How to provide more hours of talking therapies without blowing the budget
“One beauty of the stepped care model is that if it’s not working or change is not occurring you can step [the person] up to another level of therapy or change the type of therapy.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
In 2008 Waitemata DHB faced two challenges. First, a survey showed that more people wanted access to talking therapies than could be seen. Second, they lacked systems for assessing the delivery and effectiveness of talking therapy. Waitemata clinical psychologist Tina Earl and colleague Jo Rogan-Gibson identified a system that provided more hours of talking therapy, assessed progress and showed how more people are making positive changes more quickly.
Pictured right: Tina Earl.
Stepped care - the smart solution
After looking at practice internationally Tina and Jo thought the Stepped Care model from the UK could help solve their problems. It appealed because it aims to ensure people who need therapy don’t miss out, and that therapy is effective.
“If we wanted to be involved in effective talking therapy delivery, we needed some kind of model.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
The Waitemata pilot was guided by the 2007 NICE Guidelines, which state that the treatment with the best chance of achieving positive outcomes using the least invasive manner should be used. The therapy progress should be regularly reviewed and stepped up or down if needed.
Stepped Care matches service users with an intensity of therapy that suits the severity of their needs. People with higher needs receive more hours of more complex therapies (see Figure 1 for more detail). Waitemata DHB aimed split their therapy resources evenly between Level 2 and Level 3.
Figure 1. The levels of the Stepped Care.
“Dividing the intensities [of therapy] into different levels was useful,” says psychologist Vania Miteva (pictured right), “because when we had people who the team thought would do well at Level 2 it was provided by [non-psychologist] staff.”
As a result psychologists were freed to deal with more severe problems at Level 3. “It reduced the waitlist so…people could be seen sooner,” Vania explains.
Nurse Karina Cooke (pictured right), a Level 2 therapist, uses her new skills in her care coordinator role and therapy sessions.
Karina works differently now and her job is less stressful. “I don’t have to be the problem solver now,” she says. Before learning Solution Focused Therapy she would get stuck and wonder what on earth to do. “Now I get all the answers from my clients”.
A shorter pathway to better mental health
Part of the solution was a pathway to guide people through Stepped Care, so gains occur as quickly as possible. Tina Earl says that more therapy does not always mean better gains. With the Stepped Care pathway, outcomes are reviewed every eight weeks. If things aren’t improving, the person is moved to a different therapy and/or therapist, or the next level.
Figure 2. Stepped Care pathway
Figure 2 illustrates this pathway. Each person accepted for therapy:
- enters the service and is assessed
- their needs are considered by the multi-disciplinary team (MDT)
- they are quickly referred to most suitable type and intensity of therapy
- they undergo therapy for eight weeks
- their outcomes data is collated
- the outcomes of therapy are reviewed by the MDT after eight weeks
- they are discharged if the outcomes show they no longer need a clinical intervention. If not, the approach is changed.
After discharge a person can ask their GP to refer them again, if needed. Psychologist Vania likes the way the system matches clients with clinicians and therapies. “This brings much better results, much faster,” she says. Matching is determined by clinical judgment, and checked using the Session Rating Tool. The team may decide that someone who seems nearly ready to change may find motivational interviewing helpful. They also consider matches by therapist approach. Vania says she is very fast-paced. So a client who needs repetition might do better with someone who is more relaxed and patient.
“There was nothing I could say that was bad about [my previous therapist]. She did her job and did it well and gave me lots of advice but…I don’t think I would have made as much progress [if I’d kept seeing her].” - Allan, Waitemata DHB service user
Vania happily refers to another therapist if needed. One client who did not progress with Cognitive Therapy was transferred to another therapist for Solution Focused Therapy. Now “she’s doing fantastically well,” Vania says.
Changing therapists isn’t always necessary. Most know multiple therapies so can try a different approach. One of Vania’s clients only made progress when they changed therapy. “It was obvious [from the Outcome Rating Scale] that the [first] therapy wasn’t working for her,” Vania says.
Does it work?
Tina Earl and colleagues wanted to assess the impact of the new model. They asked clinicians and clients to fill out two forms in the sessions.
- The Session Rating Scale, (SRS) which measures therapist-client rapport. Where there is a good alliance, evidence has shown the client’s outcomes tend to be better.
- The Outcome Rating Scale, (ORS) which measures changes experienced due to therapy.
“People sometimes went into therapy and it turned into a black hole – we wanted to know the outcome of therapy was effective.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
Research shows outcomes improve when therapists receive feedback from clients. When the therapeutic relationship is positive and the person experiences progress, they are more likely to continue therapy and improve, so it’s worthwhile asking. (See end of story for references to relevant websites.)
Vania thinks using both the ORS and SRS ensures the clinician goes beyond rapport and provides best therapy practice. “If the client likes you and rates you high but there is no change it’s not therapy – it’s just a friendly chat,” she observes.
