Personal reformulation during the clinical associate psychologist apprenticeship: Exploratory mixed methods evaluation.

OBJECTIVES: Clinical associate psychologists (CAPs) train under the auspices of the apprenticeship programme and are a new addition to the psychological workforce. This project sought to evaluate whether a "personal reformulation" (PR) was helpful in terms of personal and professional development during the apprenticeship. METHODS: A mixed methods evaluation containing a longitudinal quantitative element and a "Big Q" qualitative element with a single cohort of N = 18 CAPs. A PR consists of a 2-hr one-to-one session and a follow-up session with a cognitive analytic psychotherapist. During a PR, a sequential diagrammatic reformulation is produced to aid recognition and revision of potentially problematic relationship patterns at work. Two outcome measures concerning reflective capacity and professional quality of life were completed at the start of the apprenticeship, pre-PR and at 3-month PR follow-up. The semi-structured interviews (n = 11) conducted at the follow-up were analysed using reflexive thematic analysis. RESULTS: Quantitative changes were limited to significant increases to general confidence and 8/12 apprentices had a reliable increase in confidence in communication. Qualitatively, five overarching themes were found: (1) gaining insight, (2) wellbeing, (3) nature of the space, (4) being an apprentice, and (5) moving forward. CONCLUSIONS: PRs were generally found to be emotionally challenging, but relatively large amounts of insight are possible from a very brief intervention that can contribute to personal and professional development during clinical training. More controlled research needs to be conducted and wider applications and evaluations of PRs in different professions would be welcome.

Can cognitive analytic therapy treat hoarding disorder? An adjudicated hermeneutic single-case efficacy design evaluation.

This paper sought to assess whether cognitive analytic therapy (CAT) was effective with a male patient meeting diagnostic criteria for hoarding disorder (HD) who had been nonresponsive to two previous courses of cognitive behaviour therapy. An adjudicated hermeneutic single-case efficacy design (HSCED) evaluation was undertaken. A rich case record (i.e., a summary document containing the case details, formulations, and detailed qualitative and quantitative outcomes) was created. The rich case record was then debated by affirmative (N = 3) and sceptic (N = 3) research teams. Expert judges (N = 3) reviewed the debate and then delivered a final verdict as to whether treatment had worked. Judges unanimously returned a verdict in favour of the sceptic position, concluding that CAT had not enabled change. Lack of change on the primary nomothetic hoarding outcome measure was particularly influential in the final judgement. In this case of HD, CAT was therefore not effective as an intervention. More research is needed before any definitive conclusions can be drawn however as to the wider utility of CAT with HD. Methodological limitations are outlined, alongside considerations for future research.

Risk factors for negative experiences during psychotherapy.

BACKGROUND: It is estimated that between 3% and 15% of patients have a negative experience of psychotherapy, but little is understood about this. AIMS: The aim of this study was to investigate the factors associated with patients' negative therapy experiences. METHOD: The data comprised 185 patient and 304 therapist questionnaires, 20 patient and 20 therapist interviews. Patients reported on an unhelpful or harmful experience of therapy, and therapists on a therapy where they thought the patient they were working with had a poor or harmful experience. These were transcribed and analysed using thematic analysis. RESULTS: There was a Lack of fit between Patient needs, Therapist skills, and Service structures. This could result in Fault Lines, a tension between Safety and containment and Power and control. This tension led to Strain and Poor Engagement, which led to Consequences following the negative therapy experience. CONCLUSIONS: Patients require clear information, choice, involvement in decision-making, explicit contracting and clarity about sessions and progress. Opportunities for patient feedback should be the norm, where the therapist and service are vigilant for signs of deterioration and solutions considered. Clinical and methodological significance of this article: Estimates of "unwanted effects," including long-lasting effects, of psychotherapy have ranged from 3% to 15%. Few empirical studies have been conducted in this area. This study aimed to address this gap and provide clinicians with a model of risk factors for negative therapy effects. The findings of this study indicate the importance of providing patients with a supportive service structure that offers clear information, choice and involvement in decision-making. Explicit contracting at the beginning of therapy and clarity about sessions and progress are also important in managing patient expectations throughout. Opportunities for patient feedback should be provided.

