Comprehensive Notes on Psychological Interventions and Therapist Wellbeing

Learning Objectives

Understand factors influencing intervention success.
Reflect on core conditions in practice.
Consider wellbeing in delivering psychological interventions.

Basics of Psychological Interventions

Assessment: Thorough evaluation of the individual.
Importance of therapist factors:
- Establishing therapeutic alliance.
- Collaborative approach to treatment.
Formulation: Developing a shared understanding of the individual's difficulties.
Therapy vs. Interventions: Understanding the distinction.
Matching interventions to presenting need.
Motivation: Assessing readiness for change.
Session structure: Organizing sessions effectively.
Gathering the individual's perception and world view.
Personalized care and support planning.
Goal setting: Defining specific and achievable goals.
Measuring change: Tracking progress and outcomes.
Dosing: Determining the appropriate amount and frequency of intervention.
Model fidelity and managing drift.
Clinical measurement.
Ethical and professional guidelines.
Cultural competence.
Dealing with the emotional content of sessions.
Supervision.
Use of digital therapy in secondary care.
Exploring frequently asked questions when starting out delivering interventions.
Looking after ourselves as well as the individuals we see.

Importance of Doing the Basics Well

Provides firm foundations for practice.
Gives the individual optimal conditions for recovery.
The more complex the presentation, the more need for simplicity in response.
Helps individuals improve as quickly as possible.
Reduces ‘process’ difficulties.
It is easy to drift from the basics in search of magic moves.

Working Alliance

Agreements on therapeutic goals.
Consensus on therapy tasks.
Relational factors between client and therapist.

Relationship Elements

Alliance.
Reactance/Resistance Level.
Client Feedback.
Client Preferences.
Goal Consensus.
Collaboration.
Empathy.
Positive Regard.
Culture.
Religion/Spirituality.

Therapeutic Relationship

A "necessary but not sufficient" condition for change (Beck, 1979).
Essential for effectiveness but not enough to guarantee positive outcomes.

Specific Techniques

Specific techniques and interventions lead to changes in thoughts, feelings, and behaviors.
- Identifying and challenging cognitive distortions.

Interventions vs. Therapy

Interventions:
- Short term focus.
- Singular targeted intervention.
- Delivered by people trained in their use.
Therapy:
- Medium-Long term focus.
- A sequence of interventions based on research.
- Delivered by accredited therapists.

NICE Recommended Psychological Therapies for Severe Mental Health (SMI)

CBT (CBT-p, CBT-B for mood problems).
CBT for Eating Disorder.
CBT for Personality Disorder.
Family Interventions for Psychosis & Bipolar Disorder.
Mentalisation Based Treatment.
Cognitive Analytic Therapy (CAT).
Dialectical Behaviour Therapy (DBT).
EMDR.
MANTRA.

Challenges for Improving Access to Psychological Therapies for People with SMI

Not enough staff with the right skills and competencies.
Not enough protected time to deliver therapy.
Limited access to training and supervision.
Not everyone believes they can make a difference.
Not prioritised within services.
Poor data on activity and outcomes.
Timing/sequencing in the context of a multidisciplinary care plan.

Assessment: Gaining Understanding

Formulation!
Open-ended conversations.
Surveys and questionnaires.
Observations.
Analyzing writings or artistic expressions.

Factors Influencing World View

Family.
Friends.
Community.
Education.
Life Experiences.
Popular Influence.

Best Practice Considerations

Power.
Relationship.
Language.
Acknowledge the person’s perspective.
Empathy & compassion.
Be reliable and open.
Appointments.
Learning as therapists.
Anti-oppression.
Practicalities.
What happens after assessment.
Communication.

Assessment Considerations

Establish rapport.
What is the problem?
How has it developed?
What keeps this problem going?
What might help?
Ability and willingness to tolerate strong emotion?
Barriers to engagement?
Risk?
Safeguarding?
Be flexible, service user-led and collaborative.
Psychoeducational materials.

Cognitive Themes

Depression: Actual or perceived loss.
Generalised Anxiety: Unpredictability.
Trauma: Persistent sense of threat or danger.
OCD: Responsibility for the prevention of harm to myself and/or others.
Panic/Health Anxiety: Catastrophic misinterpretation of bodily symptoms with an imminent focus (Panic) or future focus (Health Anxiety).
Social Anxiety: Fear of negative evaluation in social or performance situations.

