exclusion from services)
• Problems dismissed
• Not registered with a GP
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Psychological TherapiesA 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
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Cognitive Behavioural TherapyEMDR Barbara Fulton & Yvonne Drew
Depression: Moderate to SevereDepression: Mild to ModeratePanic DisorderGeneralised Anxiety DisorderSocial PhobiaOCD (Obsessive Compulsive Disorder)PTSD (Post Traumatic Stress Disorder)Hypochondriasis (Somatoform disorder) Specific Phobias
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Integrative TherapyLorraine Parker
Blends elements of a range of therapies- Gestalt- Object relations- Cognitive behavioural approaches - Attachment- PsychodynamicPersonality disorder or characterlogical issues
underlie depression and/or anxiety.
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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
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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 viewNot 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
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Not offender Rehabilitation: case study
Male, aged 45Offence history: sexual relationship with a minor
(15yrs), downloading & distributing images of childrenUnrepentant (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 depressedTherapy: Cognitive and behavioural interventions
targeting avoidance of situations perceived as difficult to escape from
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Referral ProcessProvide the service user with information about
IAPTAdvise that therapy is not compulsory Complete referral documentationQuestionnaire: this needs to be the service
users interpretation of their mood and situationService 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
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Referral Process1st appointment: Initial assessment
Assess for service suitabilityAssess for therapy suitability
(CBT, EMDR or Integrative)Agree an initial treatment plan If not suitable: signposting/referral If not suitable: OM guidance
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Assessing for CBT Suitabilitywhy 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
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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
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How OM’s can help with assessing suitability for CBT
Are the able to identify thoughts, feelings, behaviours and body sensations?
Emotion
Thought
Body sensatio
n
behaviour
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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….”
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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
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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
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How OM’s can help with assessing suitability for CBT
Are they able to accept personal responsibility in the 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?
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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 TherapyCBT checklist: the assumptions can be
difficult to meet (those who have PD or other characterlogical issues)
Transference
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CountertransferenceA redirection of feelings towards the service
userEmotional 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 towardsFeeling parental towards themOverly identify with themDifficult to supervise/relationship breaking down
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CountertransferenceIs 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 keyBe aware that countertransference is normalBe consistent with boundaries
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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)
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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
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Co-existing Drug and Alcohol Use No evidence that using substances makes usual psychological interventions ineffective
Executive
Goal directed behaviou
r
Decision making
Problem solving
Time manageme
nt
Analytical thinking
Organisational ability
if an executive function deficit exists: CBT can be adapted
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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 useInstability across drug and alcohol use can
lead to therapy disruption
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Multiple Competing Needsinc 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’
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Thank YouAny questions
………its good to talk!