Mental health clustering and psychological · The British Psychological Society St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UK ... This paper is the product of a 12

Page 1

Briefing Paper

Mental health clustering and psychologicalinterventions

Dr Donald Brechin & Dr Suzanne Heywood-Everett

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INF214/2013

Printed and published by the British Psychological Society.

© The British Psychological Society 2013

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Mental health clustering and psychological interventions 1

Executive Summary ................................................................................................................. 3

1. Introductions........................................................................................................................ 4

2. Why is this document needed?............................................................................................ 5

3. Levels of practice.................................................................................................................. 6

4. The nature of evidence........................................................................................................ 8

5. The development of the clusters......................................................................................... 9

6. What is included in the cluster pages?................................................................................ 10

7. How does this relate to existing work on competence frameworks? ................................ 12

8. Summary cluster tables ........................................................................................................ 13

9. Competence frameworks .................................................................................................... 14

Acknowledgements .................................................................................................................. 36

References................................................................................................................................ 37

Contents

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2 Mental health clustering and psychological interventions

Page 5

Mental health clustering and psychological interventions 3

The aim of this paper is to provide details of the psychological components of each carepackage within the national Mental Health Payment by Results (PbR) programme. ThePbR programme utilises twenty individual ‘care clusters’, each differentiated in terms ofpresentation, severity and duration of care, to specify the ‘package’ of care required tomeet the needs of service users. This document illustrates how NICE recommendationscan be utilised to specify the first line treatment evidence for each care package, but alsohow to incorporate other evidence that is important in considering how best to provideeffective and efficient psychological interventions for people within the clusters (i.e. RCTevidence, sufficient practice based evidence to be considered routine practice). This paperrecommends a framework by which psychological work is defined and understood basedon the type and level of skill required to deliver a particular psychological behavior withineach package of care. It primarily focuses on three levels of practice/intervention: genericintervention, condition specific intervention and complex interventions. The backgroundsourcing of this paper links directly to the paper Care Packages & Pathways (CPP) &Payment by Results (PbR) for mental health services for adults: Implications forPsychological Services (Cohen –Tovee, 2012). Links to sources of more detailedinformation are also provided.

This paper is the product of a 12 month consultation process with psychology colleaguesaround England, including senior professionals, experts in specific presentations, andnational bodies within the clinical psychology profession. Ongoing work has also beenshared with, and supported by, the National Care Packages and Pathways Project team. It istherefore hoped that the implications of this paper will be useful to professional andmanagerial leads of psychological services throughout England. The possibility of aninternational audience is also recognised by the authors, who hope this paper will also beof interest to all psychological practitioners working in mental health services. Thisdocument has direct implications for the psychological therapy workforce whilst scopingout the Care Packages and Pathways (CPP) and can be used to supplement or advancecurrent competence frameworks, including UCL competence frameworks, NationalOccupational Standards and IAPT competence frameworks. It is hoped that the clustermodel of care packaging will be an efficient and cost-effect way to advance psychologicaltherapies within the healthcare sector.

Executive Summary

Page 6

4 Mental health clustering and psychological interventions

The care clusters for mental health are a framework for planning and operationalizingmental health services and the care and support of individuals (Self et al. 2008). TheMental Health Clustering Tool (MHCT) was developed and provides an empirical toolwhich has concurrent validity. It allows for service users to be allocated to clusters on thebasis of shared needs and points to care packages linked to needs. The aim of this paper isto provide details of the components of each care package and links with NICE guidanceand standards for psychological therapies. It recommends a framework by whichpsychological work is defined and understood based on the type and level of skill requiredto deliver a particular psychological behaviour within each package of care. Thebackground sourcing of this paper links directly to the paper Care Packages & Pathways(CPP) & Payment by Results (PbR) for mental health services for adults: Implications forPsychological Services (Cohen –Tovee, 2012). This document also has direct implicationsfor the psychological therapy workforce whilst scoping out the CPP; see also ‘Planning forthe Future Psychological Therapies Workforce’ (Centre for Workforce Planning, 2012).

1. Introduction

Page 7

2. Why is this document needed?

In order to deliver appropriate packages of care for service users, commissioners, servicemanagers and providers need to be clear which interventions are required for each mentalhealth cluster, including psychological interventions. However, this is not necessarily astraightforward task.

The first challenge is that the research evidence for treatment effectiveness has largelybeen developed in relation to specific diagnostic presentations rather than bio-psycho-social approach (as utilised by the mental health clustering tool), and consequently thereis a need to align the research evidence to the clusters so that it is clear which interventionsare indicated in each cluster.

A second issue is that psychological interventions can be delivered at different levels ofintensity/complexity, and hence can be delivered by staff with different levels of training.The Improving Access to Psychological Therapies (IAPT) programme in England hasdemonstrated this very clearly, and the IAPT programme provides a clear service modelthat identifies which interventions are delivered, by which staff, and at which point in theservice user’s pathway. The model is designed to allow the maximum number of people toreceive effective interventions whilst making the most efficient use of the workforce. Again,this concept of different levels of practice needs to be aligned with the mental healthclusters so that interventions are delivered in the most effective and efficient mannerwithin PbR.

Finally, there is a need to consider the evidence that is used to determine whichinterventions are included in the different clusters and identified packages of care. Theprimary source of evidence used within the NHS in England and Wales is that provided bythe National Institute for Health and Clinical Excellence (NICE). NICE reviews the researchfindings from randomised controlled trials for the treatment of specific diagnosticconditions, and evaluates these treatments in terms of their cost effectiveness. Their findingsare published in the form of guidelines and appraisals, and these documents drive thecommissioning of NHS services in England. However, the treatment of mental healthconditions presents challenges that are difficult for RCT evaluations of diagnostic entities tofully address. Firstly, whilst diagnostic entities are helpful tools they do not wholly reflectclinical reality on the ground, where co-morbidity and the complexity of people’s lives meanthat there can be limitations to a simple diagnostically driven treatment approach. Secondly,RCTs are often blind to other treatment effects such as therapist training, therapistcompetence and use of additional treatment enhancements (e.g. outcomes monitoring andfeedback). There is a longstanding, and growing, evidence base for the importance of thesefactors in the psychological treatment of mental distress, and it is important to acknowledgethis if the mental health PbR programme is to be as effective as possible.

Therefore, this document has been developed to address these issues. It will specify thenature and range of psychological interventions that are indicated in the treatment andmanagement of the care clusters. It utilises NICE recommendations to derive the first linetreatment evidence, but also incorporates other evidence that is important in consideringhow best to provide effective and efficient psychological interventions for people withinthe clusters.

Mental health clustering and psychological interventions 5

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3. Levels of practice

Several documents have been published that articulate the need to describe psychologicalpractice at differing levels of complexity/intensity.

This approach has been most recently adopted in the stepped care model as advocated byNICE, and realised in practice through the Improving Access to Psychological Therapies(IAPT) programme in England. The IAPT programme introduced the terms ‘low intensityinterventions’ (i.e. step 2 interventions) and ‘high intensity interventions’ (i.e. step 3interventions) to describe psychological interventions delivered to differing degrees ofdetail by staff with differing levels of training. However, the IAPT programme does not goon to describe what might be different in terms of psychological interventions delivered atstep 4 and above. Indeed, one question that could possibly arise in the minds of bothservice managers and commissioners is whether there is any difference at step 4. Therefore,whilst the IAPT programme is very important in the psychological therapies landscape, itdoes not provide us with a universal language to describe all psychological interventions.

Most psychological intervention frameworks describe three levels of practice, and it seemssensible to continue to utilise this approach as it has a good fit with the stepped care/IAPTframework as well as building on previous documents. However, those three levels requiresome re-interpretation and re-description in order to fit with the present context.

In the present document, we describe the three levels of practice/intervention as follows:

n Generic interventionsn Condition-specific interventionsn Complex interventions

Generic interventionsThese interventions are targeted at populations of people (e.g. people with mentaldistress) where broad psychological principles from generic psychological theories areapplicable to large groups of people. This level covers low intensity interventions withinthe IAPT framework.

Condition-specific interventionsThis level of practice involves the application of specific psychological theories for theamelioration of specific conditions (e.g. cognitive therapy for depression), andencompasses manualised treatment approaches. This level covers the high intensityinterventions with the IAPT framework.

Complex/Multi-modal interventionsThis level of practice involves the application of theories which go beyond addressing aspecific condition/diagnosis, and allow for a more detailed understanding of the personalmeaning of experiences. Practitioners at this level may be working in an integrativeapproach, calling upon different theoretical perspectives as appropriate. This level ofworking is appropriate to step 4 work.

6 Mental health clustering and psychological interventions

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By adopting an approach that recognizes different levels of intensity (and thereforetraining) it is possible to be more targeted in relation to workforce planning. As such, thistiered approach has been applied to the clusters.

All staff working at these three different levels are required (by NICE and regulatoryprofessional bodies) to be suitably trained, qualified and supervised to deliver theseinterventions. During the consultation of this document there were also some initialdiscussions around some minimum standards required for each of these levels (seePsychotherapist Definition Feedback Nov 2012 for more recent discussion papers).

Mental health clustering and psychological interventions 7

Levels of intervention Population

Type offormulation

Psychologicalknowledge

Complex/Multimodal

Generic

Condition-specific

Highly individualisedformulations

Condition-related/Individualisedformulations

Generic principles

Multiple psychologicalmodels for dealing withchronic/complexpresentations

Psychological models as determined by specific conditions

Broad psychologicalprinciples which apply to all clients

Mental health & learning disability population

Specific group

Specific group

Specific group

Individuals

Figure 1: A visual representation of the three levels of practice

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4. The nature of evidence

The evidence that is used to inform PbR is the guidance produced by the National Institutefor Health and Clinical Excellence (NICE), and so this forms the main source of evidencefor the present document. However, although NICE reviews high quality evidence in termsof randomised controlled trials for the treatment of specific diagnostic conditions, theapplicability of this evidence to some areas of clinical practice has some limitations.

