First Step Research and Development Programmes
First Step is committed to both applying the evidence-base and also helping to develop it. We are keen to collaborate on research with other partners and also lead our own research into relevant areas. Many staff choose to become involved in the projects and find that this helps them both improve the treatments they offer but also to develop themselves professionally (and prevent therapist burnout).
We have close links with the BABCP journals and our Clinical Director is currently the Editor-in-Chief of the Cognitive Behaviour Therapist (BABCP Practitioner Journal). We are keen to foster a culture where what we do is based on the strongest evidence available and we are aware of how to adapt and flex evidence-based appraoches to provide the most effective service to our patients.
Self-Practice/ Self-Reflection (SP/SR) (Service Lead: Richard Thwaites)
SP/SR is an experiential learning and development method which involves therapists applying CBT to themselves and reflecting on the implications for themselves as therapists (and in their wider lives) and on their delivery of CBT. The current evidence suggests that this has a significant impact on the artistry of the therapy. Reflective skills and interpersonal skills (e.g. attunement, empathy) are improved which can help the therapist to apply evidence-based approaches with greater flexibility and understanding for the patient experience.
Working in collaboration with colleagues in Australia and New Zealand, First Step staff have taken part in several studies looking at the development and implementation of SP/SR programmes.
Bennett-Levy, J, & Thwaites, R. (2007). Self and self-reflection in the therapeutic relationship: A conceptual map and practical strategies for the training, supervision and self-supervision of interpersonal skills. In The therapeutic relationship in the cognitive-behavioural psychotherapies, edited by Paul Gilbert and Robert L. Leahy. London: Routledge, pp. 255-281.
Bennett-Levy, J., Thwaites, R., Chaddock, A. & Davis, M. (2009). Reflective practice in cognitive behavioural therapy: the engine of lifelong learning. In Reflective practice in psychotherapy and counselling, edited by Jacqui Stedmon and Rudi Dallos, 115-135.
Bennett-Levy J., Thwaites R., Haarhoff, B. & Perry, H. (2015). Experiencing CBT from the Inside Out: A Self-practice/Self-reflection CBT Workbook for Therapists. New York: Guilford.
Chaddock, A., Thwaites, R., Bennett-Levy, J. & Freeston, M. H (2014). Understanding individual differences in response to Self-Practice and Self-Reflection (SP/SR) during CBT training. The Cognitive Behaviour Therapist, vol. 7, e14. doi: 10.1017/S1754470X14000142
Davis, M., Thwaites, R., Freeston, M.H. & Bennett-Levy, J. (2014). A measurable impact of a self-practice/self-reflection programme on the therapeutic skills of experienced cognitive behavioural therapists. Clinical Psychology & Psychotherapy. Published online: 26 January 2014. doi:10.1002/cpp.1884.
Haarhoff, B., & Thwaites, R. (2016). Reflection in CBT. London: Sage.
Haarhoff, B., Thwaites, R., & Bennett-Levy, J. (2015). Engagement with self-practice/ self-reflection as a professional development activity: the role of therapist beliefs. Australian Psychologist, 50, 322-328. DOI: 10.1111/ap.12152
Thwaites, R., Bennett-Levy, J., & Haarhoff, B. (2015). Self-practice/self-reflection (SP/SR): contexts, challenges and ways forward. Australian Psychologist, 50, 344-349. DOI: 10.1111/ap.12166
Thwaites, R., Bennett‐Levy, J., Davis, M. & Chaddock, A. (2014). Using self‐practice and self‐reflection (SP/SR) to enhance competence and meta-competence. In A. Whittington & N. Grey (Eds.), How to Become a More Effective CBT Therapist: Mastering Metacompetence in Clinical Practice (pp.241-254). London: Routledge.
Thwaites, R., Cairns, L., Bennett-Levy, J., Johnston, L., Lowrie, R., Robinson, A., Lockhart, L., Haarhoff, B. & Perry, H (in preparation) Moving from ‘empathy dots’ to ‘experiencing CBT from the inside’: Does Self-Practice/Self-Reflection help experienced Psychological Wellbeing Practitioners to develop and maintain effective therapeutic relationships?
