Experiences of a communication-skills course for care partners of people living with dementia, empowered conversations: A qualitative framework analysis.

OBJECTIVES: Our aims were to examine whether an experiential course for care partners of people living with dementia, Empowered Conversations (EC), was acceptable to participants and to explore participants' perceptions of the impact of the course upon their communicative interactions. EC is based on an integrative model derived from psychological and linguistic theory and empirical evidence. EC is based on mentalisation theory, perceptual control theory and linguistic theory (The Communicative Impact Model). METHODS: Qualitative data were collected via 28 semistructured interviews. Framework analysis was used to analyse data. RESULTS: Three superordinate themes, 'improved communication', 'improved well-being' and 'support through others' were identified. Twenty-seven out of the 28 participants described feeling that they were able to better connect with the person living with dementia that they were supporting through attending EC. CONCLUSIONS: The findings indicated that EC was acceptable and beneficial to care partners. Care partners developed a range of strategies and understandings that enabled them to communicate better with the person they were supporting, enhanced well-being and relationships, as well as developing social networks. This is the first qualitative study to examine a psychosocial intervention for care partners of people living with dementia using a non-CBT framework and indicates that perceived control could influence how care partners respond to stress and difficulties.

A brief transdiagnostic group (the take control course) compared to individual low-intensity CBT for depression and anxiety: a randomized non-inferiority trial.

Few studies have examined brief transdiagnostic groups. The Take Control Course (TCC) was developed for patients with mild to moderate common mental health problems. We examined whether TCC is non-inferior to individual low-intensity cognitive behaviour therapy (CBT) in a single-blind individually randomised parallel non-inferiority trial. The primary outcomes were depression (PHQ9) and anxiety (GAD7) at 6-month follow-up (primary outcome point) and 12-month follow-up. The non-inferiority margin that we set, based on previous trials, corresponds to approximately 3 points on the PHQ9 and approximately 2.5 points on the GAD7. Intention-to-treat (ITT) and per-protocol (PP) analyses of 6-month data of 156 randomised patients indicated that TCC was non-inferior to individual low-intensity CBT on anxiety (ITT Coefficient = 0.24; 95% CI: -1.45 to 1.92; d = 0.04; p = .79), and depression (ITT Coefficient = 0.82; 95% CI: -1.06 to 2.69; d = 0.14; p = .39) outcomes, and functioning (ITT Coefficient = 0.69; 95% CI: -2.56 to 3.94; d = 0.08; p = .68). The findings at 12 months were inconclusive and require further testing. This randomised trial provides preliminary support that TCC is not less effective than short-term individual CBT within Improving Access to Psychological Therapies (IAPT) services.

A feasibility study of the impact of a communication-skills course, 'Empowered Conversations', for care partners of people living with dementia.

OBJECTIVES: To examine the feasibility, acceptability and impact of an experiential course for family care partners of people living with dementia, Empowered Conversations (EC). This study aimed to assess the impact of participation in an EC course on care partner stress levels, communication and mentalization (a form of relational-based empathy). METHOD: This study uses an uncontrolled pre-post-follow-up design. Follow-up was at 4-months after the initial EC session where baseline data were collected. One hundred and fifty-nine care partners were recruited. EC is a training course that has been designed to improve care partner communication, well-being and relationships. It is based on an integrative framework that targets the specific psychological, relationship and communication needs of carers. This framework informs targeted strategies and interactive exercises that facilitate carers to consider the goals and emotions of those they are caring for, alongside their own goals and emotions, and to use this to maximize good communication. RESULTS: Stress was significantly reduced across the three time points. Communication significantly improved across time. There were no significant changes in reflective functioning (mentalization). DISCUSSION: This study provides preliminary evidence that a communication-skills training course for care partners of people living with dementia is an acceptable and feasible intervention and has an impact both post-intervention and at follow-up. These findings require validation in a rigorous, randomized study.