Can more appropriate support and services be provided for people who attend the emergency department frequently? National Health Service staff views.

BACKGROUND: Interventions designed to help Emergency Department (ED) staff manage frequent attenders are labour-intensive and only benefit a small sample of frequent attenders. We aimed to use the in-depth knowledge of health professionals with experience of working with ED frequent attenders to understand the challenges of managing this group of patients and their opinions on providing more appropriate support. METHODS: Semi-structured interviews were conducted with medical and nursing ED staff, mental health liaison nurses and general practitioners (GPs). Interviews covered the following: definitions and experiences of treating frequent attenders and thoughts on alternative service provision. Vignettes of frequent attenders were used to elicit discussions on these topics. Thematic analysis of transcribed interviews was undertaken. RESULTS: Twelve health professionals were interviewed. Three groups of frequent attenders were identified: people with long-term physical conditions, mental health problems and health-related anxiety. Underlying reasons for attendance differed between the groups, highlighting the need for targeted interventions. Suggested interventions included improving self-management of long-term physical conditions; creating a 'go-to' place away from the ED for patients experiencing a mental health crisis; increasing the provision of mental health liaison services; and for patients with health-related anxiety, the role of the GP in the patients' care pathway was emphasised, as were the benefits of providing additional training for ED staff to help identify and support this group. CONCLUSION: Interventions to address frequent attendance should focus on redirection to and liaison with more appropriate services, located on the hospital site or in the community, tailored to each identified patient group.

The Contribution of Therapist Effects to Patient Dropout and Deterioration in the Psychological Therapies.

BACKGROUND: In the psychological therapies, patient outcomes are not always positive. Some patients leave therapy prematurely (dropout), while others experience deterioration in their psychological well-being. METHODS: The sample for dropout comprised patients (n = 10 521) seen by 85 therapists, who attended at least the initial session of one-to-one therapy and completed a Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at pre-treatment. The subsample for patient deterioration comprised patients (n = 6405) seen by the same 85 therapists but who attended two or more sessions, completed therapy and returned a CORE-OM at pre-treatment and post-treatment. Multilevel modelling was used to estimate the extent of therapist effects for both outcomes after controlling for patient characteristics. RESULTS: Therapist effects accounted for 12.6% of dropout variance and 10.1% of deterioration variance. Dropout rates for therapists ranged from 1.2% to 73.2%, while rates of deterioration ranged from 0% to 15.4%. There was no significant correlation between therapist dropout rate and deterioration rate (Spearman's rho = 0.07, p = 0.52). CONCLUSIONS: The methods provide a reliable means for identifying therapists who return consistently poorer rates of patient dropout and deterioration compared with their peers. The variability between therapists and the identification of patient risk factors as significant predictors has implications for the delivery of safe psychological therapy services. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Therapists play an important role in contributing to patient dropout and deterioration, irrespective of case mix. Therapist effects on patient dropout and deterioration appear to act independently. Being unemployed as a patient was the strongest predictor of both dropout and deterioration. Patient risk to self or others was also an important predictor.

Invited commentary On poverty, politics and psychology.

Associations between deprivation and mental health have long been known. This commentary discusses recent work examining this in relation to the uptake, delivery and outcomes of psychological therapies in England. These associations are complex but it is clear that implementation of evidence-based interventions should consider area-level characteristics.

Iatrogenic harm from psychological therapies--time to move on.

The problem of adverse effects of psychotherapy has been recognised for decades, yet research on causes and prevention of harm has failed to progress. There is confusion between different definitions and a lack of systematic recording and reporting. A new framework for moving this field forward is proposed.

Patient experience of negative effects of psychological treatment: results of a national survey†.

