Telephone-based CBT and the therapeutic relationship: The views and experiences of IAPT practitioners in a low-intensity service

Comparing factors associated with overall satisfaction for different forms of remote breastfeeding support in the UK

BACKGROUND

Remote forms of breastfeeding support, such as helplines and social media, offer a flexible and convenient form of support to offer help at critical points, e.g., when the risk of breastfeeding cessation is high. Currently, there is little known about who accesses different forms of remote breastfeeding support and what factors impact overall satisfaction. As part of an evaluation of the UK National Breastfeeding Helpline (NBH) (which offers breastfeeding support via a helpline and online media), we aimed to (a) understand who accesses different forms of NBH support, and (b) identify key factors associated with overall satisfaction for helpline and online media support.

METHODS

All service users who contacted the NBH between November 2021 and March 2022 were invited to participate in the evaluation via an online survey. Survey questions explored the type and timing of support, reasons for the contact, attitudes towards the help and support received, impact of the support on breastfeeding experiences and demographic factors. Chi-squared and Mann-Whitney tests explored variations in who accessed the helpline or online media. Multiple linear regression models were fitted to explore the factors related to the service users' 'overall satisfaction'. The quantitive data were combined with qualitative comments into descriptive themes.

RESULTS

Overall, online media users were significantly more likely to be younger, White, multiparous, less educated and have English as a first language compared to those who contact the helpline. Similar factors that significantly influenced overall satisfaction for both support models were the service being easy to access, receiving helpful information that met expectations, resolving breastfeeding issues, and feeling reassured and more confident. Significant factors for the helpline were callers feeling understood and more knowledgeable about breastfeeding following the call, being able to put into practice the information provided, feeling encouraged to continue breastfeeding, feeling that the volunteer gave the support that was needed, and seeking out additional support.

CONCLUSIONS

Online and helpline forms of breastfeeding support suit different demographics and call purposes. While optimal breastfeeding support needs to be accessible, flexible and instrumental, helpline users need real-time relational support to deal with more complex challenges.

Exploring Clients' Experiences of Transitioning Mental Health Nursing Care from an In-Person to a Virtual Format due to the COVID-19 Pandemic

The onset of the COVID-19 pandemic led mental health professionals to change the way they engaged with clients, often replacing in-person consultations with virtual ones via telephone or videoconferencing. While studies have investigated the delivery of virtual physical health care, only a handful have investigated the delivery of virtual mental health. These specifically focussed on the outcomes of virtual care whether experiential, practical, or empirical. The transition from in-person to virtual care delivery due to the COVID-19 pandemic has been unexplored. Accordingly, the purpose of the study was to: (1) Explore the experiences of clients who had to transition from an in-person to a virtual provision of mental health care due to the COVID-19 pandemic, and; (2) Explore the nurses' experiences of this technological transition. Using an interpretive phenomenology methodology, semi-structured interviews were conducted with nurses and clients who have experienced the in-person to virtual transition of service delivery at a tertiary mental health hospital in Ontario, Canada. In this article, we focus on the results stemming from our interviews with clients. The themes generated from the analysis of client experiences are 1) the psychosocial impact of the COVID-19 pandemic on clients, (2) mixed feelings of clients towards nursing care delivered via technological means and (3) the role of nurses regarding transitioning of in-person care to technology-mediated care. These findings are relevant as mental health care hospitals are considering how they will deliver services once concerns with the transmission of the COVID-19 virus are resolved.

Medicinal use of cannabis: A qualitative study of the perspectives of doctors and pharmacists from six African countries

We conducted a qualitative study to examine the enablers and barriers influencing the implementation of medical cannabis from the perspectives of practicing doctors and pharmacists within the African context. Interviews were conducted to investigate medical professionals' perceptions and concerns regarding medicinal cannabis. Three major themes were identified: beliefs about consequences, optimism, and environmental resources and context. Depending on the context of use, medical professionals described cannabis as potentially useful as an adjunct medicine and yet problematic owing to knowledge and social barriers, particularly religion. Implementation strategies tailored to address structural and social concerns to providing optimal care are needed to ensure that medical professionals are well versed in policy and clinical aspects.

Acceptability of a novel suicide prevention psychological therapy for people who experience non-affective psychosis

OBJECTIVES

Suicide is a leading cause of death worldwide. People experiencing psychosis are at increased risk of death by suicide. Talking therapies can alleviate suicidal thoughts, plans, and attempts. Therapies need to also be acceptable to recipients. The aim of this study was to investigate the views on psychological therapy for people experiencing psychosis and suicidality using the Theoretical Framework of Acceptability.