Firstly, many RCTs exclude people with co-morbid conditions and other complicatingfactors and so these treatments do not necessarily reflect conditions as they present toroutine NHS services. As such, purely protocol-driven treatments have to be adapted inclinical practice.

Perhaps more importantly, NICE doesn’t assess the literature on other factors that assistwith treatment efficacy (i.e. therapist factors) and the practice-based evidence literaturegenerally. There is a large body of work that suggests that therapeutic alliance andtherapist competence account for the largest amount of variance in terms of treatmentefficacy. As such, this must be considered when considering what we provide to whom.Recent work on outcomes management (e.g. sessional outcome measures and casetracking) indicates that these are important contributors to treatment efficacy. Importantly,this approach allows individual therapists to monitor their own effectiveness, and take stepsto enhance their therapeutic work.

Finally, NICE no longer review treatments that fall below the RCT threshold, and so do notencompass the valid research literature on emerging and developing therapeuticapproaches. Furthermore, the evidence base is much less clear with more complexpsychological problems such as more severe depression, personality disorders and eatingdisorders and it is generally accepted a wide range of established psychological therapiesshould be available for such problems and a focus more on formulation lead treatmentplans (ie to “draw on and integrate a wide range of interpersonal, biological, social andcultural factors”, Cole et al. 2011). This may lead to direct clinical interventions or indirectclinical work, by sharing and promoting the formulation within a multi-disciplinary team aswell as the individual service user and carer (Cole et al. 2011).

Whilst information from the NICE guidance forms the bedrock of PbR and this document,additional information is provided to support practical decision-making on the ground.This additional information takes into account other sources of evidence that has beenvalidated by practitioners and researchers in these areas of practice.

8 Mental health clustering and psychological interventions

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5. The development of the clusters

The development of the cluster pages has been led by the authors through a local need tounderstand how clusters will impact on the provision of clinical services. However, theapplicability of this work to other geographical areas was apparent early on and so theproject was extended to psychology colleagues around the country. The resultingdocument has consequently been extensively consulted upon over a twelve month period,with input from a number of senior professionals, experts in specific presentations, andnational bodies within the clinical psychology profession. The work has also been sharedwith, and supported by, the national Care Packages and Pathways Project teamwww.cppconsortium.nhs.uk. For a more detailed account of the Clusters and Care Packages,we refer to Esther Cohen Tovee’s www.bps.org.uk/carepackages paper cited earlier.

Mental health clustering and psychological interventions 9

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6. What is included in the cluster pages?

Each cluster and the associated evidence for psychological interventions are summarizedon one page for easy reference. The pages include the following information:

n Standard cluster information (i.e. cluster definitions, cluster transitions, indicativediagnoses and course);

n Psychological interventions as defined by NICE (described as first line assessment andtreatment);

n Psychological interventions not included in NICE but has passed criteria for inclusion(i.e. RCT evidence, sufficient practice based evidence to be considered routinepractice); and

n The level of psychological practice required to deliver the interventions.

10 Mental health clustering and psychological interventions

Using the cluster pages:As well as the background information relating to the description, diagnosis,impairment, risk and course of the mental health disorders included in the clusters,the cluster pages include other valuable information to facilitate workforce planning.The title of the cluster page indicates a description of the cluster; the level of practiceapparent in the treatment e.g. generic interventions, condition-specific interventionsand complex interventions and indications as to the complexity and needs of theservice user . The boxes identified by the white area of the table include the specifictreatments for each mental health problem in the cluster e.g. CBT, Guided Self Helpetc. These correspond to the first line treatments as recommended (and/or counter-indicated) by NICE guidelines stated to the left of the treatment column and secondlevel treatments as recommended through the consultation process. The cluster pagesalso indicate when consultation and/or formulation- driven care plans should beconsidered .The recommendations for the psychological therapist who delivers theseinterventions must have the necessary skills and competences and will be supervised atthe appropriate level or above to deliver these treatments. Data from these clusterexemplars can be used to inform managers and senior practitioners around thenecessary workforce plan of psychological practitioners to help decide who does what,with whom and when.

Page 13

The following principles underpin the clusters:1. It is assumed that psychological interventions should be provided as part of pathways andpackages of care and will not constitute the entirety of the package or their equivalentand meet the needs of service users (and after full discussion with the service user).

2. The provision of psychological interventions should also recognise the importance ofchoice and the readiness of the service user to benefit from interventions, at that time.

3. Identification of psychological interventions and the type and level of skills requiredwithin services should be determined by packages of care or their equivalent.

4. Service users should receive psychological interventions from practitioners who aresuitably qualified, trained and supervised.

5. It is important to recognise the three different levels of competency in the delivery ofpsychological interventions, from foundation knowledge and skills to formal therapies.

6. The effective provision of psychological interventions requires a service culture thatfacilitates and supports such work, for example, valuing staff and having shared valuesand goals.

7. The delivery of indirect psychological work through supervision and consultation to themulti-disciplinary team, service user and carer is valued and measured as a clinical activity.

Mental health clustering and psychological interventions 11

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7. How does this relate to existing work on competency frameworks?

The table below illustrates how this process was formulated from initial discussions aroundwhat is meant by psychological work; defining the different levels of complexity requiredto deliver different psychological interventions (both first and second line recommendedtreatments) depending on need. These levels are informed by who (i.e. level of trainingand expertise) those practitioners would be to deliver safe effective interventions. Finally,how the delivery of these different levels is understood is within a skills and competencyframework. This ensures that a practitioner delivering complex interventions has thenecessary skills and competences to do so. For more information on the competencyframeworks see section 10, below.

12 Mental health clustering and psychological interventions

Definition of psychological work

Existing education and training

Different levels

Generic Condition SpecificComplex

Professionalaccreditation/registration

Professionalaccountability

Psychological therapy competency frameworks

Cluster specific care package determinewho does what, with whom and when.Identify need for necessary supervision

Evidence based/drivencompetent practitioners

Workforce plan

What

Who

How

Figure 2: Overview of Mental Health Clustering and Psychological Therapies

Page 15

8. Summary cluster tables

The following pages include an overview of the psychological therapies as recommendedby NICE and further national consultation with psychological therapists.

It is anticipated that these clusters will remain live to ensure they are updated and adaptedaccording to local demographic needs and updated research and NICE recommendations.

Mental health clustering and psychological interventions 13

Page 16

C

lust

er tr

ansi

tions

M

ost l

ikel

y: N

o si

gnifi

cant

MH

pr

oble

ms

Pos

sibl

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lust

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0,

11, 1

2, 1

3, 1

4, 1

5, 1

8 R

are:

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ster

1, 7

, 16,

17,

19,

20

, 21

9.1

Clu

ster

1

Com

mon

Men

tal H

ealth

Pro

blem

s (L

ow S

ever

ity)

Gen

eric

and

Con

ditio

n S

peci

fic L

evel

Inte

rven

tions

In

dica

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Epis

ode

of C

are:

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2 W

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(Clu

ster

Rev

iew

s E

very

8 W

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) A

t thi

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e m

ay b

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it fro

m c

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low

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rven

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is li

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ost h

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nd

shou

ld ro

utin

ely

be o

ffere

d fir

st. E

vide

nce

is c

lear

that

the

serv

ice

user

can

ben

efit

from

act

ive

mon

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g an

d ps

ych-

educ

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elf h

elp.

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ympt

oms

have

not

im

prov

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tepp

ing

up to

one

or m

ore

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inte

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ther

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rm p

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gro

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t not

with

any

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ptom

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200

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phy

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l act

ivity

pro

gram

me.

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gro

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al g

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lf-he

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ased

on

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prin

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es o

f CB

T.

CC

BT

- com

pute

rised

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T.

Gro

up a

ctiv

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ses

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r wk

(45-

60 m

in) o

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wks

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May

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act a

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al

diag

nosi

s bu

t may

incl

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mild

sy

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epre

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ivity

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SH

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f tra

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MH

and

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ls u

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and

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k U

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2011

)

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H &

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ss R

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(CG

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impa

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med

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pos

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up

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1 m

onth

. R

outin

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a b

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rum

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or P

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at 1

mon

th a

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ion

inte

rven

tions

(deb

riefin

g) th

at fo

cus

on th

e tra

uma

alon

e.

14 Mental health clustering and psychological interventions

Page 17

Mental health clustering and psychological interventions 15

Clu

ster

tran

sitio

ns

Mos

t lik

ely:

No

sign

ifica

nt M

H

prob

lem

s P

ossi

ble:

Clu

ster

3&

4 U

nlik

ely:

Clu

ster

5, 6

, 8, 1

0,

11, 1

2, 1

3, 1

4, 1

5, 1

8 R

are:

C

lust

er 1

, 2, 7

, 16,

17,

19

, 20,

21

9.2

Clu

ster

2

Com

mon

Men

tal H

ealth

Pro

blem

s (L

ow S

ever

ity W

ith G

reat

er N

eed)

G

ener

ic a

nd C

ondi

tion

Spe

cific

Lev

el In

terv

entio

ns

Indi

cativ

e Ep

isod

e of

Car

e: 1

2-15

Wee

ks (C

lust

er R

evie

ws

Eve

ry 1

2 W

eeks

)

At t

his

leve

l of i

nter

vent

ion,

the

rese

arch

evi

denc

e is

cle

ar th

at th

e se

rvic

e us

er c

an b

enef

it fro

m a

low

inte

nsity

inte

rven

tion.

