IE SO INSIGHTS ISSUE 3 NOVEMBER 2020
The new normal: Strategies for digital inclusion Ross O’Brien highlights the growing digital divide
Demystifying patient language and outcomes in digital CBT Michael Ewbank shares the next big step towards improving therapy 23 years reliving trauma reframed A PTSD patient shares his story
Learnings from digital therapy delivery Now that we are in a second national lockdown I’m reminded of the inspirational coming together of mental health professionals to share expertise, words of support and wisdom across the sector. Our collective abilities to make the most of highly challenging circumstances offers hope to see out the second wave with positivity. In this edition we publish some of this wisdom from our recent Therapy Insights Festival. We also hear from one patient who brings everything into perspective revealing how thoughts can be retrained to help with our feelings. Special thanks to Ross O’Brien and Keira O’Dell for their contributed articles this month. James de Bathe, Director of Partnerships
James de Bathe, Director of Partnerships
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Contents 04
07
Demystifying patient language and
How best to connect with a patient
outcomes in digital CBT; the next step
you’ll never meet
towards improving therapy
12
Feeling hopeless with clients? How to turn things around by reflecting on
ourselves
The new normal: Strategies for digital inclusion
10
16
An introduction to the specialist area of non-epileptic attack disorder (NEAD)
20
The power of behavioural experiments for our socially anxious patients, and therapists
23
How behaving like a professional
sportsperson might improve
26
23 years reliving trauma reframed
30
Using growth curve models to support
active supervision
your CBT skills
32
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NEWS
Demystifying patient language and outcomes in digital CBT; the next step towards improving therapy Michael Ewbank introduces us to Ieso’s deep learning approach to automatic coding of session transcripts and how it enables better understanding of the relationship between patient language and outcomes in digital CBT.
categorise patient utterances (each message sent by a patient during a session). We found an association between the types of patient language and clinical outcomes in response to a course of psychotherapy, which I will discuss in this article. Identifying compliance with treatment protocols in treatment outcomes is vital to better understanding, and subsequently enhancing, the effectiveness of treatment (Kraemer et al., 2002). As CBT requires the patient to be an active participant in a collaborative process, where patients are required to learn new skills and to complete homework assignments, a patient’s willingness and desire to actively engage in treatment is an important factor in determining outcomes (Drieschner et al., 2004).
Michael Ewbank
Identifying and categorising patient statements during CBT is an important
Ieso’s aim is to constantly improve the quality of therapy through insight gained from the latest innovations and incorporating those insights
step towards developing an understanding of when and why patients are unlikely to follow a treatment plan and could help inform the development of more personal and engaging treatments.
into treatment. Our objective in this study was
Patient utterance categories
to develop a model to automatically detect what
For this study we defined a total of five patient response categories
patients say during psychotherapy and to look at
based on existing guidelines used in motivational interviewing (Glynn
how different patient responses are associated
& Moyers, 2009) (see Table 1). This categorises any patient language
with outcomes. We hope that this will enable
that moves in the direction of change as ‘change talk’ and any language
us to develop more effective and personalized
indicating a movement away from change as ‘counter-change talk’. Here,
interventions.
we defined two types of change talk: ‘Change-Talk Active’, in which a patient expresses a desire or commitment to change, and ‘Change-Talk
As we have such a large data set, with around
Exploration’, in which a patient demonstrates self-exploration by reflecting
180,000 hours of transcripts of text-based
on the processes that maintain their mental health problem. ‘Counter-
internet enabled Cognitive Behavioural Therapy
Change Talk’ included any statement that moved away from the target
(CBT), we trained a deep learning model (a type
behaviour. We included the category of ‘Describing Problems’ to capture
of machine learning) to be able to automatically
utterances in which the patient describes problems considered external
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to their presenting problem. A final category of ‘Follow/Neutral’ was included, representing patient responses which do not favour either change-talk or counter-change talk and do not fit in any other category. To train a deep-learning model, clinical scientists manually tagged each patient utterance as belonging to one of these five categories in around 300 transcripts.
Category
Definition
Examples
Change-Talk Active
Patient responses that reflect a desire or commitment to change (including evidence that they have enacted some change such as doing their homework).
“I don’t want to live like this anymore”
Change-Talk Exploration
Patient responses that reflect a past, present or future state of mind and show evidence that the patient is using self-exploration and reflection of their problems.
“So, I think that if I did that my heart would be racing, and I would get very nervous.”
Counter Change-Talk
Patient responses that move away from the target behaviour (including evidence of not-engaging in therapy).
“I was unable to do the homework”
“Yes, I did fill in my thought record. I found it really helpful.”
“I don’t think that would work” “I won’t be able to”
Follow/Neutral
Describing Problems
Patient responses which do not favour either change or counter-change talk (including simple clarifications and nontherapeutic chit-chat).
“Hello”, “Ok”, “I see”
Patient responses that describe external problems in their lives (i.e. not directly related to presenting problem).
“I’m in a lot of debt and can’t pay it off”
“Could you put that another way?” “what do you mean?”
“My mother has been very ill”
Response categories and examples used to tag patient utterances.
Association between outcomes and patient utterance categories When we look at patient responses across the course of treatment, the results revealed that the more often a patient expressed counter-change talk they less likely they were to show improvement. Describing Problems utterances and Neutral/Follow utterances were also negatively associated with improvement. By contrast, patients expressing more Change-Talk Active utterances as well as more Change-Talk Explore utterances were more likely to show improvement. Next, we investigated whether utterances in the first treatment session could predict if a patient would show reliable improvement at the end of treatment. Again, we found that Counter-Change Talk utterances were negatively associated with improvement along with, Neutral/Follow and Describing Problems utterances. By contrast, the greater the number of Change-Talk Active utterances and Change-Talk Explore utterances the more likely the patient was to show improvement. Finally, we investigated whether patient utterances in the first treatment session were predictive of -engagement, (i.e. a patient returning for a second treatment session). Counter-Change Talk utterances and
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Follow/Neutral were both negatively associated with engagement. There was a positive association between engagement and both Change-Talk Explore and Change-Talk Active utterances and also with Describing Problems utterances, which contrasts with the negative association found with reliable improvement. It could be that patients who express more external problems in the first session feel a greater initial benefit from therapy and are more motivated to return for a second treatment session, however these patients are less likely to show improvement at the end of treatment.
Conclusion Improving the effectiveness of CBT depends on an understanding not only of what aspects of therapy are effective in changing symptoms, but also an understanding of why and how patients do not engage with therapy. Measures of patient language have been shown to be a reliable predictor of outcomes in CBT, and when done at this scale we can get a real understanding of the significance of patients’ responses. Coupled with our previous work developing an automated understanding of therapist language, this approach can be used to enable a data-driven understanding of the relationship between what the therapist says, what the patient says, and clinical outcomes. We are excited about what this means in terms of improving the quality and effectiveness of therapy. The full-length, peer reviewed article can be found here.
Reliable improvement rates (%) for patients with a low and
IAPT-engagement rates (%) for patients with a low and
high number of Change-Talk Active utterances in the first
high number of Counter-Change Talk utterances in the first
treatment session. This chart shows the improvement rate
treatment session. This chart shows the engagement rate for
for patients in the first and third group for the number of
patients in the first and third group of Counter-Change Talk
Change-Talk Active utterances in the first session. The results
utterances in the first session. This reveals a 3% decrease in
show a 10% increase in improvement rates for those patients
engagement rates for patients expressing a greater number
expressing a greater number of Change-Talk
of Counter-Change Talk utterances.
Active utterances.
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COMMENT
How best to connect with a patient you’ll never meet How can you show warmth and empathy if you’re not in the room with your patient? Can therapists using online text therapy get that connection that really makes a patient feel heard and understood? Shazna Khanom, Ieso’s UK Clinical Director, gives her hints and tips on how best to connect with a patient you’ll never meet. Let’s also consider what patients find challenging in textbased online therapy. Some patients might anticipate difficulty with expressing themselves or finding the right words. They may worry about communicating their thoughts and feelings well. These are also challenges in face to face therapy. The misconception is that it will be difficult to successfully treat a patient without body language to confirm suspicions. When therapists get it right, patients say they were “my invisible hero” and that it was “a life changing experience.” They say that their therapist gave them the tools to make themselves better for life. What is it that these therapists are doing right? Shazna Khanom, UK Clinial Director
As in successful face to face therapy, the key is empathy. Written, text-based therapy offers many advantages over face to face therapy but there is often the belief that patient experience is compromised. However, it is possible to enhance that experience through your written communication style. In this article I will share some common mistakes and provide strategies to ensure you build a good rapport with your patients.
