we need to actTalking therapies:

Background information, summary of feedback from the consultation process, results of the literature review and action points.

January 2009

Published in January 2009 by Te Pou O Te Whakaaro NuiThe National Centre of Mental Health Research, Information and Workforce DevelopmentWeb www.tepou.co.nz Email info@tepou.co.nz

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Contents

PAGE

ACKNOWLEDGEMENTS .............................................................................................................1

EXECUTIVE SUMMARY ...............................................................................................................1 SECTION A 1. Background .........................................................................................................................42. Talking therapies work to date.......................................................................................43. Disclaimer .............................................................................................................................54. Peer review of this report ................................................................................................55. Clinical advice .....................................................................................................................56. Prevalence of mental illness ............................................................................................57. Policy context ....................................................................................................................68. Strategic environment ......................................................................................................69. The role of mental health and addiction services .....................................................710. The role of non-government organisations (ngos) .................................................811. The role of primary care ...................................................................................................812. The role of alternative and complementary therapies ..............................................913. The role of medication ......................................................................................................914. The role of the person receiving services (i.e. the service user/tangata whaiora/consumer/client/patient) ........................915. The aim of therapy ............................................................................................................ 1016. The role of family members ............................................................................................. 1017. The role of communities ................................................................................................. 1118. The role of the “talking therapist” ............................................................................... 11 SECTION B 1. Related national mental health agencies .......................................................................12 The Mental Health Commission (MHC) ................................................................................................12 The Mental Health Foundation .................................................................................................................122. The national workforce centres .......................................................................................12 Te Rau Matatini .........................................................................................................................................12 Matua Raki ..................................................................................................................................................13 The Werry Centre for Child & Adolescent Mental Health ..................................................................13 Le Va ............................................................................................................................................................14 Te Pou, The National Centre of Mental Health Research, Information and Workforce Development ..............................................................................................14 The Annual National Training Plan ..............................................................................................14 Skills Matter (formerly known as Post-Entry Clinical Training - PECT) ................................14 Let’s get real ......................................................................................................................................15 Dialectical Behaviour Therapy Training .......................................................................................16 Asian Mental Health Workforce Development ............................................................................16 Nursing Professional Supervision ..................................................................................................16

Valuing Leaders in Acute Inpatient Services .................................................................................17 The Australian and New Zealand Mental Health Services Conference (TheMHS) ................18 Primary Mental Health ....................................................................................................................18 Regional Workforce Coordinators (RWC) ....................................................................................18 SECTION C 1. The process of collecting feedback and information .............................................192. The literature review ........................................................................................................... 20 SECTION D 1. Feedback and findings ..................................................................................................... 212. Coordination .................................................................................................................... 213. Funding .............................................................................................................................224. The language of therapy .................................................................................................235. What is “evidence”? ......................................................................................................... 246. Preliminary findings from the literature review ......................................................257. Assessment skills ..............................................................................................................278. What are the most commonly used talking therapies in new zealand? .............279. Other therapies used .......................................................................................................3210. A proposed framework for talking therapies ............................................................33 Current Ministry of Health initiatives ......................................................................................................33 A suggested framework for talking therapies ..........................................................................................3411. Therapy risks ..................................................................................................................... 3612. The “culture” of services ............................................................................................... 3613. National service framework (nsf) ................................................................................3714. Specific population groups ............................................................................................38 Service User Workforce ..............................................................................................................................38 Opportunities to enhance talking therapies for the service user workforce .......................................38 Maori ............................................................................................................................................................38 Opportunities to enhance talking therapies for Maori .........................................................................39 Pacific Peoples .............................................................................................................................................40 Opportunities to enhance talking therapies for Pacific peoples ...........................................................41 Children and Youth ....................................................................................................................................41 Opportunities to enhance talking therapies for children and youth ....................................................42 Older People ................................................................................................................................................43 Opportunities to enhance talking therapies for older people ...............................................................43 Asian Peoples ..............................................................................................................................................44 Opportunities to enhance talking therapies for Asian adults and teenagers ......................................45 People with Alcohol and/or Drug Problems ...........................................................................................45 Opportunities to enhance talking therapies for people with alcohol and/or drug problems ...................................................................................................................................46 People with Physical and Mental Health and/or Addiction Problems ................................................47 Opportunities to enhance talking therapies for people with physical and mental health and/or addiction problems .....................................................................................47 Other Ethnic Communities .......................................................................................................................48 Opportunities to enhance talking therapies for other ethnic communities ........................................4815. Groups of Staff ................................................................................................................... 49 Registered Health Practitioners (under the HPCA Act) .......................................................................49 Psychiatry ...........................................................................................................................................49 Opportunities to enhance talking therapies in psychiatry ..........................................................50 Nursing ...............................................................................................................................................51 Opportunities to enhance talking therapies in nursing ...............................................................52 Psychology .........................................................................................................................................53

Opportunities to enhance talking therapies in psychology ........................................................55 Psychotherapy ...................................................................................................................................56 Opportunities to enhance talking therapies in psychotherapy ...................................................56 Occupational Therapy (OT) ............................................................................................................57 Opportunities to enhance talking therapies in occupational therapy .......................................57 Social Work........................................................................................................................................57 Opportunities to enhance talking therapies in social work ........................................................57 Other Mental Health and Addiction Workers ........................................................................................58 Consumer Advisors ..........................................................................................................................58 Opportunities to enhance talking therapies in mental health through consumer advisors ..................................................................................................................58 Family Advisors ................................................................................................................................58 Opportunities to enhance talking therapies through family advisors .......................................59 Community Support Workers ........................................................................................................59 Counsellors ........................................................................................................................................60 Opportunities to enhance talking therapies through counsellors ..............................................60 Addiction Practitioners ....................................................................................................................60 Opioid Substitution Treatment Workers .......................................................................................61 Other Relevant Addiction Sector Work ...................................................................................................62 Effective Intervention .......................................................................................................................62 Mental Health and Addiction Services Managers, Clinical Directors and Planners and Funders ............................................................................................................62 Peer Support Workers ......................................................................................................................63 Opportunities to enhance talking therapies through peer support workers ............................63 Work Being Undertaken in Other Relevant Areas .................................................................................64 Primary Mental Health Care ...........................................................................................................64 Opportunities to enhance talking therapies in primary health care ..........................................65 Clinical Training: a gap ..............................................................................................................................65 Group Therapy ..................................................................................................................................6516. Studies, publications and initiatives in the pipeline ............................................... 65 17. Outcome measurement in mental health and addiction services ....................... 6618. Education providers ....................................................................................................... 68 19. Conclusions and where to from here ....................................................................... 68 REFERENCES ............................................................................................................................... 71

Appendix 1 People who contributed by giving information to the content of this report ....................................................................................................75Appendix 2 Relevant ministry of health policy documents ........................................ 76Appendix 3 Suggested frameworks for talking therapies via feedback and information from the mental health, addiction and primary care sectors........................................................................................................78 Appendix 4 Talking therapies-related workforce development and training as reported by regional workforce coordinators (rwcs) ..................... 88

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ACKNOWLEDGEMENTSA project such as this cannot be undertaken without peoples’ willingness to contribute. Many people gave of their time, expertise and wisdom – indeed some people went out of their way to be helpful by putting the author in touch with several colleagues or agencies – thank you for going the extra mile!

A list of names of people and agencies contacted is in Section C of this report. Names of individuals who contributed information for this report are outlined in Appendix 1.

Te Pou would like to acknowledge Janet Peters who has led the talking therapies work and compiled this report.

EXECUTIVE SUMMARY • Thisreportwasundertakeninresponsetocallsfromserviceusersforbetteraccessto

quality talking therapies across mental health and addiction services; and to strengthen existing workforce development processes. It aims to lay a strong foundation on which to build future work.

• TePouhasissuedtwopreviousreports(We Need to Talk and We Now Need to Listen; www.tepou.co.nz) that reviewed current issues and work in this area in New Zealand.

In We Now Need to Listen a more formal consultation process was outlined in order to obtain greater feedback from the sector. This current report, We Need to Act, outlines that feedback and other workforce activity and processes that relate to talking therapies. It highlights the fact that many people are interested in talking therapies and aims to build on what has gone before.

• InMay2008aliteraturereviewexaminedtheuseofCognitiveBehaviouralTherapy(CBT), Motivational Interviewing (MI) and Dialectical Behavioural Therapy (DBT) in mental health and addiction populations. In addition, it called for findings on the use of CBT, MI and DBT with Maori, Pacific and Asian peoples; and for evidence of the use of MI as a process of engagement for people who use addiction services, and for children, adolescents and adults who use mental health and addiction services. Finally, it asked what evidence there is to suggest that an effective therapeutic relationship is critical to a positive clinical outcome for people who use mental health and addiction services.

• Thisreportdevelopsatalkingtherapiesframeworkthatbuildsonideasgeneratedthrough contributors. This shows where various talking therapies might fit for people who use services and for practitioners in mental health and addiction services.

• Overallfeedbackwassimilartothatfoundintheearlierreportsinthatallpeopleweresupportive of enhancing access to talking therapies. As would be expected individuals and groups were passionate about one or two key issues: whether it is a particular population (e.g. Maori or children and youth); or a particular therapy (e.g. DBT or psychotherapy); or a particular service (e.g. for older people or for people with alcohol and other drug (AoD) issues); or a particular issue (e.g. clinical supervision or service user input or funding); or a particular staff group (e.g. psychiatry, nursing or alcohol and drug practitioners). Few people or agencies gave feedback on the overall national picture.

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• Tobuildonexistingworkandassistfuturedevelopment,sixteenhighlevelactionsare suggested. These cover a three-year period and will be commenced in early 2009. While the actions may not cover all people (e.g. people with physical, intellectual and/or sensory disabilities who also have mental health problems), or all issues, they are a start.

• AbriefActionPlan(Draft Action Plan for talking therapies 2008-2011: Processes to increase quality, sustainability and spread of talking therapies for users of mental health and addictions services in New Zealand) that complements We Need to Act has been completed. The overall outcome will be a more informed sector and greater access to quality talking therapies across mental health and addiction services in New Zealand.

• Thesuggestedactionsare:

1: Use the phrase “talking therapies” in this work.

2: (a) Enhance staff training in basic engagement and counselling skills; (b) Draft curriculum content for basic counselling and engagement skills that could be used across disciplines as best practice for undergraduate work.

3: Include the therapies described in the table on pages 31-34 in the talking therapies framework.

4: Facilitate increased numbers of staff to train in CBT and MI in a way that they are able to practise their skills in a safe, effective and sustainable way to the benefit of services users.

5: Identify ways to provide a clear direction so that New Zealand has its own sustainable DBT training programme.

6: Include traditional therapies for Maori and Pacific peoples in the talking therapies framework.

7: The proposed framework is used in the planning and actioning of talking therapies work.

8: Recommend that talking therapies are included in the National Service Framework (NSF).

9: Develop and provide a user-friendly guide to therapies included in the framework for service users (and families/whanau) so that they are well-informed about therapy processes.

10: Undertake further work to identify the processes that will enhance talking therapies for Maori (i.e. what enhances the effectiveness of Maori practitioners working with Maori clients; and, what processes might enhance the effectiveness of practitioners of other cultures working with Maori clients).

11: Develop best (and promising) practice guidelines (i.e. similar to guidelines completed by Dunnachie): Evidence-Based Age-Appropriate Interventions- A Guide for Child and Adolescent Mental Health Services. Best practice needs to be specified for different talking therapies for population groups with different disorders. Each guideline will identify and address assessment issues and outcome measurement. Current and projected prevalence needs to be identified for planning workforce development. This will include:

• Maori • Pacificpeoples • Asianpeoples • Olderpeople • Peoplewithaddictionproblems • Refugeesandnewmigrants • Peoplewithphysicalandmentalhealth/addictionproblems

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12: Te Pou to continue to promote and support the Werry Centre’s work.

13: Communicate the talking therapies reports to all key stakeholders through a targeted communications strategy.

14: Use multiple national workforce processes to enhance the talking therapies capability of

nurses and allied staff (e.g. Skills Matter, Let’s get real, Professional Supervision and the National Training Plan).

15: Identify mechanisms that will strengthen the psychology workforce.

16: Develop and provide a brief guidance document specifically for mental health and addiction services managers and planners and funders. This will outline what therapies are used, how they are effective and why they represent value for money.

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SECTION A

1. Background

The workforce is the main resource for Mental Health and Addiction Services. Implementing strategies that value, and build a strong, effective, recovery and resiliency-focused staff is a priority for the Ministry of Health (MOH).

The (MOH) has funded five programmes to undertake this work: Te Pou (The National Centre of Mental Health Research, Information and Workforce Development), Te Rau Matatini, Matua Raki, The Werry Centre and Le Va. A number of current projects being undertaken by these Centres, that are relevant to the talking therapies work, are outlined in this report.

Te Pou has previously published two reports reviewing current issues and activities being undertaken in the talking therapies area (We Need to Talk and We Now Need to Listen; www.tepou.co.nz).

2. Talking Therapies work To daTe

The aim of this work is to look at ways to provide better access for service users to quality talking therapies. The focus is on adults using the mental health and addiction sector (while being cognizant of work being undertaken in child and adolescent services and primary mental health care).

There will always be a need for people to be able to access a range of therapies (from basic engagement and counselling skills, to specific therapeutic approaches, to complex psychological interventions) in mental health and addiction services.

The first report, We Need to Talk (www.tepou.co.nz), outlined calls for better access to talking therapies, a description of therapies used in New Zealand, some initial feedback on general issues around talking therapies canvassed from 46 mental health and addiction services staff and service users, and a brief look at who is doing what, where and with whom. Five recommendations were made and feedback from the sector was called for.

While there was a range of feedback (most were highly appreciative to a few that were strongly critical), there was general agreement on two main issues: 1. That the National Service Framework should include talking therapies in its approach

to service delivery. 2. That staff development in areas of Cognitive Behaviour Therapy (CBT) and greater

use of a structured process for engagement with people who use services Motivational Interviewing (MI) should be undertaken.

There was also general agreement that holding a talking therapies summit could be useful.The second report, We Now Need to Listen (www.tepou.co.nz), described the feedback received on the recommendations of We Need to Talk. A more formal process for more consultation was outlined and a tender process for a literature review was undertaken. The literature review: Talking Therapies: A brief review of recent literature on the evidence of the use of cognitive behaviour therapy, dialectical behaviour therapy and motivational interviewing; on cultural issues in therapies and on the therapeutic alliance. It examined the effectiveness of specific therapies (i.e. CBT, DBT, and MI) and also reviewed therapy issues for Maori, Pacific and Asian peoples.

We need to Act now outlines further feedback from the sector, the findings from the literature review and it suggests a way forward.

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3. disclaimer

A large proportion of this report concerns wider sector intelligence and activity, and has been written for the mental health and addiction sector. As it reports on sector intelligence, people’s names are often cited. With the exception of the findings from the New Zealand Guidelines Group literature review, We Need to Act does not purport to be a comprehensive examination of the international literature.

4. peer review of This reporT

Te Pou appreciates the input of the following people who undertook to peer review the two reports, We Need to Act and Action Plan for Talking Therapies 2008- 2011. All final decisions about content were made by Te Pou. Vicki Burnett Dr Bronwyn Dunnachie Dr Monique Faleafa Mary O’Hagan Anna Schofield Annemarie Wille Tania Wilson

5. clinical advice

Advice was sought from Dr Malcolm Stewart (Clinical Psychologist) on key issues relating to these reports.

6. prevalence of menTal illness

Mental health problems are recognised as a major public health problem. A World Health Organisation (WHO) study of the global burden of disease found that mental disorders make up five of the ten leading causes of disability and some 40% of all disability (physical and mental) is due to mental illness (Murray and Lopez 1997).

Te Rau Hinengaro: The New Zealand Mental Health Survey shows that 20.7% of the population meet the criteria for a mental disorder over a 12 month period, and 46.6% of the population are expected to have a mental disorder at some time in their lives. The 12 month prevalence rates for mental disorder are higher for Maori (29.5%) and the Pacific (24.4%) populations, largely due to the relative youthfulness of Maori and Pacific populations and their relative socioeconomic disadvantage (Oakley Browne et al 2006). Te Rau Hinengaro also found that co-morbidity with mental health and substance use disorders is also high. The most common mental health problems are depression, anxiety, and drug and alcohol problems.

Currently, mental health and addiction services in New Zealand are configured to treat people with the most severe mental health disorders (approximately 3% of population). However it is estimated that in fact there are 4.7% of such people. Included in this group of severe disorders are schizophrenia and bipolar disorder, severe anxiety and depression, alcohol and drug abuse. Eating disorders can also fall into this category at times, as can complex personality and post-traumatic problems.

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7. policy conTexT

The first national documents calling for better access to talking therapies for service users emanated from the Ministry of Health and Mental Health Commission. These and other policy documents directly relevant to mental health and addiction service development and to talking therapies work are outlined briefly in Appendix 2.

Related Ministry of Health initiatives

Like Minds, Like Mine

Like Minds, Like Mine is a national programme to counter the stigma and discrimination associated with mental illness. It began in 1997 in response to the 1996 Mason Report, which identified stigma and discrimination as one of the biggest barriers to recovery for people with mental illness. Like Minds is one of the first comprehensive campaigns internationally to address discrimination associated with mental illness, combining community action at a local level with nationwide strategies and media work to effect social change. The Ministry of Health funds and leads this programme but the work is undertaken by a range of national (e.g. Lifeline Aotearoa) and regional organisations.

National Depression Initiative

Launched in October 2006, the National Depression Initiative (NDI) is a key component of the government’s commitment to suicide prevention. The programme seeks to reduce the impact of depression on the lives of New Zealanders, mainly through encouraging people to seek help, and providing information and support services. These include a national helpline (i.e. via Lifeline Aotearoa) and two websites, one of which, thelowdown.co.nz, is backed up with online and text based support services for young people. The television advertising campaign aims to help people become more responsive to depression including aiding early recognition, appropriate treatment and recovery.

A Mental Health Literacy Programme

The Ministry is developing a New Zealand programme to increase knowledge about mental health and mental illness (mental health literacy).

8. sTraTegic environmenT

Mental health and addiction services operate within the same broad legislative, organisational, strategic and funding frameworks as the rest of health. As noted by the Ministry of Health (2007), factors that make mental health different from other parts of health are: • TheMentalHealthCommission(whichhasanewrolethatfocusesonadvocacyfor

people with mental illness and their families, to facilitate collaboration and integration; and to monitor progress of the National Mental Health Strategy) (www.mhc.govt.nz).

• Aring-fencedfundingstreamoccurredfromthelate1990suntilthemid-2000sthatinjected funding into mental health and addiction over and above the normal growth path for health services.

• Thefocusonrecovery(i.e.forallpeopleworkingwithservicesuserstobeabletoengage with him/her in a way that values and seeks to understand their perspective in a person-centred way; putting hope, optimism and social inclusion at the centre of any treatment plan; identifying the person’s strengths and abilities; and, working in a respectful, facilitative and empowering way) (Brown et al, 2007).

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• Thelargenumberofnon-governmentorganisations(NGOs)involvedinservicedelivery.

• Specificlegislation(e.g.theCompulsoryTreatmentundertheMentalHealth(Compulsory Assessment and Treatment) Act 1992; Misuse of Drugs Act 1975; and Alcoholism and Drug Addiction Act 1966).

• AstrengtheningfocusonprimarymentalhealthcarebytheMinistryofHealthtoensure earlier treatment for people with mental health problems who seek help from primary care.

In addition, other differences may be seen as: • Growingserviceuserinputintonationalandlocalmentalhealthandaddictionservice

processes. • Thefocusonstaffasthementalhealthsector’sgreatestresource. • Thefactthat,whiledecreasingthroughtheeffortsofprogrammessuchasLikeMinds,

Like Mine and the educative work of the Mental Health Foundation, there is still stigma around mental illness and a lack of understanding of issues around mental illness, the treatment and support that people who experience mental illness might require; and service users may also experience discrimination – all factors that lead to a reluctance for people to access mental health and addiction services.

• Thefactthatthemediausuallyfocusonnegativesituations(e.g.perceivedservicefailures) thus contributing to the stigma above.

9. The role of menTal healTh and addicTion services

Mental health and addiction services are run by District Health Boards (DHBs). DHBs are responsible for the funding, planning and direct or indirect health service provision for their respective populations.

Specialist mental health and addiction services are often called secondary services and have a focus on recovery. Services are there to serve the 3% of people who have a significant mental health or addiction problem. The latest figures from Te Rau Hinengaro (Oakley-Brown et. al, 2006) showed that the proportion of the populations suffering from severe mental health disorders in any one year is actually 4.7% (Draft Policy Advice Paper, Ministry of Health, 2008).

