Psychotherapy groups for Long Term Conditions in primary care - - PowerPoint PPT Presentation

Psychotherapy groups for Long Term Conditions in primary care

Experiences, outcomes and questions from our work with condition-general LTC groups in Talking Therapies Southwark

Who we are

• Nick Kenrick (nick.kenrick@slam.nhs.uk)

– Person-Centred Psychotherapist (UKCP) & Mindfulness Teacher – Background in foreign policy (mostly Iraq and international security issues)... and chronic fatigue! – Works to support people with LTCs and anxiety/depression through individual and group work, with a particular interest in how the latter can provide integrated, holistic support across multiple needs

• Stella Sawyer, IAPT/TTS Liaison Nurse (stella.sawyer@slam.nhs.uk)

– Background in Occupational Health nursing – PHE Nurse Physical Activity Clinical Champion – Role primarily focussed on increasing access for people with long term physical conditions and co-morbid anxiety/depression; as well as supporting therapists to provide more holistic treatments for patients.

…a therapist level view

What we plan to cover today

1. Context: IAPT services and Long Term Health Conditions

• Interventions in Talking Therapies Southwark

2. A look at two groups for LTC in our service

• Mindfulness for Health and The Wellbeing Group

3. Making sense of evaluation and outcomes

• Standard measures
• “Positive” measures
• Qualitative indicators
• Other types of outcome

4. Some of the questions, challenges and debates we see in this area, and

• ur intentions for the future

5. Questions and discussion

IAPT services and Long Term Health Conditions

A fresh mindset from NHS England (2016): “We should have fewer cases where people are unable to get physical care due to mental health problems affecting engagement and attendance (and vice versa). And we need provision of mental health support in physical health care settings – especially primary care.” This includes IAPT “Outcomes should be holistic and reward collaborative working across the system (e.g. stable housing, employment, social and physical health outcomes).” THE FIVE YEAR FORWARD VIEW FOR MENTAL HEALTH

Talking Therapies Southwark and Long Term Health Conditions

• For Talking Therapies Southwark, this started in 2012
• Process of gradual experimentation, development of new

group and individual interventions, increasing liaison, improving referral pathways and moving towards joint working with physical healthcare providers

• Continual evolution!

Our current interventions

• TTS offer psychological treatments for adults (>16) with mild to moderate

anxiety and depression. We do not treat people with severe mental illness, substance misuse issues, eating disorders, personality disorder, major cognitive deficit e.g dementia.

• Triage – telephone or face to face appt with therapist usually within 2

weeks of receipt of referral

• Foundation options offered:

– e-learning and guided self help, both supported by regular contact with therapists – Specialists workshops (e.g. bereavement; PTSD, LGBQ)/or ’rolling’ workshops covering range of topics related to psychological wellbeing – Specific interventions focused on helping people with long term physical health conditions – Mindfulness Based Cognitive Therapy

Our current interventions (continued)

• Therapist review/ Follow on options

– More individualised (1:1) help to apply the principles/strategies learnt at foundation stage

• Employment support:

– Career coaches are available for consultation for people who are unemployed/off work sick

• Other sources of help and support:

– We have strong links with community organisations and may be able to recommend places which provide additional support

• Maintaining wellbeing:

– Follow up ‘drop in’ workshops to revise and discuss strategies learnt during therapy

Our LTC-specific interventions

We offer a range of interventions/treatments aimed to help people registered with a GP in Southwark who are living with a long term physical condition(s) learn ways of managing low mood, stress, fatigue and sleep problems to support and improve wellbeing. This includes:

• Guided self help/evidence based online CBT for specific LTCs (such as

Diabetes, COPD) with regular support from a therapist

• ‘Living well with a long term condition ‘ A set of 4 weekly meetings

providing a CBT framework to help people living with the day to day challenges of living with a long term condition.

• Wellbeing Group: (2 x 12 weeks) Attendees share experiences with others

facing similar challenges, learn how to respond to the challenges of long- term illness within a CBT framework, and to access local resources that may reduce social isolation and support wellbeing

Our LTC-specific interventions (continued)

• Mindfulness for Health programme (8 weeks) to help people better

manage the challenges, pain or other difficulties on a day to day basis with mindfulness meditation practices

• Sleep management workshops: practical tips and hints to improve sleep

quality which can be of great help in improving physical and mental wellbeing

• Changes for Health course to support people in making healthy changes

to diet and lifestyle in the context of longer term behaviour change

Focus on two condition-general groups

Mindfulness for Health & The Wellbeing Group

Background decisions and debates

• Condition-specific vs condition general

– Common factors (fatigue, pain, adjustment, relational) – Specific (appropriate clinician understanding, specific interactions and limitations)

• Modality

– CBT, ACT, Mindfulness – Taking into account evidence (still emerging), patient choice – Therapeutic vs non-therapeutic needs

• Degree of integrated working

– Co-location? Joint provision? Waiting time parity? Ease of referral?

• Evaluation

– What is the aim? Recovery vs improved management. Balance of qualitative and quantitative evidence. Integrating with commissioning targets

Group 1: The Mindfulness for Health Group

• 9 week programme for people with one or more long term physical

health conditions together with depression and/or anxiety.