'It's nice to think somebody's listening to me instead of saying "oh shut up"'. People with dementia reflect on what makes communication good and meaningful.

WHAT IS KNOWN ON THE SUBJECT?: People with dementia experience cognitive decline which can affect their ability to communicate with others and consequently getting their needs met. Loneliness and social isolation are associated with depression and anxiety, while difficulties communicating may magnify such difficulties. Enhancing meaningful interactions may support maintenance of valued relationships and positive wellbeing. Although previous research has examined communicative experiences, this has been from the perspectives of professionals or caregivers. Exploring meaningful communication from the perspectives of people with dementia is crucial in supporting relationships and wellbeing. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: People with dementia can be active participants in research. They are aware of their cognitive impairments as well as social interactions and features constituting meaningful communications. People with dementia recognized carers' attempts to understand and empathize with them; allowing them to feel valued and heard, empowering them to maintain interactions. Alternatively, feeling dismissed, inferior or pressured to provide 'correct' responses deterred them from further conversations. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: People with dementia have an awareness of their relationships, communications and preferences. Thus, it is imperative to respect this population and make attempts to understand their communication as they sense this effort even when miscommunications occur. Embrace qualities that facilitate person-centred care within communications is vital as this can preserve valued relationships, support one's needs and enhance wellbeing. Such features include active listening, empathizing, being physically and mentally present, spending time to know the individual and sharing experiences, thoughts and emotions. Abstract Introduction Social isolation can be problematic for people with dementia; understanding what makes communication meaningful may reduce such risk. Scientific rationale Previous research has examined caregivers' or professionals' experiences of meaningful communication. Understanding this from the perspectives of people with dementia could enhance their interactions and wellbeing. Aim Exploring what makes communication meaningful from the perspective of people with dementia. Methods Nine dyadic interactions between a person with dementia and a family carer were filmed. Individuals with dementia watched the footage and reflected on their communications in semi-structured interviews. Results Three superordinate themes emerged. Themes 'sharing moments of emotional connection' and 'empowering one's ability to communicate' related to the experience of feeling connected, understood, valued and heard, allowing further communication. Conversely, 'inhibitors to communication' related feeling disempowered and reduced interactions. Discussion Even when carers could not understand what people with dementia attempted to communicate, their efforts to interact with them were valued and considered meaningful as they reinforce their sense of connectedness. Implications for practice Embracing a person-centred approach by actively attuning to the person and continuously attempting to empathize and understand persons with dementia can help preserve important relationships and allow the person to feel valued and interpersonally connected.

Communication Empowerment Framework: An integrative framework to support effective communication and interaction between carers and people living with dementia.

OBJECTIVES: To demonstrate the power of integrating three theoretical perspectives (Mentalization Theory, Perceptual Control Theory and the Communicative Impact model), which jointly illuminate the communication challenges and opportunities faced by family carers of people with dementia. To point the way to how this framework informs the design and delivery of carer communication and interaction training. METHOD: Conceptual synthesis based on a narrative review of relevant literature, supported by examples of family carers. RESULTS: We use the conceptual models to show how the capacity to mentalize ("holding mind in mind") offers a greater sense of control over internal and external conflicts, with the result that they can be deescalated in pursuit of mutual goals. CONCLUSIONS: The integrative conceptual framework presented here highlights specific psychological and relational mechanisms that can be targeted through carer training to enhance communication with a person living with dementia.

Use of the Method of Levels Therapy as a Low-Intensity Intervention to Work With People Experiencing Sleep Difficulties.

