Low intensity CBT by mail

Introduction: There are many low intensity (LI) cognitive behavoural therapy (CBT) solutions to the problem of limited service access. In this chapter, we aim to discuss a relatively low-technology approach to access using standard postal services-CBT by mail, or M-CBT. Bibliotherapies including M-CBT teach key concepts and self-management techniques, together with screening tools and forms to structure home practice. M-CBT differs from other bibliotherapies by segmenting interventions and mailing them at regular intervals. Most involve participants returning copies of monitoring forms or completed handouts. Therapist feedback is provided, often in personal letters that accompany the printed materials. Participants may also be given access to telephone or email support. ----- ----- M-CBT clearly fulfills criteria for an LI CBT (see Bennett-Levy et al., Chapter 1, for a definition of LI interventions). Once written, they involve little therapist time and rely heavily on self-management. However, content and overall treatment duration need not be compromised. Long-term interventions with multiple components can be delivered via this method, provided their content can be communicated in letters and engagement is maintained.

Implementing low intensity CBT in case management of clients with severe mental illness

In a previous chapter (Dean and Kavanagh, Chapter 37), the authors made a case for applying low intensity (LI) cognitive behaviour therapy (CBT) to people with serious mental illness (SMI). As in other populations, LI CBT interventions typically deal with circumscribed problems or behaviours. LI CBT retains an emphasis on self-management, has restricted content and segment length, and does not necessarily require extensive CBT training. In applying these interventions to SMI, adjustments may be needed to address cognitive and symptomatic difficulties often faced by these groups. What may take a single session in a less affected population may require several sessions or a thematic application of the strategy within case management. In some cases, the LI CBT may begin to appear more like a high-intensity (HI) intervention, albeit simple and with many LI CBT characteristics still retained. So, if goal setting were introduced in one or two sessions, it could clearly be seen as an LI intervention. When applied to several different situations and across many sessions, it may be indistinguishable from a simple HI treatment, even if it retains the same format and is effectively applied by a practitioner with limited CBT training. ----- ----- In some ways, LI CBT should be well suited to case management of patients with SMI. treating staff typically have heavy workloads, and find it difficult to apply time-consuming treatments (Singh et al. 2003). LI CBT may allow provision of support to greater numbers of service users, and allow staff to spend more time on those who need intensive and sustained support. However, the introduction of any change in practice has to address significant challenges, and LI CBT is no exception. ----- ----- Many of the issues that we face in applying LI CBT to routine case management in a mnetal health service and their potential solutions are essentially the same as in a range of other problem domains (Turner and Sanders 2006)- and, indeed, are similar to those in any adoption of innovation (Rogers 2003). Over the last 20 years, several commentators have described barriers to implementing evidence-based innovations in mental health services (Corrigan et al. 1992; Deane et al. 2006; Kavanagh et al. 1993). The aim of the current chapter is to present a cognitive behavioural conceptualisation of problems and potential solutions for dissemination of LI CBT.

Adapting low intensity CBT interventions for clients with severe mental illness

Many people with severe mental illness (SMI) such as schizophrenia, whose psychotic symptoms are effectively managed, continue to experience significant functional problems. This chapter argues that low intensity (LI) cognitive behaviour therapy (CBT; e.g. for depression, anxiety, or other issues) is applicable to these clients, and that LI CBT can be consistent with long-term case management. However, adjustments to LI CBT strategies are often necessary and boundaries between LI CBT and high intensity (HI) CBT (with more extensive practitioner contact and complexity) may become blurred. Our focus is on LI CBT's self-management emphasis, its restricted content and segment length, and potential use after limited training. In addition to exploring these issues, it draws on the authors' Collaborative Recovery (CR; Oades et al. 2005) and 'Start Over and Survive' programs (Kavanagh et al. 2004) as examples. ----- ----- Evidence for the effectiveness of LI CBT with severe mental illness is often embedded within multicomponent programs. For example, goal setting and therapeutic homework are common components of such programs, but they can also be used as discrete LI CBT interventions. A review of 40 randomised controlled trials involving recipients with schizophrenia or other sever mental illnesses has identified key components of illness management programs (Mueser et al. 2002). However, it is relatively rare for specific components of these complex interventions to be assessed in isolation. Given these constraints, the evidence for specific LI CBT interventions with severe mental ilnness is relatively limited.

