4. Improving access to psychological therapies
An integrated approach between physical and mental health goes a long way towards delivering psychological and emotional support to people with long term conditions. An initial wave of integrated IAPT testing sites was launched in January 2017 at 22 Early Implementation projects across the country. A second wave of 15 new sites, including Haringey CCG and Islington CCG, followed shortly after. Below, clinicians from different services across the North London STP region talk about what a patient might expect from fully integrated services where LTC referral pathways are already set up, and from services where specific LTC pathways are still in development.
Please be aware that this is a changing landscape, this means that waiting times vary regularly, and new pathways are always in development. As with the existing IAPT services, when it comes to severe and enduring mental illness (SMI; for example, schizophrenia, psychosis, drug and alcohol abuse, personality disorder, recurrent or severe depression) IAPT LTC will likely not be appropriate. With common mental illness (CMI; mild to moderate anxiety and depression) IAPT continues to be the service to refer to.
When it comes to different types of chronicity, for instance, in the areas of chronic pain, medically unexplained symptoms and neurological problems, some patients may be suitable for IAPT depending on patients’ readiness or ability to engage in a goal-focussed therapy, as well as emerging evidence and clinical pathways. It would be overwhelming to try to keep up to date with all of these variations in service provision so please do not hesitate to contact your IAPT service using the details on the right of this page if you are unsure who is appropriate.
Rediscovering a sense of autonomy, with Sue, CBT therapist, Let’s Talk Haringey IAPT
We often don’t know as referring clinicians what happens to our patients after we refer them to mental health services, but this sort of feedback is essential. We can often be anxious about what has happened after a referral and it can be rewarding to know when we’ve made a useful referral. Sue, a CBT Therapist with specialist training in LTCs, explains what a patient might expect from a fully integrated IAPT service and describes her work with Tom, who struggled to adjust after receiving a diagnosis of COPD.
(Want to skip ahead? Full transcripts and timings
below each video)
00:17 Can you say a bit about yourself?
So, my name’s Sue and I’m a CBT therapist. I’m accredited with BABCP and have had specific training for example in working with patients with long-term conditions. I’m interested in psychotherapy that addresses areas such as depression and types of anxiety. And I’m also very passionate about helping people who have adapted some unhelpful coping styles and want to make changes. So, that’s particularly relevant when we’re thinking about somebody who’s coping with a long-term condition
00:56 Can you say a bit about your service?
So, I work for Let’s Talk Haringey IAPT, which is an IAPT service based in north London. We provide a psychological service for individuals who are experiencing mild to moderate depression and anxiety symptoms. Typically, we’ll be working from GP surgeries and health centres, and I, for example, also do home visits for patients who are house-bound. It’s a busy service, and the aim really is to identify how we can best help, whether its through, for example, guided self-help, or face-to-face CBT therapy sessions, or even group work and digital therapies
01:47 When thinking about a potential IAPT referral, what might I listen out for as a nurse, healthcare assistant or GP?
So, a GP or nurse might hear some direct comments about the patient feeling low or anxious. But they may notice it through the way the patient expresses themselves. For example, they may say, “I used to go out and meet friends but now I just don’t want them to feel sorry for me so now I stay in”. Or, they may say, “I used to go down to the shops for the food shopping or for a paper, but now I’m concerned that it might stress me”. An anxious patient may say things like, “I’m scared of being breathless, and if I’m breathless, my legs might give way and I might fall over, and so I stay in”. Or, they could say things like, “I’m constantly searching on the internet for information about my illness, but then I don’t find anything and then I start worrying further about the condition”.
02:51 What might a patient expect straight after a referral?
The first step is to conduct a triage by telephone. This normally takes about thirty minutes. We’ll be gathering information from the patient about the main problem and how they’re experiencing it, how long they’ve experienced it, and what would really make a difference for them. We’ll also gather information about their lifestyle, medication and also any risks that they may be experiencing, any risks of self-harm, for example. Once we’ve got some information about their needs, the patient needs, we will have a look at what we can recommend as a treatment programme. Then, once that’s agreed, we will organise for the patient to come in and start treatment. There can be a waiting time, but once we start the sessions, they will occur on a weekly basis, normally up to 6 and up to 20 sessions, depending on the main presenting problems and also on NICE guidance
03:57 Case study: Tom, living with COPD
So, recently, I’ve been working with patients with COPD. I worked with a particular patient whose history was one of being able to cope with some really difficult challenges in life and being able to get through that. It became particularly difficult when they had an operation to remove a part of their lung. At that point, the patient noted that their old strategies of just muddling through and getting on with life just didn’t work. He did attend the pulmonary rehabilitation course which was very helpful to the patient so that they could learn what exercises they could do. But, once the course had finished, he very quickly lapsed into periods of not doing anything and the exercises fell away. We call this deconditioning because what happens is the patient stops exercising and their body becomes deconditioned and therefore actually taking part in exercise becomes even more difficult. As a result, they can become depressed or anxious and just really become quite isolated. This is what happened with this patient. He stopped going to collect his paper from the local shop. Also, his partner was very keen to help him and support him so started to take some of the tasks away from him. The type of negative thoughts that came up for this patient revolved around this, for example, “I can’t help my family anymore so what’s the point? My life’s not worth living”. So, this started to affect his mood as well and he stopped washing and taking part in any daily exercises
05:46 So, what happened in Tom’s treatment and what were the outcomes?