Empathy is a skill, like any other human skill. Given a chance to practice it, we can all get better at it. Empathy in a face to face situation is something we often take for granted. We all get to practice from a young age and learn from our parents, siblings and in the school playground. Some people are naturals, while others are not. Showing empathy using the written text is relatively new to most people. While the youngest generations have grown up largely communicating
The challenges of conducting therapy online What difficulties might you imagine if you were treating a
via text, people over the age of 25, practicing as therapists, did not have early childhood access to the unlimited, pervasive, emoji filled instant messaging that we use today.
patient who could neither see you nor hear you? Non-Ieso therapists think that they might not be as easily able to pick up on emotions via written text or be unable to judge the level of emotion and risk. Perhaps you would worry about dyslexia interfering with typing accuracy, or simply not typing fast
With a stranger, it is even more important to show that you are not a robot. We can do that by overplaying the human in ourselves and consciously showing high levels of empathy and understanding through text.
enough. Or you may be concerned about misinterpreting the
Empathy in written CBT
message, not having the usual rhythm and flow of a session,
Good communication should start from the beginning, which
and losing the power of non-verbal communication of body
sounds obvious. Even before the first session it starts with
language and pattern and pace of their breathing.
your welcome message to each patient. From the very first
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point of contact it is important to hit the right chord. Our best
ourselves and consciously
Written, text-based therapy offers many advantages over
showing high levels of
face to face therapy but there is often the belief that patient
empathy and understanding
experience is compromised. However, it is possible to enhance
through text.
that experience through your written communication style. In this article I will share some common mistakes and provide strategies to ensure you build a good rapport with
Empathy in written CBT Good communication should
your patients.
start from the beginning,
The challenges of conducting therapy online
before the first session it
What difficulties might you imagine if you were treating a
starts with your welcome
which sounds obvious. Even
patient who could neither see you nor hear you? Non-Ieso
message to each patient.
therapists think that they might not be as easily able to pick
From the very first point of
up on emotions via written text or be unable to judge the level
contact it is important to
of emotion and risk. Perhaps you would worry about dyslexia
hit the right chord. Our best
interfering with typing accuracy, or simply not typing fast
therapists will personalise
enough. Or you may be concerned about misinterpreting the
their welcome message
message, not having the usual rhythm and flow of a session,
by writing something that
and losing the power of non-verbal communication of body
they’ve noticed from the
language and pattern and pace of their breathing.
assessment forms. They
Let’s also consider what patients find challenging in text-based
that you’re suffering
online therapy. Some patients might anticipate difficulty with
from insomnia and I’m
might say, “I’ve noticed
expressing themselves or finding the right words. They may
looking forward to working out a way of helping you”. Good
worry about communicating their thoughts and feelings
therapists will also look at the language the patient uses in the
well. These are also challenges in face to face therapy. The
assessment form and use it to set the tone. For example, does
misconception is that it will be difficult to successfully treat a
the patient use a very formal style and sound very academic
patient without body language to confirm suspicions. When therapists get it right, patients say they were “my invisible hero” and that it was “a life changing experience.” They say that
in their writing or do they use slang and abbreviations. By reflecting the patient language style therapists can connect right from the word go.
their therapist gave them the tools to make themselves better
The dangers of emojis and copy and paste
for life. What is it that these therapists are doing right?
I advise to never copy and paste prewritten sections of text. If
As in successful face to face therapy, the key is empathy. Empathy is a skill, like any other human skill. Given a chance to practice it, we can all get better at it. Empathy in a face to face situation is something we often take for granted. We all get to practice from a young age and learn from our parents, siblings
this is necessary, edit any standard advice to make it personal to the patient. Alternatively, be honest and tell your patient that you’re going to copy and paste an explanation about CBT, or an intervention, and you’re doing that because you want to make the most of their precious therapy time.
and in the school playground. Some people are naturals, while
The question around whether emojis are appropriate in therapy
others are not. Showing empathy using the written text is
is a big one. Positive emojis such as a smiley of thumbs up can
relatively new to most people. While the youngest generations
be good but must be used sparingly. They’re really helpful for
have grown up largely communicating via text, people over
greetings and goodbyes or responding to your patient when
the age of 25, practicing as therapists, did not have early
they are showing they are pleased with themselves. If you’re
childhood access to the unlimited, pervasive, emoji filled instant
worried or nervous about whether you should use it or not, try
messaging that we use today.
and see how the patient responds. A rule of thumb is that if the patient uses emoji’s it should be ok for you to use them too.
With a stranger, it is even more important to show that you
Negative emojis such as the sad face are harder
are not a robot. We can do that by overplaying the human in
to use appropriately.
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such as, “keep going... Tell me more… I’m listening.” You want to keep the flow of what the patient is saying without distracting them. Additionally, avoid introducing interventions too early as this might make the patients feel like you’re dismissing what they are telling you. Being face to face, you have body language to gauge whether they’re ready for intervention. In written CBT this is missing, so give that little bit of time, or do a little more digging to ensure they are ready to move on to that stage.
Prepare for the end of therapy When you’re planning for discharge make sure the patient is aware that the last session is coming up. Acknowledge where they were at the start of therapy and how much progress they have made. Some patients don’t make the progress they hoped for over the course of therapy. However you can make them aware they have all the tools they need to continue making progress without you. Use the core CBT principle that the patient becomes their own therapist. Remind patients that they can return to the platform at any time to read their transcripts to remind them what to do. Most find that quite reassuring.
Listen, acknowledge and encourage During treatment it is important to read and respond to what the patient is actually saying. As CBT therapists, we have our own agenda items and we’re trying to get the right information across to help patients start their recovery, but this must not distract from what the patient says. They need to be heard. For example, if a patient opens with the fact that five years ago they had a miscarriage, never sought help for it and thinks this underlies her current problems, respond to that information immediately. An opportunity to connect is missed if you skip to asking questions that are next on your assessment criteria. Try to recall what they have mentioned earlier in their self-assessment forms to avoid the session feeling scripted and robotic. Be present with your patient even if it means going “off script”. It’s so important that the patient has the opportunity to tell their story when they are ready to, rather than when you’re ready to hear it. During treatment, if a patient is typing in long sections of text, you don’t want to interrupt them by giving feedback or starting an intervention. However, it’s odd to stay silent and simply wait. In a face to face setting you would be nodding and writing down notes, indicating to the patient that they have your full attention. In a typed session you must rely on words to tell them you’re listening. Use brief words of encouragement,
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A new sixth sense There is much to be sensed in non-verbal communication, even in the written form. It requires undivided attention and being truly present in therapy to learn this technique. Nonverbal clues can be found in the rhythm and pace of your patient’s communication; knowing the speed at which they type, the thinking time usually taken to respond, whether they usually type large sections or just brief words. If the patient’s usual flow changes, you need to dig. This is the moment where you’ll get true insight. Another indicator is when a patient spends a long time typing but when it comes up there are just a few words. Did they type something and delete it? What they typed and deleted will tell you so much more than what they edited it down to. There are clues in written text; emotions can be felt through words and anybody who has ever read a book, and fallen in love with its characters will know the power of the written word. In summary, take the time to get personal. Empathise and really listen to your patients. Look for the signs to dig deeper. To master this skill, undivided presence is the key. This all takes extra concentration and effort but in doing so, written CBT can be elevated to a whole new level, one that is very human, and a long way from feeling robotic.