Thwaites, R., Cairns, L., Bennett-Levy, J., Johnston, L., Lowrie, R., Robinson, A., Turner, M., Haarhoff, B., & Perry, H. (2015). Developing metacompetence in low intensity CBT interventions: evaluating a self-practice/self-reflection program for experienced low intensity CBT practitioners. Australian Psychologist, 50, 311-321. DOI: 10.1111/ap.12151
Adapting IAPT interventions for individuals with lower intellectual functioning (Service Lead: Richard Thwaites)
We are working closely with our colleagues in Learning Disability services to ensure we can identify individuals with lower intellectual functioning and adapt mainstream IAPT interventions to help them gain most benefit from interventions. Presentations from our LD & IAPT conference are available to download from the IAPT website www.iapt.nhs.uk
Dagnan, D., Masson, J., Thwaites, R. & Hatton, C. (2011) Poster: Training therapists using CBT for people with learning disabilities: Scale development and outcomes from four primary care mental health training groups. 11th Seattle Club Conference, 7-8 December. Selwyn College, University of Cambridge.
Dagnan, D., Masson, J., Cavagin, A., Thwaites, R. & Hatton, C. (2014). The Development of a Measure of Confidence in Delivering Therapy to People with Intellectual Disabilities. Clinical Psychology and Psychotherapy. doi: 10.1002/cpp.1898
The most recent guidance on IAPT and learning disabilities developed with reference to much of the work in Cumbria can be accessed here.
Using pre-therapy groups (Transdiagnostic Seminars) to help clients to get the most benefit from therapy (Service Lead: Ryan Askey-Jones)
This project aims to implement a series of three seminars offered to patients waiting to access step 3 CBT. The transdiagnostic seminars (TDS) were developed and piloted by Leeds IAPT between March 2013 and March 2014 and are now being rolled out across various IAPT sites in the North of England. The seminars have 2 functions; (1) to prepare patients to make the most of therapy by introducing them to some key aspects of CBT, and (2) to provide early access to self-help strategies and booklets.
The content of the 3 seminars should be of relevance to a wide population of patients with various diagnoses / presenting problems, based on the theory that common transdiagnostic processes underlie several mental health conditions.
Leeds IAPT initial evaluation concluded that:
- Consistent with the theoretical basis of the project, patients with a range of problems and diagnoses found the seminars relevant and acceptable.
- Access to TDS alone does not lead to significant improvement, but the combination of TDS + CBT was found to increase treatment completion rates and considerably enhance depression symptom improvement compared to usual CBT.
- Those patients with severe functional impairment seem to benefit most from the combined TDS + CBT approach.
In light of this evidence, offering routine access to TDS + CBT can be an effective way to improve outcomes for patients with a wide range of problems.
- The focal topic of the “Manage your mind” seminar will be worry and rumination. The therapeutic objective is to promote coping strategies to deal with problematic thinking.
- The focal topic of the “Cope with your feelings” seminar will be emotion regulation. The therapeutic objective is to promote coping strategies to deal with difficult emotions.
- The focal topic of the “Do what matters” seminar will be goal pursuit and activation. The therapeutic objective is to promote strategies to work towards personally meaningful goals.
Developing suicide risk assessment, formulation and management in First Step (Service Lead: Dave Sandford)
This covers four overlapping planned projects:
1. Developing practitioner confidence in assessment and management of suicide behaviours
- Adapt an existing measure of practitioners’ confidence in assessment and management of risk (Delgadillo, 2014).
- Validate the adapted measure.
- Use the measure to evaluate risk assessment, formulation and management training within a mental health trust.
2. Understanding and mitigating the impact of patient suicide on practitioners
- Study the impact of patient suicide on practitioners within a mental health trust initially focussing on those in the relatively new role of PWPs (Psychological Wellbeing Practitioners – providing Step 2 guided self-help) within an IAPT service using questionnaires and semi-structured interviews.
- Develop an information leaflet for practitioners and evaluate the effect of the use and distribution of this.
3. Integrated Motivational and Volitional Model– theory into practice: developing practitioners’ skills in assessment and management of suicide behaviours
- Arrange training for practitioners in IMV model (O’Connor, 2011).
- Develop psychological interventions based on the IMV.
- Deliver training in these interventions.
- Use measures including confidence measure in 1) above to gauge impact of this training.
- Audit the quality of completed risk formulations.
4. Health promotion
- Development of self-help information on First Step pages of Trust website, including provision of Safety Planning app.
- Continuing the close working we have developed with some local media organisations, dissemination of information to local press outlets to provide opportunities to spread good practice guidance.