Brief motivational interviewing for depression and anxiety

Motivational interviewing (MI)can be applied as a brief, low intensity (LI) intervention of 1-4 individualised sessions (typically 45-60 minutes in duration), including screening, assessment feedback, and psycho-education. MI is a client-centred, directive therapeutic style that enhances readiness for change by helping clients explore and resolve ambivalence (Miller and Rollnick 2002). A summary of the key components of brief MI interventions is provided in Table 16.1. There is a well-established evidence base for MI in the treatment of substance misuse (particularly alcohol misuse; Moyer et al. 2002), as well as a growing evidence for the use of MI in the treatment of other mental disorders (e.g. depression, PTSD, OCD), as well as suicidality and physical health problems (Hettema et al. 2005). Brief MI intervention can be delivered as a standalone treatment or as a motivational prelude to pharmacological and/or other psychological treatments (Hettema et al. 2005). MI has been used as an accompaniment to cognitive behavioural therapy (CBT) in the treatment of both depression and anxiety for resolving ambivalence about change and developing strategies for responding to resistance (e.g. treatment attendance, homework/medication compliance; Arkowitz et al. 2008a, 2008b). This chapter will describe how to apply brief MI interventions to the treatment of depression and anxiety as applied to the case of Megan (see Box 16.1) along with some of the challenges and potential solutions to applying MI in practice.

Evaluation of financial incentives as a quality improvement strategy in the public hospital context : clinician attitudes, design variables, and economic costs

In 2008, a three-year pilot ‘pay for performance’ (P4P) program, known as ‘Clinical Practice Improvement Payment’ (CPIP) was introduced into Queensland Health (QHealth). QHealth is a large public health sector provider of acute, community, and public health services in Queensland, Australia. The organisation has recently embarked on a significant reform agenda including a review of existing funding arrangements (Duckett et al., 2008). Partly in response to this reform agenda, a casemix funding model has been implemented to reconnect health care funding with outcomes. CPIP was conceptualised as a performance-based scheme that rewarded quality with financial incentives. This is the first time such a scheme has been implemented into the public health sector in Australia with a focus on rewarding quality, and it is unique in that it has a large state-wide focus and includes 15 Districts. CPIP initially targeted five acute and community clinical areas including Mental Health, Discharge Medication, Emergency Department, Chronic Obstructive Pulmonary Disease, and Stroke. The CPIP scheme was designed around key concepts including the identification of clinical indicators that met the set criteria of: high disease burden, a well defined single diagnostic group or intervention, significant variations in clinical outcomes and/or practices, a good evidence, and clinician control and support (Ward, Daniels, Walker & Duckett, 2007). This evaluative research targeted Phase One of implementation of the CPIP scheme from January 2008 to March 2009. A formative evaluation utilising a mixed methodology and complementarity analysis was undertaken. The research involved three research questions and aimed to determine the knowledge, understanding, and attitudes of clinicians; identify improvements to the design, administration, and monitoring of CPIP; and determine the financial and economic costs of the scheme. Three key studies were undertaken to ascertain responses to the key research questions. Firstly, a survey of clinicians was undertaken to examine levels of knowledge and understanding and their attitudes to the scheme. Secondly, the study sought to apply Statistical Process Control (SPC) to the process indicators to assess if this enhanced the scheme and a third study examined a simple economic cost analysis. The CPIP Survey of clinicians elicited 192 clinician respondents. Over 70% of these respondents were supportive of the continuation of the CPIP scheme. This finding was also supported by the results of a quantitative altitude survey that identified positive attitudes in 6 of the 7 domains-including impact, awareness and understanding and clinical relevance, all being scored positive across the combined respondent group. SPC as a trending tool may play an important role in the early identification of indicator weakness for the CPIP scheme. This evaluative research study supports a previously identified need in the literature for a phased introduction of Pay for Performance (P4P) type programs. It further highlights the value of undertaking a formal risk assessment of clinician, management, and systemic levels of literacy and competency with measurement and monitoring of quality prior to a phased implementation. This phasing can then be guided by a P4P Design Variable Matrix which provides a selection of program design options such as indicator target and payment mechanisms. It became evident that a clear process is required to standardise how clinical indicators evolve over time and direct movement towards more rigorous ‘pay for performance’ targets and the development of an optimal funding model. Use of this matrix will enable the scheme to mature and build the literacy and competency of clinicians and the organisation as implementation progresses. Furthermore, the research identified that CPIP created a spotlight on clinical indicators and incentive payments of over five million from a potential ten million was secured across the five clinical areas in the first 15 months of the scheme. This indicates that quality was rewarded in the new QHealth funding model, and despite issues being identified with the payment mechanism, funding was distributed. The economic model used identified a relative low cost of reporting (under $8,000) as opposed to funds secured of over $300,000 for mental health as an example. Movement to a full cost effectiveness study of CPIP is supported. Overall the introduction of the CPIP scheme into QHealth has been a positive and effective strategy for engaging clinicians in quality and has been the catalyst for the identification and monitoring of valuable clinical process indicators. This research has highlighted that clinicians are supportive of the scheme in general; however, there are some significant risks that include the functioning of the CPIP payment mechanism. Given clinician support for the use of a pay–for-performance methodology in QHealth, the CPIP scheme has the potential to be a powerful addition to a multi-faceted suite of quality improvement initiatives within QHealth.