• One two hour session per week, with daily home practice of 30-40

minutes

• Training in a variety of different mindfulness and meditation

practices, drawing on the standard Mindfulness Based Cognitive Therapy programme, and framed using the three motivation systems from Paul Gilbert’s Compassionate Mind work

• Adapted in particular to address experiences of pain and fatigue
• Running in an evolving form in the service since 2012

Group 2: The Wellbeing Group

• A rolling group of 12-14 topics that people can join at any time, and

stay for two rotations (up to 6 months)

• Three pillars:

– Sharing experiences – Learning tools and strategies – Connecting to local resources (partnership with the Southwark Wellbeing Hub and our Community Coordinator)

• Guest speakers with lived experience and relevant expertise
• Weekly podcast for attendees – NB those who do not absorb

written information easily

• Weekly task to complete, to explore a new coping strategy or take

steps towards a personal goal

• Monthly continuation group – “Stronger Together”
• Running in the current form since May 2016

Who comes to these groups?

• Encompasses people who have...

...many of whom are also in long-term battles with the benefits system, some are homeless, some cannot read or write, some have past traumatic experiences. Almost all have very challenging personal or family relationships in their lives and many have become quite isolated.

– Chronic pain & Fibromyalgia – Chronic fatigue – Heart disease – COPD – Stroke – Multiple Sclerosis – Musculoskeletal problems (inc. injury) – Diabetes – Arthritis – Parkinson’s disease

Assessing the groups

Making sense of evaluation and outcomes

Standard measurement and outcomes

• From 14 MfH course completers in 2018
• From 23 Wellbeing Group completers 2018

Pre Post Significance PHQ-9 12.0 8.1 p<0.01 GAD-7 10.6 7.1 p<0.01 WSAS 20.4 17.4 p<0.05 Pre Post Significance PHQ-9 15.8 13.2 p<0.01 GAD-7 12.5 11.5 (p=0.08) WSAS 23.2 23.3 (p=0.44)

What do people say about the Wellbeing Group?

“This is the first place in 10 years I feel I belong.” “This group has literally changed my life. It has helped me to find my voice and realise I am worth it” “I am so glad I have attended this group because I have learnt the following:

• 1. There are plenty of resources available - I didn't know about anything.
• 2. I am not alone! I have made new friends who understand in a way that even my

best friend cannot, as they have not been there.

• 3. I am stronger than I think.
• 4. I can regain control in little steps - my sleeping pattern, my diet, managing my

fatigue.

• 5. Speaking about it helps! Very often I find myself nodding when someone else shares

their feelings.” “I feel better - less lonely, less isolated. I have made new friends, thank you!”

Positive measures – ONS Personal Wellbeing

Mindfulness for Health (N=14) Pre Post Significance Overall, how satisfied are you with your life nowadays? 4.6 5.5 (p=0.11) Overall, how happy did you feel yesterday? 4.7 5.5 (p=0.12) Overall, to what extent do you feel the things you do in your life are worthwhile? 5.5 5.6 (p=0.46) Wellbeing Group (N=23) Pre Post Significance Overall, how satisfied are you with your life nowadays? 3.0 4.6 p<0.01 Overall, how happy did you feel yesterday? 3.3 4.9 p<0.01 Overall, to what extent do you feel the things you do in your life are worthwhile? 4.4 5.5 p<0.05

Other indicators and outcomes

• Some members of the first group are still meeting for lunch

every week three years on from first attendance. Some have supported each other to fulfil long-held ambitions, such as to go horse-rising.

• Previous and current members engage in a wide range of

community activities other services – e.g. reading groups, hydrotherapy, volunteering…

• Healthcare usage – complex to evaluate – reductions for

mindfulness, increases for Wellbeing Group?!

• Scaling effect – older group members helping newer

Questions, challenges and debates

• Joining up our work to the current commissioning framework for IAPT, which is

heavily “recovery”-focused; identifying the place for chronic needs – sometimes “dialysis” rather than cure, may not recovery but can still benefit substantially.

• Balance between measuring –ve (symptoms) and +ve (meaning, self-efficacy,

hope), and behaviours/service usage. How to make use of the qualitative reporting?

• Factoring in the multiple needs across multiple life domains, only some of which

are addressable through ‘therapy’ as narrowly defined.

• Doing all of this as part of “business as usual” (i.e. not a research project, no ring-

fenced resource)

• Some confounding factors

– Impact of benefits battles and the need to communicate difficulty – skewed incentives (some people score highly for tactical reasons) – Questionnaire fatigue – NB some who score very high on both the symptom measures and the positive measures – Healthcare usage may increase in some cases as people’s wellbeing improves

Tentative conclusions

• Condition-general groups can be very effective. Some clear common factors

(pain, fatigue, adjustment, relationships, benefit of community)

• In cases with a lot of complexity and a range of needs, a range of inputs through a

single intervention space can be both beneficial, and integrating in itself: “This group is a perfect group for me. I feel like all the different parts of myself come to every session.”

• Integrated, holistic responses involve a recognition of the fuzzy boundaries

between psychological support, social support, physical support, practical resourcing, community building, and a willingness to work across them

• Evidencing value is important, and challenging – requires ongoing dialogue with

commissioners and partners, and making sense of the range of different measures and types of evidence

Our direction for the future

• More joint working! Move to further co-location and

integration

– Gastroenterology, diabetes integrations in progress; – then to MSK? – integrated assessment and joint provision of

(i) psychologically informed physical interventions, and (ii) physiologically informed psychological interventions!

• Integrating into the IMPARTS IT platform and process
• Further development of holistic outcomes and evidence

framework, including more nuanced look at healthcare data