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Moral injury is the profound psychological distress that can arise following participating in, or witnessing, events that transgress an individual’s morals and include harming, betraying, or failure to help others, or being subjected to such events, e.g. being betrayed by leaders. It has been primarily researched in the military, but it also found in other professionals such as healthcare workers coping with the COVID-19 pandemic and civilians following a wide range of traumas. In this article, we describe how to use cognitive therapy for post-traumatic stress disorder (CT-PTSD) to treat patients presenting with moral injury-related PTSD. We outline the key techniques involved in CT-PTSD and describe their application to treating patients with moral injury-related PTSD. A case study of a healthcare worker is presented to illustrate the treatment interventions.
Key learning aims
(1) To recognise moral injury where it arises alongside PTSD.
(2) To understand how Ehlers and Clark’s cognitive model of PTSD can be applied to moral injury.
(3) To be able to apply cognitive therapy for PTSD to patients with moral injury-related PTSD.
The Coronavirus (Covid-19) pandemic is exerting unprecedented pressure on NHS Health and Social Care provisions, with frontline staff, such as those of critical care units, encountering vast practical and emotional challenges on a daily basis. Although staff are being supported through organisational provisions, facilitated by those in leadership roles, the emergence of mental health difficulties or the exacerbation of existing ones amongst these members of staff is a cause for concern. Acknowledging this, academics and healthcare professionals alike are calling for psychological support for frontline staff, which not only addresses distress during the initial phases of the outbreak but also over the months, if not years, that follow. Fortunately, mental health services and psychology professional bodies across the United Kingdom have issued guidance to meet these needs. An attempt has been made to translate these sets of guidance into clinical provisions via the recently established Homerton Covid Psychological Support (HCPS) pathway delivered by Talk Changes (Hackney & City IAPT). This article describes the phased, stepped-care and evidence-based approach that has been adopted by the service to support local frontline NHS staff. We wish to share our service design and pathway of care with other Improving Access to Psychological Therapies (IAPT) services who may also seek to support hospital frontline staff within their associated NHS Trusts and in doing so, lay the foundations of a coordinated response.
Key learning aims
(1) To understand the ways staff can be psychologically and emotionally impacted by working on the frontline of disease outbreaks.
(2) To understand the ways in which IAPT services have previously supported populations exposed to crises.
(3) To learn ways of delivering psychological support and interventions during a pandemic context based on existing guidance and research.
Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioural therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD, and describe their application to treating patients with PTSD following ICU.
Key learning aims
(1) To recognise PTSD following admissions to intensive care units (ICUs).
(2) To understand how the ICU experience can lead to PTSD development.
(3) To understand how Ehlers and Clark’s (2000) cognitive model of PTSD can be applied to post-ICU PTSD.
(4) To be able to apply cognitive therapy for PTSD to patients with post-ICU PTSD.
In the past few weeks, coronavirus disease 2019 (COVID-19) has dramatically expanded across the world. To limit the spread of COVID-19 and its negative consequences, many countries have applied strict social distancing rules. In this dramatic situation, people with eating disorders are at risk of their disorder becoming more severe or relapsing. The risk comes from multiple sources including fears of infection and the effects of social isolation, as well as the limited availability of adequate psychological and psychiatric treatments. A potential practical solution to address some of these problems is to deliver enhanced cognitive behaviour therapy (CBT-E), an evidence-based treatment for all eating disorders, remotely. In this guidance we address three main topics. First, we suggest that CBT-E is suitable for remote delivery and we consider the challenges and advantages of delivering it in this way. Second, we discuss new problems that patients with eating disorders may face in this period. We also highlight potential opportunities for adapting some aspects of CBT-E to address them. Finally, we provide guidelines about how to adapt the various stages, strategies and procedures of CBT-E for teletherapy use in the particular circumstances of COVID-19.
Key learning aims
(1) To appreciate that CBT-E is suitable for remote delivery, and to consider the main challenges and potential advantages of this way of working.