In general, the role of staff is to undertake a thorough assessment of people who attend and then work out a treatment plan (also called care plan or intervention planning) to meet with the person’s mental health and/or addiction requirements. Treatment may include talking therapies, and/or medication and/or involvement of family members/whanau. Input from cultural experts may also be required when the person is Maori, Pacific, Asian or of another ethnicity. Peer support may also be an important part of a person’s recovery along with input from a community support worker. Although most people receive treatment in the community (around 90%), admission to an inpatient unit may also be required in a minority of cases (Ministry of Health, 2007).

Talking therapies are strongly embedded in addiction treatment. The Alcohol and Drug Practitioner Competencies (2001) include counselling theory and practice as a generic competency, and Motivational Interviewing is considered a core competence in this sector.

To further talking therapies work, services need to provide a structure and environment in which all clinicians are continually up-skilled, have a career path, are supervised and valued. This is no mean feat as work in the UK has found (Repper & Brooker, 2002). These authors (together with many service users, family, clinical and management representatives) devised a system for developing the organisational context in order to increase the uptake of psychosocial strategies. This system shows a comprehensive approach to change.

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10. The role of non-governmenT organisaTions (ngos)

The NGO sector is a major player in the delivery of mental health and addiction services with about a third of all funding going to more than 400 NGOs (Ministry of Health, 2007). Services range in size from small service user-run drop-in centres, to multi-million dollar providers of residential and home-based support. NGOs provide a significant level of service in the areas of alcohol and other drug treatment (especially residential treatment), problem gambling, kaupapa Maori, services for Pacific peoples, Asian peoples, family support and residential and home-based support services (Ministry of Health, 2007).

11. The role of primary care

The role of primary care is becoming increasingly important in the identification, assessment and management of common mental health problems (e.g. depression and anxiety). In addition, primary care is also playing a growing role in assisting people with more complex mental health and addiction problems (e.g. Dowell, Garrett, Collings, McBain, Mckinlay & Stanley 2007).

The Ministry of Health is currently in the final stages of developing a sector discussion paper for primary mental health care. Primary mental health care is defined in this draft paper as “the assessment, treatment and rehabilitation of people with mental health and/or addiction problems in the primary care setting”. Although people with mild, moderate and severe mental health/addiction problems will seek to access primary health care services, the policy paper is concerned with how primary care can best meet the needs of people with mental health problems of mild to moderate severity; while building better clinical pathways with secondary providers for those who experience more severe issues.

The paper recommends that (as is consistent with a stepped care model) wherever possible, services aim to meet a patient’s needs with the least intensive (but effective) intervention possible before moving to more intensive and expensive approaches (Draft Policy Advice Paper Primary Mental Health care: Document for feedback, June 2008). Dr Dwyer’s paper will be available to the sector in 2009.

Thus We Need to Act has been developed with the primary mental health care work in mind. For example, to make both approaches complementary, the proposed framework (discussed later in this report) for talking therapies used the primary mental health care model as its foundation diagram. Including primary care workers in furthering talking therapies work will also be important. Effective communication between mental health and primary care staff will be key to providing an effective service.

Some mental health commentators noted that it is also important to emphasise the differences between some people who use primary mental health care and people who use secondary mental health care. For example, people who use mental health services generally have longer term, complex and multiple problems, and this may have implications for outcomes (e.g. progress may be slower), for staff (e.g. staff burnout); and for length of therapy (e.g. it may not be realistic to have six sessions of CBT as in primary care - fifteen may be more realistic) (Malcolm Stewart, personal communication, May 2008).

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12. The role of alTernaTive and complemenTary Therapies

It is generally acknowledged that there is a move towards more people being interested in and using such approaches in connection with physical health as well as mental health and addiction. This report does not examine the role that these approaches may play in recovery but it is an area worthy of further exploration.

13. The role of medicaTion

This report does not focus on the role of medication as either a stand alone treatment or as a component of treatment alongside a talking therapy. Suffice to say that medication can play an important part in some people’s recovery.

One document that has tackled the issues of both talking therapies and medication for children and adolescents accessing mental health services is the one published in 2008 through the Werry Centre. Evidence-Based Age-Appropriate Interventions: A Guide for Child and Adolescent Mental Health Services (CAMHS) is a helpful addition to the treatment toolkit.

In the alcohol and drug sector, too, medication may be used as part of a detoxification process, and methadone as an opioid substation treatment can also be important for the treatment of some drug users. Medication may also be part of a treatment package for people with both a mental health problem and an addiction problem (e.g. alcohol, drug or gambling problem) commonly called co-existing disorders. Medication for a person’s existing physical health problems also needs to be taken into account when psychiatric medications are given.

14. The role of The person receiving services (i .e. The service user/TangaTa whaiora/consumer/clienT/paTienT)

In New Zealand little has been documented to date on the role of the service user as the recipient of talking therapies, despite therapy being part of all mental health and addiction services to varying degrees.

Service users wish to be better informed about therapy processes (e.g. Vicki Burnett, personal communication, May 2008). In child and adolescent mental health the Werry Centre has been introducing the “Choice and Partnership Approach (CAPA)”. This approach is becoming an increasing focus of service design as it enables a closer partnership between service users, families and therapists. CAPA is a system that is now widely used in the UK. It helps services to: • dotherightthings(workingtowardsgoalsthefamilyandyoungpersonwant) • withtherightpeople(withclinicianswiththerightskills) • attherighttime(inatimelymannerwithoutwaitinglists). (www.camhsnetwork.co.uk)

For adult services the cornerstones of recovery based services are seen to be hope, self-determination over life, choice of services and social inclusion. Any therapy needs to enhance these (Mary O’Hagan, personal communication, June, 2008).

Accordingly, issues to be discussed with the therapist might include: • whattherapy(ormixoftherapies)mightbeused • whyitwasselected • expectedbenefits(andrisks) • whattheycanexpectfromthetherapist/therapy • timeframe • howtalkingtherapymightassistanymedicationregime(ifany) • physicalproblemsandmedications • wheretogetinformationonmyproblem(e.g.bipolardisorder)

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• explorationofculturalissues(e.g.Maori,Pacific,Asianorotherethnicgroup) • theroleoffamilymembersorsignificantothers(ifappropriate) • communitysupports • self-helpagencies • homework • whattodoiftheyhaveconcernsorcomplaints.

It is often assumed that discussion of these issues will occur during the dialogue that a therapist and a service user will have. Some countries have taken this a step further; in the UK a booklet for service users – Choosing Talking Therapies? (2001) – has been published. It appears that in New Zealand there is confusion about what therapies are and how they work. A similar publication for New Zealand could be considered for future development. People who are deaf, hearing-impaired, vision-impaired or who have learning disabilities will also require information in a form that is appropriate to their abilities.

15. The aim of Therapy

In general (depending on the mental health problem), therapy is aimed at identifying and reducing a person’s distress and/or grief (which may arise from a host of factors including a specific mental health problem – e.g. bipolar disorder – or through trauma, sexual, physical or emotional abuse and/or cultural beliefs); reducing symptoms and/or use of alcohol and/or drugs; and reducing risk of harm to self or others.

Treatment also could improve health-related quality of life (e.g. improving self-esteem, improving family/whanau relationships, awareness of personal strengths and communication skills, knowledge of community resources, and return to work or education (Department of Health, 2001).

The therapy process may also be influenced by many other factors (e.g. the length of time before help is sought, the severity of problems, co-existing problems, past treatments sought, attitudes towards therapy, and cultural and/or spiritual beliefs).

While there is “no high quality research evidence on the influence of primary, secondary or tertiary treatments settings on the outcome of therapy” (Department of Health, 2001, p.32) many service users in New Zealand have stated that the least intrusive setting (e.g. primary care) is preferred if at all possible. In addition as noted previously more information explaining the various therapies would be useful.

16. The role of family memBers

The issues for family members may be similar to those already mentioned for service users.

Information on how family members can best support the service user may be important. Services that use family therapy or family inclusive practices will be very familiar with working systemically with families.

It is well known that inclusion of family is expected best practice for most cultures and within approaches that take a systemic view of therapy (i.e. approaches that involve service users and the people that are in their usual environment).

Skills for working effectively with families (e.g. the skills to effectively run a family group meeting, or intensive, formal family therapy) are important, and some commentators have argued for such skills to be furthered within the talking therapies work.

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17. The role of communiTies

Community groups and communities receive information on mental health, mental illness and addiction in several ways: through mass media advertising (e.g. the Like Minds advertisements) and Like Minds community activities, websites (e.g. The Lowdown for young people), from the Mental Health Foundation, from helping agencies (e.g. LifeLine, Citizens Advice Bureau, Plunket, Maori and Pacific NGOs and Age Concern and Grey Power), from a variety of health agencies (e.g. GPs, primary health care and public health agencies) and Maori and Pacific primary care agencies.

While much is already being done, the Mental Health Foundation suggests that it would be helpful if communities were more informed about: the meaning of mental health (i.e. not just the absence of a diagnosis); sustaining health and well being (especially self help approaches); the availability of advocacy and peer support; other agencies or organisations that might assist with any underlying issues (e.g. employment, income support, housing etc.); and the role of certain other groups within communities (e.g. churches and support groups aimed at assisting people with specific problems) (Judi Clements, personal communication, May 2008).

18. The role of The “Talking TherapisT”

The “Recovery Competencies” outlined the competencies for working in the mental health workforce (Mental Health Commission, 2001). These have been incorporated into the more recent Let’s get real framework.

Several authors have described the task of the “talking therapist” (e.g. Carr, 2002; Roth & Fonagy, 2005; Roth & Pilling, 2007). Common elements of these publications are that the therapist can use his/her skills to: • successfullyengageandformatherapeuticalliancewiththeserviceuser • undertakeathoroughassessment • makeanassessmentofthetypeoftherapymostsuitedfortheperson’sproblems

– underpinning such an assessment is knowledge and experience of: o a wide range of therapies o the range of mental illnesses o the person’s strengths o what strategies have worked well for the person before/what have not o cultural issues (and where to seek cultural advice if needed) o whanau supports o community agencies. • undertaketherapyinasafe,informed,culturallyappropriateway(iftheyarenotofthe

service user’s culture) • workwiththefamilywhereverpossible • clearlydocumenttheprocess • keepcheckingwiththeserviceuseratvariouspre-definedtimesaboutprogress • “changetack”inthetherapyprocessifrequired • successfullydisengagefromtherapy–thisisanintegralpartofthetherapeutic

relationship (Roth & Pilling, 2007) • overall,toensurethattheserviceuserfeelsvaluedandaffirmedduringthetherapeutic

process.

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SECTION B

1. relaTed naTional menTal healTh agencies

It is important that the work on talking therapies fits with existing national activities.

The Mental Health Commission (MHC)

As noted in We Need to Talk, the Mental Health Commission (MHC) has been important in highlighting the need for action in several earlier documents. The MHC states that it “supports increasing the availability of talking therapies to people with experience of mental illness and/or addiction” (Selwyn Katene, personal communication May 2008).

Its publication, Te Hononga, outlines where the Commission would like to see the mental health and addiction sector in 2015: “A broad range of high-quality psychologically based therapies will be available. Specialised

interventions such as counselling, specific talking therapies and other options will be delivered in collaboration with other mental health and/or addiction services.” (Te Hononga, p60).

The Mental Health Foundation

Better access to quality talking therapies is seen important for service users by the Mental Health Foundation (Judi Clements, personal communication, July 2008).

Similarly talking therapies are viewed as essential to the recovery journey for many people “with experience of mental distress” in the recent document: Destination Recovery written by the Mental Health Advocacy Coalition (2008) and published by the Mental Health Foundation.

2. The naTional workforce cenTres

There are four national workforce centres some of which have population focus areas such as Maori, Pacific, Child & Youth. Although information about these Centres was outlined in We Need to Talk, a description of these Centres is also given in this report with emphasis on areas relevant to talking therapies work.

Each of the centres was asked to comment on talking therapies work.

Te Rau Matatini www.matatini.co.nz

Te Rau Matatini is a national organisation that aims to progress Maori health workforce development to enhance whanau ora, mental health and well-being. Te Rau Matatini’s aims are progressed through a range of projects that contribute to Maori mental health, as well as to primary care and public health workforce policies, at a national and regional level; projects that expand the Maori workforce and increase responsiveness to Maori health needs. The promotion of rewarding career opportunities for Maori and the management of scholarship processes for Maori are a major part of its role. Recently Te Rau Matatini has taken on the Effective Interventions work looking at AoD interventions in the prisons and corrections area.

A significant document recently published by Te Rau Matatini is Māori Needs Profile: A Review of the Evidence by Dr Joanne Baxter, 2008). Any work for and with Maori needs to take this work into consideration as it has significant workforce implications.

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Matua Raki www.matuaraki.org.nz

The National Addiction Treatment Workforce Development Programme (Matua Raki) was established by the National Addiction Centre and is funded by the Ministry of Health. From late 2008, this programme is hosted by Te Rau Matatini. The Matua Raki website notes: “High priority is given to developing sector infrastructure, recruitment, retention and training. This will allow for flexible career pathways that not only allow practitioners to develop necessary competencies, but also allow practitioners to move from entry level qualifications to graduate and postgraduate qualifications”.

The Programme’s aim is: “In 10 year’s time one-third of the dedicated addiction treatment workforce will have addiction-related graduate qualifications. Another third will have addiction-related postgraduate qualifications, with the remaining third having training related to their level of clinical responsibility”.

Training is delivered through universities. Staff from Matua Raki and Dr Joel Porter from Hamilton also run courses when required.

Matua Raki supports a Tertiary Training Provider network made up of those universities and private training institutions which specialise in addiction. Other training events are funded, including an annual short course to disseminate the latest research in a key area of addiction treatment.

Training in addiction is underpinned by the Practitioner Competencies for Alcohol and Drug Workers (2001) which are currently under review by the Drug and Alcohol Practitioner’s Association (DAPAANZ). DAPAANZ has established three scopes of practice: • registeredalcoholandotherdrugpractitioners • alcoholandotherdrugassociatepractitioners • alcoholandotherdrugsupportworkers.

The Werry Centre for Child & Adolescent Mental Health www.werrycentre.org.nz

The Werry Centre was established within the Department of Psychological Medicine at the University of Auckland in 2002. The aim of the Werry Centre is to improve the mental health of children and adolescents in New Zealand by: • providingorfacilitatingtrainingandsupporttotheworkforcenationally • promotinghighqualityresearchintochildandadolescentmentalhealth • advocatingforthementalhealthneedsofchildrenandadolescents • supportingthechildandadolescentmentalhealthworkforcetoprovidehighquality

care.

The Centre has three programmes: Workforce Development, Teaching and Research. The Centre is committed to evidence-based practice which is reflected in all the work of the three programmes, including training in evidence-based therapies. Please refer to the website for examples of the Centre’s work.

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Le Va www.leva.co.nz

Le Va is the newest mental health workforce development centre and sits within Te Pou. Le Va aims to improve the mental health and wellbeing of Pacific people by developing a clinically and culturally competent workforce to deliver quality services to Pacific people and their families.

The vision of Le Va is “vibrant Pacific leadership and well Pacific families”. To achieve its vision, Le Va is taking a multi-faceted approach to workforce development, with work projects covering workforce development, information, research and knowledge.

Te Pou, The National Centre of Mental Health Research, Information and Workforce Development www.tepou.co.nz

Te Pou’s work aims to grow capacity and capability in the mental health and addiction workforce. The workforce programme is focused on training and development, service user workforce, leadership development and is underpinned by the Let’s get real framework.

Te Pou’s Workforce Development programme builds on the sector’s past endeavours and has a project portfolio designed to achieve progress in each of the following areas: • WorkforceDevelopmentInfrastructure–todeveloptheabilityofDHBstoprogressthe

capability and capacity of the workforce to satisfy future service demands. • TrainingandDevelopment–tocoordinatetheseacrosseducation,healthand

employment sectors, and within the mental health sector, to align pre-service entry, orientation and ongoing development of mental health workers with service provision requirements.

• RetentionandRecruitment–todevelopnationalandregionalresponsestoissuesofretention and recruitment.

• OrganisationalDevelopment–toassistmentalhealthservicesdeveloptheorganisational culture and systems necessary to sustain their workforce.

• ResearchandEvaluation–toensurethereisinformationavailabletothesectortoinform workforce development.

Te Pou workforce projects are described on its website, and those current Te Pou projects that are particularly relevant to the talking therapies work are summarised below.

The Annual National Training Plan (NTP) The purpose of the NTP is to identify the national mental health workforce and development activities of the workforce centres in New Zealand. This Plan will be updated annually and is available on the Skills matter website www.skillsmatter.co.nz. Skills Matter (formerly the Post-Entry Clinical Training Programme - PECT)

This programme was formerly managed by the Clinical Training Agency (CTA), but as from February 2008 management transferred to Te Pou. Post-entry occurs after entry to a health profession, so that a person is eligible to practise as a health practitioner under the Health Practitioners Competence Assurance Act 2003. Clinical refers to the training’s clinical focus, with trainees spending at least 30 per cent of total programme-related hours in the direct delivery of health and disability services to service users. Training refers to a programme equivalent to at least six full-time months, leading to a postgraduate qualification.

There are ten providers of Skills Matter-funded programmes. The programme funding is for nursing and allied health staff. The funded programmes include new graduate and advanced mental health nursing, cognitive behaviour therapy, child and youth, co-existing substance use and mental health, and forensic mental health. Travel and accommodation grants are also available. Plans are underway for a postgraduate diploma in CBT.

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Funding criteria: • vocationaltraining–workinginaclinicalrole • post-entryclinicaltraining • HPCAActand/orDAPAANZ • nationallyrecognisedbytherelevantprofessionasmeetingahealthserviceskill requirement • working.6FTEwithmorethanoneyearofexperience • working.7FTEfornewgraduatesenteringthehealthservice • employer’ssupport(asoutlinedintheservicespecifications)forthetraineeinthe form of supervision and mentoring in place at commencement of the programme and during the term of the training. This will be signed off through the Memorandum of Understanding with the education provider and DHB/NGO.

The Skills Matter process potentially becomes an important vehicle for building future capability in talking therapies. For example, in the past the CTA has not funded psychology and this should be addressed in the future (e.g. Levy, 2005).

Let’s get real Let’s get real is a framework that describes the essential knowledge, skills and attitudes required to deliver effective mental health and addiction treatment services. It is explicit in stating the expectations for people who work in mental health and addiction treatment services irrespective of their role, discipline or position in the organisational structure.

The development of Let’s get real was led by the Ministry of Health and worked on with sector stakeholders. It brings together work undertaken by people in the sector over the past decade on competency and capability frameworks specific to mental health or addiction. The implementation work is being led by Te Pou and the framework will be phased in over time. Implementation started in late 2008. The Ministry has indicated that the Let’s get real framework will become part of the nationwide service framework in 2011.

As Let’s get real is a framework for the entire mental health and addiction workforce, it will strengthen shared understandings across the sector and improve transferability between organisations. Let’s get real complements the Health Practitioners Competence Assurance Act 2003; and aims to affirm best practice and increase accountability.

Real Skills is the shorthand name for the set of essential knowledge, skills and attitudes in the Let’s get real framework. The framework has seven Real Skills. 1. Working with service users. 2. Working with Māori. 3. Working with families/whānau. 4. Working within communities. 5. Challenging stigma and discrimination. 6. Law, policy and practice. 7. Professional and personal development.

Each Real Skill cannot be read in isolation. It is important to read across all of the Real Skills to see how they interrelate and connect with one another.

Each Real Skill has a broad definition and three sets of performance indicators: • essential • practitioner • leader.

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Let’s get real implementation

During the initial phase of implementation, the aims are to ensure the workforce understands Let’s get real, managers can work with the framework and organisations are supported to enable the development of Real Skills in staff. Education and training providers will also be supported to review their courses in light of Let’s get real. Te Pou is developing a range of resources to support all these aims. Talking therapies will be strongly linked to Let’s get real. For example, the Real Skill “Working with service users” requires all people working in the sector to have a basic understanding of the range of therapies and interventions; and practitioners to apply in-depth knowledge of evidence-informed therapies (including talking therapies). Dialectical Behaviour Therapy Training

The goal of this work is to give people who work in mental health and addiction services high quality training in dialectical behaviour therapy (DBT). This can include effective behavioural treatments in their tool kit to support recovery in people with the diagnosis of borderline personality disorder and other complex, difficult to treat problems. Over the last year or so, Te Pou has supported the development of high quality DBT training in New Zealand to lower the barriers (namely cost and access) to services seeking training in the most evidenced-based treatment for people with borderline personality disorder.

