Open Mind Presentation for Offender Managers

Improving Access to
Who are we?…..What do we do?
 Barbara Fulton, Lorraine Parker & Yvonne Drew
 Psychological Therapists: Open Mind Service
 Part of the wider NHS IAPT programme which
implements guidelines for people suffering with
depression and anxiety disorders
 We offer realistic and routine first-line
psychological treatment
 Based at Cobden Street: our aim is to reduce
barriers to accessing psychological treatment
(that offenders may come across)
Stepped care model
 Step 1: Recognition
 Step 2: Mild/Moderate common mental health problems
 Step 3: Moderate/Severe common mental health problems
 Step 4: Treatment resistant, Atypical and psychotic depression,
psychotic illnesses, those at significant risk, Personality disorder
 Step 5: Risk to life, severe self-neglect
• Blocking of Treatment (many offender service
users have repeated experiences of refusal
and exclusion from services)
• Problems dismissed
• Not registered with a GP
Psychological Therapies
A variety of therapies have been reviewed for their
effectiveness (Nice Guidelines)
 CBT – depression & all anxiety disorders
 IPT, BCT, Counselling, BDT- depression
(varying indications)
 CBT, EMDR- post traumatic stress disorder
Cognitive Behavioural Therapy
Barbara Fulton & Yvonne Drew
Depression: Moderate to Severe
Depression: Mild to Moderate
Panic Disorder
Generalised Anxiety Disorder
Social Phobia
OCD (Obsessive Compulsive Disorder)
PTSD (Post Traumatic Stress Disorder)
Hypochondriasis (Somatoform disorder)
Specific Phobias
Integrative Therapy
Lorraine Parker
 Blends elements of a range of therapies
- Gestalt
- Object relations
- Cognitive behavioural approaches
- Attachment
- Psychodynamic
 Personality disorder or characterlogical issues
underlie depression and/or anxiety.
Consider a referral if…..
 Depressed mood lasting for more than two weeks
 Anxious mood lasting for more than 2 weeks
 Has already been diagnosed with depression or an
anxiety disorder
 Problem behaviour: which appears to be associated
with anxiety or depression
 Sufficient time remaining: sentence/licence
Not Offender Rehabilitation
 We specifically target depression & anxiety and
not offending history
We work within psychological models formulating
the offender’s problems from their point of view
Not about prosocial modelling, reinforcement and
reward of prosocial behaviour
Offending history is only focused on if identified
as significant to their psychological problem and
Risk assessment and risk management throughout
Not offender Rehabilitation:
case study
 Male, aged 45
 Offence history: sexual relationship with a minor
(15yrs), downloading & distributing images of children
Unrepentant (makes this clear at initial meeting)
Diagnosis: agoraphobia (since release from prison)
Fear: “I could be chased, have to fight for my
survival, do damage to my attackers and then end up
back in prison”
Problems identified: Isolated and depressed
Therapy: Cognitive and behavioural interventions
targeting avoidance of situations perceived as
difficult to escape from
Referral Process
 Provide the service user with information about
Advise that therapy is not compulsory
Complete referral documentation
Questionnaire: this needs to be the service users
interpretation of their mood and situation
Service user needs to sign 2 consent forms (inc)
Return the completed referral pack & book an
available appointment slot
IAPT staff are happy to guide you
Referral Process
 1st appointment: Initial assessment
 Assess for service suitability
 Assess for therapy suitability
(CBT, EMDR or Integrative)
 Agree an initial treatment plan
 If not suitable: signposting/referral
 If not suitable: OM guidance
Assessing for CBT Suitability
why is this important?
 Service users with unfocused, multiple or very
chronic problems are least likely to benefit from
short term CBT
 Demoralisation
 CBT is not a one size fits all
How OM’s can help with assessing
suitability for CBT
 Is there potential for acceptance of the CBT
“what are your beliefs about what’s causing your
 Those with an insistence that their problem is due
to a chemical imbalance or caused by other people
are unlikely to be suitable
How OM’s can help with assessing
suitability for CBT
 Are the able to identify thoughts, feelings,
behaviours and body sensations?
How OM’s can help with assessing
suitability for CBT
 Are they able to access their own emotions in relation
to situations ?
“how did you feel when that happened……”
(look for a one word answer)
 Are they able to comment on their thoughts in
relation to situations ?
“what ran through your mind when that happened….”
How OM’s can help with assessing
suitability for CBT
 Are they goal orientated?
…do they have the ability to work on one specific
problem at a time?
….be aware of vagueness, rambling, frequent topic
changes, desire to work on all problems at once
How OM’s can help with assessing
suitability for CBT
 Do they have alliance potential?
- Note: eye contact, posture and general ‘feel’
- Poor rapport, idealising or blaming
How OM’s can help with assessing
suitability for CBT
 Are they able to accept personal responsibility in the
therapeutic process?
“what would you like to get out of therapy?....what
might your role be in that”
“you’d be expected to work on your problems in between
cbt sessions….what’s your thoughts about that?”
 Active v Passive?
Are they Anxious/Depressed……but
struggling to meet the CBT checklist???
 Seek IAPT guidance….. “It’s good to talk!”
 May be more suited for Integrative Therapy
 CBT checklist: the assumptions can be difficult to
meet (those who
 Transference
have PD or other characterlogical issues)
 A redirection of feelings towards the service user
 Emotional entanglement with a service user
 Heart sink feeling….or hot potato
Look out for:
Service user reminds you of someone you have strong
negative feelings towards
Feeling parental towards them
Overly identify with them
Difficult to supervise/relationship breaking down
Is the service user wanting help with their anxiety
or negative mood?....if not:
 Could the difficulties encountered be better
dealt with in supervision with your manager
 Reflective and reflexive practice is key
 Be aware that countertransference is normal
 Be consistent with boundaries
Co- existing Drug and Alcohol Use
 70-80% of clients in drug and alcohol services
have anxiety disorders, depression, trauma
(Weaver, 2003)
 IAPT services should be working inclusively
alongside substance misuse services to improve
outcomes (IAPT Positive Practice Guidelines)
 CBT: Co-existing anxiety/depression
(NICE guidelines (2007) Dug misuse: psychosocial Interventions)
Co-existing Drug and Alcohol Use
High Intensity
 Formal therapies delivered by IAPT therapist
CBT for depression or specific anxiety disorder
 Low Intensity
 Delivered by IAPT therapist
Guided self-help & Behavioural Activation for anxiety
disorders and depression
 Low Intensity
 Delivered by Probation Key Worker
Motivational Interviewing & Contingency Management
Co-existing Drug and Alcohol Use
No evidence that using substances makes usual
psychological interventions ineffective
if an executive function deficit
exists: CBT can be adapted
Co-existing Drug and Alcohol Use
 Accepted: experimental, recreational as well as
stable drug and alcohol use
 IAPT staff will determine stability
 Not accepted: unstable drug and alcohol use
 Instability across drug and alcohol use can lead to
therapy disruption
Multiple Competing Needs
inc personality disorder, learning disability, drug
dependence, alcohol dependence, homelessness,
domestic violence etc.............
• May lead to non attendance/disrupted therapy
sessions /poor homework compliance
• May compete with motivation for therapy and
treatment engagement
• Offender service users with multiple and competing
needs may be misunderstood as being a ‘time wasters’
Thank You
Any questions
………its good to talk!