This patient was particularly curious about the way he’d responded emotionally, and this was a good sign. We were able to explore with him the types of thoughts that he’d had and where they had come from and started to look at how he could challenge some of his negative thinking. We also looked at some of his goals. Those were a little bit difficult to begin with, what were the goals of his life going forward with COPD? The sort of questions we asked is, “how would you know if you were feeling better? How would you know if you were enjoying activities, and what sort of things do you value in life that you really want to hold on to?”. Taking steps towards improvement was actually a slow process and we had to work on things in a gradual way. So, creating, if you like, a hierarchy of things he could take part in starting with the easy ones fist. That gave the client a sense of achievement and fulfilment and allowed him to move onto new things. So, starting his exercises again, agreeing to just a short walk down to the gate at the front of his house was something he hadn’t been able to do for a few weeks. Very quickly, he was able to move towards doing that on a daily basis. And the interesting thing was that by making these small changes, the patient’s mood improved. As his mood improved, this made it easier for him to take on more tasks. The benefits of these changes, we notice, is that the patient is then less likely to refer back to the GP for situations that are causing difficulty for them.
Finding some compassion, with Nebi, CBT therapist, Let’s Talk Haringey IAPT
Nebi, CBT Therapist with specialist training in LTCs, gives us insights into the LTC IAPT team in Haringey and talks about her work with Anna, who was feeling depressed, and giving herself a hard time about her diabetes.
(Want to skip ahead? Full transcripts and timings below each video)
00:12 Can you tell us about yourself?
So, my name is Nebi and I am a CBT therapist. I work for Haringey IAPT the long-terms conditions team. So, I’ve been working with depression and anxiety for more than ten years now and also with long-term conditions within IAPT for longer than three years.
00:37 What does an integrated IAPT service look like?
We are a small team but very passionate people about LTC and we believe in what we’re doing. We also work closely with other health teams such as the diabetes self-management, smoking cessation, pulmonary rehab, cardiac rehab, pain management as well as with the GPs.
01:05 What are the differences between a CBT therapist and a psychological wellbeing practitioner and what are the waiting times for each?
It’s about 2-3 months to see a CBT therapist and 1-2 months to see Psychological Wellbeing Practitioner. One is low-intensity CBT, shorter sessions, shorter treatment. The other one is more time to look in depth into, you know, the thinking patterns and behaviour patterns.
01:32 Case study: Anna, living with Type 1 diabetes
So, I worked with this lady, this 36 years old lady, who self-referred. She had lost her job because she could not manage that because of the stress that the job involved itself as well as diabetes burnout. This lady had diabetes type 1 and she’d been living with diabetes type 1 for 25 years, which is a long time.
02:05 The assessment: what did you find out?
At times she would be micro-managing her condition. She would check her blood sugars, she would exercise, she would eat regularly, properly, she would count the carbs, so really feel, you know, in control of her diabetes. But, at other times, just feel like she couldn’t cope with all that demand, you know, and just give up. Do the insulin and inject the insulin but really not check the blood sugars… and not exercise and sometimes eat for comfort.
02:47 The treatment: what did it involve?
So, to start with, we start with a diary of, you know, the thoughts and activities that you are engaging with. She’s able to see that her eating patterns are erratic, you know, exercise is the same, sleeping pattern is the same. As well as over nothing thinking, “I lost my job, I am failure… I am not being able to manage my diabetes, I am a bad diabetic” and so on. We worked with this in a special way when we focused on the self-critical part of her thinking. She started to notice that being harsh on herself and criticising herself and calling herself names was not helping her in any way. And also, to start to transfer these compassion skills that she had for other people to herself. And to notice that really living with a long-term condition is difficult and everyone would struggle at some point. And it is okay to struggle because that is only human, when it become too much, we all suffer.
04:04 The outcomes: what changed in Anna’s physical and psychological health?
