A STRATEGY FOR THE DEVELOPMENT OF PSYCHOLOGICAL

THERAPY SERVICES

Department of Health, Social Services and Public Safety

December 2008

FOREWORD

I am delighted to launch, for consultation, A Strategy for the Development of Psychological Therapies in Northern Ireland. In doing so, I believe that improving access to psychological therapies has huge potential to improve outcomes for individuals, families and carers, and for the wider community. Improving provision of psychological therapies makes good sense. It can, for example, help individuals and families by providing early psychological interventions and, for established conditions, much can be done to relieve anxiety, depression and distress. Through a stepped-care model for psychological therapies, I want people to know what services and interventions are available to them. I aim to promote early intervention, self help and support in the community, but I also recognise the need for specialist services for people complex conditions, particularly those arising from mental health and learning disabilities. Services will need to be redesigned around the needs of individuals. Regardless of the setting in which these services are delivered, they will be designed to be person-centered and flexible. In addition, services will be delivered to agreed principles and standards, and by competent and skilled staff, who are appropriately supervised and accredited by relevant professional bodies. The Bamford Review of Mental Health & Learning Disability (2005) recognised the importance of psychological therapies. I am investing an additional £7million, recurrent from 2010/11, for implementation of this strategy. However, it is recognised that further mapping will be required in order to improve capacity and to meet future demand. I welcome consultation responses from service users and from the statutory, community, voluntary and private sectors. The consultation ends on 31 March 2008.

Michael McGimpsey MLA

Minister for Health, Social Services & Public Safety

CONTENTS

FOREWORD

1.0 Purpose of this Document

2.0 Background

• Range of therapies

• Bamford Review of Mental Health and Learning Disability

• Impact of Disability

• Cost of Mental Illness

• Working with Children and Adolescents

• Working with Families and Carers

• Current Gaps in Service Provision

3.0 The Way Forward

• The Use of Psychological Therapies

4.0 Service Principles

• Evaluation of Services

5.0 Service Redesign

• A Stepped Care Model for Adults

• A Stepped Care Model for Children and Young People

• A Stepped Care Model for People with a Learning Disability

6.0 Workforce Issues

• Staffing Requirements

• Training, Accreditation and Supervision

• Links to Professional Regulatory Bodies and Associated Issues

7.0 Prioritisation of Service Development

8.0 Conclusion

Bibliography

Reference Group Membership

Appendices

A Psychological therapies

B NICE psychological interventions for common mental health disorders

C Stepped Care Model for Children and Young People

D Stepped Care Model for People with a Learning Disability

EXECUTIVE SUMMARY

This strategy has the overarching aim of improving the health and social wellbeing of

the population of the Northern Ireland by improving access to psychological

therapies and by being more responsive to service user’s needs.

Many people in our society suffer from debilitating conditions, as a consequence of

their relatively poor physical, emotional, behavioural and/or mental health. These

can affect all age groups, for example, children and young people with emotional and

behavioural disorders, young mothers with depression, and adults of working age

who, because of their ill-health may have relationship difficulties and find it hard to

support their family and hold down a job. Older people too may have psychological

problems, including those arising from their physical disease and from social and

mental health conditions, such as isolation, depression, anxiety and bereavement.

In addition, it is acknowledged that carers need psychological support, to maintain

and improve their mental health and to assist them to look after their loved ones with

long-term physical, mental health and learning disabilities.

Improving mental wellbeing in our society, through improved access to psychological

interventions makes good sense. It can help individuals and families, for example,

through early intervention and, for established conditions, much can be done to

relieve anxiety, depression and distress regardless of the cause of the underlying

condition. Psychological interventions can help people to be independent and to live

as valued members of their community.

Even in economic terms psychological interventions have benefits, for example, by

improving an individual’s physical and mental health outcomes, their ability to work

and be economically productive. In addition, improved mental and social wellbeing

can help prevent anti social behaviour and family breakdown in children and young

people, reduce the burden of anxiety and depression, and input into the rehabilitation

of offenders. Also, by assisting in the maintenance of independence it can reduce

reliance on residential and hospital care.

Service users and their carers also want better access to a range of evidence based

therapies delivered by trained therapists. This is supported by the Bamford Review

of Mental Health and Learning Disability (2005) which supports psychological

therapies as a treatment option for common psychiatric conditions.

In developing a psychological therapies strategy, the Department of Health, Social

Services and Public Safety recognises the importance of early intervention and self

help, the development of psychological therapy services in the community and the

need for specialist services for complex conditions, particularly those arising from

mental health disabilities. Regardless of the setting in which services are to be

delivered, psychological services need to be developed to agreed principles and

standards, be delivered by competent and skilled staff and be redesigned to take

account of evidence based practice. A stepped care model is supported in this

strategy so that service users can receive the level of intervention appropriate to

their needs.

The Strategy will inform service development over the next three years. To underpin

development, an additional £7million, (recurrent) from 2010/11, will be invested.

Further mapping will be required to assess need and to improve capacity to meet

demand.

This Strategy proposes implementation of the following recommendations:

1. Psychological therapies should be a core component of mental health

and learning disability service provision. Services should be delivered

by staff with the skills and competence appropriate to the level of

interventions required.

2. Clinicians and the public should have information on the range of

psychological therapy services that are available and how to access

them.

3. Recognising the importance of psychological interventions, if a new

care pathway or service framework is being developed, especially for

mental health and learning disability conditions, due consideration

should be given to the inclusion of psychological therapies within the

pathway and service standards.

4. Service users and carers should be involved at all levels of service

development, planning and implementation of psychological therapy

services.

5. A Regional Psychotherapies Group should be established as a matter of

urgency to oversee implementation of this strategy and to advise the

Department on the future development of child and adolescent and adult

psychological therapy services. It should be representative of

commissioners, service providers, carers and users.

6. The HSC should develop an agreed service specification for relevant

therapies, taking account of the service principles contained in this

Strategy.

7. Psychological therapy services should be subject to service, therapeutic

and economic evaluation which takes account of the views of service

users and carers.

8. The organisation and delivery of psychological therapy services should

be based on a stepped care model.

9. There should be a single point of access to psychological assessment

to direct to the appropriate tier of intervention.

10. In order to improve early intervention and reduce pressure on specialist

services, a detailed map is required of demand and associated

workforce skills in adult, and child and adolescent psychotherapies with

particular reference to tiers 1 and 2 interventions and the necessary

supervision arrangements.