Formulation

“a process whereby therapist and client work collaboratively to first describe and then to explain in cognitive-behavioural terms the issues a client presents in therapy. Its primary function is to guide therapy in order to relieve client distress and build resilience.” (Kuyken, Padesky & Dudley, 2009)

Why Formulation is Important

Shared understanding of the difficulty.
Keeps a focus on treating the right thing.
Allows others involved in the individuals care to understand them and the approach taken to the care and support plan.
Relates difficulties to one another using psychological theories.
Explains the development and maintenance of difficulties.
Open to revision and re-formulation.

Formulation Implications

Vital for treatment success.
Problem lists and goals need to be adaptable and reviewed.
It is ongoing!

Identifying Problems

Specify the patient's problem list after assessment.
A typical problem list has 8 or 10 items (Persons 1989).
Having too many problems identified may reinforce the clients sense of failure.
What is achievable in the time we have?
Difficulties that cannot be directly addressed during therapy should be included in the problem list.
Therapist's failure to obtain a comprehensive problem list can jeopardise treatment (Persons, 1989).

Barriers to Identifying Problems

Shame.
May seem overwhelming/insoluble.
Embarrassing.
Tackling them is expected to be unacceptably painful and difficult.
Genuinely not considered a problem.

Example Problem List

Not being able to motivate myself in a morning.
Not really liking myself.
Unable to work.
Suicidal thoughts.

Goals

Agree on detailed, specific goals for each problem area.
State goals in positive terms.
Use SMART methodology.

Why Goals Are Important

Helps make explicit what the individual can expect from treatment.
Can identify areas of miscommunication from the assessment.
Future focused - promotes change.
Collaboration and ownership – Cements the individual as an active member of the therapeutic relationship.
Structure for interventions.
Prepares patients for discharge.
Evaluation of how it has gone

Measuring Change

Historically rare in mental health.
Resistance from practitioners.
Only fits certain approaches?
Time consuming?
Interferes with patient therapist relationship?

Central Principles for Data Collection

Data used by individuals and clinicians.
Provides tangible evidence of treatment progression.
Used by supervisors to review clinical work.
Used by managers to facilitate effective service performance.
Used by commissioners & others

Ensuring Equality and Equity of Access

Equality Act 2010.
Services legally required to recognize diverse needs.
Collect and analyze information on different experiences.
Collect information by age, ethnicity, faith, gender, diagnosis and sexuality.
Links between physical and mental health.
Used for health needs assessments.

What to Measure

A measure of problems- Dialog, iROC.
Progress (Ideographic) - Diaries, Duration, Intensity, Belief Ratings, SUDs, GBO.
Symptoms e.g. PHQ-9, GAD-7, BDI.
Diagnosis / differential diagnosis (i.e. OCI, HAI).
Wellbeing e.g. CORE, WASA, REQol-10.
Thresholds for services.
Client satisfaction (i.e. patient expérience questionnaire).

Clinical Functions of Measurement

Work collaboratively with patients.
Use interviewing and outcome measurement tools.
Agree on best treatments.
Review appropriateness of treatment.
Identify therapy targets.
Manage the therapy process.

Measurement Stages

Note the occurrence of behavior, thought, emotion, event.
Record that it has happened. (Barlow et al., 1984)

Increasing Accuracy of Self-Monitored Information

Request appropriate and meaningful information.
Emphasize the importance of self-monitoring.

Measurement Types

Frequency Count: Number of self-critical thoughts, panic attacks, arguments with spouse.
Duration of Problem: Time spent hand-washing, studying, away from home.
Self-Ratings: Used for affective or subjective state.

Rating Scales

Visual analogue scales to numerical scales with distinct response categories.

Reactivity of Self-Monitoring (Hawthorne Effect)

When the patient begins to record the occurrence of an event, its frequency changes (Barlow et al.,1984).
The monitoring interrupts an automatic chain of behaviour, and allows the person to decide whether to continue.

Self-Report Questionnaires

The most frequent sources of self-report are questionnaires (e.g. PHQ-9, GAD-7, BDI).
Content validity is particularly important and refers to the extent to which questionnaires adequately measures the relevant area. (Kirk, 1989)

Patient-Reported Outcome Measures (PROMS)

Clinical governance.
Case Supervision.
Effective communication with patients.
Patient involvement in decision making.
Effective inter-professional communication.