Con

side

r wha

t the

ser

vice

use

r has

al

read

y be

en o

ffere

d an

d in

trodu

ce a

ny c

lust

er 1

inte

rven

tions

and

/or

step

ping

up

to o

ne o

r mor

e lo

w in

tens

ity m

anua

lised

and

sho

rt te

rm e

vide

nce

base

d ap

proa

ches

del

iver

ed b

y su

itabl

y tra

ined

pra

ctiti

oner

s. S

ervi

ce u

sers

who

dec

line/

are

not a

ble

to a

cces

s on

e-to

-one

psy

chol

ogic

al th

erap

y sh

ould

hav

e ps

ycho

logi

cal t

hink

ing

form

par

t of t

heir

care

.

NIC

E G

uida

nce

Firs

t Lin

e Tr

eatm

ent

Des

crip

tion

This

gro

up h

as d

efin

ite b

ut

min

or p

robl

ems

of d

epre

ssed

m

ood,

anx

iety

or o

ther

dis

orde

r bu

t not

with

any

dis

tress

ing

psyc

hotic

sym

ptom

s. T

hey

may

ha

ve a

lread

y re

ceiv

ed c

are

asso

ciat

ed w

ith c

lust

er 1

and

re

quire

mor

e sp

ecifi

c in

terv

entio

n or

pre

viou

sly

been

su

cces

sful

ly tr

eate

d at

a h

ighe

r le

vel b

ut a

re re

-pre

sent

ing

with

lo

w le

vel s

ympt

oms.

Dep

ress

ion

(CG

90 O

ct 2

009)

CB

T: B

ehav

iour

al a

ctiv

atio

n: 1

6-20

ses

sion

s ov

er 3

-4 m

onth

s.

IPT:

16-

20 s

essi

ons

over

3-4

mon

ths.

C

ouns

elin

g: 6

-10

sess

ions

ove

r 8-1

2 w

eeks

. P

sych

o-dy

nam

ic 1

:1 lo

nger

term

for s

ervi

ce u

sers

not

resp

ondi

ng to

CB

T/IP

T.

Gro

up a

ctiv

ity p

rogr

amm

e: 3

ses

sion

s pe

r wk

(45-

60 m

in) o

ver 1

0-14

wks

.

Dia

gnos

is

F32

Dep

ress

ive

Epis

ode

(Non

-psy

chot

ic) F

40 P

hobi

c A

nxie

ty D

isor

ders

, F41

Oth

er

Anx

iety

Dis

orde

rs, F

42 O

CD

, F4

3 St

ress

Rea

ctio

n /

Adj

ustm

ent D

isor

der,

F50

E

atin

g D

isor

der.

Dep

ress

ion

& P

hysi

cal H

ealth

(C

G91

Oct

200

9)

CB

T: 1

:1 th

erap

y.

CB

T gr

oup

wor

k: 2

x p

ract

ition

ers

6-8

wee

ks.

Min

dful

ness

bas

ed c

ogni

tive

ther

apy:

8x2

hou

r mee

tings

+ 4

follo

w-u

p.

al h

ealth

pro

blem

: 15-

20 s

essi

ons

over

5-6

mon

ths

(If s

ever

e: +

m

edic

atio

n).

Gro

up a

ctiv

ity p

rogr

amm

e: 3

ses

sion

s pe

r wk

(45-

60 m

in) o

ver 1

0-14

wks

. G

roup

pee

r sup

port

(1x

wee

kly

for 8

1

2 w

eeks

).

Impa

irmen

t D

isor

der u

nlik

ely

to c

ause

se

rious

dis

rupt

ion

to w

ider

fu

nctio

ning

but

som

e pe

ople

w

ill e

xper

ienc

e m

inor

pr

oble

ms.

Anx

iety

- G

AD

(C

G11

3 Ja

n 20

11)

Non

-faci

litat

ed s

elf h

elp

(writ

ten

or e

lect

roni

c m

ater

ials

bas

ed o

n C

BT

treat

men

t prin

cipl

es) o

ver 6

wee

k pe

riod

invo

lve

min

imal

th

erap

ist c

onta

ct e

.g. o

ccas

iona

l pho

ne c

all 5

min

utes

). G

uide

d se

lf he

lp.

Psy

cho-

educ

atio

nal g

roup

s (1

:12

Par

ticip

ants

for 6

wee

ks la

stin

g 2

hour

s).

(Non

-faci

litat

ed s

elf h

elp

may

be

deliv

ered

by

GP)

. (G

SH

& p

sych

o-ed

ucat

iona

l gro

ups

may

be

cond

ucte

d by

a v

arie

ty o

f tra

ined

MH

and

oth

er h

ealth

care

pro

fess

iona

ls u

sual

ly

deliv

ered

by

PWP

and

GM

HW

).

Ris

k U

nlik

ely

to b

e a

issu

e.

Anx

iety

- P

D

(CG

113

Jan

2011

)

Brie

fer C

BT

plus

sel

f hel

p C

BT

-(7-

14 h

ours

ove

r 4 m

onth

s 1-

2 ho

urs

wee

kly)

. S

uppo

rt gr

oups

. La

rge

grou

p C

BT.

9

GSH

& p

sych

o-ed

ucat

iona

l gro

ups

may

be

cond

ucte

d by

a v

arie

ty o

f tra

ined

MH

and

oth

er h

ealth

care

pro

fess

iona

ls u

sual

ly

deliv

ered

by

PWP

and

GM

HW

). C

ours

e Th

e pr

oble

m is

like

ly to

be

shor

t ter

m a

nd re

late

d to

life

ev

ents

.

PTS

D

(CG

26 S

ept 2

006)

CB

T: T

raum

a fo

cuse

d C

BT

with

in fi

rst m

onth

of t

he e

vent

(inc

ludi

ng o

lder

chi

ldre

n) 8

-12

sess

ions

. E

MD

R 8

- 12

sess

ions

onc

e a

wee

k.

Psy

chot

hera

py N

OS

alte

rnat

ive

traum

a ba

sed

psyc

holo

gica

l tre

atm

ents

. D

o N

OT

rout

inel

y of

fer n

on-tr

aum

a fo

cuse

d in

terv

entio

ns (e

.g. r

elax

atio

n or

non

-dire

ctiv

e th

erap

y) th

at d

o no

t add

ress

trau

mat

ic

mem

orie

s.

Page 18

16 Mental health clustering and psychological interventions

Clu

ster

tran

sitio

ns

Mos

t lik

ely:

No

sign

ifica

nt

MH

pro

blem

s Po

ssib

le: C

lust

er 3

,4,5

,6,8

U

nlik

ely:

Clu

ster

10,

11,

12

, 13,

14,

15,

18

Rar

e:

Clu

ster

1, 2

, 16,

17,

19

, 20,

21

9. 3

Clu

ster

3

Non

-Psy

chot

ic D

isor

der (

Mod

erat

e Se

verit

y)

Gen

eric

and

Con

ditio

n Sp

ecifi

c Le

vel I

nter

vent

ions

In

dica

tive

Epi

sode

of C

are:

4-6

Mon

ths

(Clu

ster

Rev

iew

s E

very

4 M

onth

s)

At t

his

leve

l of i

nter

vent

ion,

the

rese

arch

evi

denc

e is

cle

ar th

at th

e se

rvic

e us

er c

an b

enef

it fr

om a

hig

h in

tens

ity 1

:1 in

terv

entio

n, d

eliv

ered

by

suita

bly

trai

ned

prac

titio

ners

. Re-

cons

ider

intr

oduc

ing

step

1 in

terv

entio

ns. T

he s

ervi

ce u

ser i

s lik

ely

to h

ave

an e

mpi

rical

ly o

r the

oret

ical

ly

deriv

ed d

iagn

osis

. Ser

vice

use

rs w

ho d

eclin

e/ar

e no

t abl

e to

acc

ess

one-

to-o

ne p

sych

olog

ical

ther

apy

shou

ld h

ave

psyc

holo

gica

l thi

nkin

g fo

rm

part

of t

heir

care

.

NIC

E G

uida

nce

Firs

t Lin

e Tr

eatm

ent

Des

crip

tion

Mod

erat

e pr

oble

ms

invo

lvin

g de

pres

sed

moo

d, a

nxie

ty o

r ot

her d

isor

der (

not i

nclu

ding

ps

ycho

sis)

.

Dep

ress

ion

(CG

90 O

ct 2

009)

CB

T: B

ehav

iour

al a

ctiv

atio

n: 2

4 se

ssio

ns o

ver 1

0 m

onth

s in

clud

ing

follo

w u

p.

IPT:

16-

20 s

essi

ons

over

3-4

mon

ths.

C

ouns

elin

g: 1

0 se

ssio

ns o

ver 1

2 w

eeks

. P

sych

o-dy

nam

ic 1

:1 lo

nger

term

for s

ervi

ce u

sers

not

resp

ondi

ng to

CB

T/IP

T.

Sho

rt te

rm p

sych

odyn

amic

ther

apy

20 s

essi

ons

over

6 m

onth

s.

Dia

gnos

is

F32

Dep

ress

ive

Epis

ode

(Non

-psy

chot

ic) F

40 P

hobi

c A

nxie

ty D

isor

ders

, F41

Oth

er

Anx

iety

Dis

orde

rs, F

42 O

CD

, F4

3 S

tress

Rea

ctio

n /

Adj

ustm

ent D

isor

der,

F50

E

atin

g D

isor

der.

Dep

ress

ion

& P

hysi

cal

Hea

lth

(CG

91 O

ct 2

009)

CB

T: 1

:1 th

erap

y.

CB

T G

roup

wor

k: 2

x p

ract

ition

ers

6-8

wee

ks.

Min

dful

ness

bas

ed c

ogni

tive

ther

apy:

8x2

hou

r mee

tings

+ 4

follo

w-u

p.

Beh

avio

ural

cou

ples

ther

apy

for t

hose

with

a c

hron

ic p

hysi

cal h

ealth

pro

blem

: 15-

20 s

essi

ons

over

5-6

mon

ths

(If s

ever

e: +

m

edic

atio

n).

