The range of psychotherapeutic settings

All mental health services are, potentially, psychotherapeutic settings, in that there is always scope for the relationships between patients and professionals (and between patients meeting together) to assist or impede recovery. This article focuses on settings where psychotherapy is the primary treatment offered: these include out-patient services where planned talking treatments are provided individually or to groups or families, as well as milieux such as psychotherapy day hospitals or therapeutic communities in which several staff members are likely to remain directly involved in each patient’s treatment. In all of these settings, a confiding working relationship is provided, in which high levels of disclosure and skilled support are expected, irrespective of the therapeutic model that is followed.

Care programming

Since the original principles summarised in Box 1 were established, guidance on the implementation of care programming has been updated in two publications by the Department of Health (1999a , b ): Effective Care Coordination in Mental Health Services (Box 2) and the National Service Framework for Mental Health (Box 3).

Effective Care Coordination in Mental Health Services reintroduced care programming as a universal system of case management to coincide with the harmonisation of procedures between health and social services care, and the abolition of case registers for patients at greatest risk. It increased the responsibility of named keyworkers to encompass all aspects of care. Two levels of care programming, ‘standard’ and ‘enhanced’, were differentiated for the first time. The latter was likely to apply if multi-agency input was required in order to reduce risk in relevant areas. Detailed guidance was provided concerning the criteria that should determine which level of care was given; care coordinators’ responsibilities in either situation; and the collection and sharing of information. The document included illustrative vignettes as well as bald statements of the measures that should be taken. Subsequent guidance has confirmed timetables for full implementation of CPA and a national audit framework to monitor this (Department of Health, 2001a ).

Despite this clarification, there has been scope for confusion. Effective Care Coordination in Mental Health Services makes plain the difference between standard and enhanced packages, and states:

Contradictions between this and Standard 4 of the National Service Framework for Mental Health (Box 3) can be reconciled by assuming that the latter is referring to ‘enhanced’ care programming only. However, in a later summary (Department of Health, 2001c ), it is explicitly stated that requirements that patients on enhanced CPA should have written plans to secure suitable employment, adequate housing and appropriate welfare benefits ‘will apply to everyone on CPA’ by March 2004.

Whether the guidance on CPA has been consistent or not, what specific comments does it make about psychotherapy? Effective Care Coordination in Mental Health Services makes little reference to the ‘care’ that patients actually receive. This is something that professionals provide, but there is not a single reference to a mental health professional as someone who might provide ‘therapy’ rather than ‘support’. An appendix provides eight vignettes to illustrate implementation of the CPA in practice. These are clear and instantly recognisable, but again contain no reference to a patient receiving psychotherapeutic help within mental health services. Two patients who need psychological interventions are denied mental health services as they do not ‘need to be subject to the CPA’ – one of these is a middle-aged man who is actively seeking help. He is losing his job, has stomach pains from excessive drinking and is now afraid he is dying following the onset of panic attacks. It is recommended he should be offered self-help literature and his general practitioner should be offered ‘support’. The advice on two other patients, candidates for psychological interventions according to current treatment guidelines (Department of Health, 2001c ; National Institute for Clinical Excellence, 2002), is as follows. A woman with a history of repeated self-cutting who discloses sexual abuse ‘may benefit from intensive support under enhanced CPA’ – but not psychotherapy (Department of Health, 1999a : case 1). A man whose disturbed behaviour is associated with hearing voices has a complex care package spelled out in which the principal role of mental health services is ‘for monitoring of his mental state and for supervision of his medication’ (case 5). That the place of psychotherapeutic interventions within mental health services is ignored or denied here suggests that their impact on the implementation of care programming received little attention when the policy was ‘modernised’. Perhaps the contribution of psychological therapists to care would have been reflected more accurately in policy on care programming if some of the principles of CPA – meeting to agree a plan and to review it in the light of developments – had applied during its own planning.

