A Pragmatic Guide to Low Intensity Psychological Therapy

Care in High Volume

1st Edition - May 17, 2023
Authors: Elizabeth Ruth, James Spiers
Language: English
Paperback ISBN:
9 7 8 - 0 - 3 2 3 - 8 8 4 9 2 - 1
eBook ISBN:
9 7 8 - 0 - 3 2 3 - 9 0 4 5 1 - 3

With the rapidly growing demand for mental health care there is a need for efficient and effective psychological treatment options. Low Intensity Psychological Therapy has be… Read more

A Pragmatic Guide to Low Intensity Psychological Therapy

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With the rapidly growing demand for mental health care there is a need for efficient and effective psychological treatment options. Low Intensity Psychological Therapy has become well established in the England Improving Access to Psychological Therapies (IAPT) programme as a beneficial and versatile treatment option for mild-moderate symptoms of depression and anxiety. A Pragmatic Guide to Low Intensity Psychological Therapy: Care in High Volume, provides a guide to Low Intensity Psychological Therapy from the perspective of the Low Intensity Practitioner. This book describes the Low Intensity role as part of a multi-disciplinary approach to psychological care. The authors use a series of case vignettes, personal experience and current literature to help navigate the context of the role and its potential for ethical and safe expansion.

Cover image
Title page
Table of Contents
Copyright
Dedication
Foreword
Acknowledgements
Introduction
References
Chapter 1: Low-intensity psychological interventions
Abstract
Who are you?
‘Low intensity’ defined
Something new
A bigger picture
Who are we, and where did we come from?
Barefoot therapy
Evolution
The land before IAPT
No help
PHASING
Self-help
Bibliotherapy
Guided self-help
Self-help resources
Low-intensity group work
Graduate Mental Health Workers
High volume
NICE
Stepped care
Options
Base or apex
Who does what?
Bringing it all together
Evidence, economics, and serendipity
Training and competencies
IAPT into action
Give me the right lever
What’s in a name?
Informed consent
Professional terms
Outcome measures
High volume and low intensity
Outcomes vs experience
Predictable problems
Stability
Really high volume, really not low intensity
Low-intensity supervision
Social context
Expand or exchange?
Psychological safety
Gaps in guidelines
What now?
References
Further reading
Chapter 2: Defining success
Abstract
Key aims for this chapter
IAPT: Debating success
The business of wellbeing
Wrong doors
Right doors
Locked doors
Revolving doors
The journey to IAPT: Kasia’s story
Urban myths: A panacea
Progressive stepped care
Stratified stepped care
Challenges with progressive stepped care in IAPT
Stepped care: My [un] successful experience
Evidence for progressive care in IAPT
Defining success: Low-intensity intervention
Defining success: Routine outcome measurement
Psychoeducational groups
Individual guided self-help
Re-humanising systems
References
Chapter 3: Training and competency
Abstract
Simple and agile
What makes us different?
Medication management
What is in an ‘intervention’?
Self-help material
Not everybody reads…
Where book and relationship meet
Stay in your shipping lane
A unifying model
Step-by-step
On teaching new practitioners
Training cultures
Manualised training
Principles to practice
Celebrating grace
Assessing competence
SPSR
Single-strand versus multi-strand
Two options for multi-strand work
Implications for ethical implementation
Complexity and burnout
Differences between high-intensity CBT and low-intensity interventions
What is our model and method?
Training a profession
Can training help with burnout?
Some solutions are worse than the cure
Don’t be common
Types of practitioner
Research to practice
Exclusion
Manualisation as the first step towards integration
Problems with ‘free-for-all’ practice
Assessment
The reflective practitioner in action
An effective course of low-intensity treatment
Reflective space
References
Further reading
Chapter 4: Working with challenging social contexts
Abstract
Key aims of this chapter
Between a clinical rock and a socially hard place
Assessment challenges in low-income areas
Social neglect
Social disorder
Problems with suitability
Anger and low-intensity intervention
Anger and IAPT
Suitability: People vs systems
Case study: Tom
Power and prognosis
Assessment phase: Tom
Second assessment session (treatment session one)
Complicated maintaining factors: Barriers to change
Dissociated systems
Motivation for change
The human story of anger and shame
Difficulty containing disclosure
Reflecting on Tom’s case
Adaptations and flexibility
Core conditions
Problems in supervision
Informed care
Neglecting and dismissing our own needs as clinicians
Reflective exercise
References
Chapter 5: The role of low-intensity psychological interventions in physical healthcare
Abstract
In this chapter
Part 1: Defining terms and background information
Part 2: Identifying themes in this area of work
Part 3: Implementation
References
Chapter 6: Working inclusively with gender and sexual diversity
Abstract
Being queer
Reflective learning task
Construction and deconstruction of LGBT identities in psychotherapy
‘Conversion’ therapy
Age as a factor in LGBT experiences