Mike Batchelor (personal communication March 2008) reported that there have been four DBT intensive training programmes, resulting in 50-80 clinicians who practise DBT regularly. In addition, over 400 people have attended introductory level training programmes. To date, one person has attained the level of accredited trainer, with more to come. The goal is to use New Zealand clinicians as trainers and have a sustainable local process for growing new therapists (John Gawith, personal communication, March 2008).

Asian Mental Health Workforce Development

Te Pou is leading some work in the area of Asian workforce development.

Dr Samson Tse has also been instrumental in obtaining feedback from Asian clinicians for this current talking therapies report. Knowledge about the use of talking therapies with Asian service users is in its infancy, and non-Asian therapists working with Asian clients at the least need to be conversant with the cultural customs and conventions embodying the fundamental values of their communities.

Nursing Professional Supervision

Mental Health Nursing and its Future: A Discussion Framework (Ministry of Health, 2006) prioritises professional supervision as one of its nine recommendations.

The Professional Supervision project will occur in seven phases. The first two have been completed. In the first, Te Pou contracted the Centre for Mental Health Research (CMHR) University of Auckland to scope what current approaches are in existence related to professional supervision in mental health services within DHBs and NGOs. This was completed at the end of June 2008 and is available on the Te Pou website: Professional Supervision for Mental Health and Addiction Nurses (available only as electronic version).

Based on the research and key stakeholder consultation, Te Pou developed six recommendations to inform further workforce development planning. Te Pou was mindful that the recommendations be robust and integrated with existing human resource infrastructure and the Let’s get real competency framework.

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The project’s revised recommendations are outlined below (as of 1 July 2008). 1. Development of National Professional Supervision Guidelines. 2. Development of a national training structure for professional supervision, which aligns to Let’s get real. 3. Training should not be model-specific but rather focus on the structure (administration, education and support) of professional supervision. 4. Accreditation processes should be developed to recognise and maintain the competency of professional supervision training and ensure alignment with Let’s get real and e-learning. 5. A national database of trained accredited supervisors will be developed. 6. Measurable evaluation must be an integral component of the professional supervision structure. Ideally this evaluation should be framed within a research paradigm.

The second phase was for the Development of National Professional Supervision Guidelines. This document will be on the website in January 2009.

The final five phases are: 1. Development of a national training structure for professional supervision, which aligns with Let’s get real and is accredited by professional bodies. 2. Expressions of interest will be issued nationally to DHBs for a professional supervision structure to be piloted in a North and South Island DHB. Non-government organisation nurses will also be integrated into the DHB pilots. 3. Development of an evaluation tool to be tested as part of the DHB and NGO pilots. 4. Once the pilot sites are selected, supervisor training will occur with the training structure, and will also be aligned with the supervisor training for CLIMATE mh E-Learning (which is being led by the Ministry of Health). The pilots will take place between 6-12 months. 5. A national database of trained and accredited supervisors.

Supervision is linked to talking therapies because staff that undertake therapy with service users require supervision, so supervisors will need to be well versed in therapy approaches. This work links to talking therapies as it is important that clinical staff undertaking therapy have access to supervision to ensure best practice.

Valuing Leaders in Acute Inpatient Services

This project will support and strengthen acute inpatient nursing leadership that promotes seamless and responsive services between community and acute inpatient settings, enabling service users to lead their own recovery. This work has grown from the Leadership recommendation from the Ministry of Health’s Mental Health Nursing and its Future: A Discussion Framework, 2006, and the consistent message that by building and strengthening nursing leadership, we can enhance the quality of mental health services provided to service users.

The project is comprised of two national nursing leadership workshops, and advice and support to design and implement initiatives in acute inpatient services. This work is closely linked to other nursing and workforce development projects, such as Let’s get real and work aimed at reducing the use of seclusion.

Te Pou awarded a number of national scholarships for acute nurses to attend a one-day workshop as part of a number of initiatives designed to strengthen the nursing workforce and build capacity in psychological approaches and talking therapies. In February 2008, Auckland University Centre of Mental Health Research and the School of Nursing ran an acute inpatient nurses workshop, led by Anne Garland, an internationally renowned nurse consultant, scholar and clinical leader in using CBT approaches in the inpatient setting.

This work is linked to talking therapies as inpatient units are an area where staff need to be highly skilled in therapeutic relationships and interventions.

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The Australian and New Zealand Mental Health Services Conference (TheMHS)

The conference (2-5 September 2008) focused on the workforce with a conference slogan of “Be the change you want”. Many papers discussed issues around effectiveness of various talking therapies as well as staff training and development. The conference proceedings will be available in 2009.

Primary Mental Health

Te Pou is leading two areas of primary mental health workforce development:

Primary mental health websiteThe Ministry of Health has contracted Te Pou to build a website dedicated to primary mental health and addiction care. The site will contain useful details about the tools and interventions being used by the primary mental health workforce and act as a central point for promoting local, national and international primary mental health service and workforce development activity.

Early Implementation GuideTe Pou was contracted by the Ministry of Health to develop a primary mental health workforce development Early Implementation Guide to identify the key components of a primary mental health workforce development infrastructure. The Early Implementation Guide is now complete and with the Ministry of Health.

There is a new emerging primary mental health workforce which will require up-skilling in various modalities including talking therapies.

Regional Workforce Coordinators (RWC)

The role of regional workforce coordinator was established in May 2004 by the Mental Health Directorate of the Ministry of Health to provide a continuous and systemic response to mental health workforce development. The four coordinators are charged with ensuring better alignment of regional projects, national policy and broader DHB health workforce networks and initiatives. They do this by: • buildingstrongrelationshipswithinandacrossthementalhealthsector. • facilitatingtheuptakeofnationalmentalhealthworkforcedevelopmentopportunities • increasingregionalfeedbackon,andparticipationin,national,regionalanddistrict

mental health workforce development planning • ensuringnationalcentresandprogrammesareresponsivetotheneedsofthemental

health sector • supportingDHBandNGOmentalhealthandaddictionworkforcedevelopment.

RWCs were contacted and asked to supply information about existing or planned talking therapies related training in their respective areas. This is outlined in Appendix 4.

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SECTION C

1. The process of collecTing feedBack and informaTion

Information sharing is a necessary foundation for any national project aimed at improving services for service users. This work could not be undertaken without the generous input from many people across the sector.

The process for collecting feedback outlined in We Now Need to Listen (and noted below) was adhered to and several additional agencies, groups and people (also noted below) were contacted. Some meetings were held, but to expedite the process most contact was by email and phone.

The purpose was to listen and gather solutions for a way to take this work forward. In order not to revisit already documented issues, the agenda under discussion was: • issuesforthegroup(otherthanwhattheymayhavealreadysubmitted,i.e.new

feedback) • examplesof“whatworks,forwhomandwhy” • solutions • ideasforthefutureprocessoftakingthisworkforward.

Meetings began with teams/groups that were most critical of the We Need to Talk report.

As outlined in We Now Need to Listen, the list of people/agencies contacted was: • serviceusersviatheBINZinternetgroupforserviceusersinNewZealand • DHBconsumeradvisors • thenationalprofessionalagenciesforpsychiatry,psychology(includingtheMaoriand

Pasifika psychology groups and the National Standing Committee on Bicultural Issues), nursing, social work, counselling, occupational therapy, psychotherapy

• DHBfamilyadvisors • Platform(fornon-governmentorganisations) • CapitalandCoastDHBregionalpersonalitydisordersteam • AucklandDHBSegarHouseclinicalteam • Asianmentalhealthandaddictionworkers • trans-culturalmentalhealthworkers • supportworkers • primarycareworkers.

Some agencies made formal written submissions; these were: • TheRoyalAustralianandNewZealandCollegeofPsychiatry(RANZCP) • TheNewZealandCollegeofClinicalPsychology(NZCCP) • TheMentalHealthFoundation • TeAoMaramatanga-TheCollegeofMentalHealthNursesInc. • TeRauMatatini • TheMentalHealthCommission.

In addition to those above, who were named in We Now Need to Listen, several other agencies and groups were contacted: • nationalworkforcecentres:TheWerryCentreforChildandAdolescentMentalHealth,

Matua Raki, Te Rau Matatini, and Le Va • DrDavidChaplow,MinistryofHealth • DrSarahDwyer,MinistryofHealth(PrimaryMentalHealthStrategy)and Professor Tony Dowell, lead researcher for the PHC Evaluation Project • DrSimonHatcherandtheresearchteamofBriefProblem-SolvingTherapies • DHBplannersandfunders • regionalworkforcecoordinators

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• clinicalleadersofOtagoDHBmentalhealthservices • psychotherapyacademicstaffatAUT.

The author also attended meetings of interested agencies as part of existing workforce processes. These were: • theDrAnneGarlandWorkshoponCBTwithinpatientnurses(AucklandUniversity,

Tamaki Campus) • theAddictionTreatmentLeadershipDay,13March2008 • Good to Great: Learning from the Field’s most effective Practitioners a two-day workshop

organised by Nelson-Marlborough DHB with Dr Scott Miller, Institute for the Study of Therapeutic Change, Chicago, US.

A call for feedback was also put in the: • NewZealandPsychologicalSocietyE-letter,31January2008 • Connections (the regular newsletter of the NZPsS).

Interested individuals also provided feedback by email. Some people also thoughtfully provided the author with additional helpful references. These are cited where possible.

Most people contacted chose to provide feedback. – Appendix 1 shows the names of those who contributed.

2. The l iTeraTure review

In parallel with the above consultation process, a literature review was put out for open tender in February 2008. This review requested an examination of the use of CBT, MI and DBT in mental health and addiction populations. CBT and MI were included as some earlier feedback suggested that these approaches were not researched on a mental health population. DBT was added to this review as significant funding has been directed to date for DBT training in New Zealand.

In addition, the review called for findings on the use of CBT, MI and DBT with Maori, Pacific and Asian peoples; and, evidence for the use of MI as a process of engagement for people who use addiction services, child and adolescents and adults. Finally it asked what evidence there is to suggest that an effective therapeutic relationship is critical to a positive clinical outcome for people who use services.

As noted earlier, the New Zealand Guidelines Group was the successful agency, and a summary of the results of this review are incorporated in this report, and posted on the Te Pou website.

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SECTION D

1. feedBack and findings

Summarising feedback

Many individuals and groups sent responses; the difficulty is in doing justice to their considered and insightful feedback. The process of distilling feedback was as follows: • keythemesweredrawnfrompeople’scomments • quotesweretakendirectlywhenapersonhadakeypointtomake • feedbackisparaphrased.

This may mean that some individual views are not taken into account and Te Pou apologises for this. On occasion, key points from earlier feedback (i.e. from We Need to Talk and We Now Need to Listen) were introduced if they were relevant to the issues under discussion.

Quite naturally, most people were passionate about one or two key issues, whether a particular population (e.g. Maori or children and youth); or a particular therapy (e.g. DBT or psychotherapy); or a particular service (e.g. for older people or for people with AoD issues); or a particular issue (e.g. clinical supervision or service user input); or a particular staff group (e.g. nursing or alcohol and drug practitioners).

Few people gave feedback on the overall national picture.

The concept of a talking therapies Summit

This idea was suggested by some people in the earlier talking therapies documents. Currently an Action Plan has been developed which lays the basic foundation for future activity in the talking therapies area.

When the foundations have been laid it will be important to gain more ideas for “where to from here” in talking therapies and a summit will be more useful at this time.

Action points

Below each section, where appropriate, an “action point or points” are been highlighted.

These are of necessity at a very high level but it is hoped that the bullet points capture an action that is “do-able” and useful for achieving our aim (i.e. to work towards enhancing access to quality talking therapies for service users).

2. coordinaTion

Several commentators talked about the need for better coordination for talking therapies.

They highlighted the need to provide national coordination, consultation, supervision and training in order to enhance the critical mass of practitioners at all levels. This desire for more training is in line with the aim of talking therapies work, that is, to enhance access by service users to quality talking therapies. Several ideas were submitted (e.g. regional centres of excellence in talking therapies or a national centre of excellence in talking therapies).

The Ministry of Health has advised that establishing another workforce centre is unrealistic in such a small population. Te Pou will be the coordinating body for the activities identified in the Action Plan.

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3. funding

Talking therapies are a core part of delivering an effective mental health and addiction service, and funding processes should reflect this. In the mental health and addiction sector talking therapies are currently funded through the NSF from the Ministry of Health. There is no specific funding stream for talking therapies work.

The Mental Health Commission was one agency who commented on funding issues. The Commission said:

“In terms of funding talking therapies, the Commission has no view on whether services should be provided in the public or private sector, as long as those who need these services have access to them. One area that has not been addressed in We Need to Talk is the complexity in the funding arrangements of talking therapies. Outside of the mental health and addiction services, these may be funded, for example, by other health services, NGOs, the service user, insurance companies, and employers, ACC, the Ministry of Justice or the Ministry of Social Development. Whilst many of these services are not targeted specifically at people with experience of mental illness and/or addiction, many service users access them, often because they cannot currently get what they require from mental health and addiction services. These funding arrangements create a fragmentation of services for people with experience of mental illness and/or addiction and increase the barriers to accessing them. This lack of cohesion also means that services are competing for the same workforce. There is a need to provide talking therapies as part of a seamless, integrated treatment system”.

The Mental Health Foundation argued for a ring-fenced budget for talking therapies work. In addition several individuals suggested that there was a need for dedicated coordinated funding, for example: “This is important as the whole initiative for more talking therapies is likely to wither without dedicated, coordinated funding” (Mary O’Hagan, personal communication, June 2008).

The issue of accessing private clinicians for service users is discussed in the RANZCP submission later in this report.

Funding for talking therapy positions

The main funding stream for talking therapy is the Ministry of Health, which funds services under the National Service Framework (ring-fenced Blueprint funding) for the 3 per cent of people with severe and enduring mental illness. Planners and funders need to work within the parameters of the NSF.

As talking therapies are a core part of mental health and addiction services, we anticipate that (as described in Let’s get real) everyone has core real skills (at different levels) when they come to work in the sector. Thus education providers and mental health and addiction services need to ensure that this occurs.

Other agencies also funding talking therapies include: • PrimaryHealthOrganisationsthrough: o Care Plus: an initiative targeting people with high health need due to chronic

conditions, acute medical or mental health needs, or terminal illness. Care Plus aims to improve chronic care management, reduce inequalities, improve primary health care teamwork and reduce the cost of services for high-need primary health users (e.g. talking therapies for people with diabetes and depression (www.moh.govt.nz).

o Services to Improve Access (SIA) funding: to reduce barriers for groups with the greatest need through additional services to improve health and improving access to existing first-contact services. It aims to reduce inequalities among those populations that are known to have the worst health status: Maori, Pacific people and those living in NZDep. index 9-10 decile areas (www.moh.govt.nz).

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• Primarymentalhealthinitiativesoffertalkingtherapies(e.g.CBT)throughprimarycare agencies.

• MinistryofSocialDevelopment(MSD):fundpeoplewhoarebenefitrecipientsandwho may have mild to moderate mental health problems with a focus on recovery to enable people to work.

• MinistryofCorrections:PsychologistsinCorrectionalfacilitiesandalsoProbationprovide therapy.

• AccidentCompensationCorporation(ACC):Psychologistsandothercliniciansundertake counselling for sexual abuse and other trauma-related conditions.

• MinistryofEducation:Psychologistsandcounsellorsinschoolsprovidecounsellingand therapy.

Future funding streams

Funding for positions may come from a wide range of funders including education, justice, health, corrections, social services, police and large corporate or philanthropic organisations. Funding for mental health and addictions staff training

Funding streams include: • TertiaryEducationCommissionFramework(e.g.CBT). • SkillsMatter(previouslyPECT)(TePou)–fundingforCBT. • DHBs–fundingfortalkingtherapiese.g.CBT,DBT(NursesDevelopmentFund,CME

for Psychology, psychiatry and AoD practitioners, via CTA funding for clinicians). • TeRauMatatini,WerryCentre,MatuaRaki(e.g.scholarshipstofundcourses). • ClinicalTrainingAgency(CTA)–whichfundspsychiatricregistrarandsomenursing

training. Future funding streams • Alloftheabove.

There are also many private psychiatrists, psychologists, counsellors and other allied health practitioners who provide talking therapies to their clients.

Summary

The majority of funding comes through contracts via the NSF. It seems unlikely that there will be dedicated funding for talking therapies within the NSF context. It would be helpful if there were a more coordinated approach so that service users can have improved access to quality therapies. This will also involve ensuring that training providers include the right curricula content.

Information for managers and planners and funders of services would be helpful so that these key staff are informed of the value of talking therapies for service users.

4. The language of Therapy

In this latest round of feedback there have been suggestions for a better term than “talking therapies”.

Several helpful alternatives to these two words have been given, for example: • “Therapeutic conversations” • “Psychological interventions” • “Psychological therapies”

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• “Psychotherapy” – it is somewhat confusing when the profession (psychotherapy) is the same as the name of the activity undertaken (psychotherapy – “to help someone engage with their distress in order to heal”).

This report suggests that we stay with “talking therapies” at this time. It appears to be understood by service users and family members and seems to be gaining credibility within the mental health and addiction sectors (e.g. it is being quoted in recent documents from various agencies). Feedback from Maori and Pacific peoples suggest that it is acceptable as Maori and Pacific both come from an oral tradition. In addition it is in line with trends in the UK (MHF et al, 2006).

Action point 1: Use the phrase “talking therapies” in this work.

5. whaT is “evidence”?

There were several comments about “evidence”, what it is and is not. These can be summarised in four key points:

1. Several people suggested that “practice-based evidence” is more important than “evidence-based practice”. There appears to be varying views about what is “practice-based evidence”. Some see this as the clinician’s view of what works based on his/her clinical experience. Others say it is more defined than that: “locally obtained evidence derived from an evaluation of the service (practice) in which the evidence is being used” (Malcolm Stewart, personal communication, May 2008).

This area is beyond the scope of this report, but suffice it to say that perhaps both types of evidence are important, as is the personal experience of the service user.

2. Other “levels” of evidence are seen as useful. Other terms used around evidence in the child and youth area have included “best- supported” or “promising” as defined by the level of research found from a review of the literature (e.g. Dunnachie, 2008).

3. Another limitation around evidence was noted: “Not all therapy approaches have been equally researched. There has been a lot of research on CBT, possibly at the expense of other approaches, so we end up not necessarily with the best but the most researched. It seems more to do with fashion than science”.

4. The usefulness (or otherwise) of a literature review based on meta-analyses and systematic reviews was commented upon. For example:

“There are methodological limitations of the use of meta-analyses, and to some extent, systematic reviews. While it may be a useful approach to attempt to simplify a picture to achieve an answer ‘does x work?’ much of value is lost in the achieving of that answer. Therapy is a complex business and one of the complexities is that people come to therapy with very different (for example) needs, learning styles and situations.

Meta-analysis can render unanswerable a more important question ‘For whom does x work?’ Additionally, the choice of inclusion and exclusion criteria may intentionally or unintentionally introduce selection biases that influence the conclusions”.

Despite the above comments it was decided to examine the literature for talking therapies work.

Another issue related to evidence was raised. If one uses the analogy of drug therapy (that is i.e. a drug is tested and rolled out for use with guidelines); then why do we not do this with talking therapies that have been tested?

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6. preliminary f indings from The l iTeraTure review

New Zealand Guidelines Group was chosen to undertake this task following an open process. The report written by Dr Tannis Laidlaw and is available on the Te Pou website www.tepou.co.nz.

This review requested an examination of the use of CBT, MI and DBT in mental health and addiction populations. In addition, it called for findings on the use of CBT, MI and DBT with Maori, Pacific and Asian peoples; and, evidence for the use of MI as a process of engagement for people who use addiction services, and for children, adolescents and adults who use services. Finally it asked what evidence there is to suggest that an effective therapeutic relationship is critical to a positive clinical outcome for people who use services.

As noted by Laidlaw (2008): “The report concentrates on clinical research that is applicable to New Zealand conditions but mentions comparison psychotherapies where appropriate. As requested, the papers reviewed are mostly post-2000, although the availability of quality papers is dependent upon the psychotherapy reviewed. Papers involving systematic reviews and meta-analyses were given priority followed by randomised controlled trials (RCTs) in an appropriate clinical area to isolate evidence-based illustrations of best therapeutic practice”.

In essence, the findings support much of the feedback from earlier talking therapies work.

The following is a summary of key points quoted from the review document:

“Question 1 (CBT): • That the evidence is strong on the use of CBT for people with: o depression (all age groups although the best evidence is for younger adults) o anxiety disorders such as Generalised Anxiety Disorder and panic o adapted CBT for Post-Traumatic Stress Disorder (PTSD). • Thatevidenceisavailable(butoflesserstrength)ontheuseofCBTforpeoplewith: o schizophrenia (for anxiety-like symptoms only) o bipolar disorder (for relapse prevention only) o children’s anxiety disorders and Obsessive Compulsive Disorder (OCD) o substance use disorders (weak recommendation after contingency management and

brief therapies like MI) o eating disorders (some evidence for bulimia only).