Anx

iety

G

AD

(CG

113

Jan

2011

)

Offe

red

eith

er d

rug

treat

men

t or h

igh-

inte

nsity

psy

chol

ogic

al in

terv

entio

n.

Man

ualis

ed C

BT:

12-

15 w

eekl

y se

ssio

ns la

stin

g 1

hour

. A

pplie

d re

laxa

tion:

12-

15 s

essi

ons

(few

er o

r mor

e de

term

ined

by

wha

t is

clin

ical

app

ropr

iate

). R

egul

ar s

uper

visi

on; a

udio

/vid

eo re

cord

ing/

outc

ome

mea

sure

s /p

refe

rred

lang

uage

.

Impa

irmen

t D

isor

der u

nlik

ely

to c

ause

di

srup

tion

to w

ider

.

Anx

iety

P

D (C

G11

3 Ja

n 20

11)

CB

T 7-

14 h

ours

ove

r 4 m

onth

s, 1

-2 h

ours

wee

kly/

sho

rt te

rm m

ore

inte

nsiv

e C

BT.

B

riefe

r CB

T su

pple

men

ted

with

app

ropr

iate

focu

sed

info

rmat

ion

and

task

s (a

roun

d 7

hour

s de

sign

ed to

inte

grat

e st

ruct

ured

se

lf he

lp m

ater

ials

. If s

ervi

ce u

ser d

oes

not r

espo

nd, c

onsi

der r

eass

essi

ng a

nd o

fferin

g ot

her t

ypes

of

inte

rven

tion/

com

bina

tion

of p

sych

olog

ical

, med

icat

ion

or b

iblio

grap

hy (s

tep1

-3).

Ris

k U

nlik

ely

to b

e a

serio

us is

sue.

Acu

te S

tres

s R

eact

ion/

M

ild P

TSD

(C

G26

Sep

t 200

6)

CB

T: T

raum

a fo

cuse

d C

BT

with

in fi

rst m

onth

of t

he e

vent

(inc

ludi

ng o

lder

chi

ldre

n).

20-2

4 se

ssio

ns o

ver 4

-10

mon

ths

incl

udin

g fo

llow

up.

E

MD

R 8

- 12

sess

ions

onc

e a

wee

k.

Psy

chot

hera

py N

OS

alte

rnat

ive

traum

a ba

sed

psyc

holo

gica

l tre

atm

ents

. Fo

r ind

ivid

uals

who

hav

e ex

perie

nced

a tr

aum

atic

eve

nt th

e sy

stem

atic

pro

visi

on to

that

indi

vidu

al a

lone

of b

rief,

sing

le-

sess

ion

inte

rven

tions

(ofte

n re

ferr

ed to

as

debr

iefin

g) th

at fo

cus

on th

e tra

umat

ic in

cide

nt s

houl

d no

t be

rout

ine

prac

tice

whe

n de

liver

ing

serv

ices

. (N

ICE

CG

26)

Wat

chfu

l wai

ting

for u

p to

4 w

eeks

afte

r tra

umat

ic e

vent

, whe

re s

ympt

oms

are

mild

and

fo

llow

up

afte

r 1 m

onth

.

Cou

rse

Sho

rt- te

rm.

OC

D B

DD

(Mild

) (C

G31

Nov

200

5)

Inte

nsiv

e.

CB

T: 2

0-24

ses

sion

s ov

er 4

-10

mon

ths

incl

udin

g fo

llow

up.

Eatin

g D

isor

der (

mild

) (C

G9

Jan

2004

) If

depr

essi

ve s

ympt

oms

com

plic

ated

by

mild

eat

ing

diso

rder

- CB

T: E

vide

nce

-bas

ed s

elf h

elp.

B

ulim

ia n

ervo

sa; b

inge

-eat

ing.

Page 19

Mental health clustering and psychological interventions 17

Clu

ster

tran

sitio

ns

Mos

t lik

ely:

No

sign

ifica

nt M

H

prob

lem

s Po

ssib

le: C

lust

er 5

,6,8

U

nlik

ely:

Clu

ster

10,

11,

12,

13,

14,

15

, 18

Rar

e:

Clu

ster

1, 2

, 3, 4

, 7, 1

6, 1

7,

19, 2

0, 2

1

9.4

Clu

ster

4

Non

-Psy

chot

ic D

isor

der (

Seve

re)

Con

ditio

n -S

peci

fic- C

ompl

ex L

evel

Inte

rven

tions

In

dica

tive

Epi

sode

of C

are:

6-1

2 M

onth

s (C

lust

er R

evie

ws

Ever

y 6

Mon

ths)

Se

rvic

e us

ers

may

fall

into

two

leve

ls o

f com

plex

ity, b

enef

iting

from

a h

igh

inte

nsity

inte

rven

tion,

but

oth

ers

with

in th

is c

lust

er n

eedi

ng to

be

offe

red

a se

cond

line

evi

denc

e ba

sed

trea

tmen

t and

/or b

eing

ste

pped

up

to w

orki

ng w

ith a

pra

ctiti

oner

del

iver

ing

mor

e c

ompl

ex le

vel p

sych

olog

ical

inte

rven

tions

, whi

ch m

ay fo

rm p

art o

f mor

e co

llabo

rativ

e pa

ckag

e of

ca

re. T

he s

ervi

ce u

ser m

ay re

quire

a lo

nger

dur

atio

n of

ther

apy.

At t

his

mor

e co

mpl

ex le

vel o

f int

erve

ntio

n, th

e re

sear

ch e

vide

nce

is c

lear

that

the

know

ledg

eabl

e an

d ex

perie

nced

ther

apis

t who

del

iver

s it

is s

uita

bly

qual

ified

and

exp

erie

nced

. Ser

vice

use

rs w

ho d

eclin

e/ar

e no

t abl

e to

acc

ess

one-

to-o

ne p

sych

olog

ical

ther

apy

shou

ld h

ave

psyc

holo

gica

l th

inki

ng fo

rm p

art o

f the

ir ca

re.

An

expe

rienc

ed p

sych

olog

ical

pra

ctiti

oner

(wor

king

at t

he c

ompl

ex le

vel)

shou

ld c

ontr

ibut

e th

e ps

ycho

logi

cal e

lem

ent t

o th

e M

DT

form

ulat

ion,

and

ad

vise

on

the

psyc

holo

gica

l asp

ects

of c

are

deliv

ered

by

the

team

/ser

vice

s.

N

ICE

Gui

danc

e Fi

rst L

ine

Trea

tmen

t Se

cond

Lin

e Tr

eatm

ent

Des

crip

tion

This

gro

up is

cha

ract

eriz

ed b

y se

vere

de

pres

sion

and

/or a

nxie

ty a

nd/o

r ot

her i

ncre

asin

g co

mpl

exity

of n

eeds

. Th

ey m

ay e

xper

ienc

e di

srup

tion

to

func

tion

in e

very

day

life

and

ther

e is

an

incr

easi

ng li

kelih

ood

of s

igni

fican

t ris

ks.

Dep

ress

ion

(CG

90 O

ct 2

009)

C

onsi

der f

irst l

ine

treat

men

ts a

s C

G90

and

re-in

trodu

cing

ste

p 2

and

3 (i.

e. c

lust

ers

1-3)

trea

tmen

ts

that

hav

e be

en in

adeq

uate

ly a

dher

ed to

(i.e

. CB

T, m

indf

ulne

ss b

ased

cog

nitiv

e th

erap

y, IP

T,

coun

selli

ng, p

sych

odyn

amic

psy

chot

hera

py, b

ehav

iour

al c

oupl

es th

erap

y fo

r tho

se w

ith c

hron

ic

phys

ical

hea

lth p

robl

ems)

. Aw

aren

ess

of d

rug

inte

ract

ions

ass

ocia

ted

with

dep

ress

ion

and

chro

nic

phys

ical

hea

lth p

robl

ems.

Whe

re d

epre

ssio

n is

sev

ere

or c

ompl

icat

ed b

y co

mpl

ex p

robl

ems

inte

grat

e ps

ycho

logi

cal c

are

with

a p

rogr

amm

e of

mul

tipro

fess

iona

l car

e H

uman

istic

. E

mot

ion

focu

sed

ther

apy;

per

son

cent

red

ther

apy

and

expe

rient

ial p

sych

othe

rapy

. A

var

iety

of s

yste

mic

/fam

ily/c

oupl

e tre

atm

ents

foun

d to

be

effe

ctiv

e.

Dia

gnos

is

F32

Dep

ress

ive

Epi

sode

(Non

-ps

ycho

tic)F

40 P

hobi

c A

nxie

ty D

isor

ders

, F4

1 O

ther

Anx

iety

Dis

orde

rs, F

42 O

CD

, F4

3 St

ress

Rea

ctio

n / A

djus

tmen

t D

isor

der,

F44

Dis

soci

ativ

e D

isor

der,

F45

Som

atof

orm

Dis

orde

r, F4

8 O

ther

N

euro

tic D

isor

ders

, F50

Eat

ing

Dis

orde

r.

Dep

ress

ion

& P

hysi

cal H

ealth

(C

G91

Oct

200

9)

Con

side

r firs

t lin

e tre

atm

ents

as

CG

90. H

owev

er, c

onsi

der i

ncre

asin

g th

e in

tens

ity a

nd d

urat

ion

of th

e in

terv

entio

ns a

nd e

nsur

e th

at th

ey c

an b

e pr

ovid

ed e

ffect

ivel

y an

d ef

ficie

ntly

on

disc

harg

e. W

here

de

pres

sion

is s

ever

e or

com

plic

ated

by

com

plex

pro

blem

s in

tegr

ate

psyc

holo

gica

l car

e w

ith a

pr

ogra

mm

e of

mul

tipro

fess

iona

l car

e. E

nsur

e cl

ose

links

with

ser

vice

s tre

atin

g ph

ysic

al h

ealth

pr

oble

ms.