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COMMENT
Feeling hopeless with clients? How to turn things around by reflecting on ourselves By Michelle Sherman, Clinical Supervisor, Ieso
explore our role as therapists; our beliefs, judgments and how this effects patients we are struggling with, by being vulnerable together; reflecting and doing some experiential exercises. I wanted to try to understand possible trends or patterns us therapists find ourselves doing, why we do these and discuss how to reflect and monitor this to bring us back to do what we know works for CBT to be effective. If you’re intrigued by this workshop, then there are ways you can have a go at running through this on your own. To do this I would like you to be aware that you need to be as open as possible to whatever comes up for you. Try not to judge this in anyway and just remain curious and try to sit with Michelle Sherman, Clinical Supervisor, Ieso
I am really passionate about mental health, advocating and battling mental health stigma and supporting therapists be patient centred, so that patients can feel supported, not judged and truly engage in therapy. I also love formulating and grasping the whole picture of someone’s
whatever comes up for you with compassion. The first thing that would be useful to think of is a case that has been particularly complex, maybe a case that you had felt particularly apprehensive about before the sessions. Have a think and write down in bullet points the specific components of their presentation. What the primary and possible secondary diagnoses were? How long they have had these problems? How many episodes? Are they on medication? Have they had therapy before? If so what kind and how many previous therapists?
story. This is a written exercise for those who
So hopefully you’re starting to make a list of the factors that are accounting
were unable to attend the workshop.
for the complexity of the presentation. I’d like you to now start to reflect on
A theme that I frequently come cross in my Clinical Supervisor role with Ieso, is the effect that our beliefs, thoughts and judgements as therapists have on patient’s treatment and
the feelings you had when you were working with them. What emotions were coming up for you? What were the specific thoughts you were having? Really take some time to pay attention to these and jot them down – to sit with them and be honest, open and curious to what comes up.
their experience of therapy. Sometimes we can
Now I would like you to think of this person as though they were a very close
become increasingly frustrated and hopeless
family member of yours. To imagine that they are someone you love and
when things aren’t moving forward as we expect
care for deeply. Again, I would like you to reflect and notice on any initial
or want them to. Particularly when patients
thoughts and feelings that come up. Are these different to before? Then
suffer from comorbidities, appear complex, have
have a think about this reaction and why this reaction may have changed
had therapy before or simply don’t engage well
after viewing them as a family member. Think how this may mean that your
with homework. This workshop was used to
very initial feelings, thoughts and assumptions may impact on how you
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therapy session was going? How were you thinking about the rest of the session and what effect did they have on you and how you conducted the session? How did this effect how you spoke to the patient? How did this effect your body language, facial expressions? How much you helped the patient? How warm and compassionate you were with them? Was your pace slower or faster? Were you allowing them time to reflect and think? Were you more or less Socratic? So, based on what you have done, did you hook in with your thoughts and feelings? Do we need to learn how to unhook from these and how might this effect how we do therapy? What about patient engagement? Lastly, imagine your mind as a stream: when it’s flowing with leaves everything is good but when we pick up a leaf and look implement therapy and whether this would have changed if you had felt about them as a family member.
at it, that’s when it can all get a bit tangled up and stop flowing. These leaves are our thoughts, feelings, and assumptions but these are just part of a large amount of content our mind has
I would like you to try and reflect on this concept a bit more. I
created. To practice unhooking from these thoughts, we can
would invite you to think of a therapy session that has gone
try to do some deep breathing for a moment; take in a deep
particularly well. Where you may have felt particularly positive
breath and breath out twice as long. Notice your surroundings
and uplifted during and/or afterwards. I would like you to
and try to notice a thought in your mind. You can notice it as
recall this therapy session in detail in your mind. Try to re-live
letters, words or as a bubble or image but put it in front of you
what was happening about those positive experiences and
as though it’s on a stage. Try to add ‘this thought I’m thinking’
explore those feelings and thoughts in detail right now. How
before it. Keep breathing and looking at the thought and
did that feel in your body? Were there any specific sensations
distance yourself from it and try to hold it lightly and let it sit
that had colours or shapes and how did this effect your
there. Now when you’re ready come out of the exercise.
physiology? What specific thoughts and assumptions were you making about this person and how the therapy session was going? How were you thinking about the rest of the session and what effect did they have on you and how you conducted the session? How did this effect how you spoke to the patient? How did this effect your body language, facial expressions? How much you helped the patient? How warm
This is one exercise you can do to stop and notice any thoughts or feelings that might be affecting how you implement therapy. You can also access supervision, take a moment to write things down but its important to do so with curiosity and kindness. To end this exercise I would like you to reflect on one thing
and compassionate you were with them? Was your pace
that’s been most helpful and one thing that you’re going to do
slower or faster? Were you allowing them time to reflect and
differently. Make a plan on how you are going to implement
think? Were you more or less Socratic?
this change ready for your next therapy session. I hope you
Next, I want you to do the same thing with a ‘bad’ therapy session. So, think of a therapy session but this time one that you perceive went ‘badly’, where you had a confrontation, or
feel that you have reflected and learnt more about yourself as a therapist and how to manage difficult therapy sessions with hope and curiosity.
were feeling frustrated or that you weren’t a good therapist.
Michelle is a psychology graduate who has worked on mental
Again, try to re-live what was happening about those negative
health wards as a health care assistant and then became
experiences and explore those feelings and thoughts in
a PWP. She previously worked as an Assistant Psychologist
detail right now. How did that feel in your body? Were there
in CAMHS and at a YOI prison. She is now now a BABCP
any specific sensations that had colours or shapes and how
Accredited CBT Therapist, EMDR Practitioner, and has applied
did this effect your physiology? What specific thoughts and
to be an Accredited Clinical Supervisor. Michelle currently
assumptions were you making about this person and how the
works full time as a Clinical Supervisor with Ieso.
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The new normal: Strategies for digital inclusion By Ross O’Brien, Digital IAPT Programme Lead London, Healthy London Partnership and Associate Director of Innovation and Technology CNWL NHS FT
pandemic, this does not apply to households with no internet data or pay-as-you-go customers, who make up over a quarter of all mobile phone subscriptions in the UK. The Good Things Foundation have undertaken a lot of good work to illustrate the barriers to and enablers towards a digital nation.
Ross O’Brien, Digital IAPT Programme Lead London
This article explores what strategies we can use to prevent digital exclusion in order to improve remote therapeutic access and digital innovations to drive forward IAPT service delivery in the future.
Digital exclusion In the UK there are many people that are not able to access services as readily as they could previously because of disruption from Covid-19. We know that we have taken great leaps forward in terms of people starting to access healthcare services digitally. We also know some of the UK’s poorest and most vulnerable households don’t have access to the internet and that this digital exclusion is having a devastating effect across the country. 1.9 million UK households have no access to the internet and 25.9 million more are reliant on pay-as-yougo mobile services to make phone calls or access healthcare, education and benefits online. Pay-as-you-go customers without the means to buy data are finding themselves shut in their homes, facing social isolation, with no means of communicating with the outside world. While the UK’s major internet providers have agreed to remove data caps on fixed-line broadband during the coronavirus
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Barriers include: •
•
•
•
Barriers specific to mental health services as a result of these
Access - not everyone can connect to the internet and
barriers include the lack of access to a device, lack of finance for data, services needing to see patients before accepting
go online
referrals, trusts stipulating use of a particular video platform.
Skills - not everyone can use the internet and online
The lack of privacy, or risk, to patients engaging in therapy at
services
home is also an issue to be aware of.
Confidence - some people fear online crime, lack trust,
What can be done?
or don’t know where to start online
The solutions to these challenges are in their infancy at present.
Motivation - not everyone sees why using the internet
However, there is a huge drive in healthcare to find solutions
could be relevant and helpful
and to enable the most digitally excluded to be able to access
Some sections of the population are more likely to be digitally excluded than others. Financially disadvantaged people such as those on lower incomes, the unemployed, less qualified and those living in social housing or homeless are most affected. Other groups who are digitally excluded include older people, the disabled and those living in rural areas. People with English as a second language are also affected.
services. Initiatives like the DevicesDotNow campaign are fantastic initiatives that are being replicated in different areas across the country, with partnerships with blue chip technology companies, working to provide support for patients who need to be able to access a device or free data. The financial premise for distribution of devices and data is similar to IAPT funding principles in that it is cheaper to give a vulnerable person a basic mobile phone with credit to access telephone healthcare than the cost to the system if they don’t have access. From an ethical point of view we need to think about what we can do to augment these new digital pathways. This means ensuring that both digital and analogue pathways continue to exist, such as by providing free phone numbers for patients to call and receive therapy or have safe infection control measures in place, so patients can still be seen in healthcare facilities.
