This protocol sets out a general approach to the delivery of low-intensity interventions for both guided self-help (GSH) and behavioural activation (BA). It assumes that an initial assessment has been undertaken and the nature of the problem (depression or an anxiety disorder) has been identified and is deemed suitable for a low-intensity intervention. The precise details of the protocol will vary depending on the nature of the anxiety disorder and as they will with the nature of the problems faced by an individual with depression.
N.1 Establishing guided self-help
or behavioural activation
This will normally take place entirely during the first contact and will require the following:
An assessment of relevant symptoms (using formal measures such as the PHQ-9 and GAD-7) and the impact on a person’s functioning, any associated risks, motivation to engage in the programme, and experience and response to previous treatments
An agreed set of goals (which have emerged from a shared decision making process) and the administration of materials (e.g. behavioural record sheets) to support the treatment plan. Psycho-education about the nature of the
problem including summarising (and normalising) the problem in a manner which facilitates the establishment of the intervention
The identification and advice on the use of the specific written materials relevant to the particular problem and identified goals
Education about the model of the intervention (emphasising the focus on service self-directed care and the role of the therapist in supporting this self-help approach) to be used and its relationship to the agreed problem(s) and goals identified
An agreed plan for the duration of the intervention and the frequency, nature and duration of the individual sessions (e.g. face-to- face contacts or telephone contacts), and the system for reviewing progress, including when necessary the process for ‘stepping-up’ care.
N.2 Duration and frequency
of sessions
The duration of sessions will vary according to the service user’s need but the initial session would not normally last more that 45 minutes, subsequent sessions typically would be expected to be of no more than 30 minutes duration but may be less in the case
of telephone contacts. The frequency of sessions will vary with service user need but might involve weekly contacts initially for two to three weeks but then could be fortnightly depending on the response to the intervention. The intervention would normally involve a minimum of eight contacts but in some cases may be less. It should not last longer than 12 weeks including, when necessary, a follow-up session. The routine monitoring of the outcome to the intervention and the degree of support needed by the service user should influence the frequency of contact.
N.3 Record keeping and outcome
monitoring
This has four elements:
The recording of the service user’s mental and behavioural state and any variation in assessed risk The use of service user’s diary and record sheets
to monitor progress and to revise and plan further interventions
The use of formal ratings such as the PHQ-9 and the GAD-7 to monitor progress
Direct feedback from the service user on progress in treatment and their satisfaction with the content and manner of delivery of the intervention.
All three elements should be used in each subsequent session to evaluate progress (in discussion with the service user) and shape the future treatment plans.
N.4 Subsequent treatment sessions
All subsequent sessions should follow the same broad agenda, this will include:An agreed agenda for the meeting
A review of progress using both the diary and record sheets and the formal measures and an assessment of any change in risk status Reinforcement of progress made
Advice on further refinement/revision of goals and advice on overcoming obstacles to the achievement of particular goals
Advice on how progress may be maintained by building in generalisation and social reinforcers of service user achieved change.
N.5 Final session and ending
the intervention
An agreed agenda for the meeting
A review of overall progress against initial and subsequent goals (using service user feedback and formal and informal assessment materials) Review and revise plans to maintain
generalisation and social reinforcers including specific advice on personal and environmental strategies to reduce the likelihood of future relapse.
Where an individual has not benefited from a low- intensity intervention, they should be stepped-up to a high-intensity intervention unless they decline the offer to do so. The decision to step-up should be based on clearly agreed and objective criteria (e.g. failure to show significant improvement on the PHQ-9 or GAD-7) which should be in place before embarking on a low-intensity interventions and which should be known to the service user at the beginning of the intervention. There should be locally agreed protocols in place for ‘stepping up’ to a higher level intervention, agreed with low and high-intensity treatment providers.