Question 2 (DBT): • Evidence at hand shows promise for DBT eventually becoming recognised as a viable

method of achieving change in a group of people notoriously [sic] difficult to either engage with or derive benefits from therapy.

• That data provided by clinical use of DBT in New Zealand could be collected and analysed to better evaluate its impact on outcomes.

• That DBT be considered to decrease the incidence of para-suicidal behaviours.

Question 3 (Ethnic minorities): • The results of this literature search confirm the assertion by Peters (2007a) that little

research has been done that draws conclusions about how psychotherapy affects the Maori, Pacific or Asian New Zealand populations.

• That future psychotherapy research could examine the viability of the various psychotherapies for different ethnic groups (e.g. Maori, Pacific and Asian populations) in New Zealand.

Question 4 (MI): • That MI is a suitable intervention in the substance use domain, particularly with alcohol,

with all age groups including youth, either as a stand-alone therapy or as a value-added component.

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• That MI can be used in conjunction with CBT to enhance engagement in mental health. • That MI is suitable for use with people with psychotic illnesses to enhance adherence.

Question 5 (Therapeutic relationship): The evidence indicates the importance of the therapeutic alliance and related non-specific factors irrespective of the nature of the intervention. It suggests the importance of ensuring that all mental health and addiction staff are well trained in developing an effective therapeutic alliance and in fostering agreement about the goals and tasks of the intervention” (Laidlaw, May 2008, p. 32).

As was noted in We Need to Talk and We Now Need to Listen, and in the literature review, the need for staff to have excellent ‘people’ skills (i.e. basic engagement and counselling skills) was again emphasised in much of the later feedback.

A group of psychologists from Auckland suggested (for example) that there is sufficient evidence (and experience) to show that common human factors (therapeutic alliance etc) of therapeutic change are more relevant than specific factors (e.g. specific skills and models such as CBT). There is a large body of evidence on the topic of the therapeutic relationship (e.g. Roth & Fonagy, 2006; Nathan & Gorman, 2007; Carr, 2002) and therapies and this report cannot do justice to this debate.

One team said:

“It must be ensured that all mental health workers have training in issues related to forming empathic relationships with clients, utilising active listening and questioning skills, and being able to tolerate and explore expressions of emotion, rather than distracting people from their distress. Whilst many workers may have had these skills touched on in their initial training, we would suggest those who consider they require basic level training in delivery of talking therapies should have these skills re-taught within the new framework” (e.g. Capital and Coast DHB staff, October, 2007).

A model of implementing nationwide basic engagement and counselling skills has been suggested. This is a kind of “warrant of fitness” approach. With this approach, staff who think they already have the skills can choose to immediately sit the exam (e.g. by video). If they pass they do not undertake training. If they do not pass, they undertake the training and then re-sit the exam. In this way staff that already have the skills do not have to re-train. This could be linked to Let’s get real and Real Skills Plus.

Another, a “core” and “advanced” approach, was suggested. In this approach the team/service does the warrant of fitness on their skill mix to identify those with advanced competencies and then establishes a team training plan to get all staff at a core level of competence.

An approach chosen by Nelson-Marlborough DHB has been the training undertaken by Dr Scott Miller (www.talkingcure.com). These training events have been very well received by staff from all disciplines. The training emphasizes the therapeutic relationship and is based on research findings as well as basic “people skills’. In addition, outcomes of the therapy/relationship are a key part of the process. Dr Miller is an accomplished, engaging and humorous trainer who tailors his sessions to the needs of the group.

As Dr Miller is coming to New Zealand in 2009 Te Pou will take advantage of this visit to offer the first of three training sessions.

Action point 2a & 2b: Enhance staff training in basic engagement and counselling skills; Draft curriculum content for basic counselling and engagement skills that could be used across disciplines as best practice for undergraduate work.

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7. assessmenT skills

Some people giving feedback noted the lack of emphasis on the development of standard skills in assessment of people’s mental health and addiction problems.

For example:“The development of skills in the assessment and formulation of problems, whatever the framework used, must be addressed. This equates to all mental health workers being able to do an appropriate functional analysis, within the talking therapies they are trained in. Such a step would increase the likelihood that interventions can be appropriately tailored to service user needs and experiences”.

It is envisaged that assessment skills will be included in the best practice guidelines (recommended later in this report).

8. whaT are The mosT commonly used Talking Therapies in new Zealand?

We Need to Talk included a table that outlined the most commonly used therapies. This was revised from the UK document1.

While there was general agreement on the content, further revision has been undertaken in some areas following feedback from the sector. Approaches may differ depending upon age, culture and degree of family/whanau participation.

Accordingly, the following revised version is now offered in a form similar to that outlined by NICE (the National Institute for Health and Clinical Excellence, UK):

Therapy How it works Conditions and NICE evidence

Cognitive behaviour therapy (CBT)

The person works with a therapist to identify negative emotions, beliefs, thoughts and behaviour to:• understandwhyandwhen

they might be harmful• understandhowtheyrelate

to the symptoms of their mental health problems

• developskillstogetridofthem or learn strategies to manage them.

Sessions are time-limited and focused on specific issues.

Evidence suggests that CBT is effective for people who experience:• depression• anxietydisorders• post-traumaticstress

disorder• obsessivecompulsive

disorder• eatingdisorders• addictionproblems• long-termmentalillness

(e.g. schizophrenia and bipolar disorders).

Computerised CBT

As with CBT above, but the therapy is provided via computer rather than in sessions with a therapist.

Evidence suggests that computerised CBT is useful for people who experience:• depression• anxietydisorders.

New research on adolescents and this mode of therapy is under way in New Zealand.

1 Evidence is from the National Institute for Health and Clinical Excellence (as known as NICE) in the UK.

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Therapy How it works Conditions and NICE evidence

Bibliotherapy As for CBT above, but delivered through a book-based system, rather than through face-to-face sessions with a therapist.

Evidence suggests that this may be useful for:• peoplewithanxiety

disorders.

Dialectic behaviour therapy (DBT)

A form of behaviour therapy designed to assist people with borderline personality disorder. Four foci are:• emotionalregulation• distresstolerance• mindfulness• interpersonaleffectiveness.

The person is encouraged to adapt their reactions to emotional triggers. Therapy is given individually or in groups and may specifically aim to reduce self- harming behaviour.

Evidence suggests that DBT is effective for people who experience:• personalitydisorder

resulting in self-harming behaviour

• persistentbingeeatingdisorder.

Psychotherapy In psychotherapy, the relationship between the therapist and the client is considered to be of central importance and where change occurs. The therapist and client explore conflicts and how these are represented in current situations and relationships, and patients are given an opportunity to explore feelings and conflicts originating in the past. Psychodynamic psychotherapy does provide more space for reflection than other psychological therapies; however, most psychotherapists use a combination of strategies depending on clients’ specific situation and needs.

Evidence suggests that focused psychotherapy is useful for treating:• depression• anxiety• somatoformdisorders• eatingdisorders• somepersonalitydisorders• possiblyasasecondary

treatment with substance misuse disorders.

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Therapy How it works Conditions and NICE evidence

Psychotherapy with children

The practice of child psychotherapy seeks to understand and alleviate a child’s emotional and psychological distress from a wide range of disturbances, including, but not limited to, disruption in their early development. With younger children, play and non-verbal actions and interactions with the therapist are used as a vehicle of communication. With older children and adolescents, language and creative media such as art work help to facilitate the therapeutic process. It is undertaken in the context of the family and the child’s wider environment.

Psychotherapy can help children whose distress is caused by chronic or terminal illness, emotional, physical or sexual abuse; through to children whose pain is manifested in severe mental health problems.

Family therapy

Also relates to Social Network Behaviour Therapy (which includes peers outside the family)

The therapist encourages dialogue among members of a family to resolve differences, and provides counselling to improve communication between them. Family therapy assists people to understand each person’s difficulties within the context of the family as a group.

Evidence suggests that this is useful for:• anorexianervosa• moderatetosevereand

persistent depression in children and young people

• familiesandcarersofpeople who experience schizophrenia.

Multi-systemic therapy

Multi-systemic therapy is an intensive family and community-based treatment that addresses the multiple determinants of serious antisocial behaviour in young offenders using an ecological approach.

Evidence suggests that this is useful for youth with antisocial behaviour and/or substance abuse; for youth diagnosed with conduct disorder, or who are currently offending.

Counselling The most basic form of psychological intervention. The person talks about their difficulties with a counsellor who plays a supportive role and may provide practical advice on problem-solving.

Evidence suggests that this is useful for:• milddepressioninchildren

and young people• addictionproblems• whereCBTandfamily

therapies are not available for people who experience schizophrenia.

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Therapy How it works Conditions and NICE evidence

Interpersonal therapy

This therapy helps people to learn to link their mood with their relationships with people close to them, and to recognise that interacting differently with people may improve both their relationships and depressive state.

Feedback suggests that the numbers of people training in interpersonal therapy is increasing in New Zealand.

Evidence suggests that interpersonal therapy is useful for:• peoplewitheating

disorders• moderatetosevere

depression in children and young people

• depressioninadultswhenthe person expresses a preference for this therapy (or the clinician feels it may be beneficial).

Problem-solving therapy

This is a brief, focused psychological intervention that aims to teach people how to identify and solve problems.

“Evidence suggests that problem-solving therapy is as effective as antidepressants in primary care and may be a useful part of chronic disease management programmes” (Dr Simon Hatcher, personal communication, 14 May 2007).

Motivational interviewing (MI) and motivational counselling (MC)

In this model the therapist focuses on issues that the person may be sensitive about in a way that avoids confrontation. Together they examine hopes and aspirations for life, relationships and work with a view to identifying barriers and achieving goals.

Evidence suggests that MI is useful as a structured approach to general engagement and motivation with people; and MC may be useful for: • peoplewithalcoholand

substance misuse problems• peoplewiththeabove

problems, plus a mental health issue

• peoplewithmentalhealthproblems

• medicationmanagement• decreasingriskbehaviours• improvingsocial

functioning.

Action point 3: Include the therapies above in the talking therapies framework.

As noted in We Now Need to Listen, most people agreed that having more staff trained in MI and CBT would be useful, the main concern being that this might occur at the expense of other therapies. For example DBT is seen as very useful in both mental health and addiction services. The main issue with DBT is that the current training via the USA is expensive and we need to work towards a sustainable New Zealand-led approach. Another example is Interpersonal Therapy also a very valuable approach. As noted in the Action Plan that sits alongside We Need to Act, the

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actions recommended do not preclude other valuable training in any of the above therapies being undertaken.

Another way of looking at the mix of therapeutic competence is to consider what a service needs to respond to its population, rather than what individuals need to be trained in (e.g. based on the Choice and Partnership Approach (CAPA) 7 Helpful Habits approach that is often used in child and adolescent services, www.camhsnetwork.uk).

An important issue raised was the need to up-skill people in cognitive behavioural strategies (i.e. specific interventions that may or may not evolve into full CBT or DBT therapies). Many people could be trained up to utilise particular cognitive and behavioural therapy strategies as part of their work without becoming fully-fledged therapists.

For example, rather than becoming full CBT therapists, many people might be able to learn to use such cognitive behavioural strategies as coping self-statements, breathing techniques, reactivation techniques, and use of distraction. Another example is from DBT – without becoming a DBT therapist, many staff may be able to help their clients with emotional regulation by learning the Dealing with Distress techniques such as Teflon mind, simple mindfulness activities, and the distraction and improving the moment strategies.

In summary, people are complex beings, so a range of therapy approaches will always be required to meet the needs of individuals and families.

As one commentator noted in a criticism of what was perceived as an overly simplistic emphasis on CBT and MI in We Need to Talk:

“Attachment, developmental stages, cognitive development, behavioural conundrums, construct dilemmas, the structure of memory, fantasy as it relates (or doesn’t) to reality, the idea of reality and our constructions of this, the way we construct and hold narratives – these, amongst many other elements, form the basis of the world in which we live” (Mark Rose, personal communication February, 2008).

However there was general agreement that by facilitating more numbers of staff to train in CBT and MI in a way that they are able to practise their skills in a safe, effective and sustainable way will be a start to enhancing access to therapies. In addition there is agreement that working towards New Zealand having its own a sustainable process for DBT training is important.

Action point 4: Facilitate increased numbers of staff to train in CBT and MI in a way that they are able to practise their skills in a safe, effective and sustainable way to the benefit of services users.

Action point 5: Contract a report examining ways to ensure that New Zealand has a clear direction for its own sustainable DBT training programme.

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9. oTher Therapies used

Section 8 outlined the most common therapies. Other therapies noted by those providing feedback include: • Trauma-focusedtherapy–somepeopleseethisasnotbeingmerelyatherapeutic

approach, but rather an approach on which to base service design and delivery. • Solution-focusedtherapy. • Mentalisation. • Schemafocusedtherapy. • TransactionalAnalysis(TA). • CognitiveAnalyticTherapy(CAT). • AcceptanceandCommitmentTherapy(ACT). • InteractiveDrawingTherapy.

Peer support

Some service users argue that new ways of working in peer support may also fit into a “therapy” model. A leader in this area, Shery Mead from the US, notes that peer support has traditionally meant informal, non-professionalised help from people who have had similar life experiences. “In mental health peers come together with many shared experiences including a negative reaction to traditional services. However without a new framework to build from it is not uncommon to find people re-enacting ‘help’ based on what was done to them. Some people take on positions of power and others fall into passive recipient roles. Therefore, all training emphasizes a critical learning experience in which people mutually explore ‘how they’ve come to know what they know.’ In other words through intentional conversations people need to examine their assumptions about who they are, what power-shared relationships can look like, and ultimately what’s possible” (www.mentalhealthpeers.com).

In this document peer support is not seen as a “therapy” per se, but rather as one of the key ingredients (sitting alongside therapy where appropriate) in enhancing recovery for service users.

Traditional therapies

In addition, people noted that there has been an increase in New Zealand in the acceptance and use of traditional Maori (and to some extent Pacific) remedies and healing practices. In some services these are used as complementary practices alongside talking therapies and (where warranted) medication. Such practices were seen by many people who gave feedback as important adjuncts to talking therapies.

Action point 6: Include traditional therapies for Maori and Pacific peoples in the talking therapies framework.

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10. a proposed framework for Talking Therapies

A key aim of this current report was to gather information from people in the sector into a talking therapies framework that might assist in the sector understanding where service users with particular mental health problems fit with specific talking therapies and therapists. While it has been argued that this might be more accurately called a “model” of service delivery we have chosen to call it a framework.

Several people or agencies provided ideas for frameworks, for example: • MariaBaker,TeRauMatatini • NewZealandCollegeofClinicalPsychologists • MalcolmStewartfortheAucklandregionalpsychologygroup.

In addition, ideas for frameworks were also obtained from existing or earlier work, for example: • Let’s get real, Ministry of Health • primarymentalhealthcarepolicyworkfortheMinistryofHealth • Pacificpeoples’models • Asianpeoples’models • theCBTcompetenciesframeworkfordepressionandanxietydisorders,Departmentof

Health, UK • theManagementAdvisoryServices(MAS)model(1989)UK.

The various frameworks suggested through feedback and documents are given in Appendix 3.

Current Ministry of Health initiatives

In any talking therapies framework, Let’s get real needs to underpin such work. Primary care, DHBs and NGOs are the mechanisms by which the framework is enacted.

Let’s get real

As noted earlier the Ministry of Health is leading this project which can be seen as a framework for the knowledge, skills and attitudes that staff need to work effectively in the sector.

Basic training in engagement and counselling skills would fit into the essential skills category.In addition “Real Skills Plus” developed by the Werry Centre is the adjunct competency framework for practitioners working with children and adolescents. It has two levels: core and specialist.

For Pacific people Seitapu: Pacific Mental Health and Addiction Cultural and Clinical will support, promote and enhance Pacific cultural competencies in the mental health and addiction workforce. For addiction workers Takarangi promotes delivery of training based on the Maori Addiction Treatment Competencies. Work on competencies for staff working with older adults has commenced in the northern region.

Primary mental health care

This work is being led by Dr Sarah Dwyer of the Ministry. Her discussion paper Primary Mental Health: A Model of Care (2008) was out for consultation in 2008. It would make sense for primary mental health care and secondary mental health care to have strong links, particularly as many service users have said that if given the choice they would rather be seen in primary care. To this end, the talking therapies framework proposes building upon the framework which has been suggested for primary mental health care. A fuller description of the primary mental health care work and its framework is documented in Appendix 3 (Figure 1).

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Important features depicted in this diagram are the wider environment (e.g. housing, employment, education and social networks) and public health-related activities to bring about a more supportive environment (e.g. Like Minds, National Depression Initiative, self care and whanau ora).

A suggested framework for talking therapies

The following framework begins to draw the threads of talking therapies issues and feedback together because it: • hasrecoveryatitscore • includesLet’s get real essential, practitioner and leader levels, and Real Skills Plus • includes(insteadoftheusual3%)afigureof4.7%whichcomesfromthedatainTe

Rau Hinengaro (Oakley-Browne, Wells, & Scott, 2006). • includesbasicengagementandcounsellingskills • includestherangeoftherapiesdescribedearlierbasedontheNICEworkandfeedback

from the New Zealand sector • includestraditionalhealingpracticesforMaoriandPacificpeoples • haseachstepofequalimportanceandvalue(despitelookinghierarchical) • buildsonprimarymentalhealthcarework(thereforeisalsoplacedwithinthewider

environment, that is: primary care, housing, employment, education etc.) • includestheManagementAdvisoryServices(MAS)workfromEngland • doesnotexcludeothertherapiesoftenusedinservices(wheretheyaresupportedby

evidence) • issituatedinthewiderenvironment(aswiththeprimarycarediagram)ofhousingetc.

and activities to promote a more supportive environment.

Please note that the talking therapies framework is only considering the 14.1% of the population who may use services in the mental health sector. This sits at the ‘pointy end’ of Dr Dwyer’s (2008) diagram which includes 100% of the population (see Appendix 3).

This framework is a beginning and it is acknowledged that it will change over time.

Action point 7: Use this proposed framework in the planning and actioning of talking therapies work.

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11. Therapy risks

As noted earlier, people suggested that service users need to be aware of the risks around therapy. Given the vulnerability of people experiencing mental health problems, there is always risk with any therapy.

One person stated: “Like medication, talk-based treatment can be dangerous. For instance exposure-based procedures for treating the effects of trauma have some of the strongest positive treatment effects of any talk-based treatment. But when done carelessly clients can be re-traumatized and even become suicidal” (Mike Batchelor, personal communication, July 2007).

In addition, staff need to be clear about the limits of therapy strategies (e.g. those staff trained in specific behavioural strategies).

All therapists have a legal and ethical responsibility to manage risk at all times in the therapeutic relationship (Tania Wilson, personal communication, June 2008). It was also noted by some commentators that practitioners have ethical responsibilities to service users under various Acts and processes. For example, the HPCA has a professional code of ethics, and responsibilities under the Health and Disability Commission. In addition, most professions adhere to a code of ethics for their practice.

The area of risk highlights the need for quality training and supervised practice (Bronwyn Dunnachie, personal communication, June 2008).

12. The “culTure” of services

We Need to Talk (and more recent feedback) suggests that some staff that practise talking therapies are very skilled to operate in a recovery-focused way and exemplify the skills, behaviour and attitudes we strive to achieve in the sector.

On the other hand, other feedback suggests that some services are dominated by a culture of safety not therapy, risk aversion, and professional “patch protection”, operating within service infrastructures that are often not supportive of therapy being undertaken in a sustainable way.

Recurring themes noted in feedback to date were: • inequalitiesofaccess,particularlyforhighriskgroupsandinruralareas • demandoutstrippingsupplyleadingtounacceptablylongwaitingtimes • lackofstrategicplanningfortalkingtherapiesasalegitimateinterventioninservices,

resulting in: o ad hoc training initiatives being undertaken that are motivated by personal

interest rather than as part of a coherent service plan o the wrong people getting the wrong training o trained staff being unable to use their new skills appropriately because of lack of

support within the service o lack of defined career pathways for therapists o scarcity of qualified supervisors, limiting both training and opportunity to

practise new skills, and little protected time for supervision.

It is well-known that creating a culture of change in the sector is not easy. Feedback suggests that the two areas in mental health often most criticised for being “medical model” or “institutional” in thinking are inpatient units and crisis mental health services. Feedback identified projects that are under way to revitalise such areas. For example, work in Counties Manukau DHB is examining the roles within the crisis mental health team (Malcolm Stewart, personal communication, May 2008). As service users have noted, the most experienced and skilled talking therapists are needed in these two important services, inpatient units and crisis mental health.