“We decided we wanted a proper evaluation of the effectiveness of the model so we got AUT on board.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
DHB staff and Auckland University of Technology (AUT) evaluated the pilot. One year after it started:
- more than twice as many people had accessed talking therapies in the pilot area as in the comparison area
- this increase was for both one-to-one and group therapy
- the percentage of contact hours devoted to talking therapy in the pilot area was over twice that in the ‘treatment as usual’ area
- ORS and SRS measures showed significant improvements in personal and social wellbeing
- most gains were made in the first eight weeks, with less progress after this.
Please contact Tina Earl if you are interested in further information.
When Allan1 first approached Rodney Adult Mental Health Services with anxiety he saw a psychologist using cognitive behavioural therapy, something he found helpful. But a few months later felt he had stopped making progress. So he found courage to say he wanted to stop.
“I did get a panic about it [thinking] maybe I should have kept seeing him,” Allan says. “But I didn’t feel I was going to get anywhere.” Through Stepped Care he started with Marcia, a nurse therapist. They discussed any problems from his week using Solution Focused Therapy.
“If I couldn’t have seen anyone after [my previous therapist] I think I would have gone downhill very quickly.” - Allan, Waitemata DHB service user
“I prefer seeing Marcia,” Allan says. “She’s pretty straightforward, and she does encourage me to do things I wouldn’t do myself.” Consequently, he now does more socially. ”I find her to be easy to relate to. And the type of therapy is more generalised. Because we’re doing it over coffee and it’s more relaxed.”
“I’ve tried so many therapists and some have been good and some have been not so good. And when you do find a good one you don’t lose them.” - Allan, Waitemata DHB service user
Allan thinks anyone who isn’t making progress should try a different therapist or approach. In this example Allan felt that he benefited from a low level approach than higher intensity therapy input.
How the rodney mental health team did it without blowing the budget
The new system was introduced without overspending. More people were trained for the same cost, for example, by a trainer running courses at the DHB instead of staff going offsite. All other changes were made using existing staff skills, facilities and equipment. “Time and energy are the resources that are required,” Tina Earl says.
“Rather than sending people off on training we brought the trainer over here from Australia, and then we could train more people.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
More therapy was delivered by training non-psychologists, such as nurses and social workers to work at Level 2, who liked the opportunity to practice therapy. This freed up specialists to focus on more severe need at Level 3.
“We don’t want therapists choosing a whole lot of therapies at random. We want to say ‘which of these therapies are needed and which do you want to do and we’ll train you up in it.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
Therapy hours were used more efficiently. Outcomes were reviewed after eight weeks and as most gains were made before then, people didn’t stay in therapy longer than they needed to.
Process for introducing the stepped care model
Tina Earl and Jo Rogan-Gibson started the project in 2008. They were joined later by Waitemata mental health staff, and a project group of 15. They went through a number of steps.
- Tina looked at international research to determine which talking therapies and delivery models worked best.
- Tina and Jo identified which talking therapies DHB staff provided at that time; and what else was needed.
- In 2010 the pilot started at Rodney Adult Mental Health Services.
- The skills and training of nurses, occupational therapists and social workers to deliver talking therapies were assessed via interviews.
- The project team developed a pathway to streamline movement through Stepped Care for service users (see Figure 2).
- Measures of outcomes and therapeutic relationships were introduced (ORS and SRS).
- Training was provided in the Stepped Care model, the outcome rating scales; and in Level 2 low intensity therapies. Supervision for therapy was also given.
- Waitemata DHB and AUT evaluated the pilot.
“What we found was that quite a few clinicians had been trained in a therapy but were not getting an opportunity to practice it.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
With successful results from the pilot, the Stepped Care model for talking therapy will now be rolled out to other mental health teams in the DHB.
Throughout the process the project team talked with mental health staff about the new model, sought feedback and discussed concerns. This helped address misunderstandings. For example, one team decided to wait 28 days before referring clients to the treatment they’d been allocated to. Once they understood that Stepped Care involves moving people quickly into therapy they changed this.
The DHB faced some major challenges in introducing the Stepped Care model.
- Overcoming resistance to doing things differently. “It takes energy to change,” Tina says. “You can have all the models but unless [staff] actually engage and adopt it you get nowhere.”
- Training staff who didn’t usually work as therapists to take on that role.
- Organising the workplace so that these staff could implement talking therapies without reducing focus on existing work, or burning out from doing two roles.
- Doing all this within budget!
“…this project was aimed at increasing therapies and training up people.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
Tina Earl identified three things that created resistance.
Collecting information on therapeutic relationships and the impact of therapy
Some staff didn’t see the point. Those who understood how research could help them were more open. Psychologist Vania Miteva used ORS and SRS even before Stepped Care. “I’m convinced that when we use that assessment we can see changes and alter what we are doing,” she says. But she understands others’ hesitation. “It is quite anxiety-provoking for the clinician to be rated,” she explains.
Assessing therapist competence
“This was a real hornets’ nest,” Tina says. The aim was to enable clinicians with the appropriate level of skills to practice competently and safely.
“The onus was on [staff] to demonstrate their competency and where people did we were happy.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
Releasing clinicians from care coordinator roles to practice talking therapies
“It relied on the goodwill of a lot of people,” Tina says, as it placed more demands on other staff. It is an on-going issue.