11. Agreed referral pathways should be developed for child and adolescent,

and adult psychological therapies that incorporate face to face

assessment by a competent mental health practitioner (band 6 or above)

to ensure that a person’s needs are appropriately addressed by a

relevant professional with the appropriate skills and level of expertise.

12. The Recommendations contained in the Review of Clinical Psychology

Workforce (2008) should be implemented.

13. A consortium of stakeholders, including accredited training providers,

should be commissioned to agree a regional approach to undergraduate

and postgraduate training to meet the requirements of a stepped care

model.

14. A supervision framework should be developed, which sets out the core

competencies and accreditation required for supervisors at the different

levels of intervention.

1.0 PURPOSE OF THIS DOCUMENT

1.1 The Department of Health, Social Services and Public Safety has identified

the development of psychological therapy services as a particular element of

its overall strategy to reform and modernise mental health and learning

disability services. This document provides a strategic framework for the

development of these services in a way that is consistent with a range of

strategies to improve health and well being and the management of long term

conditions, and the recommendations of the Bamford Review of Mental Health

and Learning Disability.

1.2 This document provides commissioners, service providers and training bodies

with:

• a strategic overview of what is needed to develop psychological therapy

services in line with the recommendations of the Bamford Review of

Mental Health and Learning Disability;

• service principles to inform the commissioning and provision of

psychological therapy services;

• a proposed service structure for the organisation of psychological therapy

services within the statutory, voluntary, community and private sectors;

and,

• recommends the underpinning training and accreditation required by

practitioners and supervisors working at the various levels within a

stepped care model.

1.3 The aim is to provide a range of services that are:

• Clinically effective

• Safe

• Cost effective

• Comprehensive

• Co-ordinated and user friendly

and delivered to a standard consistent with the National Institute for Health

and Clinical Excellence (NICE) and other relevant national guidelines.

1.4 As therapy services are provided by the statutory, voluntary and private

sectors it follows that, irrespective of which sectors services are

commissioned from, they must be provided to similar standards.

1.5 To provide the necessary cadre of trained therapists and to enable the

progressive development of services will require a comprehensive and co-

ordinated training and HR strategy to underpin the process.

2.0. BACKGROUND

2.1 In this document the term psychological therapies means “an interpersonal

process designed to modify feelings, cognitions, attitudes and behaviour

which have proved troublesome to the person (or society) seeking help from a

trained professional (STRUPP)). They are often called “talking therapies”.

2.2 Psychological therapies are an essential part of modern mental health care.

Appendix A provides further detail on these therapies. The term

‘psychological therapies’ covers a broad range of models including:

• Cognitive Behavioural Therapy;

• Psychodynamic/Psychoanalytic Psychotherapy;

• Systemic and Family Therapy

• Humanistic, Person-Centred/Experiential Therapy

(National Occupational Standards List)

2.3 The following describes the existing levels of intervention in more detail:

Primary intervention – recognition of the problem and short-term interventions

to prevent conditions becoming severe.

Secondary interventions – more intensive interventions to treat mild to

moderate conditions.

Tertiary interventions - High intensity specialist interventions to treat chronic

and complex conditions.

2.4 Psychological therapy provision is a multi-professional and multi-agency

endeavor. Psychiatrists, psychotherapists, psychologists, counsellors,

nurses, social workers, occupational therapists, arts therapists and many

other groups are involved, all of whom need to communicate and co-ordinate

effectively with one another. Therapy can also be provided by a range of

practitioners in the voluntary and private sectors.

2.5 Psychological therapies should be available to all age groups in a variety of

settings and for a range of physical, emotional, psychological and psychiatric

conditions. Their purpose is to promote individual, group and family

wellbeing, and provide effective treatment, particularly for common physical,

mental health and learning disability conditions.

2.6 In addition, it is recognised that psychological therapy intervention can play a

significant part beyond the health and social care sector, for example, in

schools and youth settings, and in the youth and adult justice systems. It is

acknowledged that many services are delivered outside of the statutory

system. The place of community, voluntary and private sector is pivotal and,

irrespective of which sector provides the service, standards for training,

accreditation and supervision should be comparable with relevant national

guidelines.

2.7 The main focus on this document is on psychological interventions in the

context of commissioning and provision of HSC services and training, with

particular reference to:-

- child and family services;

- child and adolescent mental health services;

- adult mental health services;

- learning disability services; and

- physical disability services.

Bamford Review of Mental Health and Learning Disability

2.8 The Bamford Review of Mental Health and Learning Disability noted the

advances in the sophistication and range of psychological therapy services. It

also highlighted that research shows that the use of certain therapies are

effective in the treatment of particular conditions. However, it found that

access to psychological interventions was extremely poor. A need for training

across all mental health professional groups was identified to develop the

skills of therapeutic relationship building. At the same time there was a need

to use evidence based psychological therapies.

2.9 The Bamford findings reflect the impact of Troubles related trauma on both

the adult and adolescent population and the ad hoc way in which

psychological therapy services have developed. Part of the problem has

been that there is no overall framework that acknowledges their effectiveness

on health and wellbeing; describes the current service gaps; highlights the

settings in which they should be available; and, documents the training,

competencies, supervision and accreditation which commissioners should

take account of when commissioning services.

2.10 In response to the Bamford findings on access to psychological interventions

the Department included in its 2008/09 Priorities for Action a target to reduce

waiting times fro psychological therapy to a maximum of 13 weeks by March

2009.

The Impact of Disability

2.11 The impact of disability on individuals, families and society can be profound.

For individuals the suffering and mental anguish arising from mental disability

can be extreme. Professor Lord Layard in the Depression Report (2006)

highlighted how crippling depression and anxiety can be on individuals and

our society, and how psychological interventions are both clinically and cost-

effective; thus requiring major investment. This is supported by the National

Institute for Health and Clinical Excellence (NICE) which acknowledges the

place of psychological interventions in a range of physical conditions in

addition to the management and treatment of mental health including

depression and chronic anxiety conditions.

Figure 1

2.12 Figure 1 above shows how important mental ill-health, in its broadest sense,

is on disability – accounting for over 43% of all disability. Layard et al found

that while depression and anxiety accounted for a third of all disability, they

attracted only 2% of NHS expenditure (in Northern Ireland mental health

represents 8% of HPSS spend). In addition, it was recognised that most

expenditure in mental health goes on the most seriously ill, for example, those

with major psychotic illness. Such adults are approximately only 1% of the

population and are desperately in need of care but so too are the significant

majority who suffer common conditions such as depression and chronic

anxiety disorders.