New methods of digital communication In London, just as everywhere else, we’ve all had to make a rapid shift into a digital world this year. Video conferencing has really come into its own. We’ve had to be careful when considering which video platforms are suitable in ensuring we investigate security, training needs, practical considerations and quality patient engagement. NHSX issued guidance stating that during the COVID response period, as long as a risk assessment is carried out it is acceptable to make use of the same applications that consumers are comfortable with, such as WhatsApp, Facetime and Skype. I believe that using these off the shelf applications that patients already may be familiar with, increases the potential for access into services. These technologies don’t just offer video calls which facilitate all the benefits of remote access to therapy. They also have tools that can be used in a dynamic way to improve the patient experience, such as screen sharing, chat, recording the session,
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collaborative working in Microsoft Office, transcribing of audio
reduce patient frustration. The process that we are developing
for later records and searchability, and communicating before
provides a summary of the referral information to a clinician
or afterwards to remind and thank participants.
and highlights areas of risk or urgent concern.
E-Triage
Of course, all clinical, diagnostic and treatment decisions
Referral, assessment and triage are processes which may
should remain with the clinician. The difference being that a
be prohibitive in terms of patient access. There are many
clinician starts an assessment knowing what areas to focus
assessment questions for patients that can take a long time
on and is able to have a more meaningful conversation with
to complete and huge variance in the triage process from
service users. Digital triage clearly offers significant time saving
service to service. Patient feedback can be negative and
for both clinician and service user.
patients report that the assessment starts as a data extraction exercise and there is limited time to focus on more meaningful conversations such as goals and expectations for treatment.
•
We aim for the incorporation of e-triage to:
•
Increase the speed at which patients access services
•
Increase access for vulnerable or under-served groups
Clinicians are spending a lot of time asking repetitive questions and adding data on the electronic patient record, which can be
via targeted social media advertising
frustrating for patients in need of help. Our Digital triage programme in London has been designed
•
channels
by clinicians and service users to create a referral and assessment process that ask the least amount of questions as relevant via a digital pathway. It has been possible to build logic into the forms to eliminate irrelevant questions and
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Respond to the shift of mental health needs onto digital
•
Increase the quality of care patients receive
•
Reduce unnecessary appointments
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London Digital IAPT video therapy platform The Covid19 response has seen services across the country rapidly shift IAPT clinical appointments on to a multitude of video consultation solutions. IAPT services are predicted to see a spike in referrals for months and years to come whilst the service faces reduced capacity. The issues for IAPT patients remain, with differing wait times according to postcode, differing access to types of therapy, variable access to specialist or first language therapy, variable quality and access to remote consultations. As a result, we are looking to scope a new approach to collaborative online IAPT delivery across all London ICS/STP patches and hope to develop our thinking about how we can offer enhanced IAPT services digitally into the future.
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An introduction to the specialist area of non-epileptic attack disorder (NEAD) ‘A man walks into A&E and says, ‘Dr, my foot is hurting’. The Dr examines the foot and says, ‘Good news, I know what the problem s, you have non-broken foot disorder’
Keira O’Dell is a specialist therapist in Non-Epileptic Attack Disorder and a founding member of the FND society. She shares some insight into this specialist area with Ieso Insights.
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Non-Epileptic Attack
this diagnosis often bring to therapy. There is often a desire for the
Disorder (NEAD) primarily
NEAD episodes to stop or be more manageable, but patients want
involves neurological
to dissociate from trauma, and find ways of achieving closeness,
symptoms that present
care and validation.
like organic disorders of the nervous system, but do not have an organic basis (medically unexplained, ‘functional Neurological Symptoms’; FNS) (Stone, Keira O’Dell, SpecialistTtherapist in NonEpileptic Attack Disorder and a Founding Member of the FND Society
2011). Approximately 12–20% of patients seen in epilepsy clinics may have
NEAD rather than epileptic seizures, and rates of NEAD have been estimated at around 4.9 in 100,000 per year.
Patients often say that because of their NEAD diagnosis ‘I can’t be left alone’ and focus on what they cannot do now, rather than what they could do (e.g. ‘I cant go swimming’; ‘I can’t go horse riding’. Independence is something that most NEAD patients are stripped of, and many seem torn between relief and suffocation. Interpersonally, there is always something going on in the session to be mindful of. I believe that NEAD is an interpersonal difficulty; the patient is communicating something about their needs in a way that invites a certain response from those around them. I have learnt about the many ways that dissociation can be present in people’s lives and how it can become a necessary coping
NEAD is a paroxysmal event (a sudden, intense, recurring
strategy that the body continues to do in ways that can prevent
symptom) that resembles epileptic seizures or syncopes, they are
people from learning about their safety in the present.
not associated with ictal electroencephalographic discharges. They are found under the umbrella headings of dissociative and
As my experience in this field developed I learnt about the mind
conversion disorders in psychiatric classifications.
and body connection and how to explain this to patients, which
Being a specialist therapist in Non-epileptic Attack disorder, when
Initially in my first year I would say about 90% of patients had an
I receive a referral for someone with NEAD I do not get the sinking
episode in their first session. The more I became experienced,
feeling so often described by health professionals confronted by
the more I understood, and the less people had episodes in their
this presenting issue. I chose to specialise in this field because
assessments. I cannot be certain as to why this is, but maybe
started to click with people and improve helpful engagement.
I am interested, passionate and intrigued by NEAD. That’s not to
patients came to know that I knew and understood something
say I don’t feel some anxious anticipation before a patient comes
about their problems without them having to show me. Perhaps I
through the door, as every case is unique. Offering therapy for
became less nervous, more professional and more empathic.
people with NEAD can involve frustrations, difficulties, concerns and, without doubt, imposter syndrome. NEAD is a complex
Telling them the good news!
disorder. But knowing someone personally growing up with NEAD
Many of my patients come to their first appointment having
inspired me to work in this field. I had an understanding of what
never heard of NEAD. They often expect medication and physical
NEAD was as a layperson before I was a professional. I had lived
assessment. I often bring patients into the room, explain my role
experience of how this effects the person, how it effects family
and see the confusion or frustration in their face. I have heard
members and friends, relationships and careers. It creates worry
frequently that ‘I have been passed around for years’ and ‘are you
and uncertainty in everyone around the patient, in terms of what
saying it’s because of me?’ Time and time again I have had this
the problem is and how to help.
conversation with people and I have come to see it as part of the
Before specialising I already had a sense of the complexity of
process for many.
working with NEAD having come across referrals for people
I tend to work on what people have lost as a result of having NEAD
diagnosed with NEAD. I knew how complex each case would be
episodes; life experiences, family, education, work. I listen carefully
and the difficulties that would come from working with this client
to get a sense of how it affects them. I then work backwards
group. Each case was so different and threw a new curve ball at
from the present. Someone once said that NEAD may begin as
me. However, the more cases I came across the more I started
an explainable medical episode. It could be a physical reaction to
to see how I could adjust my practice to engage and work with
something else including drug use, physical trauma and so forth.
patients. Looking back my practice has completely changed. The
Whether it is psychologically caused or medically caused, the body
first thing I learnt about was the complex agendas that people with
creates a blueprint that the body refers back to.
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There have been so many difficult, fascinating moments in my work that I could not hope to capture them all. Here are a few that are particularly moving. The teenager who started suffering from NEAD following her drink being spiked. She attended the appointment with her mother, who was shocked as I explained NEAD. She thought something was chemically wrong with her daughter’s brain and all those times taken off work to attend appointments were for nothing. Sometimes I get a hard time as a therapist, I sometimes want to say “do not shoot the messenger”. But I have an opportunity to educate, teach and install hope in what was once perceived to be a hopeless situation by the client. Her daughter was trying to communicate something to her. Even though it did not begin like that. The refugee who had experienced trauma in her homeland and was now being forced to go home. I suppose it is hard to say how my body would react to such a threat, but it is not unimaginable that I would not find myself in the same state. The divorced woman who was looking after her sick elderly mother and managing three children and a dog. She was what could be called a ‘carry on coper’, coping too well under stress, ignoring her emotional needs until her body overruled her.