BACKGROUND: To make informed choices, patients need information about negative as well as positive effects of treatments. There is little information about negative effects of psychological interventions. AIMS: To determine the prevalence of and risk factors for perceived negative effects of psychological treatment for common mental disorders. METHOD: Cross-sectional survey of people receiving psychological treatment from 184 services in England and Wales. Respondents were asked whether they had experienced lasting bad effects from the treatment they received. RESULTS: Of 14 587 respondents, 763 (5.2%) reported experiencing lasting bad effects. People aged over 65 were less likely to report such effects and sexual and ethnic minorities were more likely to report them. People who were unsure what type of therapy they received were more likely to report negative effects (odds ratio (OR) = 1.51, 95% CI 1.22-1.87), and those that stated that they were given enough information about therapy before it started were less likely to report them (OR = 0.65, 95% CI 0.54-0.79). CONCLUSIONS: One in 20 people responding to this survey reported lasting bad effects from psychological treatment. Clinicians should discuss the potential for both the positive and negative effects of therapy before it starts.

The self-management of longer-term depression: learning from the patient, a qualitative study.

BACKGROUND: Depression is a common mental health condition now viewed as chronic or long-term. More than 50 % of people will have at least one further episode of depression after their first, and therefore it requires long-term management. However, little is known about the effectiveness of self-management in depression, in particular from the patients' perspective. This study aimed to understand how people with longer-term depression manage the condition, how services can best support self-management and whether the principles and concepts of the recovery approach would be advantageous. METHODS: Semi-structured in depth interviews were carried out with 21 participants, recruited from a range of sources using maximum variation sampling. Interpretative Phenomenological Analysis was used by a diverse team comprised of service users, practitioners and academics. RESULTS: Four super-ordinate themes were found: experience of depression, the self, the wider environment, self-management strategies. Within these, several prominent sub-themes emerged of importance to the participants. These included how aspects of themselves such as hope, confidence and motivation could be powerful agents; and how engaging in a wide range of chosen activities could contribute to their emotional, mental, physical, social, spiritual and creative wellbeing. CONCLUSIONS: Services in general were not perceived to be useful in specifically facilitating self-management. Increased choice and control were needed and a greater emphasis on an individualised holistic model. Improved information was needed about how to develop strategies and locate resources, especially during the first episode of depression. These concepts echoed those of the recovery approach, which could therefore be seen as valuable in aiding the self-management of depression.

Squaring the circle: a priority-setting method for evidence-based service development, reconciling research with multiple stakeholder views.

BACKGROUND: This study demonstrates a technique to aid the implementation of research findings through an example of improving services and self-management in longer-term depression. In common with other long-term conditions, policy in this field requires innovation to be undertaken in the context of a whole system of care, be cost-effective, evidence-based and to comply with national clinical guidelines. At the same time, successful service development must be acceptable to clinicians and service users and choices must be made within limited resources. This paper describes a novel way of resolving these competing requirements by reconciling different sources and types of evidence and systematically engaging multiple stakeholder views. METHODS: The study combined results from mathematical modelling of the care pathway, research evidence on effective interventions and findings from qualitative research with service users in a series of workshops to define, refine and select candidate service improvements. A final consensus-generating workshop used structured discussion and anonymised electronic voting. This was followed by an email survey to all stakeholders, to achieve a pre-defined criterion of consensus for six suggestions for implementation. RESULTS: An initial list of over 20 ideas was grouped into four main areas. At the final workshop, each idea was presented in person, visually and in writing to 40 people, who assigned themselves to one or more of five stakeholder groups: i) service users and carers, ii) clinicians, iii) managers, iv) commissioners and v) researchers. Many belonged to more than one group. After two rounds of voting, consensus was reached on seven ideas and one runner up. The survey then confirmed the top six ideas to be tested in practice. CONCLUSIONS: The method recruited and retained people with diverse experience and views within a health community and took account of a full range of evidence. It enabled a diverse group of stakeholders to travel together in a direction that converged with the messages coming out of the research and successfully yielded priorities for service improvement that met competing requirements.