Cost of Mental Illness

2.13 The cost of mental illness to the economy of Northern Ireland is huge. A 2003

study undertaken by the NI Association for Mental Health and the Sainsbury

Centre for Mental Health ‘Counting the Costs: The Economic and Social

Costs of Mental Illness in Northern Ireland’ found that the cost of mental

illness in NI in 2002/03 was £2.8bn. In the same year the total budget for

DHSSPS was £2.4bn.

2.14 Mental illness remains the main cause of incapacity. Statistics published by

the Department for Social Development in February 2008* show the numbers

of claimants of Incapacity Benefit by diagnosis group. These show that:

43.8% have mental health or behavioural disorders

17.9% have musculoskeletal system and connective tissue diseases

10.1% have symptoms, signs and abnormal clinical and laboratory

findings

6.4% have injury, poisoning and certain other consequences of

external causes

5.9%. have circulatory system diseases

Together these conditions account for over 84% of all claimants.

*Department for Social Development: Incapacity Benefit and Severe Disablement Allowance

Summary Statistics February 2008

2.15 In 2006/7 the annual prescription costs for antidepressants and anxiolytics in

Northern Ireland were:

Year Number of Prescriptions Ingredient Cost Before

Discount

2006 2.04m £22m

2007 2.2m £21m

2.16 Many psychological interventions have been proven to be as effective as drug

therapies. General findings suggest that evidence based psychological

therapies are as effective as drugs in the short-term and that both are better

than no treatment. It has also been shown that in the longer term therapy has

a more enduring positive outcome than drugs (Depression report 2006).

Working with Children and Adolescents

2.17 Psychological interventions can provide positive long lasting outcomes for

children, young people and their families, and can in the longer term result in

cost savings for the HSC, and in improved outcomes in education, social care

and youth justice systems. Areas requiring psychological interventions

include children and adolescents with physical and mental health conditions,

fostering and adoption services, children and adolescents in care, children

affected by trauma and bereavement, eating disorders, substance abuse,

autism spectrum disorders, learning disabilities and forensic services.

2.18 The evidence of effectiveness of psychological interventions in children and

adolescents is good. A systematic review (Kennedy et al 2004) looked at the

impact of psychoanalytic psychotherapy in children and adolescents involving

children with a range of diagnoses and problems. Overall the results

demonstrated effectiveness and follow up into adulthood showed long-term

improvements. Some studies showed that younger children were more likely

to improve with treatment and that work with parents or families alongside the

individual was an important component of the treatment. The level of intensity

of the treatment varied with the severity of the disturbance with children with

emotional/internalising disorders appearing to respond to psychoanalytic

psychotherapy better than children with disruptive/externalising disorders.

2.19 In addition, specific studies identified evidence of effectiveness for children

suffering from depression, anxiety disorders, behaviour, personality disorders,

specific learning difficulties, developmental disorders, eating disorders,

deprived children and children in foster care, sexually abused girls and

children with poorly controlled diabetes.

Working with Families and Carers

2.20 Families and carers of people with a diagnosis of a mental illness play an

extremely important role in helping the recovery process and preventing

relapse of the person who is unwell. In order to do that, families/carers

require access to “family work”. The contemporary model of Family Work

aims to achieve the following: psychoeducation, involving education about

the biopsychosocial impact and the biopsychosocial treatment of the illness;

and, family education which includes, enhancing/developing coping

strategies, family well-being, getting on with their lives, key resource in

maintaining and extending social networks, managing/coping with a crisis and

recognising early signs of relapse. It also involves working in partnership with

either or both service users and carers to improve outcomes in psychosis,

thereby attempting to place service users and carers at the heart of service

delivery.

Current Service Provision

2.21 Attempts to establish the number of professionals and range of therapies

being delivered across Northern Ireland have been problematic. A point in

time survey within HSC Trusts (October 2008) found that there were 158

psychologists, 90 psychology assistants and over 60 other therapists

specifically employed within Trusts to provide psychological therapies for a

range of conditions.

2.22 Staff who provide psychological treatments but who do not have this

specifically identified in their job title – namely psychiatric nurses, social

workers, occupational therapists and psychiatrists have not been included. It

is likely that the therapeutic interventions provided by these professions will

vary depending on the services in which they are employed.

2.23 The professionals who provide services for children and adolescents in HSC

Trusts are mainly clinical psychologists, family therapists and child

psychotherapists. Clinical psychology is the largest group, with an

established clinical doctorate training at QUB for up to 10 trainees per year (a

3 year fulltime course). It is centrally funded and divided between the HSC

Trusts, with trainees normally on a training salary. Most trainees have some

experience of working as an assistant psychologist. The training is generic

but around 20% of all CP graduate work is within child and adolescent or

related children’s services. Most clinical psychologists who work with children

are normally based within CAMHS teams.

2.24 Family therapy is a relatively new profession within the HSC. Currently there

are 10 designated family therapy posts within CAHMS services in Northern

Ireland, with half of these based in the regional Family trauma Centre. There

are at least 20 more qualified family therapists practising in non designated

posts in a variety of CAMHS settings, both within the statutory, voluntary and

youth justice sectors. Some of these professionals have had family therapy

training alongside their main post -, e.g. clinical psychologist, or child

psychiatrist. Most family therapists work as part of a multidisciplinary team.

2.25 Child and Adolescent Psychoanalytic Psychotherapy (CAPP) is also a

relatively new profession in Northern Ireland. There are now 7 qualified

CAPPs with only 3 in designated HSC child and adolescent mental health

posts in two Trusts. There has recently been an appointment of a trainee in a

specialist CAMHS service. There are other child psychotherapists in NI who

are working privately. CAPP training is not available in Northern Ireland and

those who graduate from Dublin training programmes wishing to work in NI

need to obtain “top up” training to be eligible for registration with the UK

professional body- Association of Child psychotherapists.

2.26 In general practice there are no formal therapy services directly available

within the practice. However, one HSC Board has a scheme to augment

therapy services within GP practices. A “directly enhanced service” for mild to

moderate depression will also be available in early 2009. This will provide

additional resources for GPs to access counselling services that meet defined

standards and recognised accreditation. Part of the additional resources

provided in general practice will be increased availability of Cognitive

Behavioural Therapy through a computerised cognitive behavioural therapy

package, accessed by patients and supported by therapists, as appropriate.

3.0 THE WAY FORWARD

The Use of Psychological Therapies

3.1 There is now a strong evidence base for the use of psychological therapy

services in the treatment of a wide range of conditions particularly for mental

health. Appendix B (1&2) provides an overview of relevant National Institute

for Health and Clinical Excellence guidance on psychotherapeutic

interventions for common mental health disorder in children and adults.