Inter-sector leader transitions and organisation transformation : a research agenda

Faced with the need for strategic change, structural and cultural realignment, innovation and value-adding, many public sector organisations are tapping into a wider senior leadership talent pool and attracting successful leaders from other sectors (Flynn and Thompson, 2009). Leadership renewal has resulted, in some cases, in the external recruitment of whole senior leadership teams (Hockridge, 2008), raising issues about the influence of context on leader success (Pawar and Eastman, 1997) and potential leader transition failure, a costly outcome for leaders and organisations (Howard, 2001). There is little research on inter-sector leader transitions, which is surprising given the significant costs associated with leader acquisition and failure(Conger, 2010; Day and Halpin, 2004). For example, it is not clear what organizations do (or do not do) to ensure the outcomes of their significant investment in inter sector transitions are realised. In addition, it is not clear how the individual leader manages the challenging transition into a new leadership context and how their approach to leadership facilitates or inhibits successful transition (Avolio, 2010). Leader assimilation programs have been developed to assimilate new leaders (Manderscheid, 2008); however, assimilation is not necessarily a desired organisational outcome (Denis and Pineault, 2000). In this paper we critically review the limited literature on inter-sector leader transitions and transformational change outcomes and argue for a mutual accommodation approach. We draw on our own initial empirical work to propose the elements of a program for achieving this outcome from the perspective of the public organisation and the inter-sector appointee.

Safety leaders' perceptions of safety culture in a large Australian construction organisation

Safety culture in the construction industry is a growing research area. The unique nature of construction industry works – being project-based, varying in size and focus, and relying on a highly transient subcontractor workforce – means that safety culture initiatives cannot be easily translated from other industries. This paper reports on the first study in a three year collaborative industry and university research project focusing on safety culture practices and development in one of Australia’s largest global construction organisations. The first round of a modified Delphi method is reported, and describes the insights gained from 41 safety leaders’ perceptions and understandings of safety culture within the organisation. In-depth, semi-structured interviews were conducted, and will be followed by a quantitative perception survey with the same sample. Participants included Senior Executives, Corporate Managers, Project Managers, Safety Managers and Site Supervisors. Leaders’ definitions and descriptions of safety culture were primarily action-oriented and some confusion was evident due to the sometimes implicit nature of culture in organisations. Leadership was identified as a key factor for positive safety culture in the organisation, and there was an emphasis on leaders demonstrating commitment to safety, and being visible to the project-based workforce. Barriers to safety culture improvement were also identified, with managers raising diverse issues such as the transient subcontractor workforce and the challenge of maintaining safety as a priority in the absence of safety incidents, under high production pressures. This research is unique in that it derived safety culture descriptions from key stakeholders within the organisation, as opposed to imposing traditional conceptualisations of safety culture that are not customised for the organisation or the construction industry more broadly. This study forms the foundation for integrating safety culture theory and practice in the construction industry, and will be extended upon in future studies within the research program.