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However, it is suggested that some of these concerns around “culture” may be addressed by the overall actions that take place as a result of this current work (and other workforce centres’ initiatives) undertaken by Te Pou, Te Rau Matatini, Le Va and the Werry Centre.

Several people pointed out that it was critical that:• thecentressharethesamephilosophyandarealignedintermsofoverarchingobjectives• thecentrescommunicateandcollaborateeffectively.

One person noted that it would be a useful exercise to get a forum (or documentation) ofexamples where change in service culture has been successfully made and sustained. Dissemination of such activities would be useful for other services looking to do the same.

13. naTional service framework (nsf)

The Mental Health Foundation is strongly in favour of strengthened talking therapies, noting that: “Te Tāhuhu and Te Kōkiri include a broadening of the range of response of services available and this includes talking treatments” (Judi Cements, personal communication, February, 2008). She notes that a system-wide approach is needed to provide the basis for such broadening and the contracting process is an important part of that system.

The NSF provides the framework upon which mental health and addiction service contracts are based. It currently does not include talking therapies.

Feedback in both the We Need to Talk document and We Now Need to Listen showed there was unanimous agreement that talking therapies should be included in the NSF as a matter of priority.

Since the NSF is currently undergoing a review, the NSF project leader has been informed that talking therapies should be included. The following information was forwarded in March 2008.

The two essential assessment and therapy skills that need to be specified are: • MotivationalInterviewing(MI). • CognitiveBehaviourTherapy-basedskills(CBT-basedskills).

In addition staff may use any or all of a range of therapies including: • DialecticBehaviourTherapy(DBT). • Psychotherapy. • FamilyTherapy. • Multi-systemicTherapy. • Counselling. • InterpersonalTherapy(IPT). • Problem-SolvingTherapy.

Action point 8: Recommend talking therapies are included in the final version of the NSF.

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14. specif ic populaTion groups

Service User Workforce

Key issues

• “People”skills(andthetimetousethem)areseenasthemostimportantattributeof the therapist or staff member, whatever their profession or role. (This issue was identified in We Need to Talk, and is also found in the literature review.) Service users call for greater access to staff with the time to talk, as well as staff with the skills to undertake therapy.

• Crisismentalhealthservicesandinpatientunitsareseenasplaceswherepeoples’health problems are most acute, but the environment can be the least therapeutic.

Opportunities to enhance talking therapies for the service user workforce

• MorestaffskilledinCBTarecalledforbyserviceusers. • Severalpeoplereportedthattheinternet-basedprogramme“Mood Gym” is helpful. • DHBsconsidertheuseofconsumeradvisorsimportant,astheycanadvocateforbetter

access to quality talking therapies in service development. • Serviceuserscanbeviewedasbothrecipientsandaspotentialprovidersoftalking

therapies. • Wiseruseofpeersupportworkers(PSW)andcommunitysupportworkerscouldalso

be helpful. If both had training in engagement skills, communications skills and a basic understanding of therapies, they might better support clinicians undertaking talking therapy with service users.

• Serviceuserswantedmoreinformationondescriptionsoftherapies,expectedbenefitsand outcomes, timeframes, what mental health problems best fit what therapies, etc.

• “Put very experienced therapists in crisis services and inpatient units and have continuity of engagement and talking therapy following through afterwards into community services”.

• Moreresearchanddevelopmentintopeersupportisneeded.

As for Action point 2a: Enhance staff training in the service user workforce in basic engagement and counselling skills.

Action point 9: Develop and provide a user-friendly guide to therapies in the framework for service users so that they are well-informed about therapy processes.

Maori

Prevalence of disorder

Maori as a population have a higher prevalence and severity of mental disorder than others. Te Rau Hinengaro found that 51% of Maori with serious disorders, 74% of Maori with moderate disorders, and 84% of Maori with mild disorders had no contact with the health sector.

Te Rau Hinengaro notes differing patterns of sources of referral for admission, with Maori being more likely to be hospitalised through a “justice” doorway than a mental health or primary care entry point. The recent document by Baxter (2008) also highlights the need to prioritise Maori mental health and focus on initiatives that lead to improvements in Maori mental health and addiction.

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Key issues

• Cultureplaysanimportantroleinhealth,andinmentalhealth.Suggestionsforgoodpractice for doctors were documented in Best Outcomes for Maori: Practice implications (Mauri Ora Associates, 2007). This was written for the Medical Council of New Zealand but is relevant for staff working in mental health and addiction services.

• Thedocumentmentionedabovenotes:“The involvement of Maori as active participants in the drive to improve their own health can only occur if the necessary resources – including the practitioners themselves – are accessible, available, acceptable, and culturally appropriate to Maori” (p.39).

• TeRauMatatini’scontributiontothedialoguewasapaperbyMariaBakeroutliningMaori models of practice. These models of practice were documented (and are again referred to later in this report under “Frameworks/models of service”) as:

o Powhiri Poutama developed by Te Ngaru Learning Systems in the 1990s o Te Whare Tapa Wha (Durie, 1998) o Te Wheke (Pere 1984; 1991) o Paiheretia (Durie, 1999). • MariaBaker’spapernoted(asdiscussedinWe Need to Talk) that CBT is a useful tool

and is most helpful when the practitioner is informed of the cultural perspectives of clients (as reported by Durie, 2001).

• Theliteraturereviewconfirmedthatlittleworkhadbeenpublishedontalkingtherapiesfor Maori, and suggested that this should be a priority for future research in New Zealand.

Opportunities to enhance talking therapies for Maori

• WorkforceinitiativesinNewZealandhavebeenundertakentostrengthentheMaoriworkforce (e.g. the establishment of Te Rau Matatini).

• Waystostrengthenthepsychologyworkforce–aswellasbarriersandincentivestoMaori participation in the psychology workforce – have been documented (e.g. Levy, 2005) (Levy, 2002). Preliminary work has also been undertaken to examine whether a kaupapa Maori psychology is possible in the future (Milne, 2005; on

www.psychologistsboard.org.nz). • Workhasbeendonetobetterinformthenon-Maoriworkforce(e.g.workbyLevyetal.

on ensuring the HoNOS process is acceptable for Maori, 2005). • TheNewZealandCollegeofClinicalPsychologynotedintheirwrittensubmission:

“The principles underlying CBT and MI are just as applicable to Maori as other ethnicities. Application and delivery of the model (the process) may require modification. There are a growing number of Maori psychologists using CBT and its components to good effect here in NZ, presentations at the recent symposium confirmed this (papers are available to support this statement). There is also research in the pipeline that supports this. There is also evidence directly contradicting MI being ethnocentric i.e., a recent meta-analysis found the effect size for MI is greater for ethnic minority groups than for Caucasians”.

• TherightsupervisionprocessisalsoimportanttoMaori.WahanuiandBroodkoorn(2005) noted that, currently, most services provide cultural supervision and professional clinical supervision separately; yet “Maori nurses indicate the need for cultural and professional supervision to occur simultaneously as culture and practice are intertwined” (as cited in McKenna et al ,2007, p.47).

• Giventheimportanceof“gettingitrightforMaori”itisrecommendedthatTePoucontract a separate stream of work looking in depth at practice-based evidence on what works in terms of therapies for Maori (both by Maori for Maori; and by practitioners of other cultures for Maori) including what processes assist the therapy process. This would be complementary to the existing literature review and would build on the work that already exists. A starting point would be (as Maria Baker from Te Rau Matatini suggested) talking to key Maori clinicians and service users.

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Action point 10: Contract work examining what processes enhance talking therapies for Maori (i.e. what enhances the effectiveness of Maori practitioners working with Maori clients; and, what processes might enhance the effectiveness of practitioners of other cultures working with Maori clients).

Action point 11: Te Pou to contract for best (and promising) practice guidelines for talking therapies for staff working with Maori (i.e. similar to that completed by Dunnachie, 2008 for children and youth) in mental health and addiction services.

Pacific Peoples

Prevalence of disorder

Te Rau Hinengaro (2006) found that Pacific peoples carry a higher burden of mental disorder than New Zealanders in general, with a 12-month prevalence of 25% compared with 20.7% of the total New Zealand population (cited in Pacific Peoples and Mental Health, 2008). The study also reported that Pacific people born in the islands and migrating to New Zealand after the age of 18 experience far fewer mental disorders. Of New Zealand-born Pacific people, 31.4% had a 12-month prevalence of any mental disorder compared with 15.0% of Pacific people who migrated to New Zealand after the age of 18.

Key issues

• ThewayinwhichmentalhealthissuesareperceivedbysomePacificpeoplesandcommunities has a great bearing on the delivery of talking therapies. There is a common belief across Pacific cultures that ancestors have a constant spiritual and physical communication with current generations (Ministry of Health, 2008). Also, Pacific peoples view mental health as an intrinsic component of overall health and do not have words that translate into “mental illness”, as mental health is considered to be inseparable from the overall wellbeing of the body, mind and spirit (Ministry of Health, 2008).

• Te Rau Hinengaro reported that Pacific people had lower rates of mental health visits compared with other ethnic groups. Within a twelve month period, 25% of Pacific people with a serious disorder had a mental health visit in the health care sector compared with the general New Zealand population which is more than double at 58%. With a disproportionately large and growing younger population and higher rates of mental health disorders, there is a need for a culturally and clinically competent workforce and services.

• SeveralworkforceinitiativesfundedbytheMinistryofHealthhavebeenaimedatgrowing the Pacific mental health and addiction workforce.

• RecentdocumentsfromtheMinistryofHealthhavealsoaddedtoourknowledgeofPacific peoples (Pacific Peoples and Mental Health, 2008, Pacific Cultural Competencies, 2008; Pacific Peoples’ Experience of Disability, 2008; and, Pacific Youth Health, 2008).

• Thereisaneedforresearchon“whatworks”forPacificpeoplewhodoaccessservices,and the younger Pacific population should also be a focus of future research.

• Theliteraturereviewconfirmedthatlittleworkhadbeenpublishedontalkingtherapiesfor Pacific peoples, and suggested that this should be a priority for future research in New Zealand.

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Opportunities to enhance talking therapies for Pacific peoples

• Ingeneral,talkingtherapiescarriedoutbyPacificpeopleareseenasappropriateforPacific peoples, particularly when “the therapeutic relationship is privileged” (Monique Faleafa, personal communications, March 2008). CBT and MI in particular are useful for Pacific people, as they are founded on the relationship between therapist and service user.

• WorkforcedevelopmentcouldfocusonensuringmorePacificstaffaretrainedinthesetherapies.

• Parallelresearchcouldfocusoneffectivenessofsuchmeasuresandwhatadditionalcultural processes (if needed) are more likely to result in successful outcomes for Pacific peoples. Le Va would play a major role in supporting such research.

As for Action point 11: Te Pou to work with Le Va to contract for best (and promising) practice guidelines for Pacific peoples (i.e. similar to guidelines completed by Dunnachie, 2008 for children and youth).

Children and Youth

Prevalence of disorder

As noted in Dunnachie (2007), the prevalence of moderate to severe mental disorders is reported in community surveys to be around 12-15% (as found by Fonagy et al., 2000). Co-morbidity is very common and disorders are likely to persist into, or re-occur in, adulthood. Te Raukura (2007) states the overall the picture of mental health and AoD needs of children and youth in New Zealand as follows: • “Mentalillnessandsubstanceusedisordersarecommon. • Theonsetofdisordersoftenoccursearlyinlife. • Havingonedisordercanleadtothedevelopmentofotherdisorders. • Co-morbidityisverycommon,includingAoDdisorders. • Ahighproportionofdisordersarelikelytopersistorrecurduringchildhoodandinto

adult like, depending on the type of disorder and the age of presentation. • MaoriandPacificpeopleshavehigherratesofmentalillness. • Thegreatestvulnerabilityfordevelopingamentaldisorderoccursbetweentheagesof15

and 18. • Treatmentratesaregenerallylow. • Asignificantnumberofchildrenandyouthwithrelativelyseveredisordersarenotin

contact with mental health services” (p. 3).

Rates for Asian children and youth are not known (Dunnachie, 2007).

Key issues

• Thereisaneedforbetterundergraduatetraining.Itwouldhelpiftherewereuniversalcore skills across post-entry clinical training/national training agendas delivered as generic mental health skills for all life stages.

• Theevidencefortherapiesforusewithchildrenandyoungpeoplehasbeenreviewedin a very useful document Evidence-Based Age-Appropriate Interventions – A Guide for Child and Adolescent Mental Health Services (CAMHS) published this year by the Werry Centre. This report outlines interventions for this group that are either “Best- supported” or “Promising” as defined by the level of research found from a review of the literature.

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• Theaboveguidefoundthatlittleisknownaboutculturally-specificinterventionsforchildren and youth “Thus a focus on culturally appropriate interventions for children and youth is required” (Dunnachie, p11).

• Clinicianshavetobewellversedinassessmentbeforedecidingwhatinterventiontodeliver. There is universal concern among CAMHS teams that recent graduates across allied health (perhaps with the exception of psychology) are unable to complete core assessments competently.

• ForCAMHSadevelopmentalperspectiveisabsolutelyvitalasthecognitiveversusbehavioural balance needs to be finely assessed.

Opportunities to enhance talking therapies for children and youth

• E-learningenvironmentsthatareselfpacedandworkdeliveredcouldbeestablished,along with additional trained supervision and support.

• Anothersolutionistocreateagreaternumberofwell-supportedundergraduateclinical placements in CAMHS, NGOs and addiction services – something the Werry Centre is addressing in their mental health placement project.

• TheworkonRealSkillsandRealSkillsPlusattendstowhattoassess–andsoon,howto assess – in existing teams.

• Developgroupskillstrainingforgraduates–thereiscurrentlyastrongtendencyin training and service delivery to have individualistic therapy. For children and adolescents it is developmentally very appropriate to have group therapy. This also holds true for parents.

• Moreemphasisontraininginfamilytherapy. • Strongevidencesupportstheefficacyofrelaxationtrainingincertainproblems(e.g.

bulimia). • AsdescribedinEvidence-Based and Age-Appropriate Interventions, CBT is gaining

evidence for children and adolescents, so the more CAMHS staff that are trained the better.

• Familyworkskillsarevitalthoughlesswellresearched–fundamentalsinsystemicfamily therapy are key and make sense from bi-cultural and multicultural perspectives.

• Incredible Years is well researched and is recommended in the inter-sectoral strategy for severe antisocial behaviour. The Werry Centre is engaged in a train-the-trainer programme to increase the numbers of New Zealand mentors and supervisors qualified to deliver this training here (and thus overcome dependence on overseas trainers).

• “TripleP”isalsoawell-researchedbehaviourallybasedparentmanagementprogramme.

• TheWerryCentreattendstoskillsmixinteamsviathe“sevenhelpfulhabitsofeffectiveCAMHS”.

• Ensurethatservicedeliverydesignsupportsacultureoptimalforthedeliveryoftalking therapies. As mentioned earlier, the Choice & Partnership Approach strives to do this.

• Wherepossible,TePoucurrentlypromotesandsupportstheWerryCentre’swork(asthe above information shows, they already provide a great menu of talking therapies specific to these ages).

Action point 12: Te Pou to continue promoting and supporting the Werry Centre’s work.

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Older People

Prevalence of disorder

The prevalence of mental disorders is the same as for other adult groups (Chris Perkins, personal communication Match, 2008). Depression increases with age and life stress (disability and grief mainly). If you include dementia diagnosis, older people’s overall prevalence increases with age more than other age groups. There are also flow-on effects to other family members, usually the spouse and older daughters of those with dementia.

As for other countries, New Zealand has a rapidly increasing aging population, and this has significance for health and mental health services.

Greater ethnic diversity among older people is expected in the future. Prasadarao, writing in Evans et al (2007), notes that currently over 90% of people described themselves as of European descent or Pakeha. However between 2001 and 2021, the over-65 Maori population is expected to grow by 185%, the corresponding Pasifika population by 178% and the Asian population by 400% (Cornwall & Dovey, 2004; cited by Prasadarao, 2007). This author states that projections also indicate that the “old-old” (people aged 85 years and over) will have the highest growth rates over the next 50 years.

Key issues

• Themostcommondisordersaredepression,anxiety,dementia,delirium,bipolar disorder and psychosis, early and late onset (Dr Chris Perkins, personal communication, February, 2008).

• Co-existingphysicalproblemsarecommonandalcoholabusecanalsooccur(drugabuse less common in this age group).

• Otherconfoundingproblemscanbebereavement,loneliness,abuse(physical,emotional, financial or sexual), caregiver neglect and relationship issues (Prasadarao, 2007).

• Medicatingolderpeopleusingadulttherapeuticlevelscomeswithfrequentproblemsdue to co-morbid physical problems and changing metabolic issues.

• DepressionandanxietyinolderpeoplerespondwelltoCBTbutmayrequiremoresessions. Experience suggests that once older people are engaged they respond well and are adept at making behavioural change (Geraldine Hancock, Nigel George, personal communication, April, 2008).

• Althoughpsychologicalinputisaseffective,olderpeoplearemuchlesslikelythanother groups to be offered or receive psychological input owing sometimes to clinician prejudice – an “it’s not worth it” attitude – and/or a lack of resources.

• Deliriumneedstreatmentoftheunderlyingproblem(e.g.infection).

Opportunities to enhance talking therapies for older people

• Ensurethattherapistsrealisethatstigmaisabigbarrierinthewayolderpeopleperceive mental health problems. Older people are the most likely age group to come in contact with mental health professionals, mainly due to the impact of dementia. However, historically, they have been the group that has not had any contact with talking therapies approaches before. Traditionally it has been “have a problem, go to the GP, and get a pill”. Although this is changing as new generations of clinicians have a more recovery-focused practice, it is still a major stumbling block.

• Forpeoplewithdementia,therapiessuchasvalidation,reminiscenceandpersoncentred care are useful.

• Groupsareveryusefulforolderpeople.Althoughtheymayhavedifficultieswithtransport to groups, they do have the time and energy to put into them, and they can

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learn a lot from their peers. More staff trained in group work would be helpful. • Modificationsdoneedtobeconsideredfortheoldergroup,suchasforeyesight,

hearing and memory problems. • Researchislackingforthe“old-old”andforalternativetherapiessuchasDBT. • Linkingpeopleinwithcommunityagencies(e.g.groupssuchastheStroke

Foundation, Parkinson’s and Alzheimer’s Societies etc.) is very helpful.

As for Action point 11: Best (and promising) practices guidelines for talking therapies staff working with older people in mental health and addiction services.

Asian Peoples

Prevalence of disorder

Defining “Asian” is a complex process. Although the word “Asian” does not currently describe “the lived experience of any ethnic group in New Zealand” (Rasanathan, Craig & Perkins, 2004, p.14) in the health sector, we need to acknowledge that this group needs a descriptor of some sort.

“Asian peoples make up the fastest growing ethnic community in New Zealand, with official estimates indicating this diverse group of people will make up 13% of New Zealand’s population by 2021 (Chatterji, 2004). It is, therefore, appropriate that New Zealand has a mental health workforce with the right cultural capability to support the well-being of Asian service users and their families in New Zealand” (Dr Samson Tse, personal communication, February 2008).

Key issues for Asian adults

• Therapistsneedtobeawareofissuesofhomesickness,discrimination,beinga“minority group” and disempowerment for many Asian peoples.

• Asianpeoplewhoexperiencementalillnessoftenhaveinternalisedstigmaandblamethemselves for being sick.

• Languagemaybeabarriertoseekinghelp.

Key issues for Asian teenagers

Dr Chohye Park has undertaken research in New Zealand on barriers to seeking help for teenagers. She found that Asian teenagers are widely acknowledged to be difficult to engage (rates of accessing CAHMS services are very low, about 1/10 of the Maori rate and half of the Pacific rate). There are many reasons for this but they mainly centre on the parents’ beliefs. Teenagers are usually better about seeking help as they know about depression and common mental health problems from school, but the parents are the barrier. The family system is generally hierarchical and what the parents think is important, e.g.: • mistrustofWestern“system”generally–“toomuchfreedomgiventoyoung” • ifthechildissick,thefamilybelievesthat“wefailedthechild” • beliefthat“weknowourchildbest–wedon’tneedastranger’shelp” • fearofmisunderstandingduetolanguagebarriers.

Dr Chohye notes that the traditional family system in Asia encourages interdependency rather than individuation and separation from family altogether. Hence the dual identity of Asian teenagers and their two different developmental tasks in their teenager period: New Zealand – seeking separation, forming identity/individuation; versus Asian – studying hard to achieve for family name and pride and carrying on university study to obtain a reputable job in the future.