Sleep problems are common with nearly one in three people reporting disturbed sleep. In line with guidelines, most people experiencing poor sleep in the United Kingdom are referred for cognitive and behavioral treatment approaches. A large proportion of these clients are seen by Psychological Well-being Practitioners (PWPs) delivering low-intensity therapy within Improving Access to Psychological Therapies (IAPT) services. The training of PWPs in the treatment of sleep problems is limited to sleep hygiene psychoeducation. The role that sleep hygiene psychoeducation plays in improving sleep quality is unclear, especially if used as a stand-alone intervention. The article introduces method of levels (MOL) as an alternative approach explaining sleep problems by transdiagnostic mechanisms. Two clinical cases are presented to demonstrate how MOL was implemented to support clients with the perceived sleep issue. This article adds to growing evidence that a transdiagnostic approach to helping people experiencing psychological distress is needed.

What is good communication for people living with dementia? A mixed-methods systematic review.

BACKGROUND: Many strategies have been recommended to support caregivers in communicating with people who live with dementia. However, less is known about what makes communication a good and meaningful experience from the perspective of people with dementia. Understanding this may enhance the person with dementia's sense of connectedness, strengthen their relationships, and facilitate person-centered care. The current review aimed to evaluate research that examined experiences of communication in people living with dementia. Studies that examined reports provided by people with dementia, healthcare professionals, and family caregivers were included. METHODS: A mixed-methods systematic review was conducted using PsychINFO, MEDLINE, and EMBASE databases. RESULTS: After applying the eligibility criteria, 15 studies were included. Although eight of these recruited people with dementia, only one focused on their perspectives of communication experiences and the remaining studies focused on the perspectives of family caregivers and healthcare professionals. These studies either explored experiences without suggestions of communication methods, "open exploration," or through examining experiences of strategies, "exploration of strategies." A significant theme was around communication difficulties that affected interpersonal relationships and activities of daily living. Conversely, personhood strategies and a strong underlying relationship were believed to facilitate communication. The one study that examined the perspectives of people with dementia emphasized the importance of retaining valued relationships and feeling respected during communication. CONCLUSIONS: The need to involve people with dementia in research, particularly around their experiences of communication, is evident. Such research would be imperative for facilitating person-centered care, strengthening social relationships, and informing training programs.

Improving access to mental health care in an Orthodox Jewish community: a critical reflection upon the accommodation of otherness.

BACKGROUND: The English National Health Service (NHS) has significantly extended the supply of evidence based psychological interventions in primary care for people experiencing common mental health problems. Yet despite the extra resources, the accessibility of services for 'under-served' ethnic and religious minority groups, is considerably short of the levels of access that may be necessary to offset the health inequalities created by their different exposure to services, resulting in negative health outcomes. This paper offers a critical reflection upon an initiative that sought to improve access to an NHS funded primary care mental health service to one 'under-served' population, an Orthodox Jewish community in the North West of England. METHODS: A combination of qualitative and quantitative data were drawn upon including naturally occurring data, observational notes, e-mail correspondence, routinely collected demographic data and clinical outcomes measures, as well as written feedback and recorded discussions with 12 key informants. RESULTS: Improvements in access to mental health care for some people from the Orthodox Jewish community were achieved through the collaborative efforts of a distributed leadership team. The members of this leadership team were a self-selecting group of stakeholders which had a combination of local knowledge, cultural understanding, power to negotiate on behalf of their respective constituencies and expertise in mental health care. Through a process of dialogic engagement the team was able to work with the community to develop a bespoke service that accommodated its wish to maintain a distinct sense of cultural otherness. CONCLUSIONS: This critical reflection illustrates how dialogic engagement can further the mechanisms of candidacy, concordance and recursivity that are associated with improvements in access to care in under-served sections of the population, whilst simultaneously recognising the limits of constructive dialogue. Dialogue can change the dynamic of community engagement. However, the full alignment of the goals of differing constituencies may not always be possible, due the complex interaction between the multiple positions and understandings of stakeholders that are involved and the need to respect the other'-s' autonomy.

Client Perceptions of Helpfulness in Therapy: a Novel Video-Rating Methodology for Examining Process Variables at Brief Intervals During a Single Session.