“The problem with people working in other disciplines [like nursing] is that they haven’t been able to do therapy with people.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
Karina Cooke was interested in therapy even when working as a community mental health nurse and care coordinator. “So when the opportunity came up to do a workshop on Solution Focused Therapy I was excited,” she says.
Karina enjoys the change in focus and thinks it helps prevent burnout. “For years I’ve been talking about problems,” she says. “It can get a bit tedious, even for clinicians.”
Karina has also trained in DBT (Dialectic Behaviour Therapy) Lite approach. Using it she was able to see changes with someone who hadn’t responded to Solution Focused Therapy after eight weeks. “If I didn’t have the support of a psychologist I wouldn’t work [with this client] in this way, because she’s a Level 3 client and I’m a Level 2 therapist,” Karina explains. Karina took on this case because she was the person's key worker and had attended a group with her facilitated by a psychologist. When the client found that group too difficult to continue with, she had a discussion with Karina and the psychologist, and opted to continue individual therapy with Karina under the psychologist's supervision.
“We then realised that we needed more therapies because CBT and DBT do not suit everyone. We wanted to provide a greater variety of therapy because one size does not fit all.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
How does Karina manage her two roles? “I tried to fit therapy sessions in here and there but it was very stressful,” she says. “So now I keep [them] separate. Mornings are for client work, afternoons for care coordination.”
She hasn’t dropped any tasks with her new role, but did ask to go from 19-20 clients to 12. Her verdict? Karina would advise other nurses to take on the therapist role and training, because “it will help them in their work and it will help their clients”.
Strategies for success
Hugh O’Reilly (pictured right), Team Manager of Rodney Adult Mental Health Services was already enthusiastically training staff in cognitive-behavioural therapy (CBT) techniques when the idea of Stepped Care was suggested.
“It didn’t seem particularly complicated when Tina [Earl] approached me,” Hugh says. “We made quite a lot of mistakes actually, and you expect to do that in pilots.”
Tina agrees. “You can’t just introduce the Stepped Care model and bang! People pick it up,” she says. “We had to introduce this, change that. We had a lot of trial and error learning.”
When asked what she wouldn’t do again Tina quips “Everything!” Speaking seriously, she and Hugh suggest these strategies.
- Engage therapeutic staff: whether psychologists, nurses, social workers, or others. Hugh says “The first thing I’d do is sit down with the therapists – all of them – and say “this is the general framework of what we want to do but what do you think?”
- Communicate clearly: Hugh believes “the absolute key is communicate, communicate, communicate”. “With this kind of project there is potential for misunderstanding between disciplines. From the outset you need to be clear what the outcomes are.”
- Find the right people: Hugh would look for people to be champions of the project from the start, across disciplines, so they felt it was theirs. “It would have been far more successful if we’d gone a bit slower in the beginning and got that championship,” he thinks. “Getting people around you that you know are going to run with ideas is key,” Hugh adds. “Once you’ve got that, even if it’s difficult, you can make stuff happen.”
- Support from managers: Tina notes that staff need to make changes for the model to work. So it’s important managers motivate staff by pointing out potential positive outcomes, such as seeing changes in clients more quickly, while enforcing change.
- Achieve critical mass: to change the culture Hugh thinks it’s important to train enough people in talking therapies and keep discussing it. “Once that door to talking therapies [first] opens it’s very easy to introduce other talking therapies,” he says.
- Be patient: Tina says, “I think it’s about allowing for a long-term and thorough implementation – not to expect to be able to put it into practice overnight”. As changes affect multiple systems, it takes time.
- Keep planning: Hugh recommends meeting half a day every six months with the whole team, to plan and to resolve current issues.
- On-going support: some staff can be hesitant about using skills they’ve just trained in, so supervision groups that help them use the skills they’ve learned are useful.
“We needed that manager support. We had people coming in saying ‘this is what we want to do’ and we needed the backing from the manager.” - Tina Earl, Professional Leader Psychological Therapies, Waitemata DHB
The next step is a roll out to all mental health services in the whole Waitemata DHB. This will be done in conjunction with other changes that are happening to provide a better service. “The lesson has been that the model needs to be really tight,” Tina says. She thinks Stepped Care can be used elsewhere. “[It] is a common sense model – it’s not rocket science, it can be adapted.”
Hugh concludes “I’m absolutely and completely convinced that when you introduce talking therapies service users are better off, staff satisfaction increases and you do better business”.
Tina Earl, Professional Leader Psychological Therapies, Waitemata District Health Board
Phone: 09 422 2710
Fiona Clapham Howard, Project Lead, Te Pou
Phone: 03 339 3796
- See Te Pou's talking therapies guides for information on how to use talking therapies with different populations.
- Visit www.scottmiller.com to read more about the Outcomes Rating Scale and Session Rating Scale tools mentioned in this story in the articles titled: How being bad can make you better and Supershrinks: Learning from the Fields Most Effective Practitioners.
- Watch What is CDOI, a short video about the approach.
- Read Talking Therapies and the Stepped Care Model by Tina Earl, published in The Journal of the New Zealand College of Clinical Psychologists.
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