These include:

- depression;

- bipolar disorders;

- generalised anxiety states and panic disorders;

- schizophrenia;

- post traumatic stress disorder;

-Obsessive compulsive disorders;

- Anorexia nervosa and bulimia nervosa;

- self harm; and

- personality disorders.

Psychological therapies should be a core component of mental health

and learning disability service provision. Services should be delivered

by staff with the skills and competence appropriate to the level of

interventions required (Recommendation 1).

3.2 In order to make informed choices about the most appropriate therapy to

access in relation to a particular need or specific health condition clinicians

and the public should have information on the range of psychological

therapy services that are available and how to access them

(Recommendation 2).

3.3 It is acknowledged that psychological therapies can also be beneficial in a

range of other conditions, including chronic physical conditions, bereavement

and terminal care. They can also assist and support families and carers.

Recognising the breadth of conditions that can be assisted by psychological

interventions, it is recommended that: during the course of development of

a new care pathways and service frameworks, particularly for mental

health and learning disability, due consideration should be given to the

place of psychological therapies within the pathway and standards

(Recommendation 3).

3.4 People with established chronic mental health conditions, including those who

are inpatients must also benefit by investment in psychological therapies. In

this context, there is a need to balance how access to psychological therapies

is achieved to ensure that those in greatest need of intervention are not

disadvantaged and that reduction in waiting times is not achieved at the

expense of inpatient provision.

3.5 In order to develop accessible and responsive services it is essential that

future service development is informed by the views of those who use the

services and their families or carers. It is recommended that: service users

and carers should be involved at all levels of service development,

planning and implementation (Recommendation 4).

3.6 Given the range of psychological therapy models, the age spectrum and

conditions of those requiring therapeutic interventions and the various settings

in which therapies can be delivered it is recommended that: a Regional

Psychotherapies Group should be established as a matter of urgency to

oversee implementation of this strategy and to advise the Department

on the future development of child and adolescent and adult

psychological therapy services. It should be representative of

commissioners, service providers, carers and users (Recommendation

5). Its remit should include service development, training requirements,

supervision standards and a service evaluation framework.

4.0 SERVICE PRINCIPLES

4.1 It is recognised that psychological therapies can be delivered in a range of

settings and by staff with different professional backgrounds, for example,

psychologists, nurses, occupational therapists, social workers, psychiatrists,

counsellors, family therapists and arts therapists. But regardless of the

professional background or the setting in which it is delivered the service

principles for commissioning and delivery of therapies should be broadly the

same.

4.2 The key service principles which service commissioners and providers in the

statutory, voluntary, community and private sectors should work to are

outlined below. What is needed to underpin the delivery of effective and safe

therapy services are:

• evidence based interventions;

• appropriate training and skills:

• appropriate supervision: and,

• a robust monitoring and evaluation function to drive improvements.

4.3. The service principles should provide a greater focus on the needs of service

users and effective organisational arrangements.

4.4 Service users will need to have:

• Access – to psychological therapies appropriate to age, diagnosis and

severity of the condition. Services should be flexibly delivered and take

account of local needs, complexity of conditions and available

resources; services should follow a stepped care model.

• Information – information in an appropriate format on treatments

available, how to access services and likely waiting times should be

provided to service users and carers to inform decision making.

• Involvement in decision making – service users need to be involved in

decision making about their care. To do this not only involves provision

of information but also needs to be condition specific and relevant to

the age of the individual.

• Safe and effective interventions – like any other treatment,

psychological therapies can have the potential to do harm; hence there

is a need to develop a number of service and quality standards and

outcome measures to promote effective practice. Ideally, such

services should be capable of being bench-marked against other

comparable services.

• Trained staff and appropriate supervision arrangements- there is a

need for an agreed approach to effective selection criteria, recruitment,

training and supervision arrangements to provide therapies at all tiers

of psychological interventions.

• Evaluation criteria – measurement of outcomes should be able to

demonstrate, for example, access to services; improved patient

outcomes in terms of health and wellbeing; promotion of social

inclusion and improvement in employment status; and, service

user/carer satisfaction.

4.5 To ensure psychological therapy services are provided to the same standard

across all service sectors throughout Northern Ireland it is recommended that

the HSC should develop an agreed service specification for relevant

therapies, taking account of the service principles contained in this

Strategy (Recommendation 6).

Evaluation of Services

4.6 A service evaluation framework will be required to ensure local

implementation protocols meet regional standards in terms of:

• Clinical effectiveness (e.g. measures of symptom reduction, improved

psychological well-being and indices of social inclusion);

• Efficiency and cost effectiveness ;

• Accessibility targets (e.g. waiting times, meeting targeted population etc);

• Governance of workforce (e.g. training and supervision);

• Service user experience and satisfaction with service;

4.7 It is recommended that: psychological therapy services should be subject

to service, therapeutic and economic evaluation which takes account of

the views of services users and carers (Recommendation 7). The

proposed Regional Psychological Therapies Group should advise on this.

5.0 SERVICE REDESIGN

5.1 In the future, mental health and learning disability services will be structured

around a stepped care model. The model for child and adolescent mental

health services (CAMHs) will need some modification; however, the principle

should be that all services should follow a stepped care approach. The

rationale for this model is to ensure that the best intervention is delivered in

the right place, at the right time, by the right person to meet a person’s

assessed needs. Considerable work has already been undertaken to set this

in train. There is widespread support at both regional and national levels for a

similar approach to the organisation and delivery of psychological therapies.

This model has also been endorsed across professions. The model also

recognises the growing body of evidence indicating which therapies are

effective and when. It is recommended that the organisation and delivery

of psychological therapy services should be based on a stepped care

model (Recommendation 8).

A Stepped Care Model for Adults

5.2 A stepped care model assumes that patients can be delivered a range of

interventions appropriate to their assessed need. This model assumes that

there will be a “single point of access to a psychological assessment” to

direct to the appropriate tier of intervention (Recommendation 9). For

example, those people needing therapy interventions at steps 1 and 2 could

be treated with computerised cognitive behavioural therapy in general

practice, guided self-help and/or group education. Such interventions will, in

the future, be delivered in a primary care setting by different staff with a range

of skills and an appropriate level of supervision. This approach will bring the

therapies closer to the patient and improve access in line with Bamford.