A

nxie

ty

GA

D (C

G11

3 Ja

n 20

11)

CB

T: P

eopl

e w

ho h

aven

't re

ceiv

ed in

terv

entio

ns in

ste

ps 1

-3 s

houl

d ha

ve th

ese

offe

red

agai

n (s

ee

clus

ters

1-3

). If

ther

e is

insu

ffici

ent r

espo

nse,

CB

T sh

ould

be

offe

red

with

a th

erap

ist w

ith e

xper

tise

in

the

psyc

holo

gica

l tre

atm

ent o

f com

plex

, tre

atm

ent-r

efra

ctor

y an

xiet

y di

sord

ers.

A

nxie

ty

PD

(CG

113

Jan

2011

) C

BT

shou

ld b

e of

fere

d w

ith a

n ex

perie

nced

ther

apis

t. H

ome

base

d C

BT

shou

ld b

e co

nsid

ered

if c

linic

at

tend

ance

is p

robl

emat

ic. U

se s

truct

ured

pro

blem

sol

ving

if a

ppro

pria

te.

Impa

irmen

t S

ome

may

exp

erie

nce

sign

ifica

nt.

PTSD

(C

G26

Sep

t 200

6)

If de

pres

sion

/ anx

iety

com

plic

ated

by

PTS

D c

onsi

der-

CB

T: T

raum

a fo

cuse

d in

divi

dual

CB

T or

EM

DR

fo

r sev

ere

PTS

D w

ithin

1 m

onth

and

with

in 3

mon

ths

of th

e ev

ent (

incl

udin

g ol

der c

hild

ren)

con

side

r be

yond

12

sess

ions

. P

sych

othe

rapy

NO

S a

ltern

ativ

e tra

uma

base

d ps

ycho

logi

cal t

reat

men

ts.

Ris

k S

ome

may

exp

erie

nce

mod

erat

e ris

k to

sel

f thr

ough

sel

f har

m o

f sui

cida

l th

ough

ts o

r beh

avio

urs.

Self

Har

m

(CG

16; 2

004

revi

sed

Feb

2012

) P

sych

osoc

ial a

sses

smen

t. In

tens

ive

ther

apeu

tic in

terv

entio

ns (f

or a

t lea

st 3

mon

ths)

. D

BT

com

preh

ensi

ve.

DB

T fo

r ser

vice

use

rs d

iagn

osed

with

bip

olar

per

sona

lity

diso

rder

. P

sych

othe

rapy

(NO

S).

You

ng p

eopl

e: d

evel

opm

enta

l gro

up p

sych

othe

rapy

. E

ach

epis

ode

of s

elf-h

arm

sho

uld

be tr

eate

d in

its

own

right

and

a p

erso

n's

indi

vidu

al re

ason

s fo

r sel

f-ha

rm m

ay v

ary

from

epi

sode

to e

piso

de.

If bi

pola

r per

sona

lity

diso

rder

pre

sent

: CB

T: P

D: s

chem

a fo

cuse

d th

erap

y; C

BT

Psy

chod

ynam

ic p

sych

othe

rapy

. 40

ses

sion

s ov

er 1

2 m

onth

s.

PD

: 1:1

. P

sych

- NO

S: B

ased

ther

apy;

ther

apeu

tic c

omm

unity

; C

AT

- ado

lesc

ents

; STE

PP

S.

CA

T, 2

4 se

ssio

ns o

ver 1

2 m

onth

s to

targ

et s

igni

fican

t re

latio

nshi

p pr

oble

ms.

E

xplic

it m

etal

lisat

ion

grou

ps.

Cou

rse

Unl

ikel

y to

impr

ove

with

out t

reat

men

t an

d m

ay d

eter

iora

te w

ith lo

ng te

rm

impa

ct o

n fu

nctio

ning

.

OC

D B

DD

(C

G31

Nov

200

5)

If de

pres

sion

/ anx

iety

com

plic

ated

by

OC

D-c

onsi

der:

Tre

atm

ent a

t thi

s le

vel w

ill re

flect

incr

easi

ng

expe

rienc

e an

d ex

perti

se in

the

impl

emen

tatio

n of

a li

mite

d ra

nge

of th

erap

eutic

opt

ions

. CB

T w

ith

SS

RI (

incl

udin

g E

RP)

. Con

side

r fam

ily w

ork

in E

RP

, if a

ppro

pria

te. C

onsi

der h

ome

treat

men

t.

The

stud

ies

are

near

ly a

ll of

fam

ily b

ased

CB

T w

hich

is

foun

d to

be

effe

ctiv

e.

Page 20

18 Mental health clustering and psychological interventions

Clu

ster

tran

sitio

ns

Mos

t lik

ely

Poss

ible

: Clu

ster

6, 8

, 5, 7

U

nlik

ely:

Clu

ster

10,

11,

12,

13,

14,

15,

18

R

are:

C

lust

er 1

, 2, 3

, 4, 1

6, 1

7, 1

9, 2

0,

21

9. 5

Clu

ster

5

Non

-Psy

chot

ic D

isor

der (

Very

Sev

ere)

C

ompl

ex L

evel

Inte

rven

tions

In

dica

tive

Epi

sode

of C

are:

1-3

Yea

rs (C

lust

er R

evie

ws

Ever

y 6

Mon

ths)

The

serv

ice

user

s in

this

clu

ster

are

like

ly to

requ

ire m

ore

inte

nsiv

e in

put,

such

as

acce

ss to

hom

e tr

eatm

ent/

inpa

tient

s. T

he re

sear

ch e

vide

nce

is c

lear

that

the

know

ledg

eabl

e an

d ex

perie

nced

ther

apis

ts a

re re

quire

d, b

ut is

less

spe

cific

abo

ut th

e m

odal

ity re

quire

d. A

hig

h pr

opor

tion

of p

eopl

e in

this

clu

ster

will

hav

e re

ceiv

ed

psyc

holo

gica

l tre

atm

ent i

n pr

imar

y ca

re a

nd/o

r sec

onda

ry c

are.

It i

s re

com

men

ded

that

a d

etai

led

psyc

holo

gica

l for

mul

atio

n by

an

expe

rienc

ed p

sych

olog

ical

pra

ctiti

oner

(w

orki

ng a

t the

com

plex

leve

l) sh

ould

con

trib

ute

the

psyc

holo

gica

l ele

men

t to

the

MD

T fo

rmul

atio

n, a

nd a

dvis

e on

the

psyc

holo

gica

l asp

ects

of c

are

deliv

ered

by

the

team

/ser

vice

. Lon

ger t

erm

psy

chol

ogic

al th

erap

y (C

BT,

CA

T, D

BT,

psy

chod

ynam

ic/p

sych

oana

lytic

and

hum

anis

tic) m

ust b

e co

nsid

ered

. Int

erve

ntio

n pl

ans

are

likel

y to

id

entif

y w

ays

to e

nhan

ce m

otiv

atio

n to

cha

nge

/ en

gage

men

t; ad

here

nce

to a

n in

terv

entio

n; e

nhan

cing

insi

ght;

redu

cing

risk

& fo

cusi

ng o

n de

velo

ping

a c

olla

bora

tive

fo

rmul

atio

n.

Serv

ice

user

s w

ho d

eclin

e/ar

e no

t abl

e to

acc

ess

one-

to-o

ne p

sych

olog

ical

ther

apy

shou

ld h

ave

psyc

holo

gica

l thi

nkin

g fo

rm p

art o

f the

ir ca

re.

N

ICE

Gui

danc

e Fi

rst L

ine

Trea

tmen

t Se

cond

Lin

e Tr

eatm

ent

Des

crip

tion

This

gro

up w

ill b

e se

vere

ly d

epre

ssed

an

d/or

anx

ious

and

/or o

ther

. The

y w

ill n

ot

pres

ent w

ith d

istre

ssin

g ha

lluci

natio

ns o

r de

lusi

ons

but m

ay h

ave

som

e un

reas

onab

le b

elie

fs. T

hey

may

ofte

n be

at

hig

h ris

k fo

r sui

cide

and

they

may

pr

esen

t saf

egua

rdin

g is

sues

and

hav

e se

vere

dis

rupt

ion

to e

very

day

livin

g.

Dep

ress

ion

(CG

90 O

ct 2

009)

C

onsi

der f

irst l

ine

treat

men

ts a

s C

G90

. Con

side

r re-

intro

duci

ng s

tep

2 an

d 3

(i.e.

clu

ster

s 1-

3) tr

eatm

ents

that

hav

e be

en in

adeq

uate

ly a

dher

ed to

(i.e

. CB

T, m

indf

ulne

ss b

ased

co

gniti

ve th

erap

y, IP

T, c

ouns

ellin

g, p

sych

odyn

amic

psy

chot

hera

py, T

he fu

ll ra

nge

of

high

-inte

nsity

psy

chol

ogic

al in

terv

entio

ns s

houl

d no

rmal

ly b

e of

fere

d in

inpa

tient

set

tings

w

hen

ther

e is

a s

igni

fican

t ris

k of

sui

cide

, sel

f har

em o

r sel

f neg

lect

. How

ever

, con

side

r in

crea

sing

the

inte

nsity

and

dur

atio

n of

the

inte

rven

tions

and

ens

ure

that

they

can

be

prov

ided

effe

ctiv

ely

and

effic

ient

ly o

n di

scha

rge.

Hum

anis

tic

Em

otio

n fo

cuse

d th

erap

y; p

erso

n ce

nter

ed th

erap

y an

d ex

perie

ntia

l ps

ycho

ther

apy

A v

arie

ty o

f sys

tem

ic/fa

mily

/cou

ple

treat

men

ts fo

und

to b

e ef

fect

ive.

Th

e st

rong

est s

tudy

was

Lef

f et a

l. (2

000)

on

man

ualis

ed s

yste

mic

co

uple

s th

erap

y.