"The times they are a-changin'"*: 25 years of psychotherapy research--a European and Latin American perspective.

OBJECTIVE: This article discusses the 25th anniversary of the journal Psychotherapy research from a European perspective. METHOD: Based upon the reflections of one of the founding editors of the journal (David A. Shapiro), together with overviews from SPR colleagues, this article focuses on the major developments in the field of psychotherapy research in the U.K., Germany, as well as and other European countries, as well as Portugal, Spain, and Latin America. RESULTS: The Society for Psychotherapy Research (SPR), which founded the journal as its official organ, underwent a metamorphosis from a purely North American to an international scientific organization during the 1980s. The move towards a greater international audience has been mirrored in the journal, where articles from North America are increasingly balanced with articles from other, especially European, countries. CONCLUSION: The journal Psychotherapy Research has become an important journal and its development allows thoughts about the future direction of the journal as well as the research field as a whole.

Alliance ruptures and resolution during cognitive behaviour therapy with patients with borderline personality disorder.

OBJECTIVE: To explore the process of rupture resolution in cognitive behaviour therapy (CBT) with two good outcome clients with borderline personality disorder (BPD). METHOD: This study employed task-analytic methods to investigate whether the existing CBT rupture resolution model for depression could be validated. Quantitative analyses identified rupture-repair sequences and 41 rupture resolution attempts were systematically analysed. RESULTS: The final model shared similarities with the existing model although additional components, including an "external observer" were identified. Focus on affective experience was also hypothesized to be important. CONCLUSIONS: The final theoretical rupture resolution model may be a useful tool when working with BPD clients in CBT. It is however recognized that further research on data from larger samples is needed. Clinical implications for managing alliance ruptures with BPD clients are discussed.

Cost-effectiveness of an improving access to psychological therapies service.

BACKGROUND: Effective psychological therapies have been recommended for common mental health problems, such as depression and anxiety, but provision has been poor. Improving Access to Psychological Therapies (IAPT) may provide a cost-effective solution to this problem. AIMS: To determine the cost-effectiveness of IAPT at the Doncaster demonstration site (2007-2009). METHOD: An economic evaluation comparing costs and health outcomes for patients at the IAPT demonstration site with those for comparator sites, including a separate assessment of lost productivity. Sensitivity analyses were undertaken. RESULTS: The IAPT site had higher service costs and was associated with small additional gains in quality-adjusted life-years (QALYs) compared with its comparator sites, resulting in a cost per QALY gained of £29 500 using the Short Form (SF-6D). Sensitivity analysis using predicted EQ-5D scores lowered this to £16 857. Costs per reliable and clinically significant (RCS) improvement were £9440 per participant. CONCLUSIONS: Improving Access to Psychological Therapies provided a service that was probably cost-effective within the usual National Institute for Health and Clinical Excellence (NICE) threshold range of £20 000-30 000, but there was considerable uncertainty surrounding the costs and outcome differences.

Is group cognitive behaviour therapy for postnatal depression evidence-based practice? A systematic review.