DESIGN

Qualitative interview study.

METHODS

Participants were recruited from a randomised controlled trial comparing suicide prevention psychological therapy with treatment as usual. Individuals had a diagnosis of non-affective psychosis and experience of suicidal thoughts, plans and/or attempts. To assess the acceptability of the therapy, semi-structured interviews were conducted with 20 participants randomised to receive therapy. Data were deductively analysed using an adaptation of the Theoretical Framework of Acceptability.

RESULTS

Interviews (Mean = 45 min) were conducted and audio recorded with 21 participants. Data were organised into six themes: 1. Affective attitude, 2. Burden, 3. Alliance, 4. Intervention coherence, 5. Perceived effectiveness, and 6. Self-efficacy. There was no evidence of issues relating to domains of ethicality and opportunity costs associated with receiving therapy.

CONCLUSIONS

Talking about suicide was difficult and, at times, distressing, but it was perceived to be useful for understanding experiences. To be acceptable, it is important for therapists to ensure that clients' understanding of therapy aligns with expectations of effectiveness and to invest in building strong therapeutic alliances. Future research will benefit from examining therapists' experiences of delivering therapy through different modes (e.g. online, telephone).

Enhancing the quality of psychological interventions delivered by telephone in mental health services: increasing the likelihood of successful implementation using a theory of change

BACKGROUND

The implementation of new and complex interventions in mental health settings can be challenging. This paper explores the use of a Theory of Change (ToC) for intervention design and evaluation to increase the likelihood of complex interventions being effective, sustainable, and scalable. Our intervention was developed to enhance the quality of psychological interventions delivered by telephone in primary care mental health services.

METHODS

A ToC represents how our designed quality improvement intervention targeting changes at service, practitioner, and patient levels was expected to improve engagement in, and the quality of, telephone-delivered psychological therapies. The intervention was evaluated following implementation in a feasibility study within three NHS Talking Therapies services through a qualitative research design incorporating semi-structured interviews and a focus group with key stakeholders (patients, practitioners, and service leads) (N = 15). Data were analysed using the Consolidated Framework for Implementation Research (CFIR) and the ToC was examined and modified accordingly following the findings.

RESULTS

CFIR analysis highlighted a set of challenges encountered during the implementation of our service quality improvement telephone intervention that appeared to have weakened the contribution to the change mechanisms set out by the initial ToC. Findings informed changes to the intervention and refinement of the ToC and are expected to increase the likelihood of successful future implementation in a randomised controlled trial.

CONCLUSIONS

Four key recommendations that could help to optimise implementation of a complex intervention involving different key stakeholder groups in any setting were identified. These include: 1-developing a good understanding of the intervention and its value among those receiving the intervention; 2-maximising engagement from key stakeholders; 3-ensuring clear planning and communication of implementation goals; and 4-encouraging the use of strategies to monitor implementation progress.

Early evaluation of the Children and Young People's Mental Health Trailblazer programme: a rapid mixed-methods study

Background

The Children and Young People's Mental Health Trailblazer programme is funding the creation of new mental health support teams to work in schools and further education colleges. Mental health support teams directly support children and young people with 'mild to moderate' mental health problems and work with school and college staff to promote well-being for all. A new workforce of education mental health practitioners is being trained for the teams.

Objective(s)

The National Institute for Health and Care Research Birmingham, RAND and Cambridge Evaluation Rapid Evaluation Centre and Policy Innovation and Evaluation Research Unit undertook an early evaluation of the Trailblazer programme to examine the development, implementation and early progress of mental health support teams in the programme's first 25 'Trailblazer' sites.

Design

A mixed-methods evaluation, comprising three work packages: 1. Establishing the baseline and understanding the development and early impacts of the Trailblazer sites, including two rounds of surveys with key informants and participating education settings in all 25 sites. 2. More detailed research in five purposively selected Trailblazer sites, including interviews with a range of stakeholders and focus groups with children and young people. 3. Scoping and developing options for a longer-term assessment of the programme's outcomes and impacts. Fieldwork was undertaken between November 2020 and February 2022. The University of Birmingham Institute for Mental Health Youth Advisory Group was involved throughout the study, including co-producing the focus groups with children and young people.