BACKGROUND: The value of clients' reports of their experiences in therapy is widely recognized, yet quantitative methodology has rarely been used to measure clients' self-reported perceptions of what is helpful over a single session. AIMS: A video-rating method using was developed to gather data at brief intervals using process measures of client perceived experience and standardized measures of working alliance (Session Rating Scale; SRS). Data were collected over the course of a single video-recorded session of cognitive therapy (Method of Levels Therapy; Carey, 2006; Mansell et al., 2012). We examined the acceptability and feasibility of the methodology and tested the concurrent validity of the measure by utilizing theory-led constructs. METHOD: Eighteen therapy sessions were video-recorded and clients each rated a 20-minute session of therapy at two-minute intervals using repeated measures. A multi-level analysis was used to test for correlations between perceived levels of helpfulness and client process variables. RESULTS: The design proved to be feasible. Concurrent validity was borne out through high correlations between constructs. A multi-level regression examined the independent contributions of client process variables to client perceived helpfulness. Client perceived control (b = 0.39, 95% CI .05 to 0.73), the ability to talk freely (b = 0.30, SE = 0.11, 95% CI .09 to 0.51) and therapist approach (b = 0.31, SE = 0.14, 95% CI .04 to 0.57) predicted client-rated helpfulness. CONCLUSIONS: We identify a feasible and acceptable method for studying continuous measures of helpfulness and their psychological correlates during a single therapy session.

Using drawings as a reflective tool to enhance communication in dementia care.

Communication skills training can be a valuable means of supporting professional and family carers of people with dementia. Most communication skills training programmes for those caring for people with dementia focus on dementia awareness and the technical aspects of communication, such as the pace and volume of the carer's speech. However, it is also important to examine what is conveyed about a carer's internal experience in their non-verbal interactions with people living with dementia. This article explores how drawings can be used to help carers to reflect on what is communicated and question any hidden assumptions. It discusses three case studies to demonstrate the complex dynamics that may be involved in interactions with people with dementia: the loss of shared memories, facing towards someone with dementia rather than away from them, and talking about issues that may be upsetting. Drawings provide a means for carers to access their unspoken thoughts and emotions, and can help them to improve their understanding of non-verbal interactions with people who have dementia.

The Take Control Course: Conceptual Rationale for the Development of a Transdiagnostic Group for Common Mental Health Problems.

BACKGROUND: Increasingly, research supports the utility of a transdiagnostic understanding of psychopathology. However, there is no consensus regarding the theoretical approach that best explains this. Transdiagnostic interventions can offer service delivery advantages; this is explored in the current review, focusing on group modalities and primary care settings. OBJECTIVE: This review seeks to explore whether a Perceptual Control Theory (PCT) explanation of psychopathology across disorders is a valid one. Further, this review illustrates the process of developing a novel transdiagnostic intervention (Take Control Course; TCC) from a PCT theory of functioning. METHOD: Narrative review. RESULTS AND CONCLUSIONS: Considerable evidence supports key tenets of PCT. Further, PCT offers a novel perspective regarding the mechanisms by which a number of familiar techniques, such as exposure and awareness, are effective. However, additional research is required to directly test the relative contribution of some PCT mechanisms predicted to underlie psychopathology. Directions for future research are considered.

Prospective cohort feasibility study of a transdiagnostic group intervention for common mental health problems: The Take Control Course.