When to Measure

Beginning, middle and end of therapy.
Follow up sessions – 1, 3, 6 months.
Some measures might be done at each session.

Importance of Therapist Factors

Establishing therapeutic alliance and a collaborative approach to treatment

Scientist Practitioner Approach

Uses practice based evidence and evidence based practice.
Applies Critical Thinking and Formulation to Practice.
Tests hypothesis in Practice.
Uses Proven Interventions.
Practice is Informed by the Literature.
Evaluates Client Progress- Measurement

Judging Engagement in Treatment

Inclusiveness.
Support.
Mutual Respect and Partnership.
Co-creating treatment plans.
Co-creating each session.
Co-learning.
Reciprocal relationships.
Transparency, honesty and trust

Engaged in Treatment

Frequently seek questions or concerns.
Understand why you are using an intervention.
Explain the intention and evidence for interventions.
Seek assistance from their support network.
Boundaries of privacy and confidentiality

People Who Get Better Outcomes from Interventions

Know the intervention.
Match protocol to the emotional needs of patient.
Aware of drift and introducing therapy bridges.
Provide regular feedback on progress.
Roll with resistance.
Open to learning.
Avoid guessing (experiential intuition).
Use of clinical supervision … Green, (2014).

Strengthening the Working Alliance

Collaborate on goal setting.
Attend to relational skills.
Proceed at client’s pace.
Tell people what is happening next.
Validate experiences.
Be flexible and open.
Communicate competence & confidence in interventions.
Confront ruptures in the therapeutic relationship.
Don’t get overinvested in success

Individualised Care and Support: Seven Core Principles

High quality health and social care assessment.
Formulation of a person-centred plan of care including crisis and contingency plan.
Allocated named individual.
Regular clinical formulation review.
Receive the least restrictive care.
Support for and involvement of carers.
Clinical outcomes measured

Personalised Care and Support Planning

Emphasis on ‘what matters to me'.
Promoting shared decision making and co- production personalised care and support planning.
Link to outcomes for monitoring.
Outline the planned interventions
Involve family, friends, or carers.
Plans should reflect national personalised care planning standards.
Personalised, reflect the assessment and service capabilities.
Recognize fundamental needs and connections.
Sensitive to cultural identity and spiritual needs.
Safety plans and should document any relapse indicator signs.
Digitally available to staff and the person themselves.
The most important information within a plan should be easily identifiable at the top of the plan.
Services should have systems in place and set out in care plan as to how to access if key person not available.

Managing Transitions

Consideration of what works best for the person.
Information on relapse indicators.
Recommendations to the receiving care team.
Key person should facilitate introduction to and meeting of the new Key worker
Written confirmation of:
- The reason for change in care.
- A named key person and ways to contact them and the service – including a working hours telephone number and email address.
- A copy of the person’s updated care and treatment plan
- How to come back in if needed

Cultural Considerations

Population health focuses on improving the overall health of an entire population, including physical and mental well-being, while also reducing health inequalities.
It involves a proactive, preventative approach, shifting away from reactive care and targeting the factors that influence health outcomes at the population level.
This includes addressing social determinants of health, like poverty and lack of access to resources, which can significantly impact individual health
Service level response:
- Developing strategy and/or
  investing in leadership to advance equality.
- Focus on targeted outreach.
- Commission / develop training.
- Partnering with third-sector organisations
- Focus on breaking language barriers
Key principles:
- Be okay with innovating and trying different things.
- Engage with the communities you're seeking to engage.
- Lean on the experiences of others

Matching Interventions to Presenting Need

Delivering Behavioural Activation for Depression in Secondary Care Settings: The GOALs Programme Depression.
Delivering Graded Exposure for Anxiety in Secondary Care Settings: The GOALs Programme Anxiety.
Problem-Solving – Using a Structured Problem-Solving Process in Clinical Settings Anxiety.
Improving sleep Insomnia.
Helping Clients Regulate Emotions Emotional dysregulation.
Worry management Anxiety.
Developing Self-Confidence Depression

Motivation - Is it the Right Time?