Results

Substantial progress had been made implementing the programme, in challenging circumstances, and there was optimism about what it had the potential to achieve. The education mental health practitioner role had proven popular, but sites reported challenges in retaining education mental health practitioners, and turnover left mental health support teams short-staffed and needing to re-recruit. Education settings welcomed additional mental health support and reported positive early outcomes, including staff feeling more confident and having faster access to advice about mental health issues. At the same time, there were concerns about children who had mental health problems that were more serious than 'mild to moderate' but not serious enough to be accepted for specialist help, and that the interventions offered were not working well for some young people. Mental health support teams were generally spending more time supporting children with mental health problems than working with education settings to develop 'whole school' approaches to mental health and well-being, and service models in some sites appeared to be more clinically oriented, with a strong focus on mental health support teams' therapeutic functions.

Limitations

Despite efforts to maximise participation, survey response rates were relatively low and some groups were less well represented than others. We were not able to gather sufficiently detailed data to develop a typology of Trailblazer sites, as was planned.

Conclusions

Key lessons for future programme implementation include: - Whether mental health support teams should expand support to children and young people with more complex and serious mental health problems. - How to keep the twin aims of prevention and early intervention in balance. - How to retain education mental health practitioners once trained.

Future work

The findings have important implications for the design of a longer-term impact evaluation of the programme, which is due to commence in summer 2023.

Study registration

Ethical approval from the University of Birmingham (ERN_19-1400 - RG_19-190) and London School of Hygiene and Tropical Medicine (Ref: 18040) and Health Research Authority approval (IRAS 270760).

Funding

The Birmingham, RAND and Cambridge Evaluation Rapid Evaluation Centre is funded by the National Institute for Health and Care Research Health Services and Delivery Research programme (HSDR 16/138/31). The Policy Innovation and Evaluation Research Unit is funded by the NIHR Policy Research Programme (PR-PRU-1217-20602).

Exploring service users experiences of remotely delivered CBT interventions in primary care during COVID-19: An interpretative phenomenological analysis

Primary Care Mental Health Services (PMHCS) aim to provide accessible and effective psychological interventions. However, there is a scarcity of qualitative research focused on patients' experiences. Service users' experience can inform development of accessible, high-quality mental health services. Nine semi-structured interviews were analysed from Primary Care Mental Health users in Northern Scotland using Interpretative Phenomenological Analysis (IPA). Four superordinate themes were generated: Orientating to treatment, Intervention features, Change enablers, and Impact. The results identified both facilitators and barriers associated with access and psychological change; and narratives around CBT acceptability, outcomes and remote delivery. The role of GPs emerged as a key determinant of access to PMHCS. The therapeutic relationship contributed to person-centred care provision, idiosyncratic change processes and self-empowerment. A personal commitment to engage with homework was described as a crucial change enabler. Findings are discussed in relation to existing literature, practical implications and suggestions for future research.

Therapists' experiences of remote working during the COVID-19 pandemic

Objectives

To explore the experiences of therapists who delivered remote psychological therapy during the COVID-19 pandemic.

Design

This was a qualitative, phenomenological study. Interpretative Phenomenological Analysis elicited themes from semi-structured interviews.

Methods

A purposive sample of eight therapists was recruited from breast cancer services in the United Kingdom.

Results

Analysis identified three superordinate themes. Participants spoke about how their experience of remote working changed over time from an initial crisis response to a new status quo. They adapted to the specific practical and personal challenges of remote working and struggled to connect with clients as the use of technology fundamentally changed the experience of therapy.

Conclusion

Consideration should be given to the impact of remote working on therapists and the quality of their practise. Adjustments to ways of working can help to maximize the advantages of remote working while minimizing potential issues.

Health professionals' perspective towards challenges and opportunities of telehealth service provision: A scoping review

BACKGROUND

Telehealth, or healthcare offered through the internet, computers, and other devices for communication, is rapidly increasing with changing times and technological advancement. For quality and security of such services, it is crucial that professionals are competent in offering such service. Still, lack of professionals' training has been identified as one of the barriers to implementation of telehealth. Thus, to improve such training, it is crucial to identify professionals' knowledge, experience, and perspectives towards challenges and opportunities of using telehealth.

OBJECTIVE

The review's objective was to answer the research question: what is known in the literature about challenges and opportunities of telehealth service provision from the perspective of health professionals?

