Model of Service Provision

Models of Service Provision

A variety of care models have been designed to improve the capacity of mental health and psychological services to increase access to evidence based psychological therapies and interventions. These are particularly important in the face of rising demand and diminishing resources and where access to high quality, accessible interventions is key. Services should be based on a clearly defined model of care provision with an understanding of how the various practice types (particularly enhanced and specialist) and the traditional and digital delivery options relate to their choice of model.  Two of the most widely used models are matched care and stepped care¹. However, other models have been developed and may be considered further as services review how to meet the needs of people accessing psychological therapy and interventions.

Matched Care Model

 This is generally defined to be where members of the multidisciplinary (MDT) team match the therapy or intervention and the person accessing service based on the information at assessment and the client preference. This takes account of the specifics of the presentation and other factors associated with the person seeking a service.

An example

The Choice and Partnership Approach (CAPA)² is an evidence-based model of community mental health services that aims to better match services to needs and to improve timely access to care. It is a collaborative model, often used in child and adolescent settings, where the clinicians providing the assessment act as facilitators for the user and their family through a Choice Appointment which has the goal of identifying the problems that they would like help with, collaboratively reaching a shared understanding of the problem and identifying the service or clinician with the best matched skills to help them. This approach has been adopted in a number of CAMHS services in Scotland.

Stepped Care Model: This has two principles

1. Treatment/intervention should always have the best chance of delivering positive outcomes while burdening the person using services as little as possible.
2. A system of scheduled review to detect and act on non-improvement must be in place to enable ‘stepping’ up to more intensive treatments, ‘stepping down’ where a less intensive treatment becomes appropriate and ‘stepping out’ when an alternative treatment or no treatment becomes appropriate.

An example      

• In NHS England: NHS Talking Therapies for Anxiety and Depression is an example of a national approach to delivering psychological therapies and interventions to scale for common mental health difficulties. They have combined clear requirements for training and supervision of the workforce informed by the best evidence base on matching therapies and interventions across a stepped care model and using continual monitoring of routine outcomes to aid decision making for individuals.³   A stepped care model has been adopted in a number of adult mental health services and primary care services in Scotland.

Both matched and stepped care should be responsive to indicators from data gathered from monitoring measures, using this information to guide changes in the care received (for example, to step up to more specialist care), and should also be responsive to feedback from people using services.

There should be well-defined care pathways to psychological interventions and psychological therapies which support effective functioning through efficient communication between tiers. These pathways should cover both face to face and digital/remote delivery options. 

References

1 van Straten A, Tiemens B, Hakkaart L, Nolen WA, Donker MC. Stepped care vs. matched care for mood and anxiety disorders: a randomized trial in routine practice. Acta Psychiatr Scand. 2006 Jun;113(6):468-76. doi: 10.1111/j.1600-0447.2005.00731.x. PMID: 16677223.

2 Campbell LA, Clark SE, Ayn C, et alThe Choice and Partnership Approach to community mental health and addictions services: a realist-informed scoping review protocol. BMJ Open 2019;9:e033247. doi: 10.1136/bmjopen-2019-033247.

3 Clark, DM (2019). IAPT at 10 Achievements and Challenges. NHS England. Accessed at https://www.england.nhs.uk/blog/iapt-at-10-achievements-and-challenges/ on 23/08/23.

Accessibility

Services must ensure accessibility in the broadest sense and work with local data and feedback to understand barriers to accessibility.

Barriers to access can be very tangible such as restrictive referral criteria, language barriers (including lack of planning for meeting the needs of people with sensory impairment and where English is not the first language), race or culture barriers, costs (transport cost or financial implications of time off work), distance to clinic locations or lack of public transport links. Specific populations such people with a diagnosis of dementia or people with learning disabilities often experience additional complex barriers including how distress might be communicated.

There are potential barriers caused by digital access choices (cost, accessibility or skills and confidence) although digital access can also provide innovative solutions to other potential barriers for some people. Barriers can also be more subtle such as shaming or blaming language or punitive responses e.g., to nonattendance or may be related to people using services feeling disempowered or coerced.

Further information on providing inclusive services can be found in the NHS Education for Scotland Equality and Diversity Zone.

