Can a ‘return-to-work’ agenda fit within the theory and practice of CBT for depression and anxiety disorders?

Business as usual? Psychological support at a distance

The impact of COVID-19 has challenged the long accepted 'norm' in delivery of psychological therapy. Public policies designed to reduce transmission have made it extremely difficult to meet with service-users safely in the traditional face-to-face context. E-therapies have existed in theory and practice since technological progress has made them possible. They can offer a host of advantages over face-to-face equivalents, including improved access, greater flexibility for service-users and professionals, and cost savings. However, despite the emerging evidence and anticipated positive value, implementation has been slower than anticipated. Concerns have been raised by service-users, clinicians, and public health organisations, identifying significant barriers to the wide spread use of e-therapies. In the current climate, many clinicians are offering e-therapies for the first time, without prior arrangement or training, as the only viable option to continue to support their clients. This paper offers a clinically relevant review of the e-therapies literature, including effectiveness and acceptability dilemmas and challenges that need to be addressed to support the safe use and growth of e-therapies in psychology services. Further research is needed to better understand what might be lost and what gained in comparison to face-to-face therapy, and for which client groups and settings it might be most effective.

Telephone-based CBT and the therapeutic relationship: The views and experiences of IAPT practitioners in a low-intensity service

WHAT IS KNOWN ON THE SUBJECT

There is a move towards the use of new ways of delivering mental health care, particularly via an increased use of telephone therapies. Although some studies have noted the advantages of telephone-delivered therapies (e.g., removing access barriers) and reported on equivalent therapeutic effects when compared to face-to-face, there are concerns about how telephone-based therapy adversely affects the therapeutic relationship.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

It contributes new knowledge regarding psychological practitioners' experience and views about using telephone-based therapies and how this affects the therapeutic relationship.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This paper provides data about the new practitioner workforce (IAPT Psychological Wellbeing Practitioners) and adds to a growing area of research regarding their clinical role. It has relevance for mental health nursing, because health services internationally and across the professions are exploring how telehealth can improve health care. This paper suggests that mental health services need to focus on what type of therapeutic relationship their practice facilitates and on offering transparency to service users. It concludes that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to focus on what facilitates and inhibits deeper therapeutic closeness and connection.

ABSTRACT

Introduction Over-the-telephone (OTT)-delivered psychological therapies as an alternative method to face-to-face (F2F) are becoming more prevalent in mental health care. Research suggests a range of benefits of OTT use in therapy, but there are growing concerns about its consequences for the therapeutic relationship. This paper presents new knowledge regarding psychological practitioners' experience and views of OTT work and its potential effects on the therapeutic relationship in the context of the UK's Increasing Access to Psychological Therapy (IAPT) programme. Aim This paper presents IAPT practitioners' experiences and views of OTT work and its potential effects on the therapeutic relationship. Methods Completed questionnaires (exploring OTT versus F2F work) which were distributed to IAPT practitioners revealed a concern about the therapeutic relationship in OTT. To explore this further, nine in-depth semi-structured interviews with PWPs were conducted and the findings from this qualitative study are reported here. Results Practitioners noted OTT use facilitated access and flexibility for service users; however, they expressed some concern over the adverse effect of OTT on the therapeutic relationship. Discussion Although a working alliance was possible OTT, this research suggests the type of therapeutic relationship formed OTT in a "low contact-high volume" service such as IAPT needs to be better defined. By addressing this, dissonance which might arise between practitioner aims and the aims of IAPT can be reduced. This research also contributes to wider debates regarding mental health care and its provision in the UK. Implications for practice This paper concludes that mental health services need to focus on what type of therapeutic relationship their practice facilitates and to offer transparency to service users. The findings suggest that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to offer a more nuanced understanding of the concept of a therapeutic relationship and focus on what facilitates and inhibits deeper therapeutic closeness and connection.

Unfolding the values of work - therapists´ experience of addressing the return to work process in occupational rehabilitation based on Acceptance and Commitment Therapy

Background

Facilitating return to work can be challenging due to the complexity of work disability. Few studies have examined rehabilitation programs based on Acceptance and Commitment Therapy that intend to support return to work, and none have investigated therapists’ experience with providing such programs. The aim of this study was therefore to explore therapists’ experience of addressing the return to work process in an inpatient occupational rehabilitation program based on Acceptance and Commitment Therapy.