METHODS

Arksey and O'Malley's five-stage approach for scoping studies was used for the review. Studies were collected across four databases: Scopus, PubMed, ProQuest and EBSCOhost. The data from the 22 included studies were reported by using frequency counts and categorization of health professionals' experiences.

RESULTS

The findings of the review led to three categories: (1) study demographics, (2) challenges for telehealth, and (3) opportunities for telehealth. The most frequently reported challenges were issues related to communications, inadequate technology, or support, and need for training and knowledge to use the technology. The most frequent categories of opportunities related to improved access to services, benefits related to sharing of information sharing and experience and training of using technology.

DISCUSSION

Further research is needed to explore health professionals' experience of training, and to understand the type of support, resources, and training content they need to enhance their competency in telehealth provision.

Therapists' experiences of remotely delivering cognitive-behavioural or graded-exercise interventions for fatigue: a qualitative evaluation

Objective

Fatigue is a challenging feature of all inflammatory rheumatic diseases. LIFT (Lessening the Impact of Fatigue in inflammatory rheumatic diseases: a randomized Trial) included remotely delivered personalized exercise programme (PEP) or cognitive-behavioural approach (CBA) interventions. The aim of this nested qualitative evaluation was to understand rheumatology health professionals' (therapists') perspectives of delivering the interventions in the LIFT trial.

Methods

A subgroup of therapists who had delivered the personalized exercise programme (PEP) and cognitive-behavioural approach (CBA) interventions took part in semi-structured telephone interviews.

Results

Seventeen therapists (13 women and 4 men) who delivered PEP (n = 8) or CBA (n = 9) interventions participated. Five themes were identified. In 'The benefits of informative, structured training', therapists described how they were able to practice their skills, and the convenience of having the LIFT manual for reference. When 'Getting into the swing of it', supporting patients gave therapists the confidence to tailor the content of the manual to each patient. Clinical supervision supported therapists to gain feedback and request assistance when required. In 'Delivering the intervention', therapists reported that patients valued the opportunity to talk about their fatigue and challenge their beliefs. In 'Challenges in delivering the LIFT intervention', therapists struggled to work in partnership with patients who lacked motivation or stopped engaging. Finally, in 'LIFT developing clinical skills', therapists gained confidence and professional satisfaction, seeing patients' fatigue improve over time.

Conclusion

The findings support the provision of training for rheumatology health professionals to remotely deliver fatigue-management interventions. Insights from these trials can be used to better improve clinical practice and service provision.

UK clinical and community psychology: Exploring personal and professional connections

This paper explores the personal and professional connections between clinical psychologists in the United Kingdom (UK) and critical/community psychology (CCP). Specifically, it asks how clinical psychologists define the area, how they relate to it and how they apply it in their work. Twenty clinical psychologists responded to an online survey, 12 of whom went on to take part in a follow-up telephone interview. Data were analysed using inductive thematic analysis. The results are divided into three sections: i. "describing CCP": social justice and a questioning stance are considered, ii. "relating to CCP": an interplay between lifespan events and personal responses are described and iii. "applying CCP": a dynamic between role-specific applications and reality checks that either enable or constrain is illustrated. Although the continued need for a CCP is described, the results highlight both challenges and tensions of practising CCP within clinical psychology.

Better than expected: client and clinician experiences of videoconferencing therapy (VT) during the COVID-19 pandemic

Videoconferencing therapy (VT) has been an emerging medium of psychological therapy, and during the COVID-19 pandemic there has been substantial growth in its usage as a result of home working. However, there is a paucity of research into client and clinician perceptions of VT. This study sought to assess client and staff experiences of VT. This mixed methods study produced both quantitative and qualitative data. Seven clients who had previously received VT and 11 psychotherapists who had previously delivered VT were recruited from two NHS sites. Clients and psychotherapists took part in qualitative interviews which were analysed using thematic analysis. Quantitative surveys were developed based on themes generated from the interviews and were completed by 172 clients and 117 psychotherapists. These were analysed using simple percentages. VT often exceeded client and psychotherapist expectations and overall experiences of VT were generally positive, although there were mixed findings regarding the therapeutic alliance. Several barriers to VT were cited, such as IT issues, and challenges identified in conducting behavioural experiments, and potential exclusion of certain populations were also cited. The medium of VT was received well by both clients and clinicians, with advantages around convenience seemingly outweighing losses in quality of therapeutic relationship. Future research should focus on overcoming barriers to accessing VT in populations prone to digital exclusion. NHS services not currently employing VT may wish to reconsider their stance, expanding choice of therapy delivery and improving accessibility.