Dia

gnos

is

F32

Dep

ress

ive

Epi

sode

(Non

-ps

ycho

tic) F

40 P

hobi

c An

xiet

y D

isor

ders

, F4

1 O

ther

Anx

iety

Dis

orde

rs, F

42 O

CD

, F4

3 St

ress

Rea

ctio

n / A

djus

tmen

t D

isor

der,

F44

Dis

soci

ativ

e D

isor

der,

F45

Som

atof

orm

Dis

orde

r, F4

8 O

ther

Neu

rotic

D

isor

ders

, F50

Eat

ing

Dis

orde

r.

Dep

ress

ion

& P

hysi

cal

Hea

lth

(CG

91 O

ct 2

009)

Con

side

r firs

t lin

e tre

atm

ents

as

CG

90. b

ehav

iour

al c

oupl

es th

erap

y fo

r tho

se w

ith

chro

nic

phys

ical

hea

lth p

robl

ems)

. Aw

aren

ess

of d

rug

inte

ract

ions

ass

ocia

ted

with

de

pres

sion

and

chr

onic

phy

sica

l hea

lth p

robl

em. T

he fu

ll ra

nge

of h

igh-

inte

nsity

ps

ycho

logi

cal i

nter

vent

ions

sho

uld

norm

ally

be

offe

red

in in

patie

nt s

ettin

gs w

hen

ther

e is

a

sign

ifica

nt ri

sk o

f sui

cide

, sel

f har

em o

r sel

f neg

lect

. How

ever

, con

side

r inc

reas

ing

the

inte

nsity

and

dur

atio

n of

the

inte

rven

tions

and

ens

ure

that

they

can

be

prov

ided

ef

fect

ivel

y an

d ef

ficie

ntly

on

disc

harg

e.

A

nxie

ty

GA

D (C

G11

3 Ja

n 20

11)

CB

T: P

eopl

e w

ho h

aven

't re

ceiv

ed in

terv

entio

ns in

ste

ps 1

-3 s

houl

d ha

ve th

ese

offe

red

agai

n (s

ee c

lust

ers

1-3)

. If t

here

is in

suffi

cien

t res

pons

e, C

BT

shou

ld b

e of

fere

d w

ith a

th

erap

ist w

ith e

xper

tise

in th

e ps

ycho

logi

cal t

reat

men

t of c

ompl

ex, t

reat

men

t-ref

ract

ory

anxi

ety

diso

rder

s.

A

nxie

ty

PD

(CG

113

Jan

2011

) C

BT

shou

ld b

e of

fere

d w

ith a

n ex

perie

nced

ther

apis

t. H

ome

base

d C

BT

shou

ld b

e co

nsid

ered

if c

linic

atte

ndan

ce is

pro

blem

atic

. Use

stru

ctur

ed p

robl

em s

olvi

ng if

ap

prop

riate

.

Impa

irmen

t M

oder

ate

or s

ever

e pr

oble

ms

with

re

latio

nshi

ps.

Leve

l of p

robl

ems

in o

ther

ar

eas

of ro

le.

PTSD

(C

G26

Sep

t 200

6)

Con

side

r re-

intro

duci

ng s

tep

3 an

d 4

(i.e.

clu

ster

s 3-

4) tr

eatm

ents

that

hav

e be

en

inad

equa

tely

adh

ered

to, i

f app

ropr

iate

with

indi

vidu

als

need

s.

Ris

k Li

kely

mod

erat

e or

sev

ere

risk

of s

uici

de

with

oth

er p

ossi

ble

risk

(inc.

Saf

egua

rdin

g is

sues

if re

spon

sibl

e fo

r you

nger

chi

ldre

n or

vul

nera

ble

adul

ts).

Self

Har

m

(CG

16; 2

004

revi

sed

Feb

2012

)

Psy

chos

ocia

l ass

essm

ent.

Inte

nsiv

e th

erap

eutic

inte

rven

tions

(for

at l

east

3 m

onth

s).

DB

T co

mpr

ehen

sive

. D

BT

for s

ervi

ce u

sers

dia

gnos

ed w

ith b

ipol

ar p

erso

nalit

y di

sord

er.

Psy

chot

hera

py (N

OS

). Y

oung

peo

ple:

Dev

elop

men

tal g

roup

psy

chot

hera

py.

Eac

h ep

isod

e of

sel

f-har

m s

houl

d be

trea

ted

in it

s ow

n rig

ht a

nd a

per

son'

s in

divi

dual

re

ason

s fo

r sel

f-har

m m

ay v

ary

from

epi

sode

to e

piso

de.

If bi

pola

r per

sona

lity

diso

rder

Pre

sent

: CB

T: P

D: s

chem

a fo

cuse

d th

erap

y; C

BT.

P

sych

odyn

amic

psy

chot

hera

py.

40 s

essi

ons

over

12

mon

ths.

P

D: 1

:1.

Psy

ch- N

OS:

Bas

ed th

erap

y; th

erap

eutic

com

mun

ity; C

AT

- ad

oles

cent

s; S

TEPP

S.

CA

T, 2

4 se

ssio

ns o

ver 1

2 m

onth

s to

targ

et s

igni

fican

t rel

atio

nshi

p pr

oble

ms.

E

xplic

it m

enta

lisat

ion

grou

ps.

Cou

rse

Pro

babl

y kn

own

to s

ervi

ce fo

r mor

e th

an

one

year

or e

xpec

ted

to b

e kn

own

for a

n

exte

nded

per

iod.

OC

D B

DD

(C

G31

Nov

200

5)

Effe

ctiv

e tre

atm

ents

sho

uld

be o

ffere

d at

all

leve

ls. T

reat

men

t at t

his

leve

l will

refle

ct

incr

easi

ng e

xper

ienc

e an

d ex

perti

se in

the

impl

emen

tatio

n of

a li

mite

d ra

nge

of

ther

apeu

tic o

ptio

ns. C

BT

with

SS

RI (

incl

udin

g E

RP)

. Con

side

r fam

ily w

ork

in E

RP

, if

appr

opria

te.

Con

side

r hom

e tre

atm

ent.

The

stud

ies

are

near

ly a

ll of

fam

ily b

ased

CB

T w

hich

is fo

und

to b

e ef

fect

ive.

Page 21

Mental health clustering and psychological interventions 19

Clu

ster

tran

sitio

ns

Mos

t lik

ely

No

Cha

nge

Po

ssib

le: C

lust

er 7

or n

o si

gnifi

cant

M

H p

robl

ems

Unl

ikel

y: C

lust

er 8

, 10,

11,

12,

13,

14,

15

, 18

Rar

e: C

lust

er 1

, 2, 3

, 4, 5

, 16,

17,

19,

20

, 21

9.6

Clu

ster

6

Non

-Psy

chot

ic D

isor

der o

f Ove

r-Va

lued

Idea

s

Com

plex

Lev

el In

terv

entio

ns

Indi

cativ

e E

piso

de o

f Car

e: 3

Yea

rs+

(Clu

ster

Rev

iew

s Ev

ery

6 M

onth

s)

At t

his

com

plex

leve

l of i

nter

vent

ion,

the

rese

arch

evi

denc

e is

cle

ar th

at th

e kn

owle

dgea

ble

and

expe

rienc

ed th

erap

ists

are

requ

ired,

but

is le

ss s

peci

fic a

bout

the

mod

ality

re

quire

d. T

here

fore

, ser

vibl

y qu

alifi

ed a

nd

expe

rienc

ed.

It is

reco

mm

ende

d th

at lo

nger

term

psy

chol

ogic

al th

erap

y (C

BT,

CA

T, D

BT,

psy

chod

ynam

ic/p

sych

oana

lytic

and

hum

anis

tic) m

ust b

e co

nsid

ered

. Se

rvic

e us

ers

who

dec

line/

are

not a

ble

to a

cces

s on

e-to

-one

psy

chol

ogic

al th

erap

y sh

ould

hav

e ps

ycho

logi

cal t

hink

ing

form

par

t of t

heir

care

. An

expe

rienc

ed p

sych

olog

ical

pr

actit

ione

r (w

orki

ng a

t the

com

plex

leve

l) sh

ould

con

trib

ute

the

psyc

holo

gica

l ele

men

t to

the

MD

T fo

rmul

atio

n, a

nd a

dvis

e on

the

psyc

holo

gica

l asp

ects

of c

are

deliv

ered

by

the

team

/ser

vice

. C

ombi

natio

n of

bio

logi

cal a

nd p

sych

olog

ical

trea

tmen

ts o

ften

give

s be

st o

utco

mes

. N

ICE

Gui

danc

e Fi

rst L

ine

Trea

tmen

t Se

cond

Lin

e Tr

eatm

ent

Des

crip

tion

Mod

erat

e to

ver

y se

vere

dis

orde

rs th

at

are

diffi

cult

to tr

eat.

This

may

incl

ude

treat

men

t res

ista

nt e

atin

g di

sord

er, O

CD

et

c, w

here

ext

rem

e be

liefs

are

stro

ngly

he

ld, s

ome

pers

onal

ity d

isor

ders

and

en

durin

g de

pres

sion

.

Dep

ress

ion

(CG

90 O

ct 2

009)

C

onsi

der f

irst l

ine

treat

men

ts a

s C

G90

. Con

side

r re-

intro

duci

ng s

tep

2 an

d 3

(i.e.

clu

ster

s 1-

3) tr

eatm

ents

that

hav

e be

en in

adeq

uate

ly a

dher

ed to

(i.e

. CB

T, m

indf

ulne

ss b

ased

cog

nitiv

e th

erap

y, IP

T, c

ouns

ellin

g, p

sych

odyn

amic

ps

ycho

ther

apy,

beh

avio

ural

cou

ples

ther

apy

for t

hose

with

chr

onic

phy

sica

l hea

lth p

robl

ems)

. Aw

aren

ess

of d

rug

inte

ract

ions

ass

ocia

ted

with

dep

ress

ion

and

chro

nic

phys

ical

hea

lth p

robl

em. H

owev

er, c

onsi

der i

ncre

asin

g th

e in

tens

ity a

nd d

urat

ion

of th

e in

terv

entio

ns a

nd e

nsur

e th

at th

ey c

an b

e pr

ovid

ed e

ffect

ivel

y an

d ef

ficie

ntly

on

disc

harg

e.

