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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
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