Key learning aims

(1)

Experiences and Perceptions of Patients and Providers Participating in Remote Titration of Heart Failure Medication Facilitated by Telemonitoring: Qualitative Study

BACKGROUND

Guideline-directed medical therapy (GDMT), optimized to target doses, improves health outcomes in patients with heart failure. However, GDMT remains underused, with <25% of patients receiving target doses in clinical practice. A randomized controlled trial was conducted at the Peter Munk Cardiac Centre in Toronto to compare a remote GDMT titration intervention with standard in-office titration. This randomized controlled trial found that remote titration increased the proportion of patients who achieved optimal GDMT doses, decreased the time to dose optimization, and reduced the number of essential clinic visits. This paper presents findings from the qualitative component of the mixed methods study, which evaluated the implementation of the remote titration intervention.

OBJECTIVE

The objective of the qualitative component is to assess the perceptions and experiences of clinicians and patients with heart failure who participated in the remote titration intervention to identify factors that affected the implementation of the intervention.

METHODS

We conducted semistructured interviews with clinicians (n=5) and patients (n=11) who participated in the remote titration intervention. Questions probed the experiences of the participants to identify factors that can serve as barriers and facilitators to its implementation. Conventional content analysis was first used to analyze the interviews and gain direct information based on the participants' unique perspectives. Subsequently, the generated themes were delineated and mapped following a multilevel framework.

RESULTS

Patients and clinicians indicated that the intervention was easy to use, integrated well into their routines, and removed practical barriers to titration. Key implementation facilitators from the patients' perspective included the reduction in clinic visits and daily monitoring of their condition, whereas clinicians emphasized the benefits of rapid drug titration and efficient patient management. Key implementation barriers included the resources necessary to support the intervention and lack of physician remuneration.

CONCLUSIONS

This study presents results from a real-world implementation assessment of remote titration facilitated by telemonitoring. It is among the first to provide insight into the perception of the remote titration process by clinicians and patients. Our findings indicate that the relative advantages that remote titration presents over standard care strongly appeal to both clinicians and patients. However, to ensure uptake and adherence, it is important to ensure that suitable patients are enrolled and the impact on the physicians' workload is minimized. The implementation of remote titration is now more critical than ever, as it can help provide access to care for patients during times when physical distancing is required.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19705.

Telephone delivery of psychological interventions: Balancing protocol with patient-centred care

Common mental health problems of anxiety and depression affect significant proportions of the global population. Within the UK, and increasingly across western countries, a key policy response has been the introduction of high volume, low intensity psychological assessment and treatment services, such as the NHS's Improving Access to Psychological Therapies (IAPT) service, the largest service delivery model yet to be implemented at a national level (England). IAPT may be delivered in face-to-face meetings or over the telephone, as well as through other media. In order to increase access and achieve wide reach with efficient use of resources, IAPT's service models utilise relatively structured and standardised protocols, whilst aiming simultaneously to deliver a tailored and personalised experience for patients. Previous research has revealed that this can be a challenging balance for front-line practitioners to strike. Here we report research into the telephone delivery of guided self-help, low intensity interventions within IAPT, examining the challenges faced in remote delivery when combining structure with personalisation during assessment and treatment sessions. We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient's story, thereby compromising the personalisation and responsiveness of the service. Our study contributes new insights to our understanding of the association between personalisation, engagement and patient experience within high volume, low-intensity psychological treatment services. Our research on the telephone delivery of IAPT is particularly timely in view of the current global Covid-19 health crisis, as a result of which face-to-face delivery of IAPT has had to be (temporarily) suspended.

Validity of Psychiatric Evaluation of Asylum Seekers through Telephone

The goal of the psychiatric assessment of asylum seekers is to evaluate the asylum seeker's mental health and credibility. The shortage of mental health providers trained in this particular type of evaluation makes in-person evaluation not always feasible. Telephonic interview has been occasionally utilized to fill this void. The validity of such evaluations in assessing credibility has yet to be fully established. In the case of telephonic interviews, evaluators are limited with no access to facial or body language cues that can indicate deception or honesty. We will present a case of a client evaluated via telephone that was deemed credible and eventually released to pursue asylum in the US. Assessment of credibility relied solely on cues obtained from the client's narrative, reported symptoms, and their style of interaction with the evaluator. We will highlight the findings from the client's interview that supported credibility in the case and discuss the challenges of assessing asylum seeker's credibility via telephonic interview. Telephonic evaluation of credibility can be considered a valid method despite major challenges, but psychiatric evaluators should be aware of the limitations of telephonic evaluations given the high possibility of secondary gains and deception.