Psychotherapy and care planning

Why should the requirements of care programming present any ‘challenges’ to psychotherapeutic practice? Even if the role of psychological therapies in mental health services has been insufficiently recognised, it is not evident that conflicts need arise between the demands of psychotherapeutic work and care programming, given the statement of principles in Box 1. As Box 4 illustrates, it is possible to state a parallel set of principles of good practice that would apply across the psychotherapies, irrespective of the psychotherapist’s favoured model (psychodynamic, cognitive–behavioural or systemic, for example).

When framed in this way, there is a clear correspondence between Box 1 and Box 4. These principles of therapeutic practice were being widely observed long before CPA was introduced or the phrase ‘reflective practice’ was devised (the latter effectively describes the transfer of basic therapeutic disciplines to other clinical arenas). If care programming in psychotherapeutic settings was simply about applying the principles in Box 1, conflict should be less than in arenas where reflective practice had been less familiar.

However, it is clear from Box 2 that ‘effective’ care programming has been expected to achieve more than organisation of individual treatments. In essence, care programming has moved from being a tool in the delivery of clinical care to become a prescription for how a range of systems should be coordinated. With this revision, three additional major objectives are apparent, namely integration of each individual’s health and social care; streamlining of information systems; and responding to carers’ needs. Each of these is potentially problematic in psychotherapeutic settings, especially if the current expectations for ‘enhanced’ CPA were extended to all patients.

A brief survey of CPA implementation

To assess the current implementation and impact of CPA in psychotherapy, in January 2003 I conducted a survey among 20 psychotherapy consultants from different services. The majority worked wholly in dedicated out-patient services, but three consultants from therapeutic communities and two from general psychiatry also responded. Two consultants worked in Scotland, where legislative requirements are different. Only one service reported that cognitive–behavioural therapy rather than psychodynamic psychotherapy was its principal model.

Of these 20 services, 14 reported having implemented CPA for patients receiving psychotherapy. No two services appeared to be doing this in exactly the same way. Only half had a service-specific written policy outlining how implementation should be done. The actual adoption of care planning appeared to be rather lower than that reported: only 12 services reported having a written care plan for each patient, and this figure included two services that had reported themselves to be non-compliant with CPA, but used written plans for internal reasons. If evident compliance is equated instead with staff being designated as care coordinators, at least for standard CPA, then 11 services were using CPA. This group included all 10 of the services that said they had implemented CPA and were writing care plans.

Additional questioning about clinical records and staff roles revealed further variations in practice. Among the 14 services that said they used CPA, 10 reported having a summary care plan for each new patient, 8 also used a structured risk assessment, 5 used a structured clinical history, and 4 made a routine record of housing and financial circumstances. Although 11 services said that staff members acted as care coordinators, only 6 said that staff members ever acted as coordinators for enhanced CPA. Only one service reported that trainees or other non-permanent staff acted as care coordinators.

The only service that claimed to involve relatives routinely in drawing up care plans was the one offering cognitive–behavioural therapy. When the procedure for review of care plans was enquired about, it was evident only 5 of the 14 services claiming CPA had a distinct review process involving the patient.

Living with CPA

Many participants in the survey took up an invitation to comment on measures they had found personally helpful in accommodating care programming. Most of these concerned ways to minimise its negative effects through avoidance, at either institutional or personal levels. Institutionally, three opt-out positions were reported. First, some consultants had simply made no attempt to alert local managers to their lack of interest in implementing CPA, and had not as yet been asked to introduce the framework. Other consultants had fought down attempts to introduce CPA, using arguments about its inappropriateness for their client population and treatment philosophy, and had won agreements that their service should be exempt. A third position held that psychotherapy services had so much in common with primary care services that they should be considered to belong with them for CPA purposes. (For brevity, I have called these the ‘ostrich’, ‘lion’ and ‘chameleon’ positions.)