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Opportunities to enhance talking therapies for Asian adults and teenagers

• Psycho-educationforclientsandtheirfamiliestodecreasestigmaandincorrectattribution of blame.

• CBTandMIareseenbyAsiantherapistsasappropriateforAsianpeopleaslongasthetherapist develops empathy around the issues outlined above.

• Guidelinesforsafepracticeareavailableinresources(e.g.Evansetal,2007)whichwere written as best practice for psychologists in New Zealand and contain a chapter on Asian peoples.

• TePouhaspromotedseveralprojectsledbyDrSamsonTse(e.g.TheAsianRealSkills work). • AsforMaoriandPacificpeoples,researchontalkingtherapiesforAsianpeoplesis

needed.

As for Action point 11: Best (and promising) practice guidelines for talking therapies for staff working with Asian peoples in mental health and addiction services.

People with Alcohol and/or Drug Problems

Prevalence of disorder

Te Rau Hinengaro found that a high proportion of people in the New Zealand sample had drug and alcohol problems and many also had co-existing mental health problems. Internationally, the prevalence rates for co-existing mental health and alcohol and drug addiction are well established, with 30-50% of all people diagnosed with a serious mental disorder reported to also have experience of problematic alcohol and drug use (Siegfried, 1998). Dr Fraser Todd (1999) confirms the relevance of this figure in the New Zealand population.

There is less research about people with co-existing alcohol and drug addiction and mental illness, although combined experiences may be seen as the “norm rather than the exception”, with 70% of people in community alcohol and drug services in New Zealand suffering a co-existing Axis I mental health disorder in addition to their substance use disorder (Adamson et al 2006; Pulford 2002).

People accessing treatment primarily for mental illness or alcohol and other drug problems may also face a range of issues like unemployment, homelessness, disconnection from family and social networks and exclusion from many activities that make up a quality lifestyle (National Committee for Addiction Treatment - NCAT, 2008).

Key issues

• Theaddictionsectoremphasisesthatitspecialisesintalkingtherapies:“The addiction field is a sector which is built on the use of talking therapies” (Annemarie Wille, personal communication April 2008); and, “Addiction services are primarily delivered through evidence-based talking therapies at this time, maybe it is time to acknowledge this” (RANZCP submission, October 2007).

• Despitetheabove,itwasnotedthatafewCommunityAlcoholandDrugServices(CADS) are decreasing the amount of ongoing outpatient treatment they are involved in, and so risk becoming de-skilled in therapy and clinical case management in general. “They are brokers; they assess the person and then send them somewhere else for ‘treatment’. Their assessment reports are increasingly devoid of relevant treatment/management planning details because the writers don’t know how to treat people with addiction” (Professor Sellman, personal communication, April 2008).

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• MatuaRakihasbeenfocusingonco-existingdisordersandin2007publishedMental Health and Alcohol and Drug Co-existing Disorders: An integrated Experience for Whaiora? (www.matuaraki.org.nz). This reports on a project in which staff from addiction and mental health and were asked their views on a more integrated approach and to look at how more collaborative practices could occur. Results suggested that AoD workers were more cautious about working in an integrated way, found it hard to access funding for up-skilling, were not as good at identifying mental health issues, and saw mental health workers as holding negative attitudes about AoD consumers. Mental health workers’ comments reinforced the notion that the mental health and addiction sectors hold different skill sets and ways of working, that mental health workers were not as good as AoD staff in identifying AoD problems but were more accepting of a collaborative approach. The report suggested five principles for workforce development around co-existing disorders and documented nine recommendations for action.

• SomeintheAoDsectorquestionedastatementinWe Need to Talk which said that most of the work in the addiction area was undertaken by NGOs. “NGOs are not the primary providers of counselling in a number of areas; for example in Auckland NGOs remain secondary providers of treatment for addictions while the Auckland Community Alcohol and Drug Service has a current capacity of 12,000 contacts per year and a projection of further growth” (RANZCP submission, October 2007).

Opportunities to enhance talking therapies for people with alcohol and/or drug problems

• Screeningtoolsalsoprovideindependentreviewofchangeovertimeandarereadilyavailable in the addiction sector (e.g. Alcohol Use Dependence Index Tool – AUDIT, Leeds Dependence Questionnaire, and the Substance Dependence Scale). The Substances and Choices Scale (SACS) is also used for adolescents.

• Whilethestrengthofcounsellingandengagementskillsamongstaffinthissectorisacknowledged, general feedback suggests that any increase in skills of staff in both MI and CBT skills is seen as a definite bonus: “Workforce development in this area should target strengthening training in evidence-based practices, and researching outcomes” (Annemarie Wille, personal communication, April 2008).

• Jointtrainingwithmentalhealthworkerswasalsoseenasawaytostrengthenrelationships and highlight the commonalities between the two sectors.

• TheAlcoholandDrugAssociationoperatesahelplineforpeoplewithalcoholanddrugproblems. The Brief Intervention Counsellors (BICs) offer support using motivational and person-centred micro-skills, family support, and relapse prevention (Cate Kearney, personal communications, March 2008).

• Familyinclusivepracticeisseenasimportantintheaddictionsfield.“The addictions sector notes that it is vital to encourage family/whanau involvement in CBT, MI, IPT and counselling. Family involvement in the process of one-to-one therapies improves outcomes, and basic training in ‘family involvement’ has the potential to lead to significant improvement in outcomes without needing to train people in ‘special therapies’” (RANZCP submission, October, 2007). The Kina Trust operates to support organisations to develop family inclusive practices (www.kinatrust.org.nz) and has published a useful guide, Family Inclusive Practice in the Addiction Field: a guide for practitioners working with couples, families and whanau (2006), which has relevance for mental health workers too.

As for Action point 11: Develop best (and promising) practices guidelines for talking therapies for staff working with people with addiction problems in mental health and addiction services.

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People with Physical and Mental Health and/or Addiction Problems

Prevalence of disorder

Te Rau Hinengaro (the New Zealand Mental Health Survey; Oakley Brown et al 2006) found that people with mental disorders have a higher prevalence of several chronic physical conditions and chronic physical condition risk factors compared with those without mental disorders, and that those people with physical disorders have higher rates of mental disorder. Additional research from New Zealand (MaGPlE Research Group 2003) suggests about a third of people who consult primary care practitioners have a mental health problem or illness at the time of the consultation, or have experienced a mental health problem in the past year. The most commonly encountered mental health problems are depression, anxiety, and drug and alcohol problems. Therapists need to be aware of the coexistence of physical health and mental health disorders and support the individual to manage his/her own health problems.

Key issues

• Asubstantialbodyofrecentresearchshowsthatpeoplewithlong-termphysicalconditions that have co-morbid depression, anxiety or substance abuse achieve much better health outcomes if their co-morbid mental illness is treated.

• Mentaldisorderinpeoplewithphysicalconditionsisunder-recognised(andwhenitisrecognised in people with physical disorders, often little is done about it).

• Workisbeingdoneinthisareainmentalhealth(e.g.liaisonpsychiatryservicesthatspecialise in this area) and in primary care (e.g. the Ministry of Health’s draft policy advice paper: Primary Mental Health Care Document for Consultation, June 2008). The key will be to ensure both mental health/addiction and primary care workers have:

o a common understanding of the clinical, community, cultural and service issues needed for a quality primary mental health service

o practices that ensure a seamless pathway for people who need to access both primary care, and mental health and addiction services.

• Anissuethathascomeupthroughouttalkingtherapiesworkisthefearthatprimarycare will “poach” mental health and addiction services staff with expertise in talking therapies, thus adding to the workforce shortage.

Opportunities to enhance talking therapies for people with physical and mental health and/or addiction problems

• Muchworkiscentringonworkforcedevelopmentforprimarymentalhealthcare.Asnoted above, the Ministry of Health is leading work that highlights the benefits for New Zealand of investing in the primary mental health sector, thereby enabling people who have mental health problems to receive early treatments (including talking therapies) within the primary care environment.

• Liaisonpsychiatryservicesaimtoprovideamentalhealthservicetogeneralhospitals.Opportunities for increasing talking therapies include:

o education and role modelling for other staff so they feel able to identify mental disorders in their patients

o teaching brief interventions for some staff in particular settings – for example, in the emergency department when people present with substance dependence

o supervising and teaching more extensive specific therapies for some staff – for example, teaching cognitive behaviour therapy to diabetic nurses and grief counselling to breast care nurses

o “staff in liaison psychiatry services can become specialists in particular forms of talking therapies particularly suited to their setting – for example, cognitive analytic therapy in diabetes, and problem solving therapy after self harm” (Dr Simon Hatcher, personal communication, April 2008).

• Staffwhoworkinliaisonpsychiatryserviceswillbeincludedinanyworkforcedevelopment initiatives around talking therapies.

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As for Action point 11: Develop best (and promising) practice guidelines for talking therapies for staff working with people with physical and mental health/addiction problems.

Other Ethnic Communities

Stewart and Young (2007) state that New Zealand has an increasingly diverse range of other ethnic communities, each with its own specific health-related beliefs, health related behaviour and general beliefs and practices that impact upon their mental health and help-seeking (In Evans et al. 2007). Immigrants (people not born in New Zealand but who have chosen to live here), and refugees (people who left their country of origin and believe that they are unable to return to that country because of fear of persecution due to race, religion, social group or political opinions) face many challenges to their physical and mental health.

Such challenges may include language difficulties, separation from family, stigma and discrimination from the host country. In addition, for many refugees, exposure to trauma, prolonged stress or torture may have ongoing effects on their physical and mental health (Ho et al; 2002 cited in Stewart and Young, 2007).

Key issues

• Transculturalreferstoservicesforpeoplefrommigrantandrefugeebackgroundsand one submission was forwarded from such a service (Corinna Friebel, personal communication, 5 October, 2007). She notes:

o “Overseas research identified the most common barriers to equity of access as: ▶ inadequate cross-cultural knowledge and skills among health professionals,

leading to inappropriate or inadequate therapeutic approaches ▶ lack of appropriate talking therapies and support services available in client’s

first languages ▶ lack of involvement of non-majority communities in design and evaluation of

services ▶ inadequate research. o In terms of the services offered to clients, these factors have too often resulted in: ▶ difficulties in diagnosis, leading to both under- and over-diagnosis of symptoms,

and incorrect or otherwise inadequate therapeutic approaches ▶ lack of access to the full range of therapeutic modalities (e.g. emphasis on

medication, clients less likely to receive any of the language based psychological and social treatments, even when these may be more appropriate)

▶ prescription of treatments which are entirely inappropriate for cultural and linguistic reasons

▶ clients not presenting”. • AsmosttherapiesaredevelopedoutofamonoculturalWesternframeworktheymay

not necessarily translate into a therapeutic tool for a cross-cultural context: “This is due to different core values as well as linguistic reasons, especially in triadic relationships, where interpreters are involved in the therapeutic process”.

Opportunities to enhance talking therapies for other ethnic communities

• Thequalityoftherelationshipbetweentherapistandclientismorerelevantthanadhering to a particular Western therapeutic modality. “I believe that working cross-culturally requires an understanding of one’s own cultural identity and biases together with an openness and flexibility in using a variety of (Western) therapeutic approaches in conjunction with understanding and respect for traditional healing methods”.

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• Corinnasays:“I believe that there is a unique chance to build a culturally responsive public health sector in Aotearoa/New Zealand, based on the principles of our bi-cultural model and informed by local and overseas research and experience. This however will require careful and critical evaluation of current practices and best practice models and a climate of openness towards learning from each other”.

As for Action point 11: Develop best (and promising) practice guidelines for talking therapies for staff working with migrant and refugee peoples in mental health and addiction services.

15. groups of sTaff

Many different types of staff work across the mental health and addiction sector in New Zealand including registered health practitioners (psychiatrists, nurses, psychologists, psychotherapists, occupational therapists) and other mental health and addiction workers (advisors, counsellors, coordinators, etc). Each is discussed below.

Registered Health Practitioners (under the HPCA Act)

Psychiatry

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) provided written feedback to both We Need to Talk and We Now Need to Listen. Much of the content below is either paraphrased or quoted from the submission on We Now Need to Listen.

Key issues

• TheRANZCPisstronglyinfavouroftheincreasedavailabilityofsound,expertlyconducted and appropriate therapies. However, as any therapy can do harm, it is essential that the quality of therapy remains paramount, meaning that the focus should remain on providing thorough and ongoing training and support for those delivering the therapies. As with any treatment, there is also a need for regular review of progress, consideration of alternative treatments and an inclusive perspective on what treatments are effective in different settings and clinical situations. A further consideration is that while not all talking is therapy, much clinical talking can be therapeutic if it is thoughtfully and empathically done – it is therefore important that all staff have a therapeutic attitude and psychological mindedness.

• TheRANZCPispleasedtoseeincreasedacknowledgementoftheneedforarangeof therapies, and points out as an example that there is already training available for IPT in New Zealand. This is already prominent in practice guidelines both locally and internationally, has a good evidence base, and is used across a wide range of disorders. The primary advantage of IPT is that therapists use their own “signature techniques” and existing skills within an interpersonal model. As a consequence, the IPT training process is easily adapted across disciplines and is particularly applicable to nurse practitioners. An IPT training packages has already been successfully developed for New Zealand, meaning that there are people available to train and supervise this technique.

• TheRANZCPsuggestscautioninallowingunfetteredaccesstotheprivatesector.Health services in New Zealand are provided by a mix of publicly funded and privately purchased services. The USA and Australian experiences of allowing public funding of private practitioners in mental health demonstrate two outcomes likely to be undesirable in the New Zealand setting. The first is that the overall cost to the public

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purse is high, and the second is that, in Australia, the capacity in public mental health services is undermined. The experience of ACC provision for victims of sexual abuse provides another lesson. While it is likely that many people have been helped by having access to counselling for their past abuse, there is limited capacity to meaningfully audit clinical practice in this system of providing treatment, and many psychiatrists have experience of dealing with the aftermath of such counselling, especially where cases have been complex and/or with co-existing mental disorder.

• Currentdevelopmentsinprimarycarementalhealthneedtobecarefullyconsideredand any framework must be consistent with these. The evaluation of the mental health in primary care initiatives shows that it is easy for fragmentation in care to occur when psychotherapies are provided by private providers who have few everyday working links with primary care practices.

• TheRANZCPquestionedtheneedforandvalueofaliteraturereview:“There are a number of high quality reviews of psychotherapies available in the international literature. Quality reviews are expensive and it is unlikely that any local review would be resourced to provide the level of assurance regarding evidence that is actually already available”.

Opportunities to enhance talking therapies in psychiatry

• TheRANZCPsuggestedthatholdingaTalkingTherapiesSummithasthepotentialtoprogress this work. It suggests that the purpose of such an event be “articulated well in advance and that its content be directed at achieving a specific outcome, be tightly chaired, haveabout30to35participantsincludingtheMinistryofHealthandplanningandfunding staff and the outcome might be 2 to 3 pages of recommendations for progress”. The RANZCP proposed that:

o the focus of the summit be on getting a more detailed appreciation of the kinds of institutional structures and processes that would be necessary to enhance these services in the publicly funded mental health sector

o with separate discussions of the short, medium and long-term o in scenarios of a plateau in funding and some increase in funding. It will be critical to recognise that most participants will not only be “content and

practice experts” but, as expected with professional groupings, be advocates for their own vested interests.

• ThesuggestioninWe Need to Listen of a framework is an excellent basis upon which to build. This would be strengthened by some sort of clearly articulated, service-based measurable goals. The content of the framework could then be pragmatically aligned to these goals. The RANZCP envisages a relatively simple framework embedded in a few overarching principles balancing access, evidence and what is available or affordable. This would allow for local variation in skills and availability, alongside an aspirational but achievable plan for improving skill availability and diversity in the regions where they are scarce or narrow in focus.

• GiventheevidenceofsignificantmentalhealthdisparitiesadverselyaffectingMaoricompared to non-Maori, and the lack of evidence of the talking therapies described efficacy for Maori, the RANZCP supports specific exploration of Maori talking therapies. This issue has particular relevance in relation to the suggested literature review, which would need to include evidence of Maori interventions that may not be published in peer review journals as yet. Including a focus on Maori talking therapies at the Talking Therapies Summit is likely to enhance attendance of Maori and proposed outcomes, as well as demonstrating an acknowledgment of relevance to the work of all clinicians who see tangata whaiora and their whanau.

• Afurthercommentwasmadebyapsychiatristgivingfeedback.Shethoughtthatpsychiatrists appeared to be increasingly regarded by managers as too expensive to be engaging in therapy themselves. “Psychiatrists emerge from their training with more psychotherapy skills than many nurses, but are not required to keep these skills up, or at least not encouraged to do so, or to work to enhance them. This is a mistake, as it creates a distance with the general approach which in my work I find a great impediment to

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consumers getting what they need, due to the psychiatrist having quite a bit of power in the clinical team (which in itself is not automatically a problem in my view). So I think that if services were required to ensure that over the whole group of psychiatrists a significant number were actively engaged with a therapy and doing a bit of it (with proper supervision etc.) then some of this problem might reduce”.

• Theabovecommentwasechoedbyotherstaffwhodidnotunderstandingeneralwhere psychiatrists “fitted into” the framework cited earlier in this document. People found that some psychiatrists were very skilled in therapeutic approaches (and interested in expanding their skills) while others were not as “therapeutically minded”. Thus other clinicians supported the statement above to attract more psychiatrists into a therapeutic role.

Action point 13: Communicate talking therapies reports to the RANZCP.

Nursing

A group of mental health nurses from the Anne Garland Workshop held in February 2008 provided feedback through a written submission. In preparing this submission this group also sought contributions from a range of nurses across universities and mental health and addiction service settings, as well as from Te Ao Maramatanga - New Zealand College of Mental Health Nurses Inc.

Key issues

• Theroleofnurseas“therapist”appearstohavebeensomewhatlostinthe1970sasaresult of the move to generic working and the closure of therapeutic community-type agencies in mental health. Even as recently as 2006, in Mental Health Nursing and its future: A discussion Framework (Ministry of Health), there was little mention of mental health nurses playing a significant role in providing any type of psychological intervention. Lack of even basic knowledge and experience in the talking therapies area is of great concern: “The major loss of skill is in the area of talking therapies, many staff have major difficulty articulating what they are doing other than assessment or monitoring” (Lindsay Spirrett, cited in Handover, 2008).

• Thereappearstobeseriousconcernthatnursescancompletetheirundergraduatetraining with little mental health or addiction content. Some graduates can qualify from a programme with little academic content and few clinical hours leading to poor knowledge of core mental illness/mental health issues. “The problem lies with the lack of a national curriculum, the lack of consensus as to what models of intervention are taught, and the patchy nature of the clinical experience – due to the decades of graduates with the same patchy educational preparation for the role”.

• Furthertotheabove,ithasbeensuggestedthatthetraditionalpracticeofnewgraduates having their first work experience in inpatients units is also worrying. As Lindsay Spirrett wrote: “Surely people admitted to acute inpatient units because they are so unwell should have access to the service’s most experienced and skilled clinicians?”

• Manynursesarguethatakeybarriertoadoptingastrongertherapeuticnursingapproach in mental health is seen as the strong influence of the medical model.

• Itappearsthatalloftheaboveresultsinaprofessionthat(inacuteinpatientunitsparticularly) can revert to the “medical model” as no current model of nursing integrates nursing and talking therapies (“There’s no time to talk, it’s all about safety”).

• However,therearemanyexperiencednursesinleadershippositionswhocanassistwith the development of the profession.

• ItwasalsonotedthatmostDHBsdonothavestrongcareerdevelopmentprocessesin place for nursing staff. This can lead to situations where staff are sent off for

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training and return to an environment in which their new-found therapy skills are not supervised or supported, and further development is not planned; thus they are often not able to use their skills.

Opportunities to enhance talking therapies in nursing

In the context of nursing nationally: • Acohesive,sustainableworkforcedevelopmentinitiativeforthedevelopmentofskills

in talking therapies is progressed at a national, regional and DHB/NGO organisational level in which nurses as key stakeholders have an active role.

• Nursesmoveawayfromtherelianceonthebiologicalmodeltoincorporatemodelsthat include a broader range of interventions that are in harmony with the recovery approach and nursing philosophy. In doing so mental health nurses develop a model of practice that integrates nursing and talking therapy skills as the basis for:

o a training model and career pathway o a supervisory model and process o a body of research literature on which to draw. This will be attained by strategic collaboration between mental health nurses in

academic settings, clinical practice and professional bodies (such as the New Zealand Nurses Association, Mental Health Nursing Section and Te Ao Maramatanga).