5.3 On the other hand, step 3 interventions would be for moderately severe

conditions and delivered mainly in the community by staff trained to the

appropriate level of skill such as clinical psychologists, Cognitive Behavioural

Therapy (CBT) and Interpersonal Therapy (IPT) therapists, in liaison with a

psychiatrist where drug therapy is also required. For the minority of patients

with severe/complex disorders (steps 4 and 5) there is a need to access

specialist teams who have specialist therapy training.

5.4 The diagram below shows the generic stepped care model for adult

psychological therapies, the range of therapies that are delivered at the

different levels of intensity and the training and supervision required at the

different levels of intervention.

Stepped Care Models of Psychological Therapies (Adult)

Step No.

Pts.

Intens

ity

What Delivered? Who Delivers / Training?

Step 1

Recognition

and

Assessment

• Advice / support / watchful waiting / screening

• Supplemented by “single point of access”

psychological assessment service to direct to correct

tier subsequently.

Step 2

Treatment

for Mild

Disorders

• Low intensity treatments (e.g. CCBT, brief

behavioural and CBT, psycho education, guided

self-help, group education, adjustment counselling,

further assessment)

• Front line primary care

staff – trained to monitor /

screen for mental health

difficulties – resourced

with screening tool kits

and liaison with single

point of access centre.

• Low intensity (LI)

workers (Bands 4-5) –

e.g. Assistant /

Associate

Psychologists,

counsellors, mental

health workers, OTs,

nurses and SWs

(Band 6 and above)

• Leadership,

governance and

supervision provided

by Band 7-8 Clinical

Psychologists OR CBT

therapists in ratio

relationship to

number of LI workers.

Step 3

Treatment

for

Moderate

Disorders

• High intensity specific therapies - e.g. 10 +

sessions of CBT or interpersonal; therapy for

anxiety, depression, uncomplicated PTSD etc.

• Circumscribed psychological therapies where there

are evidenced based principles of treatment e.g. for

agoraphobia, panic, phobias, adjustment to illness,

recent onset non-organic presentations etc.

• High Intensity workers -

Clinical Psychologists,

CBT and IPT therapists

with liaison from

secondary care psychiatry

when pharmacological

adjuncts to therapy as

required.

• Capable of delivering

CBT protocols for mood

disorders, problem solving

therapy, EMDR, exposure

therapies etc.

Steps 4 – 5

Treatment

for Severe /

Complex

Disorders

• Integrative or highly specialised therapies – e.g.

co-morbid and complex presentations (e.g. mood,

addictions, trauma, attachment disturbances,

personality disorder; psychosis, conversion

disorders, persistent self-harm, neurological).

• Range of uni-modal, specialist therapies, plus

capacity to integrate and fit therapeutic approach to

patient where proceduralised pathways are absent or

unlikely...

• Secondary care mental

health teams comprised of

Psychiatrists, Clinical

Psychologists and other

professions with specialist

therapy training e.g.

psychodynamic, CBT,

systemic psychotherapy,

Dialectical Behaviour

Therapy, Cognitive

Analytic Therapy etc. (all

from the three main

schools of therapy as

specified in SFH);

• Specialist psychotherapy

services (e.g. for

personality disorder,

eating disorder, severe and

complex presentations.

• Services will be

supported by LI workers

to deliver circumscribed

elements of therapeutic

programmes and

psychological assessment.

A Stepped Care Model for Children and Young People

5.5 Child and adolescent mental health Services are currently provided within a

stepped structure (Appendix C) that mirrors the Stepped Care approach being

promoted in adult services. It is important that the organisational structures

within the two areas can work together to allow the seamless transition from

child to adult services.

5.6 The model is not a hierarchical model, as children often require intervention

from a number of tiers, sometimes at the same time in order to achieve the

most comprehensive treatment and care plan. Inadequate resourcing of step

2 services has resulted in significant overuse and misuse of step 3 services,

leading to long waiting lists and frustrations for referrers. Information

regarding services located within step 1 & 2 is poor and this would need to be

addressed in order to determine gaps in service provision and governance

arrangements.

5.7 Bamford has highlighted a number of key areas where service provision has

particular needs and these are important to keep at forefront of any service

developments, regardless of which Tier is being considered.

• Services need to provide for children and young people up to their 18th

birthday.

• Promoting Infant psychological wellbeing and intervention at the

earliest possible opportunity is the only way to effect long term

changes in the reduction of the need for mental health services.

• The greatest area of need is in Tier 1 & 2 service provision. Until this is

addressed Tier 3 & 4 services will continue to have an inefficient use of

resources as they attempt to “plug” other gaps.

It is recommended that: In order to improve early intervention and reduce

pressure on specialist services, a detailed map is required of demand

and associated workforce skills in child and adolescent

psychotherapies with particular reference to tier 1 and 2 interventions

and the necessary supervision arrangements (Recommendation 10).

This should be part of a comprehensive service mapping exercise to identify

current staffing levels and existing and future demand to inform future

resourcing at all levels

5.8 To ensure that the most appropriate psychological therapy is provided it is

recommended that: agreed referral pathways for child and adolescent,

and adult psychological therapies that incorporate face to face

assessment by a competent mental health practitioner (band 6 or above)

to ensure that a person’s needs are appropriately addressed by a

relevant professional with the appropriate skills and level of expertise

(Recommendation 11).

A Stepped Care Model for People with a Learning Disability

5.9 Learning disability is a life-long developmental disorder and categorised into 4

levels: mild, moderate, severe and profound learning disability. People with a

learning disability have a high incidence of epilepsy, autistic spectrum

disorder, sensory impairments and physical health conditions. They also

have a higher incidence of mental health needs than the general population.

5.10 There is a significant and growing body of evidence that demonstrates the

effectiveness of psychological therapies for people with a learning disability.

This has demonstrated that such therapies are more effective and acceptable

than pharmacological interventions for the management of a significant

number of mental health difficulties.

5.11 However, simple adaptations to the implementation of traditional

psychological therapies are often required when engaging with people with a

learning disability. The degree of adaptation will be commensurate with the

person’s specific needs. For example, a person with mild learning disability

can participate in cognitive behaviour therapy with the adaptations noted

above.

5.12 The current policy to support people with a learning disability in the

community, rather than in a hospital setting, will shape the development of

psychological therapy services and the training needs of staff delivering

therapies. An adapted stepped care model will be required and an example

is provided in Appendix D.

6.0 WORKFORCE ISSUES

6.1 Future development of psychological therapies will require a competent

workforce that has undergone required training in evidence based therapies

and are supervised appropriately by trained and experienced therapists.