OBJECTIVES: While transdiagnostic psychological treatments appear to be promising, they require greater empirical support. Further, a number of available transdiagnostic treatments are targeted at clients with a specific category of disorder, such as clients with anxiety disorders. This study is a preliminary examination of the effectiveness, feasibility, and acceptability of a new transdiagnostic six-session group-based intervention (Take Control Course; TCC) predominantly aimed at clients within primary care. The group is aimed at a broad range of clients; it is derived from an integrative transdiagnostic theory, which specifies mechanisms of psychopathology across disorders. Briefer interventions are gaining an increasing evidence base, and this study seeks to compare the TCC to an established brief intervention within primary care. DESIGN: Prospective cohort study comparing two active psychological treatments. METHODS: Take Control Course group (n = 66) was compared to a non-randomized control group of clients accessing individual low-intensity interventions (n = 43) using random-effect regression models. Primary outcomes were depression and anxiety scores; additional outcomes included social and other functioning. RESULTS: For the TCC group, changes on all pre-post outcomes were significant with moderate effect sizes. The between-group differences were not significant. CONCLUSIONS: Results show potential for TCC to be an effective intervention, but further work is required to validate these findings in a more rigorous, randomized study. PRACTITIONER POINTS: Transdiagnostic understandings of psychological distress may inform pragmatic and effective treatments that can be offered to a broad range of clients. This study describes a transdiagnostic intervention (TCC) that targets maintenance processes common across disorders, and presents initial outcome data. The TCC was found to reduce pre-post scores on measures of anxiety and depression.

Approach-Avoidance Attitudes Associated with Initial Therapy Appointment Attendance: A Prospective Study.

BACKGROUND: Initial therapy appointments have high nonattendance rates yet the reasons remain poorly understood. AIMS: This study aimed to identify positive and negative attitudes towards therapy that predicted initial attendance, informed by a perceptual control theory account of approach-avoidance conflicts in help-seeking. METHOD: A prospective study was conducted within a low intensity CBT service using first appointment attendance (n = 96) as an outcome. Measures included attitudes towards therapy, depression and anxiety scales, and demographic variables. RESULTS: Endorsement of a negative attitude item representing concern about self-disclosure was independently predictive of nonattendance. Positive attitudes predicted increased attendance, especially endorsement of motives for self-reflection, but only among less depressed individuals. CONCLUSIONS: Self-disclosure concerns contribute to therapy avoidance and having goals for self-reflection may represent approach motivation for therapy; however, the latter has less impact among more highly depressed people.

Dementia communication using empathic curiosity.

Communication skills training materials in dementia care usually focus on reminiscence. This is important because talking about past events can help people with dementia to retain their sense of self. This article examines the use of an alternative set of communication skills known as empathic curiosity, which may help to promote meaningful communication in the here and now with people who are living with dementia.

Pilot study of an investigation of psychological factors associated with first appointment nonattendance in a low-intensity service.

BACKGROUND: Nonattendance rates remain high for first therapy appointments, despite initiatives to increase access to psychological therapy. The reasons for nonattendance are poorly understood and studies of demographic and clinical predictors have produced conflicting findings. AIMS: We aimed to pilot a method for investigating psychological factors associated with first appointment attendance in a primary care mental health service. METHOD: Questionnaires were completed by individuals at the point of referral to CBT with a low-intensity service in one general practice (n = 67), including a measure of beliefs, goals and attitudes towards therapy, as well as anxiety and depression scales. Subsequent attendance at the first appointment was used as an outcome. RESULTS: Preliminary results showed that attendance was not associated with age or gender, severity of distress, or overall ratings for positive or negative attitudes towards therapy; although distress itself was associated with increased endorsement of negative attitudes. However, one specific psychological item, "Talking to a therapist will help me understand better how my mind works" had a significant association with subsequent attendance. CONCLUSIONS: The psychological factor that was associated with increased attendance may reflect the concept of psychological mindedness; however, this requires replication in a larger study. A full-scale study was deemed to be warranted based on this prospective design.

The experience of recovery from the perspective of people with common mental health problems: findings from a telephone survey.

