Revised Standards S 1a: The service routinely collects data on age, gender and ethnicity for each person referred for psychological therapy. S1b: People starting treatment with psychological therapy are representative of the local population in terms of age, gender and ethnicity. 1 S 2: A person who is referred for psychological therapy does not wait longer than 13 weeks from the time at which the initial referral is received to the time of the assessment. 2 S 3: A person who is assessed as requiring psychological therapy does not wait longer than 18 weeks from the time at which the initial referral is received to the time that treatment starts. 3 S 4: The therapy provided is in line with that recommended by the NICE guideline for the patient s condition/problem. 4 S 5: Treatment for high intensity psychological therapy is continued until recovery or for at least the minimum number of sessions recommended by the NICE guideline for the patient s condition/problem. 5 S 6: The therapist has received training to deliver the therapy provided. 6 S 7: People receiving psychological therapy experience and report a positive therapeutic relationship/helping alliance with their therapist which is comparable to that reported by people receiving treatment from other therapists/services. 7 S 8: Patients/clients report a high level of satisfaction with the treatment that they receive. 8 S 9a: The service routinely collects outcome data in order to determine the effectiveness of the interventions provided. S9b: The clinical outcomes of patients/clients receiving psychological therapy in the therapy service are comparable to those achieved to benchmarks from clinical trials and effectiveness studies and to those achieved by other therapy services. 9 S 10: The rate of attrition from commencing treatment to completing treatment is comparable to that of other therapy services. 10
References for the standards from relevant guidance literature, including NICE guidance. 1 Respecting diversity: working in partnership with service users, carers, families and colleagues to provide care and interventions that not only make a positive difference but also do so in ways that respect and value diversity including age, race, culture, disability, gender, spirituality and sexuality (DoH, 2004b, p.13). The patient s age, sex, social class or ethnic group are generally not important factors in choice of therapy and should not determine access to therapies (DoH, 2001, p.35). The full range of psychological interventions should be made available to older adults with depression, because they may have the same response to psychological interventions as younger people (NICE, 2007b, p.19). Any service user who contacts their primary health care team with a common mental health problem should have their mental health needs identified and assessed and be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it (NHS, 1999, p.9). Psychological therapy services need to be sensitive to the needs of parents They should provide flexibility within their service to choose appointment times (Mind, 2008, p.5). Psychological services should be flexible, offering weekend and evening appointments for those who are working during the day (Mind, 2008, p.6). Any individual with a common mental health problem should be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care (DoH, 2004c, p.16). Ethnic and cultural identity should be respected by referral to culturally-sensitive therapists (DoH, 2001, p.35). Psychologists have a responsibility to work with local communities to ensure that psychological therapy services provide a range of interventions that are culturally appropriate and accessible by all members of the community (BPS, 2007, p.8). Practitioners should not allow their professional relationships with clients to be prejudiced by any personal view they may hold about lifestyle, gender, age, disability, race, sexual orientation, beliefs or culture (BACP, 2007, p.6). Any service user who contacts their primary health care team with a common mental health problem should be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it (DoH, 2004c, p.12). Commissioners should be looking at the needs of the local population when commissioning psychological services and ensure that services are tailored to local needs (Mind, 2008, p. 10). Commissioning should be based on accurate assessments of the needs of particular groups of service users. These include the needs of minority groups for treatments delivered with cultural sensitivity in accessible locations (RCP & RCGP, 2008, p.30). You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, religion or belief, sexual orientation, disability (including learning disability or mental illness) or age (DoH, 2009, p.18). 2 Maximum wait for an outpatient appointment is 3 months (12 weeks) (DoH, 2002; p.11). PCTs should engage people while they are on the waiting list and tell them how long they can expect to wait (Mind, 2008, p.7). We call on the government to ensure that PCTs record their waiting times and publish these annually (Mind, 2008, p.3). The NHS should introduce waiting time measures for access to mental health treatments (Mind, 2006, p.17) The aim is to reduce the time service users wait at any point in the health and social care process e.g. between referral and the first appointment and any referrals to internal services (CSIP, 2006, p.30). We strongly support the IAPT programme s aspiration that urgent therapy be available within three to 10 days (Mind, 2008, p.3). All referrals should be acknowledged within the agreed service standard number of days of receipt by the psychologist (DCP, 2004, p.22). The NHS commits to provide convenient, easy access to services within the waiting times set out in this Handbook to the NHS Constitution (DoH, 2009, p.20).