6.2 Delivery of low and high intensity therapies to an appropriate standard

requires competent practitioners who are able to offer effective interventions.

At the same time services will need sufficient numbers of appropriately

experienced and trained supervisors familiar with the range of interventions.

Supervisors will also require support so that high quality supervision is

available to all trainees and qualified staff within the service.

Staffing Requirements

6.3 The Department of Health in England has a programme ‘Improving Access to

Psychological Therapy Services’ designed to deliver NICE-compliant services

to help people with depression and anxiety disorders. It estimates that for a

population of 250,000 people with average levels of need some 40 trained

therapists are needed. The programme recognises the need for a national

training programme to provide the necessary number of trained therapists

and enables the progressive expansion of local NICE - compliant services in

primary care settings. The basic service model envisages a team of

therapists taking referrals from GPs and delivering therapies at the required

level in primary care of community settings.

6.4 Applying the IAPTS formula (40 therapists per 250,000) to a Northern Ireland

population of 1.8m and using best estimates of current provision there is a

need for an additional 180 practitioners for levels 1-3 (Primary and

Community service levels). For level 4 (specialist interventions) and level 5

(highly specialist interventions) it is estimated that a further 160 practitioners

will be required. These figures are consistent with estimates made by

Bamford.

6.5 Available investment for psychological therapy services in the current

Comprehensive Spending Review period (2008 – 2011) of £7m will enable a

significant start to be made to recruiting additional staff to develop these

services. Developments will include the introduction of computer based CBT

for use in Primary Care and the recruitment of additional community based

therapists to improve access to therapeutic interventions. However, it is

recognised that delivering this strategy will be a longer term endeavor.

6.6 While funding is a key pre-requisite for delivering this strategy, ultimately the

timescale will be determined by the training requirements of the additional

staff at the various levels of intervention and the capacity of local training

bodies and organisations to deliver that training.

Training, Accreditation and Supervision

6.7 Those working in psychological therapy services must have relevant training,

accreditation and supervision to provide effective and safe services to

standards required by relevant bodies.

6.8 Many professional staff, e.g. nurses, social workers, occupational therapists

have already undergone training in psychological therapies. Others have

obtained accreditation with recognised therapy bodies.

6.9 Work has already begun to address some of the training needs of a range of

staff. For example, the University of Ulster has trained over 100 Health

Service staff to certificate level in CBT. QUB has trained 25 staff to

qualification level with a Masters qualification in Systemic Psychotherapy and

more than 100 Health Service staff to Intermediate and Foundation levels and

THORN training has been provided to a range of Health Service

professionals, mainly nurses.

6.10 A review of the Clinical Psychology Workforce, published earlier this year,

recognised that training in psychological therapy involved three stands –

general awareness; ability to deliver specific therapies to complex cases; and,

specialist training to provide supervision and deal with the most complex

cases. It acknowledged that there was a need to expand psychological

services into primary and community care levels. Also, there is clear scope to

develop practitioners at more junior levels than a Doctorate, thus developing

a more tiered provision of services. In addition, it also acknowledged that a

career pathway was needed to support those entering the service at various

levels, to help retain a motivated and appropriately skilled workforce in the

future. It also recommended a Trust level assessment of workforce needs to

be carried out in line with service development planning. The

Recommendations contained in the Review of Clinical Psychology

Workforce (2008) should be implemented (Recommendation 12).

6.11 The development of psychological therapy services will require a regional

approach to training that is comprehensive and co-ordinated to ensure that

practitioners have the necessary skills and competences to deliver the

relevant therapy or therapies at the appropriate level in the stepped care

model. Training approaches need to address the range of training needs

from new therapists entering this field, existing healthcare professionals

wishing to become skilled in a particular therapeutic intervention to those

providing very specialist interventions. It is recommended that; a consortium

of stakeholders including accredited training providers should be

commissioned to agree a regional approach to undergraduate and

postgraduate training requirements, with particular reference to needs

of therapists at the different levels within the stepped care model

(Recommendation 13).

6.12 A complementary training programme for supervisors must also be

implemented. It is recommended that: a supervision framework should be

developed, which sets out the core competences and accreditation

required for supervisors at the different levels of intervention

(Recommendation 14).

Links to Professional Regulatory Bodies and Associated Issues

6.13 Psychological therapists are not equivalent across professional groups and

training pathways. Traditionally psychological therapies have been delivered

by chartered clinical and counselling psychologists, psychiatrists

psychotherapists and members of other professional groups (e.g. nurses,

social workers, occupational therapists, arts psychotherapists) who have

attained additional training in single modality psychological therapies, not part

of their core professional training, accredited by relevant organisations.

Psychiatrists and psychologists who have wished to develop further expertise

in specific therapeutic modalities have also undertaken such additional

training.

6.14 Whilst psychiatry will continue with statutory regulation by GMC and Royal

College of Psychiatrists, clinical and counselling psychologists will become

subject to statutory regulation by the HPC in 2009, as well as professional

regulation by BPS for chartered status. At the same time talks are ongoing to

have non-medical psychotherapists regulated by the same body but the

timescale for this is unclear at present. It should be noted that arts

psychotherapists are already regulated by the HPC.

7.0 PRIORITISATION OF SERVICE DEVELOPMENT

7.1 Current psychological therapy services have developed in an ad hoc way.

The range and capacity of services varies significantly across HSC Trusts. It

will take time, resources and a regional training strategy to develop services

to a level that meets users’ needs and the Bamford vision. HSC will have to

focus finite resources on those areas of greatest need and where that

investment will have greatest effect. A balance will have to be achieved

between tier 1 and 2 services that provide effective early intervention and

higher levels services to meet the needs of those requiring specialist

interventions. At the same time the therapeutic needs of those in receipt of

inpatient services must not be overlooked. Service scoping and capacity

modelling exercises will help inform critical investment decisions.

7.2 It must be remembered that the Bamford vision for the development of

psychological therapy services is over a 10 to 15 year timescale. This will

require a strategic approach to service development that can be used to

inform future Comprehensive Spending Reviews to ensure the necessary

resources to underpin that development can be secured.

8.0 Conclusion

8.1 This strategy endorses the development of psychological therapies as a core

component of mental health and learning disability services. In doing so, it

acknowledges that the recommendations in this strategy will take some time

to develop and that further mapping is required, particularly at tiers 1 and 2 to

promote early intervention and timely access to care. Services need to be

developed flexibly to meet service users’ needs. It is acknowledge that many

services currently provided are delivered to a high standard by the private,

community and voluntary sectors in addition to those provided in the statutory

sectors. The implementation of a stepped care model for psychological

therapies is essential to ensure that service users access care at an

appropriate level.