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The lady who had an hour episode laying on the floor, pivoting
and what is not. We explain the pressure cooker model, where
with her feet around the walls. It must have been exhausting for
pressure from everyday builds up until the blueprint of a NEAD
her. I sat quietly continuing with my notes waiting for her to come
episode comes into action.
around. I use my instincts as a therapist and sometimes have to reflect later as to why I changed my practice for particular patients, so I can consciously learn from this.
During the 1:1 sessions we focus more on trauma, situations that may have triggered episodes, relationships that encourage it, disengage from it and work towards building a larger gap
The patient who wanted a wheelchair because, although they
between the episodes. If they can make this gap bigger…they are
walked in, they could not walk out. This complexity requires
moving forward. We try and encourage patients not to work hard
patience and attention.
on actually stopping the episode happing, instead we describe
As I am confronted by something so different with each patient, I have to respond on the spot, often doing something different, therapeutically, that goes against the interpersonal pull of the behaviour. I suppose the therapy is like a dance and we need to respond to the other person’s unexpected moves. Most NEAD patients want to keep going, but their bodies are telling them to slow down, to take a moment and pause. It communicates that things are not going well to others, when people find the words too difficult to say. It is the pressure of unmet need that builds up that they are ignoring and it needs a form for release. I ask myself in moments when I am caught off guard by an episode ‘how do I respond, how do I look?!’. I do not want to appear judgmental, but I also do not want to indicate that this is helpful, acceptable behaviour for them, or the best way they can communicate their needs. I do not want to be shut off from this in responding in a panicked way to the episode as the patient will be used to.
the situation as a fast car moving towards a brick wall. If you are going to hit the wall anyway… what can you do? They get the idea that applying the breaks sooner will lead to softer impact. Patients start applying strategies to make this impact lighter, they start looking after themselves, putting their needs first and taking time to recover after an episode. There is no model to treat NEAD. I have been told that primary care mental health departments often do not accept NEAD patients because their insurance does not cover them if their approach involves not calling an ambulance if a patient has an episode. This inspired me to make steps to change things so I conducted research into therapists’ understanding of NEAD and its treatment (awaiting publication). These findings indicated that therapists would be willing to treat NEAD patients if a model of treatment was provided. This is a complex difficulty and often it causes anxiety for therapists as well as patients. There is lack of education and teaching with NEAD or other FND disorders, so we really need to education
How I intervene with NEAD It is important to first intervene in the language used surrounding
people around this. Please follow me on LinkedIn to keep up to date with this incredibly rewarding specialism.
NEAD. We moved away from the word seizures (unless a person has a dual diagnosis with epilepsy) and instead began to use the word ‘episode’. We find that patients have their own words for this and while we want to respect their own choice we know this can be influenced by dominant medical models so we explain the reasons for the language we use. The word ‘seizure’ can at times be unhelpful, especially when the patient is trying to educate and advise carers and family members not to call an ambulance as medical intervention can compound misunderstandings of NEAD. If a person has an episode in the session, we try to manage it calmly, staying present, but leaving the patient to come around on their own, in their own time, rather than call an ambulance. Patients have an initial assessment. There is then a discussion and reflection about coping strategies; what is working for the patients
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COMMENT
The power of behavioural experiments for our socially anxious patients, and therapists By Joanne Adams, Clinical Training Lead It can be possible to combine these two types into one behavioural experiment. •
‘Widening the bandwidth’ experiments – a patient (or a therapist assisting a patient!) deliberately chooses to act outside the rules that they think are socially acceptable.
Read on to see examples of these kind of experiments and how they can be done virtually, which is useful if you offer online therapy to a patient or if your patient is unable to do these experiments face to face at this time. For many of you, you will be familiar with the Joanne Adams, Clinical Training Lead
B
ehavioural experiments are the heart of CBT and are especially important in the treatment of Social Anxiety Disorder according to the Clark and Well’s protocol for this debilitating disorder. Let’s
concept of a ‘stooge’, however, for some of you this might be a new term. A stooge is a volunteer; another therapist or colleague, who is happy to have a conversation with a patient and for that conversation to be recorded.
remind ourselves of the types of behavioural experiments we might employ
You might use a stooge for any of the experiments
during treatment for social anxiety:
outlined above if the patient recognises that they will experience too little / too much anxiety if they
•
Socialisation experiments – where the therapist and the patient
were to do the experiment with the therapist or if
have two conversations, one where the patient maintains their usual
the experiment relies on a volunteer who does not
safety behaviours and one where they drop them. This experiment
know anything about the patient’s difficulties or
can assist the patient’s understanding of their formulation and what
predictions.
might be maintaining their anxiety. •
Audio/video feedback experiment – where the patient has a conversation with another person and makes predictions about how they think they will appear or what might happen. The therapist and the patient investigate these predictions and rate how likely they are. The conversation is recorded. The therapist and patient watch this recording with the patient being asked to watch themselves as if watching a stranger. Their predictions can be observed and re-rated.
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At Ieso, we believe that solipsistic introjection (where the patient creates a mental image of their therapist as they do not ever see them) is an important factor for the effectiveness of written CBT. We would therefore not routinely recommend that a therapist and their patient meet using video technology for an experiment, so consequently the clinical team regularly host behavioural experiments and act as stooges for our patients.
Ieso Insights
Examples of these experiments include recording a conversation between a patient and a stooge often about topical subjects (for example, lockdown) where the patient deliberately practises focusing externally. A patient joins a conversation with several stooges and says something they consider inappropriate to see how the group react and a patient has a conversation with a stooge without wearing their usual make up. Following an experiment, the patient and their therapist can create a survey and send it to the stooge(s) if this would add to the learning from the experience. As these conversations are by their very nature experiential, patients experience very powerful learning and might conclude that, for example, “the conversation went much better than I was expecting and other people are more accepting that I think” and “talking to new people does not have to be a terrifying experience, perhaps I could try it a bit more”. Behavioural experiments can take a bit of time to organise and conduct, however, the feedback we have received from patients and therapists is that they are a good use of session time. Feedback from therapists who have organised behavioural experiments for our Ieso patients have reflected that they were anxious before setting up their first experiment; they worried about the technology, how hard it might be to organise the experiment, what would happen if it all went wrong. However, almost all of the therapists have reported a good experience for themselves and their patients and they encourage you to give it a try!
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If your patient is exceptionally anxious about having a video call with a stooge, this could be graded. We have hosted several experiments, with good success, where we have started with a text chat and then moved onto an audio chat before a final video chat. The focus of this article has been about using stooge behavioural experiences for social anxiety, however, if there is a good clinical rationale you could use a similar approach for various other presentations. For example, someone with health anxiety could role play visiting the GP, a passive patient could practise assertiveness skills, or a patient who fears the consequences of panic attacks could pretend to faint during a conversation. We firmly believe in making every session count and that using active change methods during and in-between sessions contributes to our patients’ recovery, so we encourage you to give virtual behavioural experiments a try. If you are anxious about doing so, then set up a behavioural experiment for yourself!