Three further positions amounted to restricted implementation. First, the survey findings that only half the services implementing CPA were providing care coordination for patients on enhanced CPA indicate that the restriction of this responsibility to patients on standard CPA is a common policy. Second, systematic avoidance of the care coordinator role was sought through referral protocols that favoured prospective patients from within the secondary system (these being likely to have a coordinator already); however, there appeared to be some risk of services assuming a pseudo-tertiary status, which imposed barriers to access if this strategy was adopted. Third, there is the position of the (mainly residential) settings in which responsibility for care planning is returned to the patient. The patient draws up an appraisal and proposal for treatment goals which is then signed by staff, rather than the other way round. Its scope in out-patient settings appears to have been relatively untested.

In terms of individual strategies to minimise conflicts and additional burden, the likely consequence of becoming a care coordinator was reported to have made the task of assessment of new patients less attractive within some psychotherapeutic settings. Conversely, from reports from some residential and out-patient services it was evident that a senior figure such as the consultant psychotherapist had come forward to act as coordinator for many patients simultaneously, enabling other staff to maintain a purely therapeutic role.

Where the role of care coordinator was not avoided, a number of strategies for making it more acceptable were reported. These included simplification of paperwork – so that summary letters served as care plans, as the passage quoted above from Effective Care Coordination in Mental Health Services recommends for standard CPA. A useful suggestion for conducting standardised risk assessment concerned use of the risk sub-scale of the Clinical Outcomes in Routine Evaluation (CORE) questionnaire when this is routinely used with new patients – a practice whose validity in detection of risk is supported by evidence from a specialist psychotherapy setting (Reference Whewell and BonannoWhewell & Bonanno, 2000).

Simplification of paperwork was also a way of reducing concerns over confidentiality aroused by the streamlining of information systems. It was interesting that so few services had electronic systems for pooling CPA data, but concerns on this score seem likely to increase with time. A more general point is apparent, that it is likely to be beneficial for psychotherapy teams to establish their own policy for implementation of CPA so that this can respect local needs in ways that a policy for the whole health care trust might not.

As the results of the survey indicate, few services have changed their practice to involve carers more meaningfully in planning and review. Indeed, because of the availability of parallel supervision or team meetings, reviews to formally satisfy CPA requirements were often literally a paper exercise, rather than an additional meeting with the patient.

Conclusions

The care programming approach has evolved into a system of case management that has not specifically taken the needs of psychotherapeutic settings into account. Although the basic philosophy of proper assessment and planned care represents little threat to psychotherapeutic work, secondary demands for broader assessment, information sharing and carer involvement can lead to genuine tensions. It is possible to realise some potential benefits and minimise disadvantages by establishing a clear service policy that takes the local circumstances and individual needs of a dedicated psychotherapy setting into account.

Multiple choice questions

1. 1 CPA requires:

   1. a psychotherapy to be provided by a multidisciplinary team

   2. b relatives to be told the outcome of a patient’s assessment

   3. c a risk assessment to be recorded

   4. d regular reviews to be conducted

   5. e employment counselling to be offered.

2. 2 Conflicts can arise with therapeutic objectives because:

   1. a care plans should be shared with patients

   2. b assessment protocols may cover social needs

   3. c care coordinators’ responsibilities exceed those of therapists

   4. d patients’ dependency may be fostered

   5. e CPA increases patients’ symptoms.

3. 3 Strengths of care programming in therapeutic settings include:

   1. a enhancement of training

   2. b clarification of roles

   3. c prevention of users’ complaints

   4. d formal risk assessment

   5. e communication with other services.

4. 4 Many psychotherapists are wary of care programming because:

   1. a patient confidentiality can be threatened

   2. b it exposes them to litigation

   3. c they are invited to meetings

   4. d its principles are misguided

   5. e it requires additional time.

5. 5 Conflicts arising from CPA implementation might be reduced by:

   1. a using electronic forms

   2. b prescribing more selective serotonin reuptake inhibitors

   3. c having a service-specific CPA policy

   4. d postponing implementation

   5. e employing a data clerk.