Supported selfhelp and selfmanagement Using the telephone to deliver low intensity interventions

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Supported self-help and self-managementUsing the
telephone to deliver low intensity interventions

• Karina Lovell

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Low intensity interventions should be accessible,
offered in multiple ways and promote individual
choice
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Why the telephone?

• More people have telephones than other modes of
  delivery
• Has the ability to overcome many of the social,
  physical, psychological and economic barriers
  which prevent access to mental health services
• Reduces client and carer economic burden of
  attending clinic appointments
• Potential for more efficient service delivery
• Offers the potential for choice and patient
  preference

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Given that

• Telephone was invented in 1867
• Samaritans have been delivering support to high
  risk, and vulnerable individuals since 1953
• NHS Direct commenced in 1988
• Most of us have a phone

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Why is it taking so long to use the telephone as
a means of delivering psychological interventions
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To think about ..

• Most of all we need to understand why the
  telephone, after being part of our lives for so
  long, has met with so much suspicion and so many
  irrational assumptions, and why there is so
  little evidence on how best to use this simple
  piece of communication technology (Toon, P.
  Editioral, BMJ, 2002).

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All low intensity interventions should be

• Effective
• Accessible
• Acceptable (to both those receiving the
  intervention, and those delivering/providing the
  intervention
• Cost effective
• Feasible

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Telephone has been used to deliver the following

• Collaborative care of depression
• Guided self help
• Minimal interventions
• Full CBT therapy

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Mental health problems

• Depression (mild, moderate and major)
• OCD
• Depression in multiple sclerosis
• Agoraphobia
• Panic disorder
• Sleep difficulties
• Alcohol and smoking

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What is the evidence base?
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Evidence base

• Systematic review of GSH found
• 34 studies (RCTs) 39 comparisons
• Overall effect of GSH medium (0.43)
• Higher effect size associated with
• Telephone/email than face to face
• 2007Gellatly J Bower P Hennessy S Richards D
  Lovell K. What Makes Self Help Interventions
  Effective in the Management of Depressive
  Symptoms? Meta-analysis and Meta-regression.
  Published online 19th February 2007
  Psychological Medicine 37, 1217-1228

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Evidence base

• The use of the telephone to deliver therapy has
  been found to be
• Superior to no treatment/wait list (Swinson,
  1995)
• Superior to treatment as usual (Simon, 2004)
• Superior to a to an alternative psychotherapy by
  telephone (Mohr,2005)
• Equal and similar to face to face delivered
  therapy in some studies (Griest, 2002
  Taylor,2003 Lovell,2005)

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Is the telephone acceptable to users

• emerging evidence that users find the telephone
  an acceptable means of receiving therapy
• Few studies have examined views qualitatively
• 2008 Bee P. Bower P. Lovell K. Gilbody S.
  Richards D. Gask L. Roach P. Psychotherapy
  Mediated by Remote Communication Technologies a
  meta-analytic review BMC Psychiatry, 2008, 8, 60
  (22nd July 2008)Bee et al, 2008

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Acceptability of telephone interventions

• Completed quantitative satisfaction with OCD
• Completed focus groups with parents and young
  people
• Completed qualitative interviews with users who
  had received CBT from a national user
  organisation (Anxiety UK)
• Completed qualitative interviews with recipients
  of CBT based guided self who absent from work
  with stress/anxiety/depression
• About to start interviews with people with
  chronic widespread pain receiving CBT delivered
  by phone

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Example of acceptability

• It is definitely, I think with children, its a
  lot more adaptable it works for my benefit I
  have to keep running around and I cant always
  get time for babysitters. Sometimes a phone call
  is so much easier (Adult user service study)
• The best thing about the phone apart from the
  fact that I did not have to miss work was that I
  can walk round Manchester and you will never
  know who I am (Adult, PCT telephone clinic)
• We appreciated the flexibility. Our son moved
  abroad for work, left home and school, and was
  able to continue TCBT through this. He has
  always found change difficult TCBT helped him
  through major changes in his life. (OCD
  adolescents)
• The telephone sessions have worked incredibly
  well for us. The help support from our
  therapist has been great. Weve felt fully
  involved and able to do things to help our child.
  TCBT has helped us to cope look to the
  future. (OCD adolescents)

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Acceptability of delivers ?

• Some resistance by MHP
• 2006 Richards D.A. Lankshear A.J. Rogers A
  Barkham M Bower P Gask L Gilbody S Lovell K.
  Developing a U.K. Protocol for Collaborative
  Care A qualitative study General Hospital
  Psychiatry. 28, (4) July-August 2006, 296-305

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Key arguments given by opponents of TT

• the lack of visual cues, and non verbal cues
  results in reduced or complete absence of the
  therapeutic alliance
• Another way of doing things on the cheap
• I did not train all these years to work in a
  call centre
• Risk (identification and management)
• I dont like using the phone
• The very essence of therapy has gone
• I dont feel I have the skills, although I did
  low intensity training, they talked about the
  phone but we were not trained to use it to
  deliver interventions
• quotes derived from clinical experience and
  running workshops

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Is the argument that the lack of visual cues
leads to a reduced/absence of therapeutic
alliance?
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Loss of visual cues!!!!!

• They did let me see a psychiatric nurse at the
  surgery who frankly I looked at and thought oh my
  god what a weirdo (Participant 12)

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Evidence (summary)

• Although there is a paucity of research examining
  therapeutic alliance with recipients of telephone
  interventions, emerging work shows that a
  positive therapeutic alliance and a comparable
  level of alliance to face to face is achieved
  with telephone delivered care (Bee, 2009)

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Overcoming resistance

• Further research is needed
• Experience of training has demonstrated a large
  shift in resistance if evidence, rationale and
  skills practice are included

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All low intensity interventions should be

• Effective (partly)
• Accessible v
• Acceptable (to those receiving the intervention v
• and those delivering/providing the intervention
  Unsure but clear resistance by some MHP
• Cost effective (absence of evidence)
• Feasible v

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Practical application

• Emphasis should be placed on your own credentials
  and therapist skills
• Elicit immediate feelings on telephone therapy
  ie any concerns/fears etc
• Elicit feedback regularly during the first few
  sessions
• Explain to clients that there will be pauses
  during the call (for note taking and thinking
  time)
• Calls should always be scheduled

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Practical application

• Emphasise that it is an appointment and ask
  client to prepare (ie questions, feedback,
  diaries ready etc)
• Use of written materials and diaries
• Agree a code for when client is unable to talk eg
  Mary Mum Dad
• Most patients want appointments between 6-8pm

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Thank you for listeningKarina.Lovell_at_manchester.a
c.uk