Читать книгу Low-intensity CBT Skills and Interventions - Группа авторов - Страница 166

 Patients demonstrating reliable improvement by their fourth LICBT treatment session have been found to be twice as likely to achieve recovery compared to those who have not (Delgadillo et al., 2014). Therefore providing a minimum of four treatment sessions before reaching a clinical decision as to whether to step up or discharge is supported (except in the case of significant early deterioration).

 As such, where reliable improvement or recovery has not been achieved by the fourth session or there has been little improvement – or worsening of symptoms – by the sixth support session, consider stepping up.

 Providing more than six support sessions has not been found to lead to better outcomes (Delgadillo et al., 2014) therefore prolonging LICBT treatment on the basis of poor treatment response is not recommended except where the patient is beginning to demonstrate significant improvement.

 Where the patient moves below the threshold for case-ness but continues to demonstrate residual symptoms, consider the benefit of additional treatment sessions to ensure symptoms are reduced. This is recommended in acknowledgement of an observed increased likelihood of relapse where there are residual symptoms at the end of treatment (Ali et al., 2017).

 The patient moves below the threshold for caseness with few residual symptoms – discharge them from the service.

Whilst recommendations exist in relation to stepping up, the LICBT practitioner should always work collaboratively with the patient to determine the wider reasons that may have impeded improvement before reaching the decision to step up. This is especially important as these reasons may act to impede engagement with a Step 3 intervention if unchecked. The COM-B model (Chapter 8) is likely to be helpful to explore difficulties for a patient engaging or using the LICBT intervention. In some cases, contextual (e.g. demand and service capacity) and subjective (e.g. therapist and patient characteristics) factors may influence practitioners to hold patients on their caseload instead of discharging or stepping up, for example due to long waiting lists (Delgadillo et al., 2015), contravening available guidelines. Presenting the patient during case-management supervision (Chapter 9) is therefore of fundamental importance in ensuring that clinical decisions to continue treatment are evidence based.