Over the course of therapy, she attended employment support which I referred her to. She found a job towards the end of the treatment. She found a job which she was much happier with. As well, her HB1C dropped. She was able to manage her anxiety about the hypos at night much better. All in all, it’s not about transforming the person, we are still the same person. But just developing some skills and creating some flexibility and feeling more in control rather than feeling controlled by the illness.
An overview of IAPT for LTCs, with Dr Chinea Eziefula
There is, of course, variation in IAPT services across
the boroughs. Dr Chinea Eziefula, Long-Term Conditions Lead in Camden IAPT
service, provides an overview of what a patient might expect from IAPT for
LTCs, who is and is not suitable, and what the situation is in Barnet, Enfield
and Camden where specific referral pathways are still in development.
(Want to skip ahead? Full transcripts and timings below each video)
00:16 Can you say a bit about yourself?
My name is Chinea. I’m a clinical psychologist and clinical co-ordinator for long-term conditions in Camden IAPT and I’m also a clinician working with physical health at the Whittington in Islington
00:33 How might clinicians be thinking about IAPT referrals in Camden, Barnet and Enfield, where specialist long-term condition pathways into IAPT are still being developed?
So, I think that the best way to hold in mind a referral for somebody where there isn’t a specific pathway would be to make a referral anyway and highlight the way in which the physical health problems impacts on the client’s mental health
00:57 What would be helpful for referring clinicians to include on referral forms?
The most important things to include in a referral for somebody who’s coming to integrated IAPT would be, first of all, the physical health diagnosis so the label, and if they have more than one diagnosis please list those as much as you can - that helps us make a plan of who sees that person and we make sure that the first point of contact is the most appropriate one for that client. So definitely lots of information about the diagnosis, how long they’ve had their physical health diagnosis and who’s involved can be really important for us. Sometimes patients come to us and they don’t have all that information to hand, so if you can put it on a referral that’s really useful. And also, I think we need to know something about the impact on mental health. So that question is really important, how it impacts on that person’s day to day and their mood and any worries or anxieties that they might have
01:55 A referral has been made, what might a patient expect and what might be expected of them?
So, a patent who comes in to see us would then be expect to be asked questions about their mental health. That’s really important that they know that, that we will ask them about their mental health, not just their physical health. We will think about how their mental health affects their physical health management. Then, we will ask who’s involved in their physical health, we might ask to liaise with the people involved in their physical health management. Then we would make a plan, together with hopefully the physical colleagues as well in a truly integrated service. I was recently referred a young woman who has type 1 diabetes. She was referred to our service through her GP and it was flagged up that she had type 1 diabetes in the referral but the main referral reason was around her feeling really low in mood and not knowing what was happening with her diabetes - because she was struggling to manage her type 1 diabetes and she was undergoing other investigations linked to that. So, when she came to us initially, she was asked a number of questions about her type 1 diabetes. For example, where she was being managed, who was in her team, thinking a little bit about how we could make contact with those clinicians in order to work out what she’s supposed to be doing or what she’d been told will help with her self-management of her diabetes. We can sometimes use this information to help set up some goals with the client about how they might want to work on addressing their mood problems, but holding in mind they things they feel they ought to be doing but maybe can’t do or are struggling to do to do with their physical health. Some of our clinicians who work in integrated IAPT will have been through specific training on diabetes and the impact of mood on diabetes and vice versa, so they might feel confident to share that with the client. If the clinicians don’t then they would look to being in touch with the clinicians being involved in the diabetes management so specialist nurses and involve them in the care. That would be a truly integrated service where we can really liaise with the clinicians and sometimes have joint consultations about particular areas where they could be learning or knowledge or growth around the link between mental and physical health
04:24 Primary care staff don’t have the time to keep up to date with all of the long-term condition resources available in each borough, can IAPT help here?
Sometimes it can be really difficult for our clients to reach out and find those groups and interventions that might exist in the community, really helpful resources, really helpful charities that are already out there… Diabetes UK, the British Lung Foundation… services like that have been around for ages and are really supportive to our clients with these conditions. I think when someone has depression, it might get in the way of being able to reach out to services that could help them to manage their condition better. So, when somebody does have these problems with depression or anxiety, for instance, in terms of being able to reach out, we can get involved and a referral can be wholly appropriate if it’s somebody who’s struggled to reach those groups or those expert patient groups or charities because they’re feeling low or feeling really worried. We would get involved and we would do an intervention about the anxiety and the depression and think about the person’s physical health and try and help them to get to those support groups. We might know about them in IAPT services because we would have done a lot of work in early pilot work on pathways to find out what already exists in the community. If a GP is just curious about what services exist out there, I think the best thing to do is probably just to call the local IAPT service and ask to speak to the long-term condition co-ordinator or a member of the long-term condition teams who can then signpost them, rather than making a referral for signposting - which isn’t something we would want to encourage too much
06:06 Who might not be suitable for IAPT for long-term conditions?