Social relationships: Power and intersectionality
Minority stress modelling
LGBT access and outcomes in mainstream UK psychological services
Outcomes: Considering therapeutic paradigms
The journey to therapy as LGBTQ+
LGBT visibility: Reducing access barriers?
Affirmative practice
Active inclusion vs inactive tokenism
The LGBT champion
Common fears: Working with gender and sexual diversity
Case study: David
Assessment of risk
Initial impressions
Adjustments to the service policy
Session 2: Barriers to engagement (COM-B)
Five areas: The right here, right now
Complex problem or complex context?
Fine-tuning the problem
Supervision: Fine-tuning the intervention
Session 3: Selecting materials
Guided self-help: Standardisation
Equality of access vs equity of access
Adaptations in guided self-help
Deficits vs strengths
Sessions 4–8: Outcome and ending
Challenges to the alliance: Therapeutic boundaries
Reflecting on the work with David
Summary and reflective task
Next steps to active inclusive practice
References
Chapter 7: Psychological practitioner wellbeing
Abstract
Why wellbeing?
Mapping the problems
High-volume, low-intensity work
Recognition, reward, and respect
Comparative deprivation
Complex work
Not a guru
Normalising Step 2.5
Clinical drift
Supervision and reflection
Target driven
Micromanagement
Progression frustration
Consequences
What are vicarious trauma, compassion fatigue, and burnout?
Sick leave
Loss of reward
Complaints and whistleblowing
Go private?
Plugging the gaps
Consequences
So what are we going to do?
Progressing a career
Role definition
Specialisation
Negotiating targets
Recognition
Gaslight …
… Or learn
Top tips: Do’s
Top tips: Don’ts
Finally
There’s always room for a sequel
References
Chapter 8: Navigating relationships and therapeutic boundaries
Abstract
Key aims of this chapter
Professional boundaries in human services
The mill pond
The wing mirror
Therapist effects
Challenges with engagement
Patients who drop out of treatment
Relational drift
Therapeutic content and process
Low-intensity coaches
Low-intensity psychological practitioners
The laboratory vs home testing kits
Clinical drift
Upward vs downward drift
Intentionality of drift
Understanding therapeutic relationships
Transference and countertransference
Transference relationship
Transference
Countertransference
Case vignette: Jane
Navigating ethical relationships in low-intensity practice
Exiting defensive practice
The relational dynamics of systems
Relational challenges in the current IAPT system in England
Understanding ruptures in systems: Whose anxiety is this?
Navigating relational boundaries in systems
The importance of empathic and compassionate relationships
Key messages
References
Chapter 9: Reflecting on interpersonal practice
Abstract
Key aims of this chapter
Personal motivation for LICBT training
The seesaw of valuing
Relevance to low-intensity practice
Devaluing between groups
Anxiety around patient engagement: The training year
Therapeutic working alliance
Becoming a low-intensity supervisor and university marker
Barriers to the interpersonal alliance
Low therapeutic alliance
Avoidance and control
Cheerleaders
The quarterback
The reflective practitioner: Compassionate challenge
Addressing problems with interpersonal skills
Reflections from beyond the Emerald city
References
Chapter 10: Supervision
Abstract
Key aims of this chapter
Functions and use of supervision in the psychological professions
Line management versus clinical supervision
Mentoring versus clinical supervision
Leadership versus line management
Monitoring fitness to practice
Case management versus clinical supervision
The function of high-volume case management: Supervision versus leadership
Clinical skills groups
Contextualising the low-intensity supervisory model in England
Variation within the current model of low-intensity supervision
Further challenges with the current model of low-intensity supervision
Is the current low-intensity supervisory model fit for purpose?
So what do we do about the current challenges with supervision?
Supervision contracts
Recording sessions
Upscaling the current model of low-intensity supervision
Implementing low-intensity clinical supervision
References
Chapter 11: Professional identity
Abstract
Learning aims for this chapter
The tug of war
Some outside support
Describing an umbrella
Not just CBT
Towards a definition
The power of an acronym
Professional status
Core professions
Progression
Direction of growth
Imposition
Tribes
Different, but equivalent?
Never alone
Evidence-based costs
Counselling in IAPT
The dawn of a new age
Tension in the team
Trainee practitioner recruitment
The HEE announcement
Status and inclusion
‘Oh bother’
Next steps
References
Further reading
Chapter 12: Discussing international applications
Abstract
Aims of this chapter
The future of low-intensity practice in England
Low-intensity interventions in the United Kingdom
Qualification and training
How will training be funded outside of the NHS?
Stepped care as an international model for service delivery
The wider world
Core principles of low-intensity psychological practice
Targets
Lessons learned from IAPT
Back to barefoot
References
Index

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