BACKGROUND: For people with common mental health problems such as depression and anxiety related disorders the understanding of what recovery means and what it may entail is less fully developed than for people with less common mental health problems such as schizophrenia. AIM: The aim of this telephone survey was to obtain a clearer conception and better understanding of the value of recovery from the perspective of service users who have experienced common mental health problems. METHODS: Data was collected from telephone interviews with 98 service users using a mixture of quantitative and qualitative methods. RESULTS: The service users' quantitative ratings of their subjective improvement indicated that recovery was a state of being that was manifestly different from the experience of being unwell. The data from the qualitative interviews corroborated these findings. A central theme that also emerged from the analysis of the data was that recovery was associated with having a greater sense of balance and control. Service users indicated that this sense of balance and control operated on many levels, however it was most significant in the context of dealing with their most salient concerns and pursuing their personal goals. CONCLUSION: More emphasis may need to be placed on enabling service users to identify their salient concerns and pursue their personal goals in order to give them the sense of balance and control they are looking for.

Case management for high-intensity service users: towards a relational approach to care co-ordination.

This study is based on a formative evaluation of a case management service for high-intensity service users in Northern England. The evaluation had three main purposes: (i) to assess the quality of the organisational infrastructure; (ii) to obtain a better understanding of the key influences that played a role in shaping the development of the service; and (iii) to identify potential changes in practice that may help to improve the quality of service provision. The evaluation was informed by Gittell's relational co-ordination theory, which focuses upon cross-boundary working practices that facilitate task integration. The Assessment of Chronic Illness Care Survey was used to assess the organisational infrastructure and qualitative interviews with front line staff were conducted to explore the key influences that shaped the development of the service. A high level of strategic commitment and political support for integrated working was identified. However, the quality of care co-ordination was variable. The most prominent operational factor that appeared to influence the scope and quality of care co-ordination was the pattern of interaction between the case managers and their co-workers. The co-ordination of patient care was much more effective in integrated co-ordination networks. Key features included clearly defined, task focussed, relational workspaces with interactive forums where case managers could engage with co-workers in discussions about the management of interdependent care activities. In dispersed co-ordination networks with fewer relational workspaces, the case managers struggled to work as effectively. The evaluation concluded that the creation of flexible and efficient task focused relational workspaces that are systemically managed and adequately resourced could help to improve the quality of care co-ordination, particularly in dispersed networks.

Patient registries: a central component of the chronic care model.

Patient registries are a central component of the Chronic Care Model and research suggests that their use is associated with improved outcomes for patients with a range of chronic diseases. This article begins by outlining the case for using patient registries and it identifies some of the issues that need to be considered when setting up a registry. The second part of the article describes how a patient registry was used to support a newly established active case management service. The case study teases out some of the practical constraints and contextual factors that affected the development and implementation of patient registry. However it also highlights that the patient registry was highly valued by front line clinicians who used it, as it was an effective caseload and performance management tool.

Gatekeeping access to community mental health teams: a qualitative study.

BACKGROUND: Gatekeeping access to services at the interface with primary care has been identified as one of the key issues that community mental health teams (CMHTs) have to confront. OBJECTIVES: The aim of this study was to develop a better understanding of the contextual influences that impact upon the outcome of gatekeeping decisions. DESIGN: An interview-based qualitative study, informed by the philosophy of critical realism. SETTING: An urban catchment area in Northern England. PARTICIPANTS: Twenty-nine interviews were conducted with gatekeeping clinicians and service managers. METHOD: A convenience sample of clinicians was initially approached to take part in a series of semi-structured interviews. This was followed up by a purposive sample of clinicians and service managers, as specific contextual influences were identified and explored in detail. The emerging analysis was then subjected to critical scrutiny by a further sample of gatekeeping clinicians. FINDINGS: A clear hierarchy of appropriateness was identified with four dimensions: severity, risk, beneficence and a moral dimension. It was suggested that the salient contextual influences that shaped the hierarchy were: (a) the need to fit in with strategic planning directives, (b) the burden of responsibility that clinicians carried, (c) the high number of referrals and the relatively slow turnover of patients on clinical caseloads, (d) the position of CMHTs in the economy of care and (e) the character of the relationship between clinicians and service managers. CONCLUSION: The findings from the study support a multi-level view of the gatekeeping process within CMHTs, which takes account of the role that key contextual influences play in shaping the range of options that are available to gatekeeping clinicians.