So, I think that the standard exclusion criteria for IAPT still exists. So, we are still an IAPT service even though we are integrated IAPT so that means we wouldn’t see people who are in immediate crisis and currently suicidal and thinking about ending their life. We wouldn’t see people who have psychosis or a diagnosis which are better suited to secondary care settings
06:37 What about when a long-term condition is affecting a patient in a way that puts them at significant risk?
I think that there are many clients out there who have significant problems with low mood and anxiety to the point where it’s really, really getting in the way of self-management. Their condition is at a point where it’s really unsafe for them to be managing their condition in the way they are, so if people are really worried to that extent, I think that some of those clients might not be suitable for IAPT. They might be better suited to being seen in a specialist health psychology setting. An example could be somebody who has severely poorly managed type 2 diabetes where they are having hypos frequently, they have neuropathy and its extremely bad and that might not be getting better and the person isn’t managing their condition at all. I think in that case, it’s important to have an MDT input around that person that involves the specialist nurses and specialist psychologists who work with that context, health psychologists who work with diabetes, in that example. That would be the best source of support. There are community services that are commissioned by CCGs who work with clients who are really severely unwell in terms of their health management. They wouldn’t be suitable to IAPT or integrated IAPT in my opinion. This is particularly relevant for people who might present with chronic pain or medically unexplained symptoms or neurological problems and there are specific services for these quite complex conditions. It’s really important that people go to the right place and we don’t want to send people to an IAPT service if actually there are other services that might better meet their needs
08:38 What if I’m not sure where a patient should be referred to?
If you’re not sure about who to refer or where they need to go or what services exist around this condition and this person, it’s best to just call and check in with the IAPT service. We’re always available and we’re so happy to receive consultations
08:59 What are the waiting times?
In terms of referrals, we try to meet this 6 week target which is a target for all IAPT services, integrated or otherwise. We are expecting to see people within 6 weeks for at least an initial consultation. I think we try to meet that target as much as possible in all of the IAPT services. So, I can talk about what happens in Camden and what to expect for clients in Camden, for example, with the self-referrals and step 2 and step 3. That might vary in different boroughs depending on the resources and also the number of referrals that they’re getting at any point in time which can vary for every service
09:40 So, for instance, what about waiting times in Camden?
For example, in Camden, if somebody self-refers to our service, the turnaround in terms of being able to contact the client would be within 48 hours they would hear from us, so they would at least know what’s happening with their referral, whether or not they’re going to wait to hear from a clinicians or if they are going to be booked in or not. If it is a referral from a GP or a referrer has made the referral, the wait to contact the client might need a bit longer, but we would always let the referrer know if there are any issues with the referral. In terms of when the person would be seen, our model at the moment is that if the person comes in at step 2, so that means they might be having some contact with our Psychological Wellbeing Practitioners, that they get booked in between 4 to 6 weeks for an initial consultation. That’s the general wait at step 2. If the client comes in at step 3, the wait is a little bit longer. Sometimes it’s unclear to say exactly when they would be seen, but they would always be contacted in some way, or the referrer would always be contacted in some way to let you know about the outcome of that referral and what’s happening. I think its helpful to say that if you’re ever wondering and wanting to know what’s happened with a referral, its always best to just check in and call the service, or send an email using nhs.net, and we can let you know what’s happening with the referral
11:05 Where do ‘medically unexplained’ or persistent physical symptoms fit into this?
At integrated IAPT, we are thinking very much about how, at step 3, which is the higher step of care, how we work with medically unexplained symptoms. Many of our clinicians will have been on training on how to work with people specifically with chronic fatigue syndrome and IBS. They are evidence-based treatments for those conditions, in terms of CBT therapies specifically for IBS and chronic fatigue syndrome. We are trying to think about pathways for those patients within IAPT services and it depends on the borough and whether or not those pathways are established. I think that in Camden it is something we are looking into exploring with our GPs. It doesn’t exist quite yet but it will exist and that’s something that will happen in IAPT services across the board in the years to come. If you do have clients with those conditions, I think it’s worth thinking about medically unexplained symptoms but specifically IBS and chronic fatigue when you think of medically unexplained symptoms and who to refer to IAPT.
You can register your interest for the Supporting good mental health in your patients with long term conditions training events in your borough.
A range of useful existing resources, some of which are mentioned in the training videos.