(2) To identify and discuss the additional eating disorder-related problems that may arise as a result of COVID-19, as well as potential opportunities for adapting some aspects of CBT-E to address them.
(3) To learn how to adapt CBT-E for remote delivery to address the consequences of COVID-19. Specifically, to consider adaptations to the assessment and preparation phase, the four stages of treatment and its use with underweight patients and adolescents.
The recent COVID-19 pandemic has triggered a surge in anxiety across the globe. Much of the public’s behavioural and emotional response to the virus can be understood through the framework of terror management theory, which proposes that fear of death drives much of human behaviour. In the context of the current pandemic, death anxiety, a recently proposed transdiagnostic construct, appears especially relevant. Fear of death has recently been shown to predict not only anxiety related to COVID-19, but also to play a causal role in various mental health conditions. Given this, it is argued that treatment programmes in mental health may need to broaden their focus to directly target the dread of death. Notably, cognitive behavioural therapy (CBT) has been shown to produce significant reductions in death anxiety. As such, it is possible that complementing current treatments with specific CBT techniques addressing fears of death may ensure enhanced long-term symptom reduction. Further research is essential in order to examine whether treating death anxiety will indeed improve long-term outcomes, and prevent the emergence of future disorders in vulnerable populations.
Key learning aims
(1) To understand terror management theory and its theoretical explanation of death anxiety in the context of COVID-19.
(2) To understand the transdiagnostic role of death anxiety in mental health disorders.
(3) To understand current treatment approaches for directly targeting death anxiety, and the importance of doing so to improve long-term treatment outcomes.
People with obsessive compulsive disorder (OCD) are likely to be more susceptible to the mental health impact of COVID-19. This paper shares the perspectives of expert clinicians working with OCD considering how to identify OCD in the context of COVID-19, changes in the presentation, and importantly what to consider when undertaking cognitive behaviour therapy (CBT) for OCD in the current climate. The expert consensus is that although the presentation of OCD and treatment may have become more difficult, CBT should still continue remotely unless there are specific reasons for it not to, e.g. increase in risk, no access to computer, or exposure tasks or behavioural experiments cannot be undertaken. The authors highlight some of the considerations to take in CBT in light of our current understanding of COVID-19, including therapists and clients taking calculated risks when developing behavioural experiments and exposure tasks, considering viral loading and vulnerability factors. Special considerations for young people and perinatal women are discussed, as well as foreseeing what life may be like for those with OCD after the pandemic is over.
Key learning aims
(1) To learn how to identify OCD in the context of COVID-19 and consider the differences between following government guidelines and OCD.
(2) To consider the presentation of OCD in context of COVID-19, with regard to cognitive and behavioural processes.
(3) Review factors to be considered when embarking on CBT for OCD during the pandemic.
(4) Considerations in CBT for OCD, including weighing up costs and benefits of behavioural experiments or exposure tasks in light of our current understanding of the risks associated with COVID-19.
Remote delivery of evidence-based psychological therapies via video conference has become particularly relevant following the COVID-19 pandemic, and is likely to be an on-going method of treatment delivery post-COVID. Remotely delivered therapy could be of particular benefit for people with social anxiety disorder (SAD), who tend to avoid or delay seeking face-to-face therapy, often due to anxiety about travelling to appointments and meeting mental health professionals in person. Individual cognitive therapy for SAD (CT-SAD), based on the Clark and Wells (1995) model, is a highly effective treatment that is recommended as a first-line intervention in NICE guidance (NICE, 2013). All of the key features of face-to-face CT-SAD (including video feedback, attention training, behavioural experiments and memory-focused techniques) can be adapted for remote delivery. In this paper, we provide guidance for clinicians on how to deliver CT-SAD remotely, and suggest novel ways for therapists and patients to overcome the challenges of carrying out a range of behavioural experiments during remote treatment delivery.
Key learning aims
(1) To learn how to deliver all of the core interventions of CT-SAD remotely.
(2) To learn novel ways of carrying out behavioural experiments remotely when some in-person social situations might not be possible.