Considerations when planning for accessibility

• Direct/Self-Referral Options: Direct access options can be part of a range of methods to improve accessibility, but services should consider how use of this option may be impacted by other factors, such as people feeling disempowered.
• Active Outreach to all communities that might be underserved for a range of reasons should be encouraged. This can be done in partnership with people who use services and build on understanding of the barriers such as deprivation, ethnicity or age.  Helpful guidance is provided such as the British Association for Behavioural and Cognitive Psychotherapies Black, Asian and Minority Ethnic Positive Practice Guide.
• Different Approaches to Delivery such as work with or support for family and carers or considering the wider therapeutic milieu in an in-patient ward can be necessary to achieve and sustain a robust and supportive context for the person engaging in psychological therapy or intervention. Adapting the duration and format of delivery (i.e., individual or group delivery) of psychological therapies and interventions to meet the person’s needs should also be considered.
• Digital Access: The risk of digital exclusion should be planned for. The evidence summary for supporting technology enabled delivery of psychological therapies and interventions is available here

Workforce Competencies and Skills

Competence Based Approach 

Psychological therapies and psychological interventions need to be delivered within a wider health, social care and 3^rd sector system which has staff trained, and able to deliver with confidence and competence within the values and principles expected in Scottish services.

The Matrix has described 4 types of psychological practice which can be linked to a range of different competences

• Informed Psychological care
• Skilled Psychological care
• Enhanced Psychological practice
• Specialist Psychological practice

The Matrix is primarily focussed on enhanced and specialist psychological practice as this is the focus of psychological therapies and interventions. Informed and skilled care is also essential to ensure effective delivery across all services in Scotland. For instance, these practices include effective communication, empathy, relationship development and an ability to adapt usual practice to the needs of a range of groups in the population such as neurodiverse people or people with dementia. 

Knowledge and Skills Frameworks

Delivery of psychological therapies and interventions should be underpinned by evidence-based competency frameworks, and the skills and competences acquired through high quality training and developed in practice through access to supervision.

The four practice types (informed, skilled, enhanced and specialist) underpin the range of Knowledge and Skills Frameworks which have been published nationally. These reflect the need for services to understand the range of psychological skills that are required to deliver effective practice in many settings. All the current knowledge and Skills Frameworks available here https://www.nes.scot.nhs.uk/our-work/provision-of-psychological-interventions-and-therapies-guidance/

Safety

Psychological Therapy Safety

As with all healthcare interventions, psychological therapies have the potential to have unwanted, or adverse effects and this should be planned for in service delivery. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically^1,2,3. Reports of serious adverse events are increasingly included in research trials and gathered as part of service provision. A survey carried out in NHS England indicated that around 5% of people accessing therapy said they had experienced ‘lasting bad effects’ which they associated with their therapy experience⁴.

Professional bodies, such as the British Psychological Society⁵ are raising awareness of the area and, where the evidence exists, it is included in national guidelines, such as NICE and SIGN, and is reflected in the evidence review for the relevant topic in the Matrix.

Within the existing literature a range of potential harms and adverse effects are considered, from issues related to therapy not providing benefit, adverse events associated with psychological therapies delivered as designed, and therapy being delivered unprofessionally or abusively⁷. Research trials typically investigate adverse effects in the same way as trials for medical interventions, but we are covering all potentially negative impacts including experiences that can be predicted but are uncomfortable or unpleasant. This might include facing fears or situations that have been avoided.

Where there is evidence of serious or frequent negative consequences for a particular intervention, this information is included in the Matrix topic summaries.

Therapy that, when delivered correctly, can be of benefit while also leading to unwelcome effects:

Engaging with psychological therapy is not a neutral activity and can have practical and emotional consequences, such as emotional overwhelm, time taken away from work/family, requirement to be vulnerable and share sensitive personal information, which can be taxing. There may also be a grief/loss response when the therapy ends, even when therapy has been of benefit. Similarly, therapy may lead to a recognition of past distress and changes in current relationships. While potentially beneficial, these aspects may be difficult experiences.

Psychological therapies can help people to improve their mental health, but there is always a risk of deterioration or a worsening of problems and symptoms such as anxiety, depression, or suicidal thoughts. In some areas, recurrence of symptoms can be part of the course of the mental health difficulty and people may also work with practitioners to develop a wellness recovery action plan if that is anticipated.

Therapy that is ineffective:

 There are various reasons why a therapy or intervention can be ineffective. When this is associated with evidence-based practice being delivered as designed yet not working for an individual it can lead to individual sense of hopelessness, self-blame and further distress if there is a sense that ‘I can’t be helped’ ⁷.  A lack of adaptation to individual needs, such as cultural factors or neurodiversity can also reduce efficacy (see information below on how the Matrix guidance can support these adaptations).

Therapy that is harmful when delivered correctly:

High quality evidence has been used to identify where psychological therapies that are ineffective/harmful when delivered as designed and as such are no longer recommended, for example psychological debriefing to prevent PTSD^{2, 8}. Arguably, psychological therapies that do not have an established evidence base (drawing from replicated outcomes in high quality research) may be later identified as ineffective/harmful, which is why guidelines, such as the Matrix, are based on best evidence rather than clinical experience or single study outcomes alone.