- Sharing of good practice with physical health services and General Practice staff
Delgadillo J et al (2014) Confidence in the face of risk: the Risk Assessment and Management Self-Efficacy Study (RAMSES). The Psychiatric Bulletin; in press. doi: 10.1192/pb.bp.112.040394.
O’Connor, R.C. (2011). The integrated motivational-volitional model of suicidal behaviour. Crisis, 32, 295-298.
Self Management after Therapy : relapse prevention (Service Lead: Dave Sandford)
SMArT is a project which is currently being developed by the South West Yorkshire Partnership NHS Foundation Trust and the University of Huddersfield.
First Step is pleased to be working in collaboration with Professor Mike Lucock of the University of Huddersfield to pilot this intervention in Cumbria. This project aims to develop and evaluate a new intervention to support individuals and prevent relapse after they have been discharged from a psychological intervention for depression. Seven Psychological Wellbeing Practitioners will pilot the delivery of SMArT and feed into the provisional stages of this research. SMArT is a self-management support intervention based on the application of implementation intentions to the management of depression.
Reducing burnout in staff using MBCT (Service Lead: Ryan Askey-Jones)
The quality of care for clients with mental health problems is closely linked to the quality of staff entrusted with delivering this care. Staff who are overwhelmed or emotionally exhausted with their jobs are less likely to provide optimal client care. Burnout can result in staff not being able to give themselves at a psychological level, often developing a negative attitude about their clients, evaluating themselves negatively and feeling dissatisfied with their accomplishments (Maslach et al 1986).
Due to this issue of burnout amongst health care professionals, a number of studies have attempted to address this issue utilising mindfulness based stress reduction (MBSR) and mindfulness based cognitive therapy (MBCT) as a way of reducing stress. Participants were encouraged to practice mindfulness with the intention to provide them with tools for managing stress, and to decentre from habitual mental reactions that worsen stress and exacerbate the ability to problem solve effectively (Kabat-Zinn, 1990). This course utilised a mind-body approach and incorporated yoga, meditation and informal practice which encouraged participants to bring mindfulness into everyday life. Participants were also encouraged to practise meditation for up to an hour every day (Kabat-Zinn, 1990). With this in mind, it was decided to pilot MBCT with a group of First Step Practitioners and fellow Trust staff and measure the impact on their wellbeing.
Adapting IAPT interventions for individuals with a long term condition (Service Lead: Dave Sandford)
People with a long term physical health condition (LTC) are 2 to 3 times more likely to experience a common mental health problem such as anxiety or depression.
The First Step pilot study investigated a collaborative care approach to delivering a low intensity psychological intervention to this population. Six Psychological Wellbeing Practitioners (PWP) working across 13 GP practices received referrals for 161 people. Eighty-one people engaged in between 2 to 7 sessions of guided self-help and achieved a recovery rate of 57%. Case studies of three patients with a co-morbid LTC and anxiety disorder and/or depression were presented. The study demonstrated that 1) low intensity psychological intervention can be effective with this population 2) the delivery of true collaborative care can be challenging in practice 3) integrating elements of collaborative care into standard practice can improve the delivery of low intensity interventions for people with a common mental health problem and a co-morbid LTC. The training and lessons learnt from this project were subsequently rolled out to all First Step PWPs and their supervisors.
Northern IAPT Practice Research Network
First Step is pleased to be part of this network which brings together representatives from a number of psychological therapy services aligned to the English 'Improving Access to Psychological Therapies' (IAPT) programme. At present, the membership of this network is entirely comprised of IAPT services in the north of England. The PRN is supported by academic collaborators with demonstrated expertise and track record in psychotherapy research and practice-based evidence.
We are currently part of two of their ongoing research projects
1. Providing historical data from Stress Control in Cumbria
2. Implementing Transdiagnostic Seminars (TDS) which are pre-therapy groups to help individuals gain most benefit from Step 3 interventions.
Using cCBT to help individuals with depression and/or an anxiety disorder alongside an LTC (Service Lead: Dave Sandford)
People with Diabetes, COPD, or Heart Disease and concurrent anxiety or depression now have access to specifically designed SilverCloud cCBT programmes. First Step is working with SilverCloud to pilot these new programmes alongside the existing cCBT modules. Outcome data will be used to assess the effectiveness of this approach.