3 Maximum wait for an outpatient appointment is 3 months (12 weeks) (DoH, 2002; p.11). The treatment of choice is available promptly (NICE, 2007, p.46). (Anxiety audit criteria). PCTs should engage people while they are on the waiting list and tell them how long they can expect to wait (Mind, 2008, p.7). We call on the government to ensure that PCTs record their waiting times and publish these annually (Mind, 2008, p.3). The NHS should introduce waiting time measures for access to mental health treatments (Mind, 2006, p.17) The aim is to reduce the time service users wait at any point in the health and social care process e.g. between referral and the first appointment and any referrals to internal services (CSIP, 2006, p.30). We strongly support the IAPT programme s aspiration that urgent therapy be available within three to 10 days. (Mind, 2008, p.3). From the end of December 2008, patients can expect to start their consultant-led treatment within a maximum of 18 weeks form referral for non-urgent conditions unless they choose to wait longer or it is clinically appropriate that they do so. Although the maximum is 18 weeks many patients will receive treatment much sooner than that (DoH, 2009, p.20). 4 The NHS will do more to clarify what high-quality care looks like, by supporting NICE in developing quality standards that can be used by commissioners and providers to assess current practices and to inform the commitments they make to patients about what quality of services to expect (DoH, 2009, p.31). Anxiety A patient with panic disorder is offered any of the following types of intervention, and the person s preference is taken into account: psychological therapy pharmacological therapy self-help (NICE, 2007, p.46) A patient with longer-term generalised anxiety disorder is offered any of the following types of intervention, and the person s preference is taken into account: psychological therapy pharmacological therapy self help (NICE, 2007, p.46) Depression Depressive disorders may be treated effectively with psychological therapy with best evidence for cognitive behaviour therapy and interpersonal therapy, and some evidence for a number of other structured therapies, including short-term psychodynamic therapy (DoH, 2001, p.37). Anxiety disorders with marked symptomatic anxiety (panic disorder, agoraphobia, social phobia, OCD, simple phobias, GAD) are likely to benefit from CBT (DoH, 2001, p.37). Generic counselling is NOT recommended as the main intervention for severe and complex mental health problems or personality disorders (DoH, 2001, p.37). The following structured therapies, delivered by appropriately trained practitioners, are effective for some people with depression: CBT, behaviour therapy, interpersonal therapy, structured problemsolving (WHO, 2005; NICE, 2009b, 15). When considering individual psychological treatments for moderate, severe and treatment-resistant depression, the treatment of choice is CBT or IPT or BA. (NICE, 2009b, p.15). People with a persistent subthreshold depressive symptom or middle to moderate depression, consider offering one or more of the following interventions, guided by the person s preference: individual guided self-help based on principles of CBT, ccbt, structured group physical activity programme (NICE,2009a, 183). ccbt should be provided via a stand-alone computer-based or web-based programme, include an explanation of the CBT model, be supported by a trained practitioner who provides limited facilitation, take place over 9-12 weeks (NICE,2009a, 183). Physical activity programmes for people with persistent subthreshold depressive symptoms or mild to moderate depression should be delivered in groups supported by a competent practitioner, typically consist of 3 sessions per week of 45mins-1hour over 10-14 weeks (NICE,2009a, 184). Offer people with depression advise on sleep hygiene if needed (NICE,2009a, 183).