 Therapy that is unprofessionally delivered:

There are therapy specific factors which can be harmful, such as poor fit between therapist and client, poor communication, short-term therapy raising issues ⁶ that are not appropriately managed. Psychological therapy or interventions could also be delivered by a practitioner without the necessary training, supervision and governance supports.

Therapy that is delivered by someone who is abusive:

There is a risk of therapist being abusive as there is with any context, although services and systems will do everything possible to reduce this risk. This risk could involve physical, sexual, or emotional abuse and anyone accessing services who feels any of these are happening, should be encouraged to report this as soon as you feel able or share with someone who can support them to do that.

We do not have a complete understanding of what causes harm in psychological therapy and how to prevent it. Evidence indicates that there can be differences between patients' and therapists' perceptions of negative effects of therapy, with practitioners possibly underestimating their impact^6,7 and this should be explored further in future research and in service design. Practitioners and people accessing psychological therapies should weigh the risks and benefits of psychological therapies before starting treatment with therapists encouraging discussion of concerns.

The following areas outline how the Matrix can support management of the risks of harm associated with psychological therapies:

• Psychological therapies and interventions should be a good fit for the person accessing services, with the best evidenced intervention available and with adaptations for presenting needs based on psychological formulation. Guides on best practices are available throughout the Matrix including adaptations based on developmental stage, neurodiversity, presentations in particular settings and co-occurring conditions.
• Psychological therapies and interventions should be delivered by a practitioner who is appropriately trained and supervised. The potential harms for people not accessing appropriate treatment can be significant, including longer duration of symptoms and impact on their overall wellbeing and functioning.

• Collaborative, trauma informed and person-centered care: Practitioners delivering psychological therapies and interventions should do so under the framework of principles and values set out by the Scottish Government Psychological Therapies specification and Mental health policy. This includes open discussions about what to expect in treatment, management of information and feedback on progress. Information about complaints processes should also be transparent and accessible. The informed consent process should include information about personal costs of therapy, known potential for increased likelihood of adverse effects (where available) and candour about what is not known. Practitioners should be open to hearing what people accessing services find difficult, notice if there is no progress (ideally using routine outcome measures) and respond as appropriate.

• Governance and boundaries: Supervision and training guidance helps support practitioners to manage the use of personal information, work within professional boundaries and provide effective care.

Psychological therapies can be a helpful treatment for mental health problems, but it is important to be aware of the risks and personal consequences involved. People accessing therapies and interventions can find out further information at NHS Inform and in the Psychological Therapies Specification. People should also be able to raise concerns and complain. Guidance on providing feedback, complaints and rights is available on NHS Inform. Following the suggestions above can minimize the risks of harm and maximise the benefits of therapy.

References:

1 Duggan, C., Parry, G, McMurran M, Davidson K, Dennis J,(2014) The Recording of Adverse Events from Psychological Treatments in Clinical Trials: Evidence from a review of NIHR funded trials.Trials, 15, 335-45. DOI: 10.1186/1745-6215-15-335URL: http://www.trialsjournal.com/content/15/1/335

2 Lilienfeld, S.O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53–70. https://pubmed.ncbi.nlm.nih.gov/26151919/

3 Rhule, D. (2005). Take care to do no harm. Professional Psychology, 36, 618–625.

4 Crawford, M., Thana, L., Farquharson, L., Palmer, L., Hancock, E., Bassett, P., Clarke, J., & Parry, G. (2016). Patient experience of negative effects of psychological treatment: results of a national survey The British Journal of Psychiatry, 208 (3), 260-265 DOI: 10.1192/bjp.bp.114.162628

5 https://www.bps.org.uk/psychologist/when-therapy-causes-harm

 6 Curran, Joe; Parry, Glenys D.; Hardy, Gillian E.; Darling, Jennifer; Mason, Ann-Marie; Chambers, Eleni. How Does Therapy Harm? A Model of Adverse Process Using Task Analysis in the Meta-Synthesis of Service Users' Experience. Frontiers in Psychology. Vol 10. 2020.

7 Mc Glanaghy E, Jackson JL, Morris P, Prentice W, Dougall N, Hutton P. Discerning the adverse effects of psychological therapy: Consensus between experts by experience and therapists. Clin Psychol Psychother. 2022 Mar;29(2):579-589. doi: 10.1002/cpp.2648. Epub 2021 Jul 21. PMID: 34260130. https://pubmed.ncbi.nlm.nih.gov/34260130/

8 Rose SC, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000560. DOI: 10.1002/14651858.CD000560. Accessed 13 July 2023. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000560/full