Top tips for organising virtual behavioural experiments •
Ask your patient to cover up the picture of themselves that will appear on their screen during the video call (otherwise their self-focus will be further increased)
•
Make sure that your patient and the stooge is fully aware of the experiment that is going to take place and ideally attend if you are a therapist (if you are a therapist working with online/written CBT then attend with your webcam off)
•
Make sure you have agreed with your service which video technology platform to use and that you are happy with where the video is temporarily being stored and how you can transfer the video to the patient. Consider using a patient consent form and explain these aspects to your patient
•
Remember to press record but don’t be too concerned if the video fails to record – the patient is very likely to have learnt something from the conversation itself
Sources Clark, D., M. (2001). A Cognitive Perspective on Social Phobia. In W.R Crozier and L. E. Alden (Eds.) International Handbook of Social Anxiety: Concepts, Research and Interventions Relating to the Self and Shyness (pp. 405 – 430) John Wiley & Sons Ltd. Wells, A (1997). Cognitive Therapy of Anxiety Disorder – A Practice Manual and Conceptual Guide. Chichester: John Wiley & Sons Clark, D. M., Wild, J., Warnock-Parkes, E., Kerr A., & Thew G (2020), Treating Social Anxiety Disorder remotely with Cognitive Therapy for SAD. Webinar hosted by the National IAPT team on 5th May 2020
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How being like a professional sportsperson/musician might improve your CBT skills; the role of deliberate practice By Joanne Adams, Clinical Training Lead and Kate Tilbury, Supervision Lead At Ieso Digital Health we have a clear mission
Potentially the lack of pressure, scrutiny and feedback from performances
to ‘help therapists to be the best that they can
(like you would get if you let a goal in during a football match, for example)
be’ and this is seen very strongly in the training
might explain why certain medical professionals, including some therapists,
and supervision that we offer. We incorporate
do not dedicate the time to deliberately practice their skills, outside of
evidence based processes into the readily
routine therapy sessions.
available, free, support that we give to our Clinical Affiliates to enable them to offer the best
Drawing from our reading, and our own experience of DP, we would like to
kind of therapy possible to our patients.
propose that if therapists are able to engage in DP then this may actually have an impact on their patients’ clinical outcomes. Chow et al. (2015)
Whilst training and supervision aims to be
studied a subset of psychotherapists in a study (17 of 69 therapists) to
as experiential and involve as many active
examine the relationship between therapist’s demographic variables and
techniques as possible (for example, using role
patient outcomes. They found that the amount of DP (and not years of
play, reflection, sharing examples…) the concept
experience or highest qualification) was a significant predictor of outcomes.
of ‘deliberate practise’ has come to our attention recently. We are keen to share this learning and our personal experience of deliberate practise not only with our clinical affiliates but also with
Those therapists who were ranked as being in the top quartile in terms of patient outcomes were spending 2.81 times more time in DP in a typical working week than the lower ranked therapists.
our fellow CBT therapists, supervisors, trainers
DP is targeted practice (Whittington, 2014), not just dealing with routine
and service leads working in the NHS. This was
situations or learning passively (Rousmanier, Goodyear, Smiller & Wampold,
demonstrated by a festival talk about this topic
2017) on skills that you are not doing very well at, over an extended period of
aimed at anyone attending the festival and also a
time. It involves using training activities that are tackled through repetition
workshop for our clinical affiliates.
to gradually improve skills (Ericsson & Lehmann, 1996).
Deliberate practice (DP) is what we know
DP for therapists covers a range of different types of activities; from viewing
professional sports men and woman, musicians,
training videos to reviewing therapy sessions and from live supervision to
business professionals, surgeons and chess
focused learning. You may be interested to learn that Chow et al. (2015) did
players do; when they deliberately practise their
not find an association with the type of activity and client outcome. This
skills (Chow, Miller, Seidel, Kane & Thornton,
gives you the freedom to choose the most appropriate type of DP for the
2015). An example of this might be a golfer
area that you may choose to work on. Please see the box below for some
spending an afternoon trying to put a hole in one! It is believed that extended DP (rather than
further examples.
number of hours at work) is what leads to a
In the science of expertise and in Chow et al’s research, DP is done outside
professional’s superior performance (Chow et
of typical working hours. Whilst the research does not specify how many
al., 2015).
hours we may need to do, if the “expert” therapists were doing 2.81 more
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hours than the less effective therapists we may imagine that they were doing at least 3 hours of DP per week, outside of their working hours. We know that for many therapists this may be a tall order and given that Rousmanier et al. (2017) acknowledge that DP may not be enjoyable or immediately rewarding, how might we encourage you to consider completing DP? Whilst the literature we have presented here does not specify this, we encourage you to consider what might be a realistic amount of DP for you to commit to given your current circumstances? If you are a supervisor, trainer or service lead what might be realistic for you to encourage your therapists to do? We invite you to think about what we have shared with you about how this practise can improve professionals’ performance and ask you to consider the benefits of DP to you as a therapist. Might it improve your patients’ chances of recovery? Even though DP might be difficult to do, might it ultimately improve your enjoyment in delivering CBT? If you are interested in starting DP then you could aim to follow the cycle of excellence (Rousmanier et al 2017): 1.
Think about your strengths and areas that need improving (this might involve personal reflection)
2.
Seek feedback on these areas (this might involve seeking feedback from your supervisor or your patients or using your patient outcome data)
3.
Engage in DP! This will involve planning, rehearsing and then completing and repeating DP tasks over and over again until they become routine
4.
Evaluate the outcome of your DP and then continue with the cycle…
DP often involves a “coach” who may give a professional their training activities to practise. As a therapist you could ask your supervisor to suggest training activities for you or if this is not possible, you may find it useful to buddy up with a peer therapist so that you can practise together and offer feedback to each other. It can be daunting to approach your supervisor and ask them to help you identify an area that you need to improve upon. However, we know that therapists over-estimate their abilities (for example, Brosan, Reynolds, & Moore, 2007) so this suggests there is room for improvement. At the World Congress in
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2019, Judith Beck herself said that she is a better therapist now than she was 5 years ago and that training to be an excellent therapist can take a lifetime! Training and supervision both have a place in helping us to become better therapists and we propose that DP is an effective way of spanning training and supervision in order to help more patients recover. We hope that this case study will give you a final encouragement to engage with DP:
Read the case study here Joanne Adams has identified a CBT skill that she would like to improve upon. This area has been selected through personal reflection and refined through discussion in supervision. Kate Tilbury, Joanne’s supervisor, proposed two hypotheses for this area – that either it is a skill that needs improving or Joanne has high standards for how this skill should be performed. Joanne will review some of her previous cases to gather some objective feedback on whether this is a skill that needs improving or whether it is a skill that she needs to gain more confidence in using. Regardless of which hypothesis is correct, DP will be useful in this case. Joanne and Kate used supervision to plan a series of activities to address the chosen CBT area, for example, role playing this skill repeatedly with a volunteer. As this is a skill which is used often in therapy, Joanne will also take current examples of using this skill with patients to supervision with Kate for some honest feedback. This DP is starting to get underway and we hope to be able to update you on this in due course!
Sign up for updates
Examples of DP • Case discussion • Formulation • Read, watch or listen to your therapy sessions. Have a key question in mind • Attend a lecture, tutorial or workshop or read an article/listen to a podcast. Have a critical learning question you are seeking to answer in mind • Observe a more experienced clinicians/watch a
training video • Use supervision as actively and experientially as possible • Join a book club • engage in some e-learning • Plan for and reflect on a specific therapy session • Do self–practice/self-reflection
References Brosan, L., Reynolds, S., & Moore, R. G. (2007). Factors Associated with Competence in Cognitive Therapists. Behavioural and cognitive psychotherapy, 35, (2), 117 – 190. Chow, D. L., Miller, S. D., Seidel, J.A., Kane, R. T. & Thornton, J. A. (2015). The Role of Deliberate Practice in the Development of Highly Effective Psychotherapists Psychotherapy, 52, 3, 337 – 345 Ericsson, K. & Lehmann, A. (1996) Expert and Exceptional Performance: Evidence of Maximal Adaptation to Task Constraints, Annual Review of Psychology, February 1996 Rousmanier, T., Goodyear, R., Smiller, S. D. & Wampold, B. (2017). The Cycle of Excellence. Using Deliberate Practice to Improve Supervision and Training. Wiley: Blackwell Whittington, A (2014) Take Control of your Training for Competence and Metacompetence. In A. Whittington & N. Grey (Eds.), How to Become a More Effective CBT Therapist, Mastering Metacompetence in Clinical Practice (pp 17 30). West Sussex: John Wiley & Sons, Ltd.
