1. IAPT Improving Access to Psychological Therapies

2. 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)

3. 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

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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. Not offender Rehabilitation: case study
Male, aged 45
Offence history: sexual relationship with a minor (15yrs), 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

11. 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

12. Referral Process 1st 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

13. 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

14. 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

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

16. 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….” .

17. 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

18. 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

19. 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?

20. 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

21. 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

22. 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

23. 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)

24. 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
Delivered by Probation Key Worker
Motivational Interviewing & Contingency Management

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

26. 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

27. 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’

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