• Existingnationalworkforceprocesseswillassistinenhancingthementalhealthcapability of nursing (e.g. post-entry clinical training, Let’s get real, Real Skills Plus, supervision project and the National Training Plan).

• Amodelsubmittedfortalkingtherapieswork(seethesectiononframeworksandAppendix 2 for this model) be considered.

In the academic context: • Ithasbeensuggestedthata“centreofexcellence”modelmaybeausefulavenuefor

nursing to pursue. For example, a university may choose to specialise in postgraduate training in talking therapies for nursing.

• We Need to Act will communicate concerns about the academic quality of mental health nursing and suggestions for improvement, that is, that:

o the fundamental skills that underpin the establishment and development of therapeutic relationships and readiness for working in a talking therapy environment are specifically taught in undergraduate nursing training

o such skills include a strong emphasis on experiential practice of communication skills and engagement techniques

o the skills are extensively built on in entry to specialty practice programmes at new graduate level by all tertiary providers (again with an emphasis on experiential learning where possible).

In the service context: • ResearchandexperienceintheUKhaveshownthatthefollowingstrategieshave

worked to embed a culture of “therapeutic mindedness” and use of therapy strategies (e.g. CBT, DBT) in services:

o the knowledge that good therapeutic skills will protect (both the service user and the clinician)

o focus on strategies first (not therapies) o top down and bottom up approaches o strong leadership “this will happen” o dedicated resource person (i.e. specialist in therapy approaches) o well-informed medical staff who support the change o active promotion of therapeutic approaches by management o change led by clinical nurse specialist and nurse leaders o playing to staff member’s strengths o public acknowledgement of good work (Garland, personal communication, April

2008).

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• Accesstoclinicalsupervisionmayalsoenhancetherapeuticapproaches.Workwasrecently undertaken as part of Te Pou’s projects on professional supervision (McKenna et al (2007)) which examined clinical supervision in New Zealand. A practical way forward is currently under development via Te Pou.

• Workdonefora Master of Nursing by Jenny Nichols in 2007 supported the points made above, that is, that some factors in current services can serve to promote the use of CBT in mental health services (and some factors can hinder its use).

• Documentingsuccessstoriesmaybeusefulfornursingasaprofessiontoshowwhatcan be achieved with the right support.

As for Action point 13: Communicate talking therapies reports to the national nursing groups.

As for Action point 2a & 2b: Train staff in basic engagement and counselling skills; Draft curriculum content for basic counselling and engagement skills that could be used across discipline as best practice for undergraduate works.

Action point 14: Use multiple national workforce processes and frameworks to enhance the mental health capability of nurses (e.g. post-entry clinical training, Let’s get real, Te Raukura, professional supervision, and the National Training Plan).

Psychology

Feedback came from a written submission by the College of Clinical Psychologists (NZCCP), psychologists from Waitemata DHB, Counties Manukau DHB and many individuals. A NZCCP member outlined a possible framework for talking therapies which will be discussed in the section on frameworks further on in this report.

Key issues

• InNewZealandasof1January2009,therewere2009psychologistspractisinginNewZealand (Psychologists Board, www.psychologistsboard.org.nz). This figure is made up of a variety of different scopes so not all those people work in mental health:

o clinical scope: 1061 o educational scope: 163 o psychologist scope: 669 o interns: 109 o trainees: 7• ThePsychologistsBoardalsoreportsthattherearemanymorefemalepsychologists

than male (1433 females and 576 males). • Ofthe1140(76.4%)psychologistswhorepliedtotheannualMinistryofHealthsurvey,

the majority 371 (28.3%) stated that they were working for a DHB and 24% work in private practice (NZHIS, 2008).

• Thelackoftalkingtherapieswashighlightedinseveralsubmissions.Forexample:“The difficulty is that psychological interventions are considered to be optional or at best auxiliary in mental health services” (Auckland Regional Forum of Psychologists, March, 2008).

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• Akeyissueforpsychologistsseemstobeaquestionofwheretheirfuturerolelies.Richards (1994) in Giving Psychology Away notes that James (1994) describes one of the central dilemmas facing psychologists: Should they become increasingly involved in training other health professionals to implement psychological procedures? What are the ultimate implications for their profession if they do so? This paper argues that because of their training, psychologists possess a thorough understanding of psychological theory and should therefore assume responsibility for its application. Richards suggests that the ultimate well-being of service users may best be served by psychologists occupying consultant roles within the health-care system.

• Onepersonechoedthethoughtsofothers:“I have no problem with non-psychologists providing evidence-based therapies. I just want them to do it well” (Emily Cooney, personal communication, October, 2007). A minority argued that only psychologists should be doing therapy.

• Inlinewithotherfeedback,psychologistsingeneralthoughtthatfurtherupskillingin CBT and MI was useful but not as “core competencies” in mental health (as the We Need to Talk report stated). The NZCCP stated “While many of the new roles (e.g. support worker, employment consultant, recreation support) have much value to add for consumers, they do not – and should not – include provision for formal talking therapies such as CBT”.

• Theimportanceofbasiccurriculaisalsonoted:“The priority should be on underpinning competency in basic interpersonal/counselling skills and gaining a solid knowledge of major mental disorders and thorough safety/suicidality assessment and formulation before ANY therapy is undertaken”.

• Yet-to-be-publishedresearchfromacademicswhoteachCBTsuggests:“Students come to the course with limited background knowledge about conditioning, behaviour change, cognitive psychology and assessment. It is simply not possible to cover these areas in as much depth in a one year course as would happen during a psychology degree. However, students are trained to an adequate level to practise competently under the supervision of a clinical psychologist (and there is good evidence that non-psychologists can practice CBT effectively). Training mental health workers in the use of CBT reduces distress for them in that they are more able to make sense of the client’s presentation and to intervene effectively, rather than spending time unproductively”. This same work found that there were some barriers to fuller use of what students of CBT had learned in a one-year course. High caseloads, high acuity of peoples served and having a case management role in particular, appeared to be barriers to CBT use. In addition, results suggest limited workplace support for ongoing skill development (e.g. access to supervision, further training and reading materials) and little monitoring of their practice through supervision.

• TheNZCCPnotedthatthosewhogavefeedbackonWe Need to Talk – stating that the CBT literature is mainly based on a non-mental health population and so is “inappropriate for mental health” – are wrong. “The history of CBT is well documented and the briefest literature search on CBT for depression, for example, will give thousands of references. The application of CBT to addictions is also quite well supported. Motivational Interviewing has been extensively used and evaluated in the addictions area and there is a recent book on the use of motivational interviewing in mental health (Arkowitz, 2008) that summarises the relevant literature. The research base for the effectiveness of CBT is primarily among people who meet the criteria for mental disorders. It is the treatment of choice for people with anxiety disorders, and is at least as effective as medication for most people with depressive disorders. It is also used among people with psychotic disorders and is often a component of the treatment of substance use disorders too (not just MI)”. As Dr Kate Scott notes: “This is not to say that CBT is the only evidence-based treatment for mental disorders, but it is to say that its evidence base is among those with mental disorders, and it has the most substantial evidence base across the range of mental disorders, among the talking therapies”. The NZCCP also noted that there is plenty of literature supporting the use of CBT with complex presentations.

• Twosubmissionsfromgroupsofpsychologistsnoted:“Practice-based evidence trumps

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evidence-based practice” (Waitemata DHB and regional psychologists’ forum, April 2008).

• Thereisaneedtoputinplaceprocessesthatmeasurechangeovertimeintherapy.

Opportunities to enhance talking therapies in psychology

• TheWerryCentrehascontractedareportthatwillconsiderwaysforCAMHStorecruit and retain psychologists. A document by Dr Malcolm Stewart and Dr Ian Lambie suggests strategies to strengthen the child and adolescent content:

o in universities – (e.g. fund a diploma of child, adolescent and family cognitive behaviour therapy) and have a specified minimum standard of child and adolescent content in academic programmes, and create “centres of excellence” or specialty centres in child and adolescent

o in services – have staff attendance in high-level child and adolescent training as an indicator of the quality of the service provider, create conditions of employment attractive to psychologists, and develop strategies to better support Maori and Pacific psychologists.

• Manypsychologistsnotedanurgentneedformoreinternpsychologiststobetrainedwithin mental health and addiction services. The following quote is typical of feedback received: “The number of positions is currently limited by lack of funding provided with no provision for PECT funding. National arrangements for training of intern psychologists are haphazard and inequitable. We recommend the funding for workforce development be directed towards increasing the number of paid clinical placements for intern psychologists”. (Capital and Coast DHB clinical psychologists, October, 2007).

• Buildingonexistingpsychologycentres(e.g.ThePsychologyCentreinHamilton)andthat operated via Otago would seem to be a useful way of approaching strengthening training and supervision of psychologists. The website of The Psychology Centre notes: “The centre is the operational arm of the Waikato Clinical Psychology Educational Trust, a charitable trust partly funded by Waikato District Health Board, and functioning in association with Health Waikato and the University of Waikato Clinical Psychology postgraduate diploma programme. The Centre has multiple functions, i.e., training and education, programme development, research (applied and applicable), clinical service delivery, consultation, and supervision” (www.tpc.org.nz).

• Re-examineprocessesforsupervisionforregistration. • Aspsychologistscanprovideanimportantroleinsupervisionandtrainingof

practitioners learning CBT and MI, there needs to be more of them. The NZCCP and other individual psychologists urge Te Pou through Skills Matter, to redress years of CTA’s unwillingness to fund internships on clinical psychology training. This lack of funding has led to restricted numbers of psychologists entering the mental health workforce.

• Thereissupportforasteppedcareapproachandforwell-trainedstafftobefreedfromcase management in order to assist with supervision and training of other practitioners learning CBT and MI.

• NZCCPsuggeststhatTePoucarefullyconsidertheinfrastructureneededtoimplementCBT and MI within mental health services. Availability of high quality academic courses is necessary but not sufficient to create a culture change and achieve effective implementation within DHB clinical services. It is vital that regular supervision be part of the learning process, and that there are skilled supervisors available in the clinical environment.

• Thepossibleintroductionofanewdegreefocusingonmentalhealthandaddiction(similar to that established in health psychology) should be explored.

• Somepeoplethinkitisimportanttorecognisethedifferencebetween,forexample,CBT therapy and CBT skills. While are important, those psychologists (and other disciplines) who are competent CBT therapists are different from clinicians who practice CBT skills.

• Psychologistswanttobeincludedinnationalplanningprocesses.

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As for Action point 13: Communicate the talking therapies reports to national psychology groups.

Action point 15: Contract work examining ways to strengthen the psychology workforce.

Psychotherapy

Key issues

• Psychotherapistsappeartohavedifficultiesregardingtheirplaceandrolewithinmental health and addiction services. For example, most DHBs will not appoint a psychotherapist to a “therapy” position. Anecdotal feedback suggests that Waitemata and Hawke’s Bay are the only DHBs to appoint psychotherapists in adult mental health services. Child psychotherapists are slightly more common and play a valued role in CAMHS.

• Thereareseveralpossibleexplanationsforthis.Untilrecentlytheywerenotaregistered profession under the HPCA Act (however, this process has been put in place); managers (and others) are not quite sure what psychotherapists “do”; and there is a perception that any therapy being undertaken by a psychotherapists will take a long time and be costly in an environment where getting people seen and treated in order to move on to the next person is the norm.

• TheseissueswerediscussedinameetingwiththeheadofthePsychotherapyAssociation. It was suggested to them that they had a “public relations” problem in that other staff do not appear to be clear about what they offer as a profession, and for whom? The challenge was given to this group (and to Psychotherapy staff at AUT) to examine why the profession does not yet have a recognised and valued place within mental health and addiction services.

• Ahelpfuldocument(unpublished)providedthroughfeedbackwasIs Psychotherapy Any Good? A review of evidence relating to psychodynamic psychotherapy and the nature of psychodynamic assessment by Sean Manning, October 2006.

Opportunities to enhance talking therapies in psychotherapy

• Psychotherapyhasbeenanuntappedworkforceforavarietyofreasons.AsthePresident of NZAP says: “If the Ministry accepts the value of a multi-modal, multi-phasal framework for talking therapies and supports the practice of psychotherapy, we think that the DHB managers will begin to be more open to developing career structures for psychotherapists within the mental health services.

• The time is right for psychotherapy to become more visible. Moves from the Ministry to require that in future ‘talking therapies’ are provided in all mental health services comes at the same time that psychotherapy is becoming a registered health profession This synchronicity makes us hopeful that, in future, DHBs will be more open to employing qualified psychotherapists.

• Those services that have employed psychotherapists are aware that psychotherapists do not only provide clinical services, but they can be a useful resource for staff through supervision, consultation and can make valuable contributions to training and team development. Experience in Auckland DHB suggests that once psychotherapists are employed, DHBs will develop mental health service standards that include psychotherapy and better career paths will be developed, which will in turn, serve to encourage more people to see psychotherapy as a viable career option.

• We see that associations like NZAP as well as the new Psychotherapy Board can help by providing more material about the application and the benefits of psychotherapy. NZAP is committed to developing material that can be used to educate consumers, the general

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public and clinicians about what psychotherapy is and when it can be useful” (Roz Broadmore, personal communication, April 2008).

• Psychotherapyisnowincludedinthetalkingtherapiesframework(asshownbelowinSection C8).

As for Action point 13: Communicate the talking therapies reports to national psychotherapy groups.

Occupational Therapy (OT)

Key issues

• Manyoccupationaltherapistsdonotpractiseinmentalhealth. • Staffshortagesincreasethelikelihoodthatstaffwillbecomemoregenericintheir

practice and practise in a more risk aversive way. • ItwasnotedthattheMinistryofHealthappearstobeparticularlymedically-driven,

with most documents to the sector focusing on risks and medical terminology rather than therapeutic approaches or being “psychologically-minded”.

Opportunities to enhance talking therapies in occupational therapy

• Allowstafftopractisefromtheirdiscipline-specificfocus,thusenablingarangeofpsychological/psychosocial interventions to be practised.

• Focusonstrengthsandwellness. • SeveralDHBsaredoingstock-takesoftheirtalkingtherapieswork–thiswillbehelpful

in future planning. • Includeoccupationaltherapistsinnationalplanningprocesses.

As for Action point 13: Communicate the talking therapies reports to the national OT agency.

Social Work

Key issues

• SocialworkprofessionalleadersandadvisorsofDHBshaverecentlycompletedadocument which outlines an agreed practice framework for social workers working in DHBs generally (including mental health and addiction services). The document defines social work, workers’ roles, settings, processes, theoretical assumptions assessment and activity.

• Socialworkersworkacrosshealthinavarietyofwaysandsomechoosetospecialiseand train in talking therapies (e.g. family therapy).

• Undergraduatedegreesincludelittlementalhealthcontent,andsomeDHBs(e.g.Auckland DHB) have chosen to offer additional training in mental health and addiction issues.

Opportunities to enhance talking therapies in social work

• ThereisgeneralagreementthatCBTandMIareappropriateprocessestobefurtherdeveloped for mental health and addiction services.

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• Socialworkerswhoworkinmentalhealtharesupportiveofincreasedtalkingtherapies. • Includesocialworkinnationalplanningprocesses.

As for Action point 13: Communicate the talking therapies reports to the national Social Work group.

Other Mental Health and Addiction Workers

Consumer Advisors

Key issues

• Consumeradvisorsplayarolethatisfocusedonimprovingtheserviceorsystem.Theyagain highlighted issues raised in We Need to Talk, that is the need for staff to have:

o excellent listening, communication and engagement skills o the time to talk with service users o the ability to share information. • Anotherareathatwasdiscussedwasaclient’sability(orrather,lackofit)tochange

key workers if they feel unable to progress with a particular clinician. As one person noted: “I personally feel that there should be some sort of cut-off point for engagement/progress. If the client is not engaging or making progress with their clinician by a certain appointment, then there should be some sort of a review of their case and what the issue with engagement is. There should be acknowledgement that there is sometimes a genuine need to be able to change your key worker if you do not get on with the one you are assigned, as not everyone can be all things to all people. It’s all about listening to the underlying messages as well as what clients are saying” (Dianne Black, personal communication January 2008).

Opportunities to enhance talking therapies in mental health through consumer advisors

• Asnotedearlier,anupdatedversionoftheTePoufundedconsumeradvisortrainingis being delivered by Blueprint Centre for Learning. It has been suggested that this training could include basic information about talking therapies (especially CBT and MI) so that advisors can better support service users in accessing talking therapies and better support service development in this area.

As for action point 2a: Enhance consumer advisor training in basic engagement and counselling skills.

As for Action point 13: Communicate the talking therapies reports to the national consumer advisor group

Family Advisors

Key issues

• Familymemberswantbetteraccesstotherapyforserviceuserswhererequired. • Onoccasion,familymembersmayalsorequirecounsellingsupportfromagencies

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such as SF (Supporting Families). Sometimes there are negative consequences on family relationships after a mental health crisis situation, so the main purpose of talking therapy would be to help family and service user make sense of and repair the relationship.

• Itwouldbehelpfultohavewritteninformationthatmayhelptobetterinformfamilymembers about different therapies and their benefits.

• ThelaunchoftheCarers’Strategyon29April2008inWellingtonisseenasalandmarkstep for families supporting people with health and disability needs (this is available on www.msd.govt.nz).

Opportunities to enhance talking therapies through family advisors

• Strongerinclusionoffamilyadvisorsinservicedevelopment(ofmentalhealthandaddiction services) in New Zealand would lead to stronger advocacy for talking therapies.

• Familyinclusivepracticeshouldbeseenaspartofstandardservicepracticenationwide.

• Iffamilymembersarebetterinformedabouttalkingtherapiestheycanbettersupportthe therapy process for service users.

• OnefamilyadvisorfromAucklandnotedtheusefulnessofaparticulartypeoftraining:“I would like to put in a plug for voice hearing workshops currently delivered in ADHB by Debra Lampshire and Helen Hamer which draw on CBT and DBT skills. It would be great to see this offered to service users in other DHBs. They have recently delivered a workshop to families/whanau with excellent feedback from families which will be delivered on an ongoing basis” (Leigh Murray, personal communication May 2008).

As for Action point 13: Communicate the talking therapies reports to the national family advisors group.

Community Support Workers New Zealand has one of the largest mental health and addiction NGO sectors in the world delivering a wide range of community-based support services that account for one third of the total national mental health expenditure. Non-government organisations have developed services that are recovery focused, people centered, culturally responsive and linked to reducing social inequalities that improve the overall health of people living with a mental illness. The NGO support workforce usually has the most contact with people that use services. It is currently estimated that over 50 different occupations are working in support services and an emerging trend appears to be the development of the peer support worker. The NgOIT 2007 Workforce Survey identified that 77 per cent of support workers had undergraduate certificates or diplomas, postgraduate qualifications or degrees, and that there were a number of registered health professionals employed in support services.

Future mental health and addiction service development will depend on robust NGO workforce development and the sector will need to choose the most useful tools and practices that support the complexity and diversity of the NGO workforce.

As with feedback from other staff groups, feedback from community support workers suggests that it would be useful for training to include: • communicationskills(basiclistening,waystodevelopeffectiveengagement,building trust etc). • abasicintroductiontodifferenttherapiesandtheparttheymayplayintherecovery process (e.g. CBT, MI, psychotherapy, DBT etc) and models (e.g. the Strengths Model).

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As for Action point 2a: Enhance support worker training in basic engagement and counselling skills.

As for Action point 13: Communicate the talking therapies reports to support workers.

Counsellors

Key issues

• Around3000counsellorsmaybemembersofoneormorecounselling.associations(e.g. NZAC, New Zealand Association of Counsellors; DAPANZ, Drug and Alcohol Practitioners; NZCCA, Christian Counsellors and Te Wahiki Tautoko, Maori Counsellors).

• NZACisseekingregistrationundertheHPCAAct. • NZACPresidentAnitaBocchinostates:“There are 12 approved training programmes

and criteria for membership is a practice which is based on assessment and evaluation of the client’s problem(s). While we currently have a rigorous application process towards membership, our membership committee is completing a process of revising membership criteria so that, among other things, members must now have completed counselling trainingtoaminimumofNZQALevel6,aminimumof500hoursintotalofsupervisedpractice, completed a minimum of 20 hours of individual personal counselling as a client and demonstrates on-going commitment to personal growth. They will have been interviewed by a panel of Members on behalf of the Membership Committee and have had their suitability for Membership confirmed by interview.”

• AsNZACisnotyetaregisteredprofessionundertheHPCAAct,manyDHBsareunwilling to employ their members in mental health services (however, they are employed in addiction services).

• MostcounsellorsareemployedintheaddictionandNGOsectorsbuttheyarealsoemployed in specialist mental health services (e.g. CAMHS).