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23 years reliving trauma reframed Kevin Cowley is a 48-year-old father of two teenage boys. This is his personal account of the Hillsborough disaster, his years of suffering and eventual road to recovery through online CBT with Ieso therapist, Hazel Dobson.
separate ways and people trying to get out and eventually we had no real control. We knew that we were there early so we remained calm because we were used to the usual crowds in the terraces. We had no control over our direction of travel. We were carried down the tunnel by the strength of the people going in. There was no deliberate crowd surge and no anti-social behaviour, it was just people going in, but there were more people attending and they weren’t being dealt with sufficiently. There were no barriers in place or queuing system. It was semi-final day; everyone was excited, and we didn’t think much more of what was happening. Eventually, the crowds built up to such a degree that people started to get Kevin Cowley
distressed. I couldn’t move my hands away from my pockets. People were starting to groan, which I later realised were
In April 1989, when I was 17 years old, I attended a football match at Hillsborough stadium with a friend from school. On the day in question, I had the misfortune of being a young fan standing just behind the main goal on the terraces, attending a match that became a disaster.
grown men crying. People were starting to panic. The team came out onto the pitch to warm up. It was the most beautiful of days, so sunny, so clear. There was nobody to alert that there was a problem. My friend and I became separated by the movement in the crowd. It became unsettling. I realised
We arrived at the grounds early to find a position near the
I had to think about myself now. It soon became a life or death
front so that we could see the players, to enjoy the sights and
situation.
smells of being really close up. We’d been to the same ground the year before but this year the whole situation was different. There were no safety checks on entry, which was not unusual back then. It was overwhelmed with people when we arrived with many thousands of people all turning up at the same time and the speed of entry was extremely slow. Before going through the turnstile my friend’s coat was taken off just by the surge of the crowd.
The football game kicked off. I distinctly remember that I couldn’t raise my hand over my head. Peter Beardsley hit the bar of the goal at the other end of the pitch. Everyone rose upwards, excited because it was almost a goal. That’s when it happened. From behind me, the loudest noise pierced the air. A noise which reverberated through me that day, and throughout the following years. It was the sound of one of the crash barriers breaking. When that happened, everyone
We started to get carried around, almost like being in water
went down like human dominoes. People were still coming in.
with the strong currents, with people starting to move in
Everyone went down and under, scattered under the bodies
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“I can’t quite explain how much online CBT helped me. I’m able to cope with memories that have been restocked, restored. It changed my life.”
and under the people. I lost track of time. I don’t
a man sitting up high on the fence, straddling
know how long I was under there. I presume I
between the central pens. He was throwing
was unconscious. I woke up amongst the dead
his hands around gesturing for someone to
and the dying.
grab him and climb out. I managed to hold his
I’d walked out the door as a 17-year-old expecting to go to football match. The situation I now found myself in was to fight for my life or die. I became embroiled in what I felt was like a huge fight.
hand, climb up and jump down to then stand. I looked back to where I’d come from. The people trapped had died in the confines of those pens, they couldn’t get out, they had nowhere to go.
There was a man with dark hair, greasy from all
I had no first aid training and no real authority
the sweat. We both realised that there was no
as a 17-year-old, so I wandered aimlessly. I
way out other than by trying to use each other
remember the players being there, but I didn’t
to get up and towards the edge. All around me
speak to them, despite being a huge Liverpool
were people who had failed in their attempt to
fan. I was oblivious to them and they just left the
get out. Some of them were dead. Some of them
pitch. I didn’t know what to do. I was wandering
were dying. There were sounds of moaning,
around in a state of shock and things started
crying, smells of urine, smells of vomit, smells
happening around me. I gathered my senses
of sweat.
and realised that people were taking out the dead and the dying on stretchers made from
The man with greasy hair and I locked eyes and
the old advertising boards. I joined in to help
we both realised that this was it. A big part of my
carry one. I think the person on it was dead, but
ongoing nightmare was the fact that I used him
I couldn’t be sure and no-one checked. I had no
to climb out. It’s a difficult thing to talk about. I
idea what to do but felt I had to help. I had no
pulled myself up on his shoulders. I don’t know
idea where my friend was. I was still looking out
if he’s one of the 96 people that died that day. It
for myself, before thinking about others, which
has always a source of real hurt and real pain.
again was a huge obstacle for me in later life.
I don’t really have the words to describe what it
Carrying the stretcher, we ran down towards the
feels like to stand on dead bodies. But I had to do
Nottingham Forest end where the opposition’s
that to get out. I managed to climb up. There was
fans were watching. People started to spit on
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us, calling us scum, hurling abuse. Once we turned the corner towards what the gymnasium, I expected some sort of operational response from uniformed police or ambulance services, all of whom were absent. As we turned into what I thought would be a triage section, we found nothing, no help. We just left the unconscious man in an ever-growing pile of bodies in a darkened room. I was astounded to realise no-one was helping us, we were on our own. I started to feel woozy and sweaty, but I managed to go back and do another rescue on a stretcher. The same scenario repeated. I broke down and started to cry. I didn’t know what to do with myself. I was afraid. The shock had finally broken into fear and emotion. I fell by the side of the stand, collapsed and started to sob. I stayed there until a South Yorkshire policeman came along and kicked me to see if I was alive. He said, “Are you alive you scouse bastard?” I mumbled that I was okay, and he took my details. I’d always supported the police, I was raised to be honest, to not do anything wrong. I was just left there, 17 years old and alone while the official rescue eventually started. People continued to die around me on the pitch, but we had no way of helping further or leaving. Eventually the ground was opened, and we were allowed to walk out. It was as though nothing unusual had happened apart from the fact that there was hardly anyone on the coach. I later learned my friend had been taken to hospital with broken ribs and a broken leg. It was a very long journey home. When I arrived home my whole family was there, huddled together in the smoke-filled living room. My parents and grandparents grabbed me, but I didn’t know what to do. I just went upstairs and stayed there alone, on edge of the emotion. The next day there was a service at a cathedral in Liverpool, and when the singing started and I began to cry. My mum told my dad to see how I was but I had nothing to say. At school the principal sat eight of us on the stage in front of the whole college. He said, “These boys were at Hillsborough, if they start acting strange you know where I am.” I felt on show. I didn’t feel supported and there was nothing offered like seeing a GP or opportunity to talk to anyone about it. So, I bottled it away. Eventually I started to come to terms with it, but not in a good way. The overwhelming sense from the press and the public was that they blamed us for what happened. They told the world we were scum because we dropped the dead and urinated on “brave cops”, none of which was true I’d often binge drink to cope with what had happened because when I was drunk the hurt wasn’t there anymore. I still had nightmares about it. All the parts of it were still there for me. I thought I was dealing with it, but I obviously wasn’t. In late 1995 I met my wife and two years later we married. I never told her what happened really. I was ashamed of it. I thought that I was the person that needed to deal with it. I thought everyone was looking down at me, thinking I was in the wrong.
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The way I was dealing with it, was not the best but it felt right
through my Hillsborough experience in every detail. So much
to me. There have been flare-ups of times of real difficulty
so, that on some nights after messaging online with her about
which imposed on my life and in ways that I didn’t realise were
Hillsborough, I’d have physical reactions. Every time we had
wrong and seemed to become my normal. I had insomnia,
a session, we start by gauging the situation where she would
nightmares and daytime intrusions. People would ask if I was
ask how I was, how the previous week had gone. We’d discuss
alright, but I knew that I had to cope with it in my way.
coping mechanisms, happy thoughts and key words that I
Our first son had been born in 2002 and I thought, I didn’t deserve to have him, because a lot of people hadn’t come
could think about and photographs of the boys. Things that I could look at and lock into a good place. It gave me strength.
home that day from Hillsborough. I thought I don’t deserve
Hazel helped me rework the memories. Memories that
to have happiness. It started to overwhelm me. By 2004 I’d
were so bad, so intrusive. They were all encompassing. They
become a person that I didn’t want to be; I was out of control.
intruded every day of my life, leaving me feel unable to cope.
I started to drink even more to get more blind drunk until
Hazel taught me how to reorder the memories and to place
my wife started to push me to open up and tell her what was
them onto a shelf. These were memories that would never go
wrong. It was a difficult time. But that was when it started
away but she sorted them into memories that I could deal with.
to change.