Hum

anis

tic

Em

otio

n fo

cuse

d th

erap

y; P

erso

n ce

ntre

d th

erap

y an

d ex

perie

ntia

l psy

chot

hera

py.

A v

arie

ty o

f sys

tem

ic/fa

mily

/cou

ple

treat

men

ts fo

und

to b

e ef

fect

ive.

The

st

rong

est s

tudy

was

Lef

f et a

l. (2

000)

on

man

ualis

ed s

yste

mic

cou

ples

ther

apy.

Dep

ress

ion

&

Phys

ical

Hea

lth (C

G91

Oct

20

09)

Con

side

r firs

t lin

e tre

atm

ents

as

CG

90.

How

ever

, con

side

r inc

reas

ing

the

inte

nsity

and

dur

atio

n of

the

inte

rven

tions

and

ens

ure

that

they

can

be

prov

ided

effe

ctiv

ely

and

effic

ient

ly o

n di

scha

rge.

Dia

gnos

is

F32

Dep

ress

ive

Epi

sode

(Non

-psy

chot

ic)

F33

Rec

urre

nt D

epre

ssiv

e E

piso

de (n

on

psy

chot

ic) F

40 P

hobi

c A

nxie

ty D

isor

ders

, F4

1 O

ther

Anx

iety

Dis

orde

rs, F

42 O

CD

, F4

3 S

tress

Rea

ctio

n / A

djus

tmen

t Dis

orde

r, F4

4 D

isso

ciat

ive

Dis

orde

r, F4

5 S

omat

ofor

m D

isor

der,

F48

Oth

er N

euro

tic

Dis

orde

rs, F

50 E

atin

g D

isor

der &

som

e F6

0 (P

erso

nalit

y D

isor

ders

).

Anx

iety

GA

D

(CG

113

Jan

2011

) C

BT:

Peo

ple

who

hav

en't

rece

ived

inte

rven

tions

in s

teps

1-3

sho

uld

have

thes

e of

fere

d ag

ain

(see

clu

ster

s 1-

3). I

f th

ere

is in

suffi

cien

t res

pons

e, C

BT

shou

ld b

e of

fere

d w

ith a

ther

apis

t with

exp

ertis

e in

the

psyc

holo

gica

l tre

atm

ent

of c

ompl

ex, t

reat

men

t-ref

ract

ory

anxi

ety

diso

rder

s.

Aw

aren

ess

of d

rug

inte

ract

ions

ass

ocia

ted

with

anx

iety

.

A

nxie

ty P

D

(CG

113

Jan

2011

) C

BT

shou

ld b

e of

fere

d w

ith a

n ex

perie

nced

ther

apis

t. H

ome

base

d C

BT

shou

ld b

e co

nsid

ered

if c

linic

atte

ndan

ce

is p

robl

emat

ic. U

se s

truct

ured

pro

blem

sol

ving

if a

ppro

pria

te.

PTSD

(C

G26

Sep

t 200

6)

CB

T: T

raum

a fo

cuse

d in

divi

dual

CBT

or E

MD

R fo

r sev

ere

PTS

D w

ithin

1 m

onth

and

with

in 3

mon

ths

of th

e ev

ent

(incl

udin

g ol

der c

hild

ren)

con

side

r bey

ond

12 s

essi

ons.

P

sych

othe

rapy

NO

S a

ltern

ativ

e tra

uma

base

d ps

ycho

logi

cal t

reat

men

ts.

Impa

irmen

t Li

kely

to s

erio

usly

affe

ct a

ctiv

ity a

nd ro

le

func

tioni

ng in

man

y w

ays.

Self

Har

m

(CG

16; 2

004

revi

sed

Feb

2012

) Psy

chos

ocia

l ass

essm

ent.

Inte

nsiv

e th

erap

eutic

inte

rven

tions

(for

at l

east

3 m

onth

s).

DB

T co

mpr

ehen

sive

. D

BT

for s

ervi

ce u

sers

dia

gnos

ed w

ith b

ipol

ar p

erso

nalit

y di

sord

er.

Psy

chot

hera

py (N

OS

). Y

oung

peo

ple:

Dev

elop

men

tal g

roup

psy

chot

hera

py.

Eac

h ep

isod

e of

sel

f-har

m s

houl

d be

trea

ted

in it

s ow

n rig

ht a

nd a

per

son'

s in

divi

dual

reas

ons

for s

elf-h

arm

may

va

ry fr

om e

piso

de to

epi

sode

.

If bi

pola

r per

sona

lity

diso

rder

Pre

sent

: CB

T:

PD

: Sch

ema

Focu

sed

Ther

apy;

CB

T P

sych

odyn

amic

psy

chot

hera

py.

40 s

essi

ons

over

12

mon

ths.

P

D: 1

:1.

Psy

ch- N

OS

: Bas

ed T

hera

py; T

hera

peut

ic

Com

mun

ity; C

AT

- ado

lesc

ents

; STE

PP

S.

CA

T, 2

4 se

ssio

ns o

ver 1

2 m

onth

s to

targ

et

sign

ifica

nt re

latio

nshi

p pr

oble

ms.

E

xplic

it m

etal

lisat

ion

grou

ps.

Ris

k U

nlik

ely

to b

e a

maj

or fe

atur

e bu

t sa

fegu

ardi

ng m

ay b

e an

issu

es if

any

re

spon

sibi

lity

for y

oung

chi

ldre

n or

vu

lner

able

dep

ende

nt a

dults

.

OC

D B

D

(CG

31 N

ov 2

005)

In

tens

ive.

CB

T: 2

0-24

ses

sion

s ov

er 4

-10

mon

ths

incl

udin

g fo

llow

up.

Tr

eatm

ents

sho

uld

be o

ffere

d at

all

leve

ls. T

reat

men

t at t

his

leve

l will

refle

ct in

crea

sing

exp

erie

nce

and

expe

rtise

in

the

impl

emen

tatio

n of

a li

mite

d ra

nge

of th

erap

eutic

opt

ions

. CB

T w

ith S

SR

I (in

clud

ing

ER

P).

Con

side

r fam

ily w

ork

in E

RP,

if a

ppro

pria

te.

Con

side

r hom

e tre

atm

ent.

The

stud

ies

are

near

ly a

ll of

fam

ily b

ased

C

BT

whi

ch is

foun

d to

be

effe

ctiv

e.

Cou

rse

The

prob

lem

s w

ith b

e en

durin

g.

Eatin

g D

isor

der

(CG

9 Ja

n 20

04)

Con

side

r evi

denc

e ba

sed

GS

H.

Ano

rexi

a ne

rvos

a: C

onsi

der 1

:1 C

AT/

CB

E/IP

T/fo

cal d

ynam

ic th

erap

y/fa

mily

inte

rven

tions

- 6 m

onth

s du

ratio

n.

Con

side

r mov

e to

inte

nsiv

e fo

rms

of tr

eatm

ent-

indi

vidu

al th

erap

y an

d fa

mily

wor

k; d

ay c

are

or in

patie

nts.

In

patie

nts

focu

sed

psyc

hoth

erap

y N

OS

on

eatin

g be

havi

our &

atti

tude

s to

wei

ght/s

hape

. B

ulim

ia n

ervo

sa C

BT-

BN

/IPT.

Adm

issi

on a

s in

patie

nt o

r day

pat

ient

con

side

red

if ris

k of

sui

cide

or s

ever

e se

lf ha

rm

or m

ore

inte

nsiv

e ou

tpat

ient

s.

Bin

ge e

atin

g di

sord

er- (

CBT

-BE

D).

ED

NO

S c

lose

st tr

eatm

ent.

Con

side

r DB

T w

hen

pers

onal

ity d

isor

der

is c

ompl

icat

ing

treat

men

t out

com

es

/con

side

r for

inpa

tient

s al

ongs

ide

othe

r tre

atm

ents

. S

ome

evid

ence

of e

ffect

iven

ess

of fa

mily

th

erap

y w

ith a

dults

and

an

ongo

ing

RC

T of

two

form

s of

man

ualis

ed s

yste

mic

th

erap

ies

in th

e U

SA. F

amily

ther

apis

ts

repo

rt m

ore

succ

ess

with

clie

nts

unde

r 21.

Page 22

20 Mental health clustering and psychological interventions

C

lust

er tr

ansi

tions

M

ost l

ikel

y N

o C

hang

e

Pos

sibl

e:

Unl

ikel

y:

No

sign

ifica

nt M

H

prob

lem

s, C

lust

er 8

, 10,

11,

12,

13,

14

, 15,

16,

17,

18

Rar

e:

Clu

ster

1, 2

, 3, 4

, 5, 6

, 19,

20

, 21

9.7

Clu

ster

7

Non

-Psy

chot

ic D

isor

der (

Hig

h D

isab

ility)

C

ondi

tion

Spe

cific

and

Com

plex

Lev

el In

terv

entio

ns

Indi

cativ

e E

piso

de o

f Car

e: 3

+ Y

ears

(Clu

ster

Rev

iew

s A

nnua

lly)

At th

is c

ompl

ex le

vel o

f int

erve

ntio

n, th

e re

sear

ch e

vide

nce

is c

lear

that

the

know

ledg

eabl

e an

d ex

perie

nced

ther

apis

ts a

nd th

eir c

linic

al ju

dgem

ent a

nd d

etai

led

form

ulat

ion

is re

quire

d, b

ut is

less

spe

cific

abo

ut th

e ty

pe o

f mod

ality

requ

ired.