Opportunities to enhance talking therapies through counsellors

• Attainmentofregistration(underwhateverumbrella)willbeamajorleapforwardforthis group.

• Thosecounsellors/practitionerswhocurrentlyworkinmentalhealthoraddictionservices should be part of any workforce development opportunities.

• Ithasbeensuggestedthatthisgroupwouldbenefitfromatrainingpathwayinmentalhealth and addiction as a speciality.

• Thisisagroupthatisrelativelyuntappedinmentalhealthservicesand(whenregistered or the equivalent) it could add to the workforce of the future.

As for Action point 13: Communicate the talking therapies reports to the national counsellors group.

Addiction Practitioners

The addiction workforce is comprised of workers from all the professions mentioned earlier, and has its own practitioner competencies, also mentioned earlier. These practitioner competencies are in the early stages of review by the Drug and Alcohol Practitioner’s Association Aotearoa - New Zealand (DAPAANZ) and supported by Matua Raki. The role of talking therapies in such competencies is likely to be maintained and further clarified.

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As noted on the Matua Raki website, DAPAANZ represents the professional interests of its members – the practitioners and clinicians working in addiction treatment. Anyone with an interest in addiction treatment can apply for membership. Membership offers the benefits of belonging to a professional organisation with a code of ethics and the opportunity to contribute to the development of the addiction treatment workforce. In addition, experienced qualified practitioners can apply for registration of practitioner competency. This attests to their ability to work with addiction at an independent clinical case manager level. Current registered practitioners are listed on the site (www.matuaraki.org.nz).

The purpose of DAPAANZ, as noted on the website DAPAANZ Works, is: • “Tosupportandassistinthedevelopmentofculturalcompetenciesandofclinicians

working with people from an ethnic base, particularly Maori and Pacific peoples. • Tosupportthescopingofanddevelopmentofcompetencystandardsforcliniciansworking

in specific or support roles in the field. • Toadvocateforandsupportthedevelopmentofclearpathwaysbywhichclinicianscan

move from support roles to Registered Accredited Practitioner competence and beyond, should they choose.

• Todevelopaprocessformaintenanceofprofessionalstandardsandcontinuingprofessional development for registered accredited practitioners.

• Tocontinuetomanagetheregistrationprocessforaccreditedpractitionersovertheshortto medium-term.

• ToapplyfortheregistrationofalcoholanddrugcliniciansundertheHealthPractitioners’Competency Assurance Act.

• Toimplementaprocessformanagingcomplaintsagainstitsmembersonthegroundsofcompetence or ethical standards” (www.matuaraki.org.nz).

As for Action point 13: Communicate the talking therapies reports to the national addiction practitioners group

Opioid Substitution Treatment Workers

Raine Berry is currently conducting a review of the 2003 Opioid Substitution Treatment Practice Guidelines. This involves around 150 staff nationwide, with the most being in Auckland, Wellington and Christchurch. Most staff would be trained in Motivational Interviewing, some with CBT and a few with DBT. The service user group may present with a range of co-existing problems with around 70% having some sort of past trauma, suggesting that access to staff expert in this area would be useful. She has found during the review process that there appears to be variability around the country in the case management role, with some people undertaking a lot of counselling (e.g. using CBT techniques, Motivational Enhancement Counselling, family and/or couples counselling and the strengths model); while others see their role as more of a brokerage one in which they seek talking therapies if needed from other agencies or staff; and still others see the role as primarily that of monitoring drug use. Raine suggests that a standard skill set may be useful for this group of staff. The most useful start may be providing CBT training for those who are not currently expert as well as training in the use of family inclusive practice. The revised Guidelines should be available to services early in 2009.

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Other Relevant Addiction Sector Work

Effective Intervention

As noted on the Matua Raki website: “In New Zealand approximately 200,000 people are arrested each year, and a significant number are under the influence of alcohol and other drugs (AoD) at the time of arrest. It is estimated that up to 80% of offenders who appear in court have an AoD problem, and that 83% of prisoners in New Zealand have had a substance misuse disorder at some time in their lives against 32% in the general population.” Effective Intervention projects involve a series of accelerated workforce initiatives, including the development of secondments, scholarships and internships, for which Te Rau Matatini is responsible. The development and establishment of mobile training teams and intermediate and specialist AoD training programmes are being jointly led by Te Rau Matatini and Matua Raki. One project involves the development of Mobile Training to support the AoD and related workforces working with those under sentence in the community. This will be via accessible, short course training. Some early work has been completed, including a stock-take of the existing AoD mobile training programmes and a literature review. A Request for Proposal was issued in January, and the successful contractors are Abacus Counselling Training & Supervision and Hall, McMasters & Associates. These experienced training organisations have partnered to develop mobile training content and to pilot mobile training packages which were delivered between July and September 2008 (www.matuaraki.org.nz).

Mental Health and Addiction Services Managers, Clinical Directors and Planners and Funders

Te Pou has been working with the national planners and funders and their subcommittee to carry out two projects which will contribute to the training and professional development requirements of this group.

The first of these two projects is a website for planners and funders, which was launched on 8 July 2008. The website was developed in collaboration with planners and funders. It is a secure site, with password protected login, featuring information and resources specific to the role. It is designed to support people new to the role as well as provide the more experienced with a place to network and share ideas and professional knowledge. Secondly, a seminar series has been developed in associated with Blueprint Centre for Learning with the guidance of planners and funders.

Feedback suggests that where services in which managers, clinical directors and planning and funding staff all support a “therapeutic” approach to service provision, clinical staff feel valued, and structures and processes are put in place to support their continuing development.

However, many of those contacted believed that managers and planners and funders of services need to have a better understanding of what therapies are used, how they are effective, why they represent value for money and which service delivery systems support efficient use of therapy. This could be a brief written document led by a sub-group of clinical directors. An excellent example of this is the “Investing in addiction treatment” document published on the Matua Raki website by NCAT (2008). Following the document dissemination, a discussion could be held (if warranted) at one of the current Ministry of Health-led regular meetings.

Staff have questioned how some DHBs manage to fund additional talking therapy training and others do not. It appears that, in general, the larger DHBs are able to fund extra training. Opportunities could therefore exist for the smaller and larger DHBs to consider more of a regional approach to some of this work.

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As for Action point 13: Communicate the talking therapies reports to managers, clinical directors and planning and funding staff.

Action point 16: Develop and provide a brief document specifically for mental health and addiction services managers and planning and funding staff outlining what therapies are used, how they can be effective, why they represent value for money and which service delivery systems support efficient use of therapy.

Peer Support Workers

Peer support workers are a service model that has arisen out of the recovery approach to mental health service delivery. Peer support workers believe that all people have the potential to have a life worth living. “For people with experience of mental illness we call this recovery. Recovery is not just managing your mental illness; it is about actively working towards the life you want” (www.mindandbody.co.nz). Peer support services usually offer people the opportunity to work with someone who has been through this process. They will support service users on their recovery journey, whether in an inpatient setting or in the community. “Peer support services will encourage you to take responsibility for your own recovery. You actively promote your wellness by connecting or reconnecting with your whanau/family and friends, jobs, home and community. You decide where you live, how you manage your money and how your spiritual needs are met”. (www.mindandbody.co.nz).

The belief is that we all have talents, skills and aspirations that are the foundation for recovery. Therefore a peer support worker can support service users to make positive changes in their life by helping them to: • identifytheirstrengthsanddesires • setgoals • planthenecessarystepstoachievethem.

Peer support workers have varied backgrounds and experiences, but all peer support workers have personal experience of significant mental illness and insights gained from their experience. “We know recovery because we live it” is the basis of the peer support relationship. People are generally able to choose the worker they feel most comfortable working with.

Key issues

• Fundingforpeersupportservicescurrentlycomesoutofsmallpocketsofmoney(e.g.the Mental Health Commission). As one peer support service leader said: “If we are serious about providing services that are really focused on recovery we would shift funding from services that come out of the “institutional” era (e.g. inpatient units), and we would instead put that money into services that grew out of the recovery era” (Jim Burdett, personal communication, April 2008).

• Thepeersupportmodelhasalowerprofileintheaddictionsector,butthenthesectorworkforce includes many who have personal experience of recovery from addictions. Kaupapa Maori peer support models have recently emerged in the addiction sector as a model.

Opportunities to enhance talking therapies through peer support workers

• Peersupportworkerswouldneedtobepartofanymovestoprovideinformationand/or training on engagement skills and having a basic knowledge of the range of therapies.

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• JimBurdettsays: “Peer support is, in effect, a “talking therapy” – although the clinical term ‘therapy’ is not appropriate for a role explicitly non-clinical. However, while not a professional role, a properly trained peer support worker uses aspects of social work, occupational therapy and counselling” (Personal communication, May 2008).

As for Action point 2a: Enhance peer support worker training in basic engagement and counselling skills.

As for Action point 13: Communicate the talking therapies reports to peer support groups.

Work Being Undertaken in Other Relevant Areas

Primary Mental Health Care

The Ministry of Health is currently drafting a policy paper on primary mental health care. This paper is important, as primary care is increasingly positioned to provide more talking therapies to people with mild to moderate mental health problems.

Key issues

• Betterintegrationbetweenprimarycareandsecondaryservicesisseentobeneededand work is under way via the primary mental health initiatives to deliver this. This has not yet been a focus of the Ministry of Health but is planned (Christan Johnston, personal communication, February 2008).

• Acommonlanguageamongprimarycareandmentalhealthwouldbehelpful(TonyDowell, personal communication, February 2008). Primary care workers see that mental health and addiction services use “jargon-filled” language. An example of inappropriate language is the mental health concept of “recovery”. This word does not sit well in the primary care arena according to primary care practitioners. They see that the recovery approach was critical when deinstitutionalisation was occurring, but primary care sees itself as focusing on wellness – both physical and mental. At a recent meeting the argument was made: “While the word ‘recovery’ might be misunderstood and not seen to apply to primary care, at least some of the underlying principles do still apply. While the concept of getting back things that have been lost (e.g. friends, home and/or job) may not be as relevant for primary care as secondary care, patients in primary care still want to be able to live well (in the presence or absence of symptoms), have meaning in their lives, and be able to make their own decisions about the care they receive (self-determination). Instead of the focus being on regaining meaning in life, the focus is perhaps more on retaining meaning in life - but there will be still be plenty of examples of people being seen by primary care for whom the focus WILL be on regaining meaning in life. This is a debate the sector still needs to have.”

• WorkintheUKbyTrask(2005)foundthatthenatureandqualityofinter-professionalconversation may be important mediating factors in addressing covert barriers to integration between primary and specialist mental health services. Financial pressures in the system may lead to failure on the part of management to sanction and encourage opportunities for inter-professional conversation and the geographical distance between places of work may also limit opportunities for contact.

• Oneimplicationofhavingmoretherapyinprimarycaremaybethatexperiencedtherapists from secondary services would be enticed to work in the primary care setting, thus increasing the workforce problem that already exists in secondary services. However, it was pointed out that an advantage could be that strengthening therapy

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in secondary services would provide a supervisory and consultation resource for less advanced therapies working in primary care.

Opportunities to enhance talking therapies in primary health care

• Collaborativeeffortsbetweenprimarycareandmentalhealthonintegrationusingthediagrammatic model depicted in the Ministry’s policy paper (i.e. shown in Appendix 2) would be useful. Such work could include better ways to communicate, clarity over duration of treatment, better promotion of “wellness” and resilience by mental health and addiction services.

• Primarymentalhealthcareispromotinga“steppedcare”approachtoservicedelivery(see Appendix 2 for a description of this model).

Clinical Training: a gap

Group Therapy

An issue that was raised by people across many areas is the lack of use of group work. It was acknowledged that very few people are left in mental health services that have the skills to undertake such work (although group work is probably stronger in the addiction sector).

It was noted that in the US the American Group Psychotherapy Association has published practice Guidelines for Group Psychotherapy (2007). These Guidelines note that the group setting is an agent for change and group leaders pay careful attention to the three primary forces operating at all times in such a therapy group: individual dynamics; interpersonal dynamics; and group as a whole dynamics. The task of the group leader is to integrate these components into a coherent, fluid and complementary process, mindful at all times that there are multiple variables, such as stage of group development, strengths of group members, mental health issues of individual members, and individual and group resistances, that influence what type of intervention should be emphasised at any particular time in the group (AGPA, 2007).

16. sTudies, puBlicaTions and iniTiaTives in The pipel ine

A Zelen randomised controlled trial of problem solving therapy in people who self harm. This is a study noted in We Need to Talk and funded by the Accident Compensation Corporation. Dr Simon Hatcher and his team recruited patients from four centres in New Zealand who presented to a general hospital after intentionally harming themselves – usually by taking an overdose of medication. The main exclusions were patients who were still at school, had cognitive impairment, were currently psychotic, had been admitted to a psychiatric unit or had established borderline personality disorder (receiving DBT or written management plan). The intervention was six to eight sessions of problem solving therapy over two months after the episode of self harm. The main outcomes are measures of psychological distress (anxiety and depression), predictors of further self harm (hopelessness and suicidal thoughts), quality of life, health service use and repetition of self harm. Patients have been followed up at three months and one year after their index episode of self harm. Over two years 593 people consented to be part of the trial. Of these, 299 received treatment as usual and 253 received problem solving therapy. After three months and a year, those who received the problem solving therapy were significantly less depressed, less suicidal and less hopeless. People who received problem solving therapy also used fewer hospital resources. Those people who presented with self harm for the first time were less likely to harm themselves again if they received problem solving therapy compared to treatment as usual. The analysis of the data and preparation of papers related to this study is currently in progress.

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New Zealand Guidelines Group

Funded by the Ministry of Health, the New Zealand Guidelines Group (NZGG) has completed the document Identification of Common Mental Disorders and Management of Depression in Primary Care. This document is a helpful addition to the primary care (and overall health and mental health) toolkit.

Auckland DHB Keyworker Training – “Recovery”

This training was developed to address the lack of tailored training programmes for this group of staff. The keyworker training was very comprehensive and based on the Treaty of Waitangi and cultural safety, recovery competencies for mental health workers, local and international best practice in therapies, and working with family/whanau (Jamieson et al; 2006). An evaluation of the pilot programme showed that staff in the programme found it very helpful in working more effectively with services users. The northern region is supporting the adaptation and implementation of this training for the other northern region DHBs, with Waitemata Health’s implementation commencing in 2009.

17. ouTcome measuremenT in menTal healTh and

addicTion services

If an agreed programme of strategies was put in place to enhance service users’ access to talking therapies – how might we measure such increased access? There is a need to assess whether any existing measure or information collected is relevant to the enhancement of talking therapies.

Outcome measures

Several measures of outcome are being developed under the Te Pou Research Programme, and the Te Pou Information Programme will have the responsibility for the implementation of outcome measures.

Using such measures, enhancement of access to talking therapies should (in theory) show up as enhanced progress in service users’ lives.

Service user measures

The development of Taku Reo Taku Mauri Ora (My Voice, My Life) is being led by Case Consulting and the measure is in the final stages of development. Te Pou will work closely with Case Consulting to develop data definitions, rating rules, interpretation and reporting guidelines.Implementation processes are currently being reviewed by the Ministry of Health.

In addition, individual clinicians may choose to apply any one of a variety of Quality of Life measures, or measures of symptoms (e.g. of anxiety).

Existing measures of outcome

Since 2005, the Ministry of Health has required mental health services of DHBs to collect the Health of the Nation Outcomes Scales (HoNOS) suite of measures. These are: HoNOS, HoNOSCA, and HoNOS 65+. In the future HoNOS LD and HoNOS secure may be added to the suite.

This work is coordinated by Te Pou under a process called MH-SMART (Mental Health Standard Measures of Assessement and Recovery). Currently DHBs are at varying levels of collection and thus have differing levels of information available to them. Te Pou has contracted for a report which will provide a general stock-take on the state of play of all measures. This report is currently being finalised.

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Measures in development

The Alcohol and Drug Outcome Project (ADOPT, 2004) presented findings and recommendations in both outcome measure design and development towards validation as a psychometrically sound instrument for measuring outcomes for users of Alcohol and Other Drug (AOD) Services.

The goal of the ADOPT project is to identify a psychometrically sound outcomes measure that is suitable for use within the Alcohol and Other Drug Services sector.

The aims of phase two of the ADOPT project (the ADOPT II project) is to refine the Routine Outcome Measurement Questionnaire (ROMQ) developed in ADOPT phase one and to test it with a clinical population.

Assessment of progress

A system of measurement based on the work of Dr Scott Miller (www.talkingcure.com) is used by some individual clinicians in New Zealand. He has developed two simple, one-page measures that are completed in conjunction with the service user (and whanau or significant others), which take less than two minutes to complete. The Outcome Ratings Scale measures service users’ perceptions of whether they are benefiting from the service provided. The Session Rating Scale measures the strength of the alliance between the provider and service user. In essence, one measure is used at the beginning of each session (to assess change since the last session), and one is used at the end of each session (to assess progress in that particular session).

All information is talked through with the service users at all stages of the process.

The software then incorporates the scale results into results reporting for the service users and all levels of an organisation, it identifies people/therapists at risk for failure and provides feedback messages designed to improve outcomes. It’s already being used at several behavioural health care organizations in the US, including the US Navy and Magellan Health Services.

Robyn Byers recently brought Dr Miller to Nelson-Marlborough to run a two-day workshop for clinical staff called “Supershrinks – good from great”.

Robyn notes “The clinical session/outcome scales are more specific to individual therapy and as such they are valuable tools for the service user (and family/whanau where appropriate) and the clinician to track progress. It is also possible to compare data to USA norms. To facilitate this, there is computer program for clinicians (A.S.I.S.T. - Admin, Scoring, Interpretation and Data Scoring Tool). They can be aggregated for use in professional and service development. It could easily be part of the existing (and proposed) suite of measures” (Robyn Byers, personal communication, April, 2008).

Two services in Nelson-Marlborough, an Early Intervention for Psychosis Service and an outpatient clinic for adults, have started to use these measures.

In summary the best (and promising) practice guidelines should include outcome measurement in their content.

Action point 11: Te Pou to contract for best (and promising) practice guidelines for Maori, Pacific and Asian (i.e. similar to guidelines completed by Dunnachie, 2008 for children and youth) and include outcome measurement in their content

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18. educaTion providers

As noted earlier in this report, many who gave feedback suggested that undergraduate training for professions entering mental health is now more likely to be deficient in content relating to basic engagement and counselling skills (as compared to several years ago when such skills were seen as more important to teach). It has been suggested that a review is carried out to assess what is being taught, in order to better strengthen these skills across disciplines. As a prerequisite, the identification of specific skills, attitudes and behaviours (e.g. real skills) relating to basic counselling and engagement skills would need to occur in order to have a template against which curricula could be assessed.

Action point 2a & 2b: Enhance staff training in basic engagement and counselling skills; Draft curriculum content for basic counselling and engagement skills that could be used across disciplines as best practice for undergraduate work.

19. conclusions and where To from here

This report has shown that many people in the mental health and addiction sector would like to see a more coordinated approach to providing a range of talking therapies.

Key issues that will be addressed by talking therapies work

Enhanced access to quality talking therapies for service users through: • Enhancingcoordinationandbestpracticeoftalkingtherapies. • Enhancingexperientiallearningaroundessentialcommunicationandengagement

skills. • Promotingmentalhealthcontentonengagementskillsandtalkingtherapiesby

nursing and allied health. • Strengtheningthepsychologyworkforce. • EnhancingourknowledgearoundwhatworksforMaoriandtangatawhaiora/whanau. • EnhancingourknowledgearoundwhatworksforPacificpeoples. • EnhancingourknowledgearoundwhatworksforAsianpeoples. • Enhancingourknowledgearoundwhatworksformigrantandrefugeepopulations. • Informingthefundingandplanningprocess. • Utilisingexistingworkforcedevelopmentstrategiestofurtherthiswork.

The “Action Plan”

A draft Action Plan has been written to sit alongside We Need to Act, making its action points operational.

Key national workforce processes that will be informed by the Action Plan

All processes will have input from service users and will be further informed by: • TheNationalTrainingPlan • SkillsMatter • Let’s get real • ProfessionalSupervision

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Action points

Each action point outlined in We Need to Act will form the basis for the brief draft Action Plan for 2008 to 2011 which will sit alongside this current document and be the basis for future activities.

Action point 1: Use the phrase “talking therapies” in this work.

Action point 2: (a) Enhance staff training in basic engagement and counselling skills; (b) Draft curriculum content for basic counselling and engagement skills that could be used across disciplines as best practice for undergraduate work.

Action point 3: Include the talking therapies noted in the box on pages 27-30 in the framework.

Action point 4: Facilitate increased numbers of staff to train in CBT and MI in a