Building the foundations : skill acquisition in children

Introduction: Why we need to base childrens’ sport and physical education on the principles of dynamical systems theory and ecological psychology As the childhood years are crucial for developing many physical skills as well as establishing the groundwork leading to lifelong participation in sport and physical activities, (Orlick & Botterill, 1977, p. 11) it is essential to examine current practice to make sure it is meeting the needs of children. In recent papers (e.g. Renshaw, Davids, Chow & Shuttleworth, in press; Renshaw, Davids, Chow & Hammond, in review; Chow et al., 2009) we have highlighted that a guiding theoretical framework is needed to provide a principled approach to teaching and coaching and that the approach must be evidence- based and focused on mechanism and not just on operational issues such as practice, competition and programme management (Lyle, 2002). There is a need to demonstrate how nonlinear pedagogy underpins teaching and coaching practice for children given that some of the current approaches underpinning children’s sport and P.E. may not be leading to optimal results. For example, little time is spent undertaking physical activities (Tinning, 2006) and much of this practice is not representative of the competition demands of the performance environment (Kirk & McPhail, 2002; Renshaw et al., 2008). Proponents of a non- linear pedagogy advocate the design of practice by applying key concepts such as the mutuality of the performer and environment, the tight coupling of perception and action, and the emergence of movement solutions due to self organisation under constraints (see Renshaw, et al., in press). As skills are shaped by the unique interacting individual, task and environmental constraints in these learning environments, small changes to individual structural (e.g. factors such as height or limb length) or functional constraints (e.g. factors such as motivation, perceptual skills, strength that can be acquired), task rules, equipment, or environmental constraints can lead to dramatic changes in movement patterns adopted by learners to solve performance problems. The aim of this chapter is to provide real life examples for teachers and coaches who wish to adopt the ideas of non- linear pedagogy in their practice. Specifically, I will provide examples related to specific issues related to individual constraints in children and in particular the unique challenges facing coaches when individual constraints are changing due to growth and development. Part two focuses on understanding how cultural environmental constraints impact on children’s sport. This is an area that has received very little attention but plays a very important part in the long- term development of sporting expertise. Finally, I will look at how coaches can manipulate task constraints to create effective learning environments for young children.

Understanding intraaortic balloon pumping

Intraaortic balloon pumping (IABP) is an established treatment for the support of a failing heart (Christenson, Simonet et al. 1997). It is a process undertaken in most level two and three intensive care units. Despite IABP appearing complex, the principles are straightforward. A sausage shaped intraaortic balloon (IAB) about 250 millimetres long and 15 millimetres in diameter, is placed in the descending aorta and attached to an external pump. The external pump then inflates and deflates the IAB in synchrony with cardiac contraction. The primary purpose of this is the support of a compromised heart with a simultaneous increase in myocardial oxygen supply, and decrease in myocardial oxygen demand (Overwalder, 1999). As a nurse it is worthwhile understanding the principles of IABP. As a hospital intervention, it’s exposure to nursing is high.

Having a yarn about smoking : using action research to develop a 'no smoking' policy within an Aboriginal health organisation

Objectives: This article reports on a culturally appropriate process of development of a smoke-free workplace policy within the peak Aboriginal Controlled Community Health Organisation in Victoria, Australia. Smoking is acknowledged as being responsible for at least 20% of all deaths in Aboriginal communities in Australia, and many Aboriginal health workers smoke. Methods: The smoke-free workplace policy was developed using the iterative, discursive and experience-based methodology of Participatory Action Research, combined with the culturally embedded concept of ‘having a yarn’. Results: Staff members initially identified smoking as a topic to be avoided within workplace discussions. This was due, in part, to grief (everyone had suffered a smoking related bereavement). Further, there was anxiety that discussing smoking would result in culturally difficult conflict. The use of yarning opened up a safe space for discussion and debate,enabling development of a policy that was accepted across the organisation. Conclusions: Within Aboriginal organisations, it is not sufficient to focus on the outcomes of policy development. Rather, due attention must be paid to the process employed in development of policy, particularly when that policy is directly related to an emotionally and communally weighted topic such as smoking.

The importance of organisational culture to improve a project selection process : case of public infrastructure project in Indonesia

Project selection is a decision-making process that is not merely influenced by technical aspects but also by the people who involved in the process. Organisational culture is described as a set of values and norms that are shared by people within the organisation that affects the way they interact with each other and with stakeholders from outside the organisation. The aim of this paper is to emphasize the importance of organisational culture on improving the quality of decisions in the project selection process, in addition to the influence of technical aspects of a project. The discussion is based on an extensive literature review and, as such, represents the first part of a research agenda investigating the impact of organisational culture on the project selection process applicable specifically to road infrastructure contracts. Four existing models of organisational culture (Denison 1990; Cameron and Quinn 2006; Hofstede 2001; Glaser et al 1987) are discussed and reviewed in view of their use in the larger research project to investigate the impact of culture on identified critical elements of decision-making. An understating of the way organisational culture impacts on project selection will increase the likelihood in future of relevant government departments selecting projects that achieve their stated organisational goals.