Transtheoretical Model of Change (Prochaska & DiClemente):
- pre-contemplation: No intention of changing behavior.
- contemplation: Aware a problem exists. No commitment to action.
- preparation: Intent upon taking action.
- action: Active modification of behavior.
- maintainence: Sustained change- new behaviour replaces old.
- relapse: Fall back into old patterns of behaviour

Strategies for Low Motivation

Determine baseline motivation.
Think about specific activities you want to see by intervening and focus on.
Breakdown series of steps to achieve goals.
Frame action in terms of tolerating discomfort.
Challenge - Waiting to feel better before doing things.
Cost/benefit analysis of action vs inaction

Using Techniques

Between session work – Our attitude to it determines if it gets gone.
Skill learning- as with every skill you will get better with practise!

Between Session Work

Set between session work collaboratively.
Make it a no-lose proposition.
Ensure patient can do between session work.
Give a rationale for the between session work.
Provide written instructions.
Start between session work in the session & discuss potential barriers.
Formulate resistance/Non-completion.
Prepare for a possible negative outcome.
Always review between session work

Theoretical Underpinning, Model Fidelity and Managing Drift

Based on assumption that most emotional and behavioral reactions are learned.
Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting
Mowrer's (1947) - two-stage theory of fear:
- fear is acquired through classical conditioning and,
- Individuals avoid the feared stimulus, extinction cannot take place and thus the fear is maintained via operant conditioning

Danger of Delayed Focus on Behavior

Ignore a powerful therapeutic ingredient.
Fail to use behavior change to promote cognitive change (Beck et al., 1979).
Not addressing low motivation and feeling overwhelmed.
Missed opportunity for collaboration, treatment engagement, & importance of homework.
Fail to address avoidance, withdrawal, & passivity.
Focus on cognition before behavior (“cart before the horse”)
Safety Behaviours: Things we do that we believe keep us safe. These may keep our attention on the threat.

Simple Behavioral Application

Anxiety: Maintained by Avoidance and use of safety seeking behaviours.
Depression: Maintained by Avoidance and reduced Activity
Our Target Behaviours: The things the individual does too much?.
Problems due to the frequency, intensity, or duration of behaviours being too high for a particular environment or circumstance, (e.g. an individual with OCD who cleans the house for up to 4 hours a day).
Our Target Behaviours: The things the individual does do enough of?.
A behaviour may present a problem because it occurs at an insufficient frequency, and an inadequate intensity, or in an inappropriate form
Example, agoraphobia, Social Anxiety

Delivering Behavioural Activation for Depression in Secondary Care Settings: The GOALs Programme

By focusing on increasing engagement in pleasurable and meaningful activities, it aims to create a positive feedback loop, leading to improved mood and reduced depressive symptoms.
The rationale is that increased activity and positive experiences can counteract the downward spiral of depression, helping individuals regain a sense of control and purpose

Delivering Exposure for Anxiety in Secondary Care Settings: The GOALs Programme

Avoiding an object/situation because of the feelings, emotions and physical symptoms that occur.
Avoidance maintains the cycle.
Avoidance prevents us finding out thoughts are untrue or that behaviour and physical sensations can be controlled

How Does Exposure Work?

Foa and Kozak: Modifying fear structures in brain (about the triggers, the meaning and the response) by presenting incompatible information of safety.
Needs to be done in a situation of emotional arousal (Why?)
Recent research (Powers et al 2007) says that memories are not unlearned but are trumped by new learning.

Conditions for Exposure

Graded.
Focused.
Prolonged.
Repeated

Behavioral Model of Sleep Problems

Bed becomes classically associated with being awake.
Treatment goal is to associate bed with being asleep

Helping Clients Regulate Emotions

Inconsistent or Ineffective Parenting.
Exposure to Trauma and Neglect:..Early childhood trauma, such as abuse or neglect, can significantly impact a child's emotional development.
Conflict and Stress.
Social Interactions.
Cognitive Development:..Cognitive understanding of emotions, such as recognizing and understanding the causes and consequences of different emotions, plays a role in emotional regulation.

Worry Management & Problem Solving

The behavioral rationale for worry suggests that excessive worry and anxiety are often maintained by avoidance behaviors and a tendency to focus on negative outcomes.
This can create a cycle where individuals avoid situations or thoughts that trigger anxiety, further reinforcing their avoidance and limiting opportunities for positive experiences.