They would no longer jump out on me when walking down the
I started to look into ways of dealing with it. In 2004 I went to see my GP and she suggested CBT. I was sent to see a trainee therapist, but it didn’t do much for me at all. I came away from it thinking I’d tried but I just had to handle it. I carried on in my daily life, unable to work, with regular traumatic flare-ups. I tried to move on with the support of my family, and we were blessed with another boy. Eventually, in 2012, the Hillsborough independent panel reports were published. It mentioned that we weren’t to blame and that we had done nothing wrong. Having that published in an official government document made me feel different about myself. The inquests said we were not to blame for the deaths of the people and that what we had done was
streets, hearing a loud noise and thinking it was the domino effect again. I’d have physical reactions to the reordering. I’d wake up in the morning and feel stiff, because in my head I’d worked so hard at talking about what it felt like to have my arms pinned, unable to move. It can’t have been easy for Hazel; it certainly wasn’t easy for me. We reordered the memory about the fight in my mind, with the guy with the greasy hair, which was huge in my head. It was almost like a light switching on and my life has never been the same. I cried that night. The man with the dark hair stopped being someone that I probably killed and became someone who was probably my guardian angel. He helped me to live. I was crying at this revelation.
above and beyond what anyone could have done on that day. I
I can’t quite explain how much online CBT helped me. When
felt, for the first time, pride in what I’d done.
I came out of it, I was in a very a different place. I’m able to
My life changed again. I started to talk more openly about Hillsborough. I started to feel better able to talk and pride in what I’d achieved, not only on that day, but subsequently in my life because I’m still here. A lot of people aren’t, and a lot of people are still in the dark. I feel that I’ve stepped out into the light, because the real help for me, help that I never expected to come, came through online CBT. I went to see the GP, but he was indifferent. On my way out I saw a poster for online CBT. I thought I needed to try this as I was in a stronger place. I’ve never actually met my therapist, Hazel Dobson, but she is probably one of the finest people I’ve ever dealt with, because she didn’t judge me. She listened to what I said, and we went
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cope with memories that have been restocked, restored. I knew where they were and they wouldn’t surprise me anymore. I had the coping mechanisms that I’d been working on. Suddenly, life became different because my Hillsborough experience wasn’t in control of me anymore. I was able to look back at it and realise what had happened. I bought into it to such a degree that it changed my life. I now talk about my experiences because I’m in a place where I can talk about them. I’m only able to do so because of what online CBT has done for me. I hope I’ve given a little insight into what can be achieved. I tell anyone suffering to look into Ieso and online CBT. It should be lauded, not only for my own personal success, but for how it continues to help people in my situation.
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COMMENT
Using growth curve models to support active supervision Kate Tilbury, Supervision Lead, talks about the benefits of one of Ieso’s pilot projects that could become a medical tool.
some differences are entirely normal. When the baby’s growth rate falls outside of the confidence interval, either above or below on various growth charts, then immediate follow up, monitoring, or intervention would be initiated. There is a large body of evidence to support the application of growth curve analysis to psychotherapy. Lambert et al. (2003) was the first to show that timely feedback on cases where ‘signals’ suggested drift could have a positive impact on therapeutic outcomes. Shimokawa et al. (2010) conducted a meta-analyses (research to derive more global findings from lots of relevant research studies that have taken Kate Tilbury, Supervision Lead
Growth curve analysis, or trajectory analysis, is a
place on the same concept) and found that the use of Outcome Feedback prevented deterioration by 2.3 times.
set of techniques for modelling change over time.
Whilst there are many factors that operate to impact on therapy
A growth curve model is used to give immediate
outcomes figures, we know that therapist variables account from as
feedback versus what is expected from a wide
little as 5.1% (Chow, 2015) to 11% (Delgadillo et al., 2017). We know that
dataset. It is used to summarise data over time
therapy performance is private business, quite rightly so! However, this
into a smooth curve and is especially useful in
does create an interesting phenomenon that therapists are less likely to
measuring individual change over childhood
engage in deliberate practice, a practice common in the sporting and
years or lifetime.
music professions where skill acquisition and refinement are continuously developed. My colleague, Joanne Adams, and I explain how to improve on
A good example, that most people can readily
this in another article.
identify with, is the application of growth curve models for peri-natal women who receive routine scans at pre-set times in a baby’s development in utero. The scans do not happen by chance. Millions of data on peri-natal women tracking a baby’s progress against a baby’s development dictate when a scan should be performed. Once a scan is completed the results
There are other therapist factors that might be relevant too, such as burnout and lowered job satisfaction. What other factors may be at play to affect therapy outcomes? The therapy process: making sure there are clear and defined goals, expectations of therapy, and a strong alliance all have significance. Patient demographics can also reliably predict if someone is going to respond dramatically to treatment and reach recovery or respond more modestly.
will be compared to a vast data set, that allows
The aforementioned factors are relevant as they need to be built into
clinicians to know what ‘normal’ is, i.e. what
a growth curve model in order to predict with accuracy the recovery
growth is typical for healthy development. There
trajectory that someone should take if they respond as the majority of
is a confidence level to allow for differences as
people do to their diagnosed metal health problem. This is referred to
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in the literature as Expected Treatment Response (Delgadillo et at 2017). So, a growth curve predicting expected treatment response will look different (more favourable) for someone who has milder symptoms at the start of therapy, than someone who starts with severe scores and perhaps has other co-morbidities, such as drug and alcohol difficulties, or is living with a long-term health condition. Off track cases are flagged up when someone deteriorates outside of the predicted confidence intervals. When a patients symptoms track in the lowest 10% for a patient like them at presentation, it is a signal that intervention may be needed to support the therapist treating them. At Ieso we believe we are a perfect test bed for this approach. As an online provider of psychotherapy the growth curve data can be disseminated at the first sign of ‘off track’ to both supervisor and therapist, without delay. The therapist and patient can explore together what might be causing the deterioration. Once noted and discussed the therapist is then advised to bring this case to supervision so that the block can be formulated and a plan derived. In most cases, it is estimated that an intervention will be possible, and once the block is unplugged, change methods (the active ingredients in therapy) can continue to effect change. In some cases, the block is not amenable to change, however one can still find great value in acknowledging and recognising a set-back in someone’s journey. To have control over accepting the current state allows new goals to emerge that carry their own benefits and impact on symptoms. Below is what we typically see within the clinical team. We have created our own internal growth curve analysis model. They show patients that have gone “off track” in the PHQ9 or GAD7 assessment questionnaires. We can use these growth curves in supervision as a guide of where to start looking. In the example chart, we would review the therapy transcripts in sessions 5 and 6 to see if we can uncover some clues as to why this patient’s score has gone off-track. We expect 10% of patients to respond much better than expected and 10% to go off-track in a negative way.
Growth curves are designed to alert us to the fact that what we are observing is not typical or predicted. It can indicate deterioration beyond what is normal. We are developing this as a tool that can be used in therapy and supervision. Ideally it should be used to investigate and correct a path as soon as possible. This is a tool that offers scientific solution. There will always be cases that go off track but by being aware of that a therapist can investigate and take steps to avoid a further spike in those assessment scores. We are very excited to use growth curve models in service, please do watch the webinar to learn more and await further information regarding how to be part of the growth curve pilot project.
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At Ieso we are committed to delivering world-class mental healthcare
We have one overriding mission here at Ieso that rings true with all of our people. We are truly passionate about making people better; driving improvements and breakthroughs in mental healthcare for everyone. Our patients are at the centre of everything we do.
Our cutting-edge technology Imagine for a moment capturing the collective knowledge of the world’s leading and most effective therapists. Then imagine taking that collective knowledge, and by using deep learning techniques, natural language processing engines and sophisticated artificial intelligence practices, being able to make every therapist better. Imagine those learnings translated into clinical practice guidance tools that provide patient-personalised guidance to therapists, to improve the therapy being delivered and as a result, get patients better, faster.
How you can be a part of it We are entering an exciting stage of growth and looking for likeminded, enthusiastic and positive people to join our expanding team. Find out more at www.iesohealth.com/en-gb/careers The next issue will be a special focus providing coverage of the Therapy Insights Festival. Register to attend this free online event here. Subscribe here to receive the next issue automatically. This magazine was produced by Huuha Ltd. If you have any feedback, or would like to contribute to the next issue, please email hello@huuha.co.uk
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Contact us today envelope info@iesohealth.com phone-alt 0800 074 5560 map-marker-alt
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