8.2 Further work will be required to ensure that there is an appropriate skill mix,

training and supervision at all levels of intervention. Key to the success of

this strategy will be the development of agreed service specifications which

will embed key service principles to be implemented across the HSC.

Fundamental to the success of this strategy will be the Regional

Psychotherapy Group to co-ordinate action.

Bibliography

Psychological therapies in psychiatry and primary care – June 2008 – Royal College

of Psychiatrists

The effectiveness of family therapy and systemic interventions for child-focused

problems (a paper by Alan Carr)

The effectiveness of family therapy and systemic interventions for adult-focused

problems (a paper by Alan Carr)

The Way Forward - Making Progress in the Development of Psychological Therapies

Services for Adults

Psychotherapy Services – A Strategy for Northern Ireland

Psychological Therapy Services – Child and Adolescent

The Contribution of Child and Adolescent Psychotherapy to New Ways of Working

for CAMHS – April 2008

The Cost Effectiveness of Developing Child and Adolescent Psychotherapy Services

– January 2008

Psychological Therapy Review Blueprint

Psychological Therapy Review Workforce Training

Psychological Services – Post RPA – SAC Paper

Psychology in Primary Care – SAC Paper

Associated Family Therapy Report on Evidence Base for Systemic Family Therapy

Stratton, P (2005). Report On The Evidence Base Of Systemic Family Therapy from

the Association for Family Therapy.

Workforce Planning – Training and Supervision

Psychology and Psychological Therapies and Psychotherapy Provision

Standards of good practice for counselling services in Northern Ireland (a paper by

John Parks)

Psychological Therapy Services for people with a Learning Disability - October 2008

Psychological Therapy Review Blueprint – plus expanded table to include training

info

Association of Child Psychotherapists: The Continuing Professional Development

Scheme – November 2003 (a paper by Mary Walker and Beverley Tydeman)

ACP Quality Standards for Training – May 2007 (a paper by Child Psychotherapists)

Assistant Child Psychotherapists (a paper by Child Psychotherapist David Hadley)

CAMHs and Stepped Care

Stepped care model table plus training – KG

Draft operational policy for APTS from Western Trust – May 2007

A revised description of Family Therapy outline PM

Training/supervision/work force on Child Psychotherapy

Step Care model diagram for Children and Adolescents

The Impact of the Conflict on Mental Health of the Population of NI – October 2008

Total frequency and cost of all items classified in bnf 4.3 and 4.1.2 for 2006 and

2007

The effectiveness of family therapy and systemic interventions for child-focused

problems

Psychological Therapy Services Evaluation

New Ways of Working for Applied Psychologists (NWWAP) Final Report 2007

Thorn Training QUB

Department of Health (2004) Improving Access to Psychological Therapies

Organising and Delivering Psychological Therapies

Department of Health (2008) Improving Access to Psychological Therapies

Implementation Plan: National guidelines for regional delivery

Reference Group Membership

Dr Maura Briscoe DHSSPS (Chair)

Joyce Cairns DHSSPS

Dr Ian McMaster DHSSPS

Colin McMinn DHSSPS

Lord Alderdice Psychological Therapy Centre, Knockbracken

Dr Stephen Bergin Commissioners representative

Dr Cathal Cassidy Chair, NI Division Royal College of Psychiatrists

Dr Michael Duffy UU Magee

Mary Emerson Head Occupational Therapist Western HSC Trust

Dr Kate Gillespie NI Centre for Trauma and Transformation

Arlene Healy Family Trauma Centre

Pauline Mahon Child and Adolescent Psychoanalytic Psychotherapy (NI)

Group

Bernard McAnaney Western HSC Trust

May McCann CAUSE

Chris McCusker QUB

Dr Maria O’Kane Chair, Faculty of Psychotherapy, Royal College of

Psychiatrists

Tom O’Leary GP

Isobel Reilly Pathway Co-Ordinator Systemic/Family Therapy Training

QUB

Dr Nicola Rooney Chair, NI Division of Clinical Psychology

APPENDIX A Cognitive Behavioural Therapy

Cognitive and behavioural psychotherapies are a range of therapies based on concepts and

principles derived from psychological models of human emotion and behaviour. They

include a wide range of treatment approaches for emotional disorders, along a continuum

from structured individual psychotherapy to self-help material. The term ‘Cognitive-

Behavioural Therapy’ (CBT) is variously used to refer to behaviour therapy, cognitive

therapy, and to therapy based on the pragmatic combination of principles of behavioural and

cognitive theories.

(taken from http://www.babcp.com/about-cbt/ - British Association for Behavioural and

Cognitive Psychotherapies)

Psychodynamic/Psychoanalytic Psychotherapy

The terms Psychoanalytic Psychotherapy and Psychodynamic Psychotherapy are used

interchangeably. Psychoanalytic / psychodynamic psychotherapy can be used in a wide

variety of conditions in which people have emotional or relationship difficulties and is not

aimed at specific disorders.

(taken from http://www.psychotherapy.slam.nhs.uk/Default.aspx?tabid=520 - SLAM

Psychological therapies)

Psychoanalytic relationships are generated by the desire to find meaning as well as relief

from psychological suffering.

In psychoanalytic psychotherapy particular attention is paid to analysing transference and

resistance issues, so that the patient is helped to find a more creative relationship between

conscious and unconscious processes and to discover their own personal truths.

(taken from http://www.psychotherapy.org.uk/analytical_psychology.html - UK Council for

Psychotherapy)

Systemic and Family Therapy Systemic Family Therapy provides effective help for people with an extraordinarily wide

range of difficulties. The range covers childhood conditions such as conduct and mood

disorders, eating disorders, and drug misuse; and in adults, couple difficulties and severe

psychiatric conditions such as schizophrenia. Throughout the life span, it is shown to be

effective in treatment and management of depression and chronic physical illness, and the

problems that can arise as families change their constitution or their way of life.

(taken from http://www.aft.org.uk/docs/evidencedocsept05creditedSS.doc - The Association

for Family Therapy)

Humanistic, Person-Centred/Experiential Therapy

Person-centered therapy, which is also known as client-centered, non-directive, or Rogerian

therapy, is an approach to counseling and psychotherapy that places much of the

responsibility for the treatment process on the client, with the therapist taking a nondirective

role. Two primary goals of person-centered therapy are increased self-esteem and greater

openness to experience. Some of the related changes that this form of therapy seeks to foster

in clients include closer agreement between the client's idealized and actual selves; better

self-understanding; lower levels of defensiveness, guilt, and insecurity; more positive and

comfortable relationships with others; and an increased capacity to experience and express

feelings at the moment they occur.

