Evaluation of an ACT Trans-Diagnostic Pathway in an NHS Community Mental Health Team for Adults Dr. Thomas Richardson Clinical Psychologist (1,2) Dr. Lorraine Bell Consultant Clinical Psychologist (1) 1. Mental Health Recovery Teams, Solent NHS Trust, Portsmouth, UK 2. School of Psychology, University of Southampton, UK

Our Service National Health Service (NHS) Community Mental Health Recovery Team for Adults Secondary Care: Severe and Enduring problems Service covers whole of Portsmouth Wide range of problems: psychosis, bipolar disorder, personality disorders etc. Comorbidity the norm Most band 6 staff (nurses, occupational therapists and social workers) required to train in a therapy: DBT, CBT for psychosis or ACT

ACT Pathway Psychological therapies service offers CBT, DBT, Schema Focused Therapy, CAT, EMDR, Mindfulness and Psychoeducation Groups 6 pathways: Emotional Dysregulation, Psychosis, Depression, Trauma, Anxiety, Trans-Diagnostic ACT placed on transdiagnostic pathway (alongside CAT) and depression pathway (alongside CBT)

ACT Training Between Oct 2013 – Feb 2014, over 5 days n=9 psychological therapists (2 from Eating Disorders) n=11 non-psychologist staff (psychiatric nurses, OTs and SWs) Training delivered by two Consultant Clinical Psychologists: experienced in using ACT in secondary mental health Dr. Helen Bolderston and Prof. Sue Clarke, Bournemouth University Department of Mental Health Fortnightly supervision 12-16 sessions of individual ACT Attempted to identify patients who were less complex but didn’t find many! Explain we increased number of sessions to 16 for second case Couple exceptions: one 24 sessions, one only 6

Retention of Therapists At present ACT currently delivered by: 5/11 of non-psychologist staff originally trained (2 maternity leave, 1 retired, 1 left service, 2 opted out) 6/9 psychologist staff originally trained (2 maternity, 1 adoption leave) Five remaining staff committed: agreed to attend regular supervision and take on two cases (with support from managers)

Method Aims: Determine if evaluation effective and whether differences in psychologists versus non-psychologist staff Case series: measures given pre and post therapy, 3-month follow up. CORE: A 34 item measure of global mental health (e.g. I have felt OK about myself) PHQ-9: A 9 item measure of depression (e.g. Little pleasure in doing things) Valued Living Questionnaire: how important values such as family are, how much currently living in line with values Cognitive Fusion Questionnaire: 7 item measure of ‘Cognitive Fusion’ (e.g. I struggle with my thoughts) - 6 month data not yet available

Method Statistical analysis General Linear Model (Mixed Factorial ANOVA) Time X Clinician All subscales analysed Intent to Treat Analysis For Follow-Up: Last Observation Carried Forward

Sample Characteristics 18 participants in service evaluation so far 14 women, 4 men Recurrent depression most common primary diagnosis (one bipolar disorder) Most had co-morbidity: PTSD, Anxiety Disorder, Personality Disorder Traits, Physical Health problems, Alcohol Problems, Transient Psychotic Disorder. A number had attempted suicide in past One Anorexia and Two Bulimia cases Majority had had other therapies in past

Results: Post-Treatment (n=18) Statistically significant improvement for: CORE Total: F=10.2, p<.01 CORE Total (-Risk): F=12.9, p<.01 CORE Functioning: F=14.7, p<.001 CORE Problems and Symptoms: F=18.5, p<.001 CORE Well-Being: F=18.9, p<.001 PHQ (Depression): F=18.8, p<.001 Valued Living: Importance: F=7.6 p<.05 Valued Living: Action: F=7.7, p<.05 Cognitive fusion: Valued: F=14.6, p<.01 No improvement for: CORE Risk: F=.08, p>.05 - Risk explain only a few questions so not sensitive to change

Results: 3-Month Follow-Up (n=15) Statistically significant improvement for: CORE Problems and Symptoms: F=7.9, p<.05 CORE Total (-Risk) F=14.9, p<.01 PHQ (Depression): F=7.0, p<.05 Cognitive fusion: F=7.7, p<.05 Trend for: CORE Total: F=4.2, p<.10 CORE Functioning: F=3.7, p<.10 No improvement for: CORE Risk: F=0.0, p>.05 CORE WellBeing F=3.0, p>.05 Valued Living: Importance: F=1.1, p>.05 or Action: F=0.2, p>.05

Results: By Clinician Post-Treatment, no significant interaction between changes over time and clinician (8 psychologists, 10 non- psychologists): Wilks Lambda: F(10,7)=1.8, p>.05 Drop out higher: non-psychologists: 36.4% (n=4) dropped out Psychologists: 12.5% (n=1) dropped out Psychologists also took on the more complex cases: high risk, co-morbid personality disorder, physical health problems etc.

Results: By Clinician At three months (7 psychologists, 8 non-psychologists) Trend for outcomes on CORE Total (-Risk) better for psychologists than non-psychologists: F=3.6, p<.10

Conclusions ACT effective as a component of depression and trans- diagnostic pathways for complex secondary care population Improvements in global mental health, depression, cognitive fusion and values post-treatment Partially maintained at follow- up (data collection ongoing) High rates of therapist attrition for non-psychologist staff Higher drop out for non-psychologist staff non-psychologist staff who stay committed to delivering ACT have good outcomes similar to psychologists Possibility that longer-term outcomes better for psychologists - Following up at 6 month but data not yet available