An Exploratory Brief Head-To-Head Non-Inferiority Comparison of an Internet-Based and a Telephone-Delivered CBT Intervention for Adults with Depression

BACKGROUND

Telephone-administered psychotherapy (tCBT) and internet-based treatments (iCBT) may overcome barriers to mental health treatment. TCBT has demonstrated efficacy similar to traditional psychotherapy, however, few studies have compared iCBT to efficacious interventions. This exploratory study examined the noninferiority of iCBT relative to tCBT. We also explored pretreatment moderators of outcome and assessed treatment dropout.

METHODS

As a secondary exploratory analysis of a 304-participant randomized noninferiority trial, we compared iCBT, the first level of a stepped-care intervention, with tCBT on depression outcome after 5 weeks of treatment (prior to stepping). Multiple linear regression models were fit to examine moderators of 5-week depression. Differences in dropout were examined using Kaplan-Meier survival analysis.

RESULTS

After 5 weeks of treatment, both interventions significantly reduced depression severity. The effect size difference between the two interventions was d=0.004 [90% CI=-0.19 to 0.19]; the CI did not cross the non-inferiority margin. Pretreatment depression was significantly associated with depression at week 5. The relationship between cognitive strategy usefulness and depression at week 5 differed between interventions, controlling for pretreatment depression. There was no significant difference in dropout between interventions.

LIMITATIONS

Given the stepped-care trial design, iCBT and tCBT could not be compared at the end of treatment or follow-up. Analyses were exploratory and should be interpreted with caution.

CONCLUSIONS

A large sample, powered for noninferiority, found iCBT no less efficacious than tCBT at reducing depression symptoms after five weeks of treatment.

What influences practitioners' readiness to deliver psychological interventions by telephone? A qualitative study of behaviour change using the Theoretical Domains Framework

BACKGROUND

Contemporary health policy is shifting towards remotely delivered care. A growing need to provide effective and accessible services, with maximal population reach has stimulated demand for flexible and efficient service models. The implementation of evidence-based practice has been slow, leaving many services ill equipped to respond to requests for non-face-to-face delivery. To address this translation gap, and provide empirically derived evidence to support large-scale practice change, our study aimed to explore practitioners' perspectives of the factors that enhance the delivery of a NICE-recommended psychological intervention, i.e. guided self-help by telephone (GSH-T), in routine care. We used the Theoretical Domains Framework (TDF) to analyse our data, identify essential behaviour change processes and encourage the successful implementation of remote working in clinical practice.

METHOD

Thirty-four psychological wellbeing practitioners (PWPs) from the UK NHS Improving Access to Psychological Therapies (IAPT) services were interviewed. Data were first analysed inductively, with codes cross-matched deductively to the TDF.

RESULTS

Analysis identified barriers to the delivery, engagement and implementation of GSH-T, within eight domains from the TDF: (i) Deficits in practitioner knowledge, (ii) Sub-optimal practitioner telephone skills, (iii) Practitioners' lack of beliefs in telephone capabilities and self-confidence, (iv) Practitioners' negative beliefs about consequences, (v) Negative emotions, (vi) Professional role expectations (vii) Negative social influences, and (viii) Challenges in the environmental context and resources. A degree of interdependence was observed between the TDF domains, such that improvements in one domain were often reported to confer secondary advantages in another.

CONCLUSIONS

Multiple TDF domains emerge as relevant to improve delivery of GSH-T; and these domains are theoretically and practically interlinked. A multicomponent approach is recommended to facilitate the shift from in-person to telephone-based service delivery models, and prompt behaviour change at practitioner, patient and service levels. At a minimum, the development of practitioners' telephone skills, an increase in clients' awareness of telephone-based treatment, dilution of negative preconceptions about telephone treatment, and robust service level guidance and standards for implementation are required. This is the first study that provides clear direction on how to improve telephone delivery and optimise implementation, aligning with current mental health policy and service improvement.