Developing Self-Confidence

Low confidence manifests in various behavioral patterns.
Individuals may engage in self-criticism, avoid challenges, seek external validation, or exhibit perfectionism.
They might also display defensive or aggressive behaviors as a way of compensating for their feelings of inadequacy.
Furthermore, low self-esteem can lead to social withdrawal, difficulty making decisions, and even risky behaviors.

Reasons for Drift

Desire for novelty and Incorporation of New Methods.
Feeling Overwhelmed by Rigidity.
Emotional Reactions and Safety Behaviors
overestimating their own skills or underestimating the client's potential
Peer influence and lack of Supervision.
Therapist inhibiting Beliefs (TIB’s).
Client Factors

Dosing

The dose-response effect refers to the relationship between the dose (e.g., length, frequency) of treatment and the subsequent probability of improvement.
Interventions in are designed to be delivered in up to 12 sessions. There is inconclusive evidence in clinical samples with chronic and severe mental disorders as to the correct dose.
Optimal doses of psychotherapy in routine settings range between 4 – 26 sessions and vary according to setting, clinical population and outcome measures
Weekly intervention appears to accelerate the rate of improvement compared to less frequent schedules.

Ethical and Professional Guidelines

Clinicians are expected to maintain honesty, fairness, and respect in their interactions with clients, avoiding any actions that could exploit or harm them.
Avoidance of Harmful Relationships
Proper Supervision and Competence
Respect for Client Rights - Clinicians must respect the client's rights to privacy, autonomy, and access to information about their treatment.
Honesty and Transparency
Professional Boundaries

Dealing with the Emotional Content of Sessions

Regular Supervision.
Balance diary commitments.
Peer support.
Set boundaries – Own and individual.
Resilience plan

What if I Don't Do it Right?

If you don’t start you will never get it right and individual's won't benefit.
Your default setting is being kind

Addressing Lack of Progress

People tell us!
Progress monitoring data showing no change or worsening.
A plot of progress monitoring data showing no change or worsening.
A suicide attempt, hospitalization, or other crisis.
Your observations of patient/client behavior (e.g., frequent cancellations).
Your feelings about the case (e.g., discouraged).
Patient statements (e.g., “I’m not getting better,“ I’m getting worse.”).
Statements from patient’s family members (“She’s not improving.”).
Statements from other providers

Questions Helpful in Addressing Lack of Progress

Are there relational issues?
Case formulation is missing, unclear, incomplete, or unhelpful.
Treatment goals are missing, vague, unrealistic, or the patient and I do not fully agree on them.
The treatment dose is not adequate to meet the client’s needs (e.g., sessions are too infrequent), or the patient needs adjunctive treatment (e.g., pharmacotherapy) or a different treatment.
The client and/or therapist is not fully engaged in or compliant with the treatment plan.
My behaviors and/or those of the patient are interfering with the treatment (e.g., patient routinely comes late to the session and I do not address that issue).
Social factors impacting?
Client is ambivalent about changing, perhaps due to low confidence about being able to do it.

Looking After Ourselves

We work in a challenging service.
We provide this for patients but often overlook ourselves.
Limited training is available in dealing with the emotional aspects of our work roles
Physical Activity:..What types? How often? Why?
Food intake: Calories? Male / Female Good fats / bad fats How much fat per day? Salt intake per day? Plate portion? The Balanced Plate

8 Tips for Healthy Eating

Base your meals on starchy foods.
Eat lots of fruit and veg.
Eat more fish.
Cut down on saturated fat and sugar.
Eat less salt.
Get active and be a healthy weight.
Don't get thirsty.
Don’t skip breakfast.

Effects of excessive alcohol

Increased risk of cancer, diabetes and liver disease
Poor sleep
Increased risk of depression
Increased risk of dependence
Affects cognitive function
Feeling less alert, more groggy, sluggish
Feeling stressed and ability to cope reduces with reduced sleep and sluggishness
Increased disinhibitions leading to poor decision making, and consequences
Costly – affects finances and priorities
Can impact on relationships
Increases signs of ageing
Weight gain

Health Effects of Sleep Deprivation

High blood pressure.
Heart disease.
Stroke.
Lower overall immunity.
Increased risk of diabetes.
Lower fertility rate

The Big Impact of Small Changes

big impacts…. FROM SMALL CHANGES