A h

igh

prop

ortio

n of

peo

ple

in th

is c

lust

er w

ill h

ave

rece

ived

psy

chol

ogic

al tr

eatm

ent i

n pr

imar

y ca

re a

nd/o

r sec

onda

ry c

are

The

focu

s is

like

ly to

be

base

d on

a re

cove

ry m

odel

and

inte

rven

tions

offe

red

are

likel

y to

be

dete

rmin

ed b

y w

hat h

as b

een

offe

red

in th

e pa

st a

nd w

hat h

as b

een

help

ful.

Psyc

holo

gica

l for

mul

atio

n is

like

ly to

focu

s on

the

ther

apeu

tic a

spec

ts o

f del

iver

ing

inte

rven

tions

, suc

h as

read

ines

s to

cha

nge,

on

the

mod

ality

of t

hera

py (C

BT

vs. C

AT v

s.

rapi

st w

ho d

eliv

ers

it is

sui

tabl

y qu

alifi

ed a

nd e

xper

ienc

ed. I

t is

reco

mm

ende

d th

at lo

nger

term

psy

chol

ogic

al th

erap

y (C

BT,

CAT

, DB

T,

psyc

hody

nam

ic/p

sych

oana

lytic

and

hum

anis

tic) m

ust b

e co

nsid

ered

and

/or t

he s

ervi

ce u

ser s

houl

d ha

ve p

sych

olog

ical

thin

king

form

par

t of t

heir

care

. An

expe

rienc

ed p

sych

olog

ical

pra

ctiti

oner

(wor

king

at t

he c

ompl

ex le

vel)

shou

ld c

ontr

ibut

e th

e ps

ycho

logi

cal e

lem

ent t

o th

e M

DT

form

ulat

ion,

and

adv

ise

on th

e ps

ycho

logi

cal a

spec

ts o

f car

e de

liver

ed b

y th

e te

am/s

ervi

ce.

N

ICE

Gui

danc

e Fi

rst L

ine

Trea

tmen

t Se

cond

Lin

e Tr

eatm

ent

Des

crip

tion

This

gro

up s

uffe

rs fr

om m

oder

ate

to s

ever

e di

sord

ers

that

are

ver

y di

sabl

ing.

The

y w

ill h

ave

rece

ived

tre

atm

ent f

or a

num

ber o

f yea

rs

and

alth

ough

they

may

hav

e im

prov

emen

t in

posi

tive

sym

ptom

s co

nsid

erab

le d

isab

ility

rem

ains

that

is

like

ly to

affe

ct ro

le fu

nctio

ning

in

man

y w

ays.

Dep

ress

ion

(CG

90 O

ct 2

009)

C

onsi

der f

irst l

ine

treat

men

ts a

s C

G90

. re-

intro

duci

ng s

tep

2 an

d 3

(i.e.

clu

ster

s 1-

3) tr

eatm

ents

that

hav

e be

en in

adeq

uate

ly a

dher

ed to

(i.e

. CB

T, M

indf

ulne

ss B

ased

C

ogni

tive

Ther

apy,

IPT,

cou

nsel

ling,

psy

chod

ynam

ic p

sych

othe

rapy

,. Th

e fu

ll ra

nge

of h

igh-

inte

nsity

psy

chol

ogic

al in

terv

entio

ns s

houl

d no

rmal

ly b

e of

fere

d in

inpa

tient

se

tting

s w

hen

ther

e is

a s

igni

fican

t ris

k of

sui

cide

, sel

f har

em o

r sel

f neg

lect

.. H

owev

er, c

onsi

der i

ncre

asin

g th

e in

tens

ity a

nd d

urat

ion

of th

e in

terv

entio

ns a

nd

ensu

re th

at th

ey c

an b

e pr

ovid

ed e

ffect

ivel

y an

d ef

ficie

ntly

on

disc

harg

e.

Hum

anis

tic.

Emot

ion

Focu

sed

Ther

apy;

Per

son

Cen

tere

d Th

erap

y an

d E

xper

ient

ial P

sych

othe

rapy

. N

on-d

irect

ive

coun

selin

g at

hom

e D

epre

ssio

n no

t res

pond

ing,

ev

iden

ce o

n st

rate

gies

is li

mite

d- th

eref

ore

a co

nsul

tatio

n m

odel

is re

com

men

ded.

A

var

iety

of s

yste

mic

/fam

ily/c

oupl

e tre

atm

ents

foun

d to

be

effe

ctiv

e. T

he s

trong

est s

tudy

was

Lef

f et a

l. (2

000)

on

man

ualis

ed s

yste

mic

cou

ples

ther

apy.

D

epre

ssio

n &

P

hysi

cal H

ealth

(CG

91 O

ct

2009

)

Con

side

r firs

t lin

e tre

atm

ents

as

CG

90. C

onsi

der b

ehav

iour

al c

oupl

es th

erap

y fo

r th

ose

with

chr

onic

phy

sica

l hea

lth p

robl

ems)

. Aw

aren

ess

of d

rug

inte

ract

ions

as

soci

ated

with

dep

ress

ion

and

chro

nic

phys

ical

hea

lth p

robl

em. T

he fu

ll ra

nge

of

high

-inte

nsity

psy

chol

ogic

al in

terv

entio

ns s

houl

d no

rmal

ly b

e of

fere

d in

inpa

tient

se

tting

s w

hen

ther

e is

a s

igni

fican

t ris

k of

sui

cide

, sel

f har

em o

r sel

f neg

lect

.. H

owev

er, c

onsi

der i

ncre

asin

g th

e in

tens

ity a

nd d

urat

ion

of th

e in

terv

entio

ns a

nd

ensu

re th

at th

ey c

an b

e pr

ovid

ed e

ffect

ivel

y an

d ef

ficie

ntly

on

disc

harg

e.

Dia

gnos

is

F32

Dep

ress

ive

Epi

sode

(Non

-ps

ycho

tic) F

33

Rec

urre

nt

Dep

ress

ive

Epi

sode

(non

psyc

hotic

) F40

Pho

bic

Anx

iety

D

isor

ders

, F41

Oth

er A

nxie

ty

Dis

orde

rs, F

42 O

CD

, F43

Stre

ss

Rea

ctio

n / A

djus

tmen

t Dis

orde

r, F4

4 D

isso

ciat

ive

Dis

orde

r, F4

5 S

omat

ofor

m D

isor

der,

F48

Oth

er

Neu

rotic

Dis

orde

rs, F

50 E

atin

g D

isor

der &

som

e F6

0 (P

erso

nalit

y D

isor

ders

).

Anx

iety

GA

D

(CG

113

Jan

2011

) C

BT:

Peo

ple

who

hav

en't

rece

ived

inte

rven

tions

in s

teps

1-3

sho

uld

have

thes

e of

fere

d ag

ain

(see

clu

ster

s 1-

3). I

f the

re is

insu

ffici

ent r

espo

nse,

CBT

sho

uld

be

offe

red

with

a th

erap

ist w

ith e

xper

tise

in th

e ps

ycho

logi

cal t

reat

men

t of c

ompl

ex,

treat

men

t-ref

ract

ory

anxi

ety

diso

rder

s.

CB

T po

ssib

ly h

ome

base

d/st

ruct

ured

pro

blem

sol

ving

.

A

nxie

ty P

D

(CG

113

Jan

2011

) C

BT

shou

ld b

e of

fere

d w

ith a

n ex

perie

nced

ther

apis

t. H

ome

base

d C

BT

shou

ld b

e co

nsid

ered

if c

linic

atte

ndan

ce is

pro

blem

atic

. Use

stru

ctur

ed p

robl

em s

olvi

ng if

ap

prop

riate

.

P

TSD

(C

G26

Sep

t 200

6)

CB

T: T

raum

a fo

cuse

d in

divi

dual

CB

T or

EM

DR

for s

ever

e P

TSD

with

in 1

mon

th

and

with

in 3

mon

ths

of th

e ev

ent (

incl

udin

g ol

der c

hild

ren)

con

side

r bey

ond

12

sess

ions

P

sych

othe

rapy

NO

S a

ltern

ativ

e tra

uma

base

d ps

ycho

logi

cal t

reat

men

ts.

If se

rvic

e us

er n

ot a

ble

to e

ngag

e in

act

ive

treat

men

t, co

nsul

tatio

n an

d fo

rmul

atio

n m

odel

reco

mm

ende

d to

info

rm

care

pla

n w

ith re

gula

r rev

iew

s.

Impa

irmen

t Li

kely

to s

erio

usly

affe

ct a

ctiv

ity

and

role

func

tioni

ng in

man

y w

ays.

Sel

f Har

m

(CG

16; 2

004

revi

sed

Feb

2012

) P

sych

osoc

ial a

sses

smen

t: In

tens

ive

ther

apeu

tic in

terv

entio

ns o

ver 3

+ m

onth

s.

DB

T co

mpr

ehen

sive

. D

BT

for s

ervi

ce u

sers

dia

gnos

ed w

ith b

ipol

ar p

erso

nalit

y di

sord

er.

Psy

chot

hera

py (N

OS

). Y

oung

peo

ple:

Dev

elop

men

tal g

roup

psy

chot

hera

py.

Eac

h ep

isod

e of

sel

f-har

m s

houl

d be

trea

ted

in it

s ow

n rig

ht a

nd a

per

son'

s in

divi

dual

reas

ons

for s

elf-h

arm

may

var

y fro

m e

piso

de to

epi

sode

.

Rev

iew

inte

rven

tions

with

ser

vice

use

rs fr

om re

com

men

ded

bipo

lar p

erso

nalit

y di

sord

er s

econ

d lin

e tre

atm

ents

(clu

ster

6).

If se

rvic

e us

er n

ot a

ble

to e

ngag

e in

act

ive

treat

men

t, C

onsu

ltatio

n an

d fo

rmul

atio

n m

odel

reco

mm

ende

d w

ith re

gula

r re

view

s.