People with a persistent subthreshold depressive symptom or middle to moderate depression who have not benefited from a low intensity psychosocial intervention should be offered CBT, IPT, or BA (despite less robust evidence) or couples therapy if they have a regular partner (NICE, 2009a, p. 250-1) Group CBT should be offered to patients with moderate or severe depression who do not take or who refuse antidepressant treatment or low intensity psychosocial interventions (NICE, 2009a, p.250). People with depression who decline an antidepressant, CBT, IPT, BA and behavioural couples therapy should be offered counselling or short-term psychodynamic psychotherapy (NICE, 2009a, p.251). For people with moderate or severe depression, provide a combination of antidepressant medication and a high-intensity psychological intervention (CBT or IPT) (Nice, 2009, p. 251). The choice of intervention should be influenced by the duration of the episode of depression and the trajectory of symptoms; previous course of depression and response to treatment; likelihood of adherence to treatment and any potential adverse effects; person s treatment preference and priorities (NICE, 2009a, p. 251). Mindfulness-based CBT, usually delivered in groups of 8-15 for the prevention of relapse (NICE, 2009a, p.254). For a person whose depression has not responded to either pharmacological or psychological interventions, consider combining antidepressant medication with CBT (NICE, 2009, p. 252). Panic disorder: Cognitive behavioural therapy (CBT) should be used. Briefer CBT should be supplemented with appropriate focused information and tasks. Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials. For a few people, more intensive CBT over a very short period of time might be appropriate. (NICE, 2007, p.16). Anxiety: CBT should be used. Briefer CBT should be supplemented with appropriate focused information and tasks. Where briefer CBT is used, it should be around 8 10 hours and be designed to integrate with structured self-help materials. (NICE, 2007, p.24). Interventions should be made available to older adults with depression, because they may have the same response to psychological interventions as younger people (NICE, 2007b, p.19).* Recommendations on older adults were not updated in 2009 due to dearth of new evidence. Follow-up/relapse: People with depression who are considered to be at significant risk of relapse should be offered individual CBT (if relapses despite anti-depressant/and or have significant history of depression)/ mindfulness-based cognitive therapy if currently well but have experience 3 or more previous episodes of depression (NICE 2009, p. 254). For all people with depression who are having CBT for relapse prevention, the duration of treatment should typically be in the range of 16-30 sessions over 3-4 months If the duration needs to be extended, it should consist of 2 session per week for the first 2 to 3 weeks of treatment. Additional follow-up sessions should typically consist of 4-6 sessions over the following 6 months.(nice, 2009, p.254). Mindfulness-based CBT, usually delivered in groups of 8-15 for the prevention of relapse (NICE, 2009a, p.254). 5 Therapies of fewer than 8 sessions are unlikely to be optimally effective for most moderate to severe mental health problems. Often 16 sessions or more are required to achieve lasting change in social and personality functioning (DoH, 2001, p.35). Depression For people having individual CBT duration of treatment should typically be in the range of 16-20 sessions over 3 to 4 months providing 2 sessions per week in the first 2-3 weeks for people with moderate to severe depression and including follow up over 3-6 months(nice, 2009a, p.252). For people having IPT treatment should typically be in the range of 16-20 sessions over 3 to 4 months providing 2 sessions per week in the first 2-3 weeks for people with moderate to severe depression and including follow up over 3-6 months(nice, 2009a, p.252). Behavioural couple-focused therapy for depression should normally be based on behavioural principles, and an adequate course or therapy should be 15 to 20 sessions over 5 to 6 months. (NICE, 2009a, p.252).
For all people with persistent subthreshold depressive symptoms or mild to moderate depression having counselling, the duration of treatment should be typically in the range of 6-10 sessions over 8-12 weeks.(nice, 2009a, p.252). For all people with mild to moderate depression having short-term psychodynamic psychotherapy, the duration of treatment should typically be in the range of 16-20 sessions over 4-6 months. (NICE, 2009a, p.252). Duration should normally be within the limits outlined in NICE guidance reduced if remission achieved and increase if progress being made but there is agreement between practitioner and person with depression that further sessions are required (NICE, 2009a, p. 253) Panic disorder: 1. CBT in the optimal range of duration (7 14 hours in total) should be offered. For most people, CBT should take the form of weekly sessions of 1 2 hours and should be completed within a maximum of 4 months of commencement. 2. Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured selfhelp materials. 3. For a few people, more intensive CBT over a very short period of time might be appropriate. (NICE, 2007, p.16). Anxiety: 1. CBT in the optimal range of duration (16 20 hours in total) should be offered. 2. For most people, CBT should take the form of weekly sessions of 1 2 hours and be complete within a maximum of 4 months from commencement. 