Methods

This was a qualitative interview study supported by participant observation. Therapists were interviewed regarding their experiences with addressing return to work in an inpatient occupational rehabilitation program based on Acceptance and Commitment Therapy. In addition, the rehabilitation program was investigated through participant observation. The interviews were analysed according to Interpretative Phenomenological Analysis and informed by an analysis of field notes from the participant observation.

Results

Acceptance and Commitment Therapy was experienced as a meaningful approach to facilitate return to work, as it allowed therapists to address all relevant aspects of the individual participant’s life that might influence work participation. The therapists’ twofold goal was to support participants in building both a meaningful life and sustainable work participation. To do so, they attempted to instil long-term and interrelated processes concerning ownership, causes of sick leave, relation to expectations, the values of work, and the scope of agency.

Conclusion

Unfolding values connected to work participation might reconcile the tension between work and family life by integrating work with other areas of life. Providing work participation with personal meaning also seems especially commensurable with a context where economy presents a poor incentive for return to work. Therapists should, however, be attentive to the need to secure the prominence of return to work by relating participants’ chosen themes explicitly to their return to work process. Therapists should also be aware of the dilemma that may arise when they attempt to refrain from providing advice while simultaneously encouraging actions they consider appropriate to facilitate sustainable work participation. In addition, having an individual-oriented approach to occupational rehabilitation may obscure the extent to which return to work is a multi-stakeholder process.

Enabling the return-to-work process among people with affective disorders: A multiple-case study

BACKGROUND

The Individual Enabling and Support (IES) model is an adapted, supported employment program developed to meet motivational, cognitive and time-use needs of people with affective disorders. Vocational programs for this target group have been developed but more knowledge is needed about the important characteristics and perceived usefulness of the programs. The aim of this study was to illustrate the IES model and process from multiple perspectives.

METHODS

Five participants were included in this multiple-case study. The material comprised interviews with participants, intervention documents, memos and interviews with employment specialists. Within and cross-case analyzes and an analytical generalization were performed.

RESULTS

The cases illustrated different IES processes, and the theme; Enabling engagement in return to work (RTW) was formulated. Continuous support from the employment specialist and a focus on personal resources and motivation were essential to overcome low self-confidence regarding RTW. Motivational, cognitive and time-use strategies gave an opportunity to learn new behavior and coping strategies for job seeking, getting employed and working.

CONCLUSION

Providing a combination of these strategies integrated with supported employment could promote self-efficacy and engagement in the RTW process among people on sick leave due to an affective disorder.

How do workers with common mental disorders experience a multidisciplinary return-to-work intervention? A qualitative study

PURPOSE

Long-term sick leave due to common mental disorders (CMD) is an increasing problem in many countries. Recent reviews indicate that return to work (RTW) interventions have limited effect on reducing sickness absence among this group of sick-listed. The aims of this study were to investigate how sick-listed persons with CMD experienced participating in an RTW intervention and how workability assessments and RTW activities influenced their RTW-process, and to examine the working mechanisms of the intervention. The gained knowledge can help improve future RTW intervention design and implementation.

METHODS

In-depth interviews were conducted with 17 participants on sick leave due to CMD who participated in an RTW intervention. Interviews were conducted at three time points with each participant. Principles of interpretative phenomenological analyses guided the analysis.

RESULTS

The workability assessment consultations and RTW activities such as psychoeducative group sessions and individual sessions with psychologist could result in both motivation and frustration depending on the extent to which the RTW professionals practiced what we have termed an individual approach to the sick-listed person.

CONCLUSIONS

The individual approach seems necessary for the realization of the positive potential in the RTW intervention. However, the fact that RTW professionals are both the facilitators and the controllers of the sick-listed persons' RTW process is an inherent paradox in the intervention, which can impede the necessary establishment of a high-quality relationship between the sick-listed persons and RTW professionals.