COGNITIVE BEHAVIOUR THERAPY SERVICE
Annual Report, September 2003 - August 2004.

Current therapy staff:

Alex Nuthall, Senior therapist & Service Manager (full-time)
Sharon Matthews, Senior therapist and clinical lead for psychosis (full-time)
Dr. Lisa Bird, Specialist Clinical Psychologist (4 days)
Caroline Reeve, therapist (full-time, joined CBT service in Aug 2004)
Lucy Cotterill, therapist (3 days, joined CBT service in Aug 2004)
Kathy Yapp, assistant administrator (half-time, joined CBT Service in Aug 04).

In addition, one therapist post remains vacant due to difficulties in recruiting suitably qualified practitioners.

The primary aim of the CBT Service is to provide and develop access to Cognitive Behaviour Therapy (CBT) for adults in Shropshire with mental health problems, who would most benefit from this form of psychological therapy. As this is still a relatively small service with a few specialist therapists covering the whole county, the main strategy remains for the therapists to concentrate their direct clinical work on clients requiring specialist treatment programmes, whilst at the same time supporting the growth across the mental health services of safe, effective non-specialist interventions based on this approach by training and supervision of other interested staff.

The most significant development in the service this year has been a new contract with the PCT to set up weekly CBT clinics in rural localities across the county, as a means of improving access in these areas, with the emphasis on brief/early intervention. The ongoing central CBT Service based at Chaddeslode House, Shrewsbury, and Dawley Centre for the Telford & Wrekin area, continues to offer more substantial and intensive programmes of individual and group therapy.

Therapy work.
Summary statistics for clients seen and therapy provided by the service are shown in table 1 below.

The overall pattern and level of referrals to the service county-wide remains largely consistent with that in previous years, the majority being directly from primary care.
However, there is a continuing upward trend in the numbers of referrals received within the department of psychological therapies which request some form of CBT, associated in part with dissemination across the county by the PCT, of national protocols and guidelines promoting CBT for treating common mental health problems. As it is simply not feasible for the CBT service to take on all of these referrals (20-25 per month in each area), it remains a significant challenge to identify and make appropriate therapy provision, resulting in an ongoing 12-month waiting list for specialist therapy, and continuing substantial unmet need for CBT to be found on waiting lists of other services within the Department and elsewhere, eg. CMHTs.

Table 1: CBT provided Sept 03 - Aug 04.

	Shropshire	T & W	Total
Referrals accepted	148	92	240
Source: GP	81	54	135
Psychiatrist	29	23	52
CMHT	19	7	26
Counselling/Psychology	9	4	13
Other	10	4	14
Did not respond/attend	41	14	55
Seen for assessment	107	78	185
Therapy offered: Individual	61	50	111
Group	30	19	49
Unsuitable/advice only/referred on	16	9	25

Presenting Problems:

Depression 47
Obsessive-compulsive 29
Phobia 20
Chronic Fatigue 16
Panic/Agoraphobia 16
Social anxiety 15
Generalised anxiety 13
Compulsive behaviours 9
Post-traumatic stress 8
Psychosis 8
Other 4

Therapy services available. Current waiting time:

Individual programme 12 months
Depression group 6 months
Chronic Fatigue group 6 months
Hearing Voices group open
OCD group open

Therapy outcomes.
Progress and outcome in CBT is assessed with most clients who take up therapy, using individual problem severity and goal attainment self-ratings and in some cases other standardised psychometric measures relevant to the presenting problem, eg. Beck Depression Inventory. Progress is assessed pre, mid and post-treatment and up to one year follow-up. Across the full range of clients completing a course of CBT (group and individual), overall outcomes between therapists and a mean of 12 sessions are approximately as follows:

Much improved (75-100% change): 20%
Moderately improved (50-75%) 40%
Slightly improved (25-50%) 20%
Unimproved (0-25%) 20%

Attrition from CBT is around 20% at initial referral and assessment, and about 30% overall, including clients who do not complete therapy. There is a re-referral rate of about 8%, mostly clients who did not take up therapy when first offered. The only significant complaints expressed about the CBT Service concern the long waiting list.

Teaching, Training and Supervision.

Alex Nuthall has continued a secondment to Staffordshire University as Senior Mental Health Lecturer to provide an introductory course Foundation Skills for Cognitive Behaviour Therapy, as part of the Faculty of Science continuing professional development programme. The course ran twice during the year, with teaching contributions from the other CBT therapists, and a total of 26 students, mostly mental health practitioners from both Shropshire and Staffordshire PCTs.

There continues to be strong interest in introductory and basic level training in CBT, but difficulties in resourcing adequate follow-on clinical support and supervision from the CBT Service remain a significant limitation in disseminating non-specialist CBT skills to patient care. A limited number of ongoing small-scale supervised clinical placements within the CBT service have been supported this year between the therapists. The University placement for second year mental health nursing students has remained suspended due to difficulties committing adequate therapist time whilst the service is being redeveloped.

Other training contributions by the CBT Service in Shropshire this year include: a day workshop on CBT for psychosis, a half-day workshop on CBT approach to health anxiety and hypochondriasis for GPs and hospital doctors, and a number of short talks and presentations to groups of health service staff in different settings.

All CBT therapists have continued to maintain and develop their expertise through attendance at national and regional training events of 1-3 days' duration, supported by ongoing regular shared clinical supervision and case discussion.

Research.
A substantial pilot study has been completed within the CBT service this year, examining the use of CBT-based early intervention for panic attacks at hospital A & E departments. The promising findings have important implications for prevention of panic disorder (a major mental health problem) which warrant further research, and publication of the results is in preparation.

CBT Service plans and projects for the coming year.

* Establish and evaluate the new primary care CBT clinics across the county.
* Address under-resourcing of CBT service provision in Telford & Wrekin.
* Promote development of CBT for psychosis across the county by the PCT in line with NSF and NICE guidelines.
* Collaborate with Chaddeslode and Dawley therapy centres to review, clarify and develop appropriate CBT-based referral and treatment pathways, and reduce waiting lists for this form of therapy.
* Research qualitative aspects of clients' experience of their therapy and contact with the CBT service.
* Develop more substantial training placements for locally based, suitably qualified mental health practitioners, and resume university student placement.
* Develop ongoing, systematic, small group CBT supervision across the county to support dissemination of safe, effective non-specialist CBT in other settings.

Next report: Autumn 2005.

Alex Nuthall
CBT Service Manager November 2004.