The paper forms part of a series of papers outlining the theoretical framework for a new model of uncertainty distress (this paper), treatment implications arising from the model, and empirical tests of the model. We define uncertainty distress as the subjective negative emotions experienced in response to the as yet unknown aspects of a given situation. In the first paper we draw on a robust body of research on distinct areas including: threat models of anxiety, perceived illness uncertainty and intolerance of uncertainty. We explore how threat and uncertainty are separable in anxiety and how we can understand behaviours in response to uncertainty. Finally, we propose a clinically, theoretically and empirically informed model for uncertainty distress, and outline how this model can be tested. Caveats, clinical applications and practitioner key points are briefly included, although these are more fully outlined in the treatment implications article. While we outline this model in the context of novel coronavirus (COVID-19), the model has broader applications to both mental and physical health care settings.
Key learning aims
(1) To define the concept of uncertainty distress.
(2) To understand the role of threat, over-estimation of threat, perceived uncertainty, actual uncertainty, and intolerance of uncertainty in distress maintenance.
(3) To understand how people may behave in response to uncertainty distress.
The worldwide coronavirus pandemic has forced health services to adapt their delivery to protect the health of all concerned, and avoid service users facing severe disruption. Improving Access to Psychological Therapies (IAPT) services in particular are having to explore remote working methods to continue functioning. Australian IAPT services have utilised remote delivery methods and disruptive technologies at their core from inception. This was to maintain fidelity and clinical governance across vast distances but has allowed training, supervision and service delivery to continue virtually uninterrupted through coronavirus restrictions. On this basis, key recommendations for remote working are outlined. Remote methods are defined as (1) real time delivery, (2) independent delivery and (3) blended delivery. These are applied across three broad areas of remote training, remote clinical supervision and remote service delivery. Recommendations may be of great benefit to IAPT training institutions, clinical supervisors and service providers considering a move towards remote delivery. Challenges, adaptations and examples of applying remote methods are outlined, including case examples of methods applied to low-intensity and high-intensity cognitive behavioural therapy. Remote methods can safeguard service continuity in times of worldwide crisis and can contribute to reducing the impact of increased mental health presentations post-COVID-19.
Key learning aims
(1) To understand the core areas of remote training, clinical supervision and service delivery.
(2) To review and distinguish between three broad methods of remote working.
(3) To understand how to plan remote working via key recommendations and case examples.
Infectious disease outbreaks have occurred sporadically over the centuries. The most significant ones of this century, as reported by the World Health Organization, include the EVD epidemic, SARS pandemic, Swine Flu pandemic and MERS pandemic. The long-term mental health consequences of outbreaks are as profound as physical ones and can last for years post-outbreak. This highlights the need for enhancing the preparedness of pragmatic mental health service provision. Due to its magnitude, the novel COVID-19 pandemic has proven to be the most impactful. Compared with previous outbreaks, COVID-19 has also occurred at higher rates in frontline staff in addition to patients. As COVID-19 is more contagious than earlier outbreaks, there is a need to identify infected people quickly and isolate them and their contacts. This is the current context in which mental health services including IAPT have had to operate. Evidently, Improving Access to Psychological Therapies (IAPT) services are a major mental health service provider in the UK that have demonstrated variability in their response to COVID-19. While some IAPT services quickly adapted their existing strengths and resources (e.g. remote working), other services were less prepared. To date, there are no clear unitary guidelines on how IAPT services can use their pre-existing resources to respond to the long-term effects of outbreaks. In light of this, the current paper aims to reflect on the lessons learned from past outbreaks in order to consider how an enhanced remit of IAPT might integrate with other services to meet the long-term needs of patients and staff affected by COVID-19.
Key learning aims
(1) To understand the development of IAPT within the NHS mental health services.
(2) To understand the nature of past outbreaks and COVID-19.
(3) To reflect on lessons from past outbreaks in order to understand how IAPT can respond to the long-term effects of COVID-19.