(taken from http://www.minddisorders.com/Ob-Ps/Person-centered-therapy.html - Encyclopaedia of Mental Disorders

APPENDIX B (1)

A summary of NICE guidance for psychological therapies by disorder and client age group

Depression Bipolar

Disorder

Panic &

Generalised

Anxiety

Schizophrenia PTSD Obsessive

Compulsive

& Body

Dysmorphic

Disorder

Anorexia

Nervosa

Bulimia

Nervosa

Self Harm Personality

Disorder

Children

MILD

Guided self help

Nondirective

supportive

therapy

Group CBT

MOD-SEVERE

CBT, IPT,

Short term FT

Systematic FT

Child

Psychotherapy

Primary

intervention

of Structured

psychological

therapy

(With

medication)

Symptom focus

Problem solving

Social

functioning

education

No current

nice guidance

No nice

guidance for

childhood onset

schizophrenia

CBT 8-

12+

sessions

Involve

families

CBT

ERP

Involve

family

Home

Visits may be

needed

In extreme

cases

inpatient

support may

be needed

CAT

CBT

IPT

Focal

psychodynamic

therapy

Family

interventions

CBT

Other

psychological

treatments

IPT

DBT

Focus on

underlying

problems e.g.

Depression/

Anxiety/

Personality

disorder

Developmental

group

psychotherapy

APPENDIX B (2)

Depression Bipolar

disorder

Panic &

Generalised

Anxiety

Schizophrenia PTSD Obsessive

Compulsive

& Body

Dysmorphic

Disorder

Anorexia

Nervosa

Bulimia

Nervosa

Self Harm Personality

Disorder

Children

MILD

guided self

help

Nondirective

supportive

therapy

Group CBT

MOD-SEVERE

CBT, IPT,

Short term FT

Systematic FT

Child

Psychotherapy

Primary

intervention

of Structured

psychological

therapy

(With

medication)

Symptom

Focus

Problem

solving

Social

functioning

education

No current

nice

guidance

No nice

guidance for

childhood

onset

schizophrenia

CBT 8-

12+

sessions

involve

families

Focus on

underlying

problems e.g.

Depression/

Anxiety/

Personality

Disorder

Developmental

Group

psychotherapy

Adults

of

working

age

CBT & IPT

16-20 sessions

Over 9 months

Couple

Therapy

Psychodynamic

Psychotherapy

Counselling

Secondary

structured

psychological

interventions

Symptom

focus

Problem

solving

Social

functioning

education

CBT post

acute phase

16 sessions

for mild to

moderate

CBT

(Home

visits may

be needed)

Structured

problem

solving

Counselling

Also need to

treat co-

morbid

problems

CBT

Family

interventions

CBT

EMDR

Psychodynamic

Psychotherapy

Hydrotherapy

CBT

ERP

involve

family

Home

Visits may be

needed

In extreme

Cases

Inpatient

support may

be needed

CAT

CBT

IPT

Focal

psychodynamic

Therapy

Family

interventions

CBT

Other

Psychological

Treatments

IPT

DBT

Focus on

underlying

problems e.g.

Depression/

Anxiety/

Personality

disorder

DBT

CAT

Schema-

focused CBT

Dynamic

Psychotherapy

Therapeutic

Community

Older

adults

No specific nice

guidance

Limited

evidence as

adult

No specific

nice

guidance

No nice

guidance for

late onset

Schizophrenia

No specific nice

guidance

No specific

nice

guidance

No specific

nice guidance

No specific

nice guidance

Extra

emphasis on

depression, ill

health and risk

No specific

nice guidance

CAT – Cognitive Analytical Therapy CBT – Cognitive Behavioural Therapy IPT – Interpersonal Therapy FT – Family Therapy

EMDR – Eye movement Desensitization and Reprocessing ERP – Exposure Response Prevention Schema – focused CBT

Dynamic Psychotherapy DBT – Dialectical Behaviour Therapy Therapeutic Community Developmental group psychotherapy

Couple therapy Counselling Structured Problem Solving Short term FT

Systemic FT Child Psychotherapy

APPENDIX C STEPPED CARE MODEL FOR CHILDREN TIERED

MODEL

STEPPED CARE MODEL/

WHAT DELIVERED?

WHO DELIVERS?

TIER 1

TIER 2

• Children/young people/families present

with psychological concerns

• Vulnerable children and families

identified

• Advice/Support

• Screening/Initial Assessment

• Clear pathways of referral

• Mild Disorders

• Low-medium Intensity Interventions

• Group Psycho-education

• Guided self Help

• Parent Training Groups

• Behaviour Management Groups

• Counselling

• Moderate Disorders

• High Intensity Interventions

• Specialist Therapy Input

• Specialist Assessments

• ADHD / ASD Clinics

• Specific evidence base therapies -

CBT / EMDR

• Assessments of needs of children in

care homes

• General Practitioners

• Health Visitors

• Adoption/Fostering

Services

• Midwives – acute and

community

• Projects such as SURE

START/ EXTERN

• Social Services

• Community

Paediatricians

• Community Paediatric

Nurses

• Family Centres

• PMHW

• School Counsellors

• Voluntary

Organisations e.g.:

PAPPA/NSPCC/

Barnardos/new Life

Counselling/ Contact

Youth

• Social services

• Behaviour Therapists

• Assistant/Associate

Psychologists

• Educational Psychology

• Primary Care Workers

• High Intensity

Workers: Clinical

psychologists /

Specialist PMHW /

CBT and IPT

therapists/ Family

therapists/ Child

Psychotherapists/

Specialist SW /

Specialist Community

Paediatricians

• Tier 3 Liaison

TIER 3

• Outpatient treatment for severe and

complex mental health disorders

• Personality Disorders

• Services to juvenile justice

• Multidisciplinary child

and adolescent mental

health teams with

specialist training in a

range of therapeutic

STEP 1

STEP 2

STEP 3

STEP 4

• Specialist Child Care Centre

• Specialist services e.g.: eating

disorder, drug & alcohol abuse

• Complex co-morbid disorders e.g.:

attachment/ASD/ADHD

assessments and

interventions

TIER 4

• Inpatient treatment for severe and

complex mental health disorders /

personality disorders

STEP 5

APPENDIX D