BACKGROUND: There is evidence that psychological therapies including cognitive behaviour therapy (CBT) may be effective in reducing postnatal depression (PND) when offered to individuals. In clinical practice, this is also implemented in a group therapy format, which, although not recommended in guidelines, is seen as a cost-effective alternative. To consider the extent to which group methods can be seen as evidence-based, we systematically review and synthesise the evidence for the efficacy of group CBT compared to currently used packages of care for women with PND, and we discuss further factors which may contribute to clinician confidence in implementing an intervention. METHODS: Seventeen electronic databases were searched. All full papers were read by two reviewers and a third reviewer was consulted in the event of a disagreement on inclusion. Selected studies were quality assessed, using the Cochrane Risk of Bias Tool, were data extracted by two reviewers using a standardised data extraction form and statistically synthesised where appropriate using the fixed-effect inverse-variance method. RESULTS: Seven studies met the inclusion criteria. Meta-analyses showed group CBT to be effective in reducing depression compared to routine primary care, usual care or waiting list groups. A pooled effect size of d = 0.57 (95% CI 0.34 to 0.80, p < 0.001) was observed at 10-13 weeks post-randomisation, reducing to d = 0.28 (95% CI 0.03 to 0.53, p = 0.025) at 6 months. The non-randomised comparisons against waiting list controls at 10-13 weeks was associated with a larger effect size of d = 0.94 (95% CI 0.42 to 1.47, p < 0.001). However due to the limitations of the available data, such as ill-specified definitions of the CBT component of the group programmes, these results should be interpreted with caution. CONCLUSIONS: Although the evidence available is limited, group CBT was shown to be effective. We argue, therefore, that there is sufficient evidence to implement group CBT, conditional upon routinely collected outcomes being benchmarked against those obtained in trials of individual CBT, and with other important factors such as patient preference, clinical experience, and information from the local context taken into account when making the treatment decision.

Innovation in health economic modelling of service improvements for longer-term depression: demonstration in a local health community.

BACKGROUND: The purpose of the analysis was to develop a health economic model to estimate the costs and health benefits of alternative National Health Service (NHS) service configurations for people with longer-term depression. METHOD: Modelling methods were used to develop a conceptual and health economic model of the current configuration of services in Sheffield, England for people with longer-term depression. Data and assumptions were synthesised to estimate cost per Quality Adjusted Life Years (QALYs). RESULTS: Three service changes were developed and resulted in increased QALYs at increased cost. Versus current care, the incremental cost-effectiveness ratio (ICER) for a self-referral service was £11,378 per QALY. The ICER was £2,227 per QALY for the dropout reduction service and £223 per QALY for an increase in non-therapy services. These results were robust when compared to current cost-effectiveness thresholds and accounting for uncertainty. CONCLUSIONS: Cost-effective service improvements for longer-term depression have been identified. Also identified were limitations of the current evidence for the long term impact of services.

Clinical Effectiveness and Cost-Effectiveness of Supported Mindfulness-Based Cognitive Therapy Self-help Compared With Supported Cognitive Behavioral Therapy Self-help for Adults Experiencing Depression: The Low-Intensity Guided Help Through Mindfulness (LIGHTMind) Randomized Clinical Trial.

Importance: Depression is prevalent. Treatment guidelines recommend practitioner-supported cognitive behavioral therapy self-help (CBT-SH) for mild to moderate depression in adults; however, dropout rates are high. Alternative approaches are required. Objective: To determine if practitioner-supported mindfulness-based cognitive therapy self-help (MBCT-SH) is superior to practitioner-supported CBT-SH at reducing depressive symptom severity at 16 weeks postrandomization among patients with mild to moderate depression and secondarily to examine if practitioner-supported MBCT-SH is cost-effective compared with practitioner-supported CBT-SH. Design, Setting, and Participants: This was an assessor- and participant-blinded superiority randomized clinical trial with 1:1 automated online allocation stratified by center and depression severity comparing practitioner-supported MBCT-SH with practitioner-supported CBT-SH for adults experiencing mild to moderate depression. Recruitment took place between November 24, 2017, and January 31, 2020. The study took place in 10 publicly funded psychological therapy services in England (Improving Access to Psychological Therapies [IAPT]). A total of 600 clients attending IAPT services were assessed for eligibility, and 410 were enrolled. Participants met diagnostic criteria for mild to moderate depression. Data were analyzed from January to October 2021. Interventions: Participants received a copy of either an MBCT-SH or CBT-SH workbook and were offered 6 support sessions with a trained practitioner. Main Outcomes and Measures: The preregistered primary outcome was Patient Health Questionnaire (PHQ-9) score at 16 weeks postrandomization. The primary analysis was intention-to-treat with treatment arms masked. Results: Of 410 randomized participants, 255 (62.2%) were female, and the median (IQR) age was 32 (25-45) years. At 16 weeks postrandomization, practitioner-supported MBCT-SH (n = 204; mean [SD] PHQ-9 score, 7.2 [4.8]) led to significantly greater reductions in depression symptom severity compared with practitioner-supported CBT-SH (n = 206; mean [SD] PHQ-9 score, 8.6 [5.5]), with a between-group difference of -1.5 PHQ-9 points (95% CI, -2.6 to -0.4; P = .009; d = -0.36). The probability of MBCT-SH being cost-effective compared with CBT-SH exceeded 95%. However, although between-group effects on secondary outcomes were in the hypothesized direction, they were mostly nonsignificant. Three serious adverse events were reported, all deemed not study related. Conclusions and Relevance: In this randomized clinical trial, practitioner-supported MBCT-SH was superior to standard recommended treatment (ie, practitioner-supported CBT-SH) for mild to moderate depression in terms of both clinical effectiveness and cost-effectiveness. Findings suggest that MBCT-SH for mild to moderate depression should be routinely offered to adults in primary care services. Trial Registration: isrctn.org Identifier: ISRCTN13495752.