Business as usual? Psychological support at a distance

The impact of COVID-19 has challenged the long accepted 'norm' in delivery of psychological therapy. Public policies designed to reduce transmission have made it extremely difficult to meet with service-users safely in the traditional face-to-face context. E-therapies have existed in theory and practice since technological progress has made them possible. They can offer a host of advantages over face-to-face equivalents, including improved access, greater flexibility for service-users and professionals, and cost savings. However, despite the emerging evidence and anticipated positive value, implementation has been slower than anticipated. Concerns have been raised by service-users, clinicians, and public health organisations, identifying significant barriers to the wide spread use of e-therapies. In the current climate, many clinicians are offering e-therapies for the first time, without prior arrangement or training, as the only viable option to continue to support their clients. This paper offers a clinically relevant review of the e-therapies literature, including effectiveness and acceptability dilemmas and challenges that need to be addressed to support the safe use and growth of e-therapies in psychology services. Further research is needed to better understand what might be lost and what gained in comparison to face-to-face therapy, and for which client groups and settings it might be most effective.

Adapting IAPT services to support frontline NHS staff during the Covid-19 pandemic: the Homerton Covid Psychological Support (HCPS) pathway

The Coronavirus (Covid-19) pandemic is exerting unprecedented pressure on NHS Health and Social Care provisions, with frontline staff, such as those of critical care units, encountering vast practical and emotional challenges on a daily basis. Although staff are being supported through organisational provisions, facilitated by those in leadership roles, the emergence of mental health difficulties or the exacerbation of existing ones amongst these members of staff is a cause for concern. Acknowledging this, academics and healthcare professionals alike are calling for psychological support for frontline staff, which not only addresses distress during the initial phases of the outbreak but also over the months, if not years, that follow. Fortunately, mental health services and psychology professional bodies across the United Kingdom have issued guidance to meet these needs. An attempt has been made to translate these sets of guidance into clinical provisions via the recently established Homerton Covid Psychological Support (HCPS) pathway delivered by Talk Changes (Hackney & City IAPT). This article describes the phased, stepped-care and evidence-based approach that has been adopted by the service to support local frontline NHS staff. We wish to share our service design and pathway of care with other Improving Access to Psychological Therapies (IAPT) services who may also seek to support hospital frontline staff within their associated NHS Trusts and in doing so, lay the foundations of a coordinated response.

KEY LEARNING AIMS

(1)To understand the ways staff can be psychologically and emotionally impacted by working on the frontline of disease outbreaks.(2)To understand the ways in which IAPT services have previously supported populations exposed to crises.(3)To learn ways of delivering psychological support and interventions during a pandemic context based on existing guidance and research.

'I didn't know what to expect': Exploring patient perspectives to identify targets for change to improve telephone-delivered psychological interventions

BACKGROUND

Remote delivery of psychological interventions to meet growing demand has been increasing worldwide. Telephone-delivered psychological treatment has been shown to be equally effective and as satisfactory to patients as face-to-face treatment. Despite robust research evidence, however, obstacles remain to the acceptance of telephone-delivered treatment in practice. This study aimed to explore those issues using a phenomenological approach from a patient perspective to identify areas for change in current provision through the use of theoretically based acceptability and behaviour change frameworks.

METHODS

Twenty-eight semi-structured interviews with patients experiencing symptoms of common mental health problems, waiting, receiving or having recently received telephone-delivered psychological treatment via the UK National Health Service's Improving Access to Psychological Therapies (IAPT) programme. Interviews were recorded, transcribed verbatim, and analysed using the Theoretical Domains Framework (TDF) and Theoretical Framework of Acceptability (TFA).

RESULTS

The majority of data clustered within five key domains of the TDF (knowledge, skills, cognitive and interpersonal, environmental context and resources, beliefs about capabilities, beliefs about consequences) and mapped to all constructs of the TFA (affective attitude, ethicality, intervention coherence, self-efficacy, burden, opportunity costs, and perceived effectiveness). Themes highlighted that early stages of treatment can be affected by lack of patient knowledge and understanding, reservations about treatment efficacy, and practical obstacles such as absent non-verbal communication, which is deemed important in the development of therapeutic alliance. Yet post-treatment, patients can reflect more positively, and report gaining benefit from treatment. However, despite this, many patients say that if they were to return for future treatment, they would choose to see a practitioner face-to-face.

CONCLUSIONS

Using a combination of theoretically underpinned models has allowed the identification of key targets for change. Addressing knowledge deficits to shift attitudes, highlighting the merits of telephone delivered treatment and addressing skills and practical issues may increase acceptability of, and engagement with, telephone-delivered treatment.

Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies

BACKGROUND

Despite comparable clinical outcomes, therapists and patients express reservations about the delivery of psychological therapy by telephone. These concerns centre around the quality of the therapeutic relationship and the ability to exercise professional skill and judgement in the absence of visual cues. However, the empirical evidence base for such perceptions has not been clearly established.

METHODS

We conducted a systematic review to establish what is known empirically about interactional differences between psychotherapeutic encounters conducted face-to-face vs. by telephone.

RESULTS

The review identified 15 studies that used situated, comparative approaches to exploring interactional aspects of telephone and face-to-face psychological therapy. These studies revealed evidence of little difference between modes in terms of therapeutic alliance, disclosure, empathy, attentiveness or participation. However, telephone therapy sessions were significantly shorter than those conducted face-to-face.

LIMITATIONS

We identified only a small number of heterogeneous studies, many of which used non-randomised, opportunity samples and did not use validated measures to assess the constructs under investigation. Disparate therapeutic modalities were used across studies and samples included both clinically diagnosed and non-clinical populations.

CONCLUSIONS

Available evidence suggests a lack of support for the viewpoint that the telephone has a detrimental effect on interactional aspects of psychological therapy. The challenge for clinical practice is to translate this evidence into a change in practitioner and patient attitudes and behaviours. In order to do so, it is important to understand and address the breadth of factors that underpin ongoing ambivalence towards the telephone mode, which pose a barrier to wider implementation.

Delivery of Compassionate Mental Health Care in a Digital Technology-Driven Age: Scoping Review

BACKGROUND

Compassion is a vital component to the achievement of positive health outcomes, particularly in mental health care. The rise of digital technologies may influence the delivery of compassionate care, and thus this relationship between compassion and digital health care needs to be better understood.

OBJECTIVE

This scoping review aimed to identify existing digital technologies being used by patients and health professionals in the delivery of mental health care, understand how digital technologies are being used in the delivery of compassionate mental health care, and determine the facilitators of and barriers to digital technology use among patients and health professionals in the delivery of compassionate mental health care.

METHODS

We conducted this scoping review through a search of Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online (MEDLINE), MEDLINE In-Process and EPub Ahead of Print, PsycINFO, and Web of Science for articles published from 1990 to 2019.

RESULTS

Of the 4472 articles screened, 37 articles were included for data extraction. Telemedicine was the most widely used technology by mental health professionals. Digital technologies were described as facilitating compassionate care and were classified using a conceptual model to identify each digital intersection with compassionate care. Facilitators of and barriers to providing compassionate care through digital technology were identified, including increased safety for providers, health care professional perceptions and abilities, and the use of picture-in-picture feedback to evaluate social cues.

CONCLUSIONS

Implementing digital technology into mental health care can improve the current delivery of compassionate care and create novel ways to provide compassion. However, as this is a new area of study, mental health professionals and organizations alike should be mindful that compassionate human-centered care is maintained in the delivery of digital health care. Future research could develop tools to facilitate and evaluate the enactment of compassion within digital health care.

A randomized noninferiority trial evaluating remotely-delivered stepped care for depression using internet cognitive behavioral therapy (CBT) and telephone CBT

This trial examined whether a stepped care program for depression, which initiated treatment with internet cognitive behavioral therapy, including telephone and messaging support, and stepped up non-responders to telephone-administered cognitive behavioral therapy (tCBT), was noninferior, less costly to deliver, and as acceptable to patients compared to tCBT alone. Adults with a diagnosis of major depressive episode (MDE) were randomized to receive up to 20 weeks of stepped care or tCBT. Stepped care (n = 134) was noninferior to tCBT (n = 136) with an end-of-treatment effect size of d = 0.03 and a 6-month post-treatment effect size of d = -0.07 [90% CI 0.29 to 0.14]. Therapist time in stepped care was 5.26 (SD = 3.08) hours versus 10.16 (SD 4.01) for tCBT (p < 0.0001), with a delivery cost difference of $-364.32 [95% CI $-423.68 to $-304.96]. There was no significant difference in pre-treatment preferences (p = 0.10) or treatment dropout (39 in stepped care; 27 in tCBT; p = 0.14). tCBT patients were significantly more satisfied than stepped care patients with the treatment they received (p < 0.0001). These findings indicate that stepped care was less costly to deliver, but no less effective than tCBT. There was no significant difference in treatment preference or completion, however satisfaction with treatment was higher in tCBT than stepped care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01906476.