3. Where briefer CBT is used, it should be around 8 10 hours and be designed to integrate with structured self-help materials. (NICE, 2007, p.24) 6 The attainment and maintenance of ethical standards in behavioural treatment, informal or formal are dependent upon appropriate attitudes to patient care and a high level of proficiency. For the achievement of both it is necessary that at least as great a priority is given to training in these treatments as is given to training for other types of therapy (RCP, 1997, p.14). The practitioner is responsible for learning about and taking account of the different protocols, conventions and customs that can pertain to different working contexts and cultures (BACP, 2007, p.8). A commitment to good practice requires practitioners to keep up to date with the latest knowledge and respond to changing circumstances (BACP, 2007, p.5). It is important that counselors are aware of the evidence base that underpins their work and that they are able to respond to it appropriately. This means that practitioners should not only keep up with the latest research but also be a critical reader of it (BACP, 2004, p.38). Research is a complex process of critical and scientific enquiry and it is considered essential for counselors to inform and validate their practice (BACP, 2004, p.38). Personal development and learning: Keeping up-to-date with changes in practice and participating in life-long learning, personal and professional development for one s self and colleagues through supervision, appraisal and reflective practice (DoH, 2004b, p.18). Practitioners have a responsibility to monitor and maintain their fitness to practise at a level that enables them to provide an effective service (BACP, 2007, p.7). [Therapists] must keep your professional knowledge and skills up to date (HPC, 2008, p.3). BACP recommends that counsellors in the NHS undertake 30 hours of CPD a year post qualification, and become familiar with portfolio learning and all that it means (BACP, 2004, p.38). All applicants for BACP individual practitioner accreditation are required to have had 40 hours of personal therapy experience (BACP, 2004, p.30). 7 Effectiveness of all types of therapy depends on the patient and therapist forming a good working relationship (DoH, 2001, p.35).
Working in partnership: Developing and maintaining constructive working relationships with service users, carers, families, colleagues, lay people and wider community networks (DoH, 2004b, p.3). Patient preference should inform treatment choice, particularly where the research evidence does not indicate a clear choice of therapy (DoH, 2001, p.36). Psychologists should respect the knowledge, insight, experience and expertise of clients, relevant parties, and members of the general public (BPS, 2006, p.10). Patient preference and the experience and outcome of previous treatment(s) should be considered when deciding on treatment (NICE, 2007b, p.12). The patient shares decision-making with the healthcare professionals during the process of diagnosis and in all phases of care (Audit criteria in NICE). To facilitate shared decision-making, evidence-based information about treatments should be available and discussion of the possible options should take place (NICE, 2007, p.10). [The therapists] must act in the best interest of service users (HPC, 2008, p.3). The patient shares decision-making with the healthcare professionals during the process of diagnosis and in all phases of care (NICE, 2007, p.45). Increase the reliability of therapeutic interventions by enabling service users and carers to be at the centre of decision-making and establishing systems that support meaningful service user and carer involvement and participation (CSIP, 2006, p.26). 8 It is important that people wishing simply to comment on services should have a distinct route to do so without having their input [it] as a complaint. (DoH, 2001b, p.99). Incorporate routine measures of outcome in psychological therapies service, including quality of life and service user satisfaction, waiting times, clinical outcomes, quality of life, service user and carer satisfaction, governance (DCP, 2007, p.19). 9 The success of the IAPT programme will rest on its ability to demonstrate good clinical outcomes. Psychologists have an important role in advising local services as to routine clinical data collection, and how to guarantee and monitor good and appropriate clinical outcomes (BPS, 2007, p.10). [anxiety] Outcomes are monitored using short, self-complete questionnaires (NICE, 2007, p.47). All clinical psychologists should be responsible for monitoring and evaluating their work (DCP, 2004, p.35). Explore means to measure outcomes routinely, including quality of life and service user satisfaction (DoH, 2004, p.40) Short, self-complete questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible (panic disorder & GAD) (NICE, 2007, p.33). There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of that process should be determined on a case-by-case basis (NICE, 2007, p.32). [outcome assessment] instruments should be implemented by counsellors skilled and trained in using them (BACP, 2004, p.40). All psychology departments should regularly evaluate their work using clinical audit techniques, outcomes measures and quality monitoring tools (DCP, 2004, p.35). Commissioning decisions should focus on outcomes rather than process and in particular services need to be able to demonstrate acceptability, accessibility, equity, effectiveness, efficiency, and safety (DCP, 2007, p.18). 10 There are positive advantages of services based in primary care practices (for example, lower dropout rates) and these services are often preferred by patients (NICE Anxiety quick reference guide amended, p.4)
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