Can the impact of public involvement on research be evaluated? A mixed methods study.

BACKGROUND: Public involvement is central to health and social research policies, yet few systematic evaluations of its impact have been carried out, raising questions about the feasibility of evaluating the impact of public involvement. OBJECTIVE: To investigate whether it is feasible to evaluate the impact of public involvement on health and social research. METHODS: Mixed methods including a two-round Delphi study with pre-specified 80% consensus criterion, with follow-up interviews. UK and international panellists came from different settings, including universities, health and social care institutions and charitable organizations. They comprised researchers, members of the public, research managers, commissioners and policy makers, self-selected as having knowledge and/or experience of public involvement in health and/or social research; 124 completed both rounds of the Delphi process. A purposive sample of 14 panellists was interviewed. RESULTS: Consensus was reached that it is feasible to evaluate the impact of public involvement on 5 of 16 impact issues: identifying and prioritizing research topics, disseminating research findings and on key stakeholders. Qualitative analysis revealed the complexities of evaluating a process that is subjective and socially constructed. While many panellists believed that it is morally right to involve the public in research, they also considered that it is appropriate to evaluate the impact of public involvement. CONCLUSIONS: This study found consensus among panellists that it is feasible to evaluate the impact of public involvement on some research processes, outcomes and on key stakeholders. The value of public involvement and the importance of evaluating its impact were endorsed.

How valid and responsive are generic health status measures, such as EQ-5D and SF-36, in schizophrenia? A systematic review.

OBJECTIVES: Generic health status measures such as the short form health survey (SF-36) and EuroQol-5D (EQ-5D) are increasingly being used to inform health policy. They are claimed to be applicable across disease areas and have started to be used within mental health research. This review aims to assess the construct validity and responsiveness of four generic health status measures in schizophrenia, including the preference-based SF-6D and EQ-5D. METHOD: A systematic review of the literature was undertaken. Ten databases were searched from inception to August 2009 and reference lists scrutinized to identify relevant studies. Studies were appraised and data extracted. A narrative synthesis was performed of the evidence on construct validity including known groups validity (detecting a difference in health-related quality of life (HRQL) scores between two different groups such as samples from the general population and people with schizophrenia), convergent validity (strength of association between generic HRQL and other measures (e.g., symptom or functional), and responsiveness. Responsiveness was considered by: 1) differences in generic HRQL measure scores in responders/non-responders and 2) correlation between changes on generic HRQL measures and changes in specific measures obtained from patients and clinicians. RESULTS: Thirty-three studies were identified that provided data on the validity and/or responsiveness of the instruments. Most of the evidence concerns the SF-36 and EQ-5D, and for these instruments there was evidence for known group validity. The evidence for convergent validity and responsiveness was mixed, with studies presenting contradictory results. CONCLUSION: Although the evidence base is limited in a number of important respects, including problems with the measures used to develop constructs in the validation studies, it is sufficient to raise doubts about the use of generic measures of health like the EQ-5D and SF-36 in patients with schizophrenia.

Detecting referral and selection bias by the anonymous linkage of practice, hospital and clinic data using Secure and Private Record Linkage (SAPREL): case study from the evaluation of the Improved Access to Psychological Therapy (IAPT) service.

BACKGROUND: The evaluation of demonstration sites set up to provide improved access to psychological therapies (IAPT) comprised the study of all people identified as having common mental health problems (CMHP), those referred to the IAPT service, and a sample of attenders studied in-depth. Information technology makes it feasible to link practice, hospital and IAPT clinic data to evaluate the representativeness of these samples. However, researchers do not have permission to browse and link these data without the patients' consent. OBJECTIVE: To demonstrate the use of a mixed deterministic-probabilistic method of secure and private record linkage (SAPREL)--to describe selection bias in subjects chosen for in-depth evaluation. METHOD: We extracted, pseudonymised and used fuzzy logic to link multiple health records without the researcher knowing the patient's identity. The method can be characterised as a three party protocol mainly using deterministic algorithms with dynamic linking strategies; though incorporating some elements of probabilistic linkage. Within the data providers' safe haven we extracted: Demographic data, hospital utilisation and IAPT clinic data; converted post code to index of multiple deprivation (IMD); and identified people with CMHP. We contrasted the age, gender, ethnicity and IMD for the in-depth evaluation sample with people referred to IAPT, use hospital services, and the population as a whole. RESULTS: The in IAPT-in-depth group had a mean age of 43.1 years; CI: 41.0-45.2 (n=166); the IAPT-referred 40.2 years; CI: 39.4-40.9 (n=1118); and those with CMHP 43.6 years SEM 0.15. (n=12210). Whilst around 67% of those with a CMHP were women, compared to 70% of those referred to IAPT, and 75% of those subject to in-depth evaluation (Chi square p<0.001). The mean IMD score for the in-depth evaluation group was 36.6; CI: 34.2-38.9; (n=166); of those referred to IAPT 38.7; CI: 37.9-39.6; (n=1117); and of people with CMHP 37.6; CI 37.3-37.9; (n=12143). CONCLUSIONS: The sample studied in-depth were older, more likely female, and less deprived than people with CMHP, and fewer had recorded ethnic minority status. Anonymous linkage using SAPREL provides insight into the representativeness of a study population and possible adjustment for selection bias.

Developing a competence framework for cognitive analytic therapy.

OBJECTIVE: This paper describes the development and summarizes the content of a competence framework for delivery of cognitive analytic therapy (CAT). DESIGN: The framework was developed using the evidence-based method developed by Roth and Pilling (2008, Behavioural and Cognitive Psychotherapy, 36, 129). METHODS: A review of the CAT outcome literature identified where CAT interventions had evidence of efficacy. Standard texts on CAT were primary sources for details of theory and practice. This process was supported by an expert reference group (ERG). The role of the ERG was to provide professional advice on areas where the evidence base was lacking, but where CAT interventions were commonly used by therapists trained in the model. RESULTS: A framework was produced and structured in terms of core knowledge, core skills, and meta-competences (which require therapeutic judgement rather than simple adherence to a treatment protocol). CONCLUSIONS: The framework enables trainees, service users, service managers, and commissioners to better understand a) the core features of CAT and b) what competences need to be in place for CAT to be skilfully delivered in practice. PRACTITIONER POINTS: It is possible to define the core competences of CAT. Whilst generic competences are important, there are five CAT-specific domains of competence. The CAT-specific competences reflect the three-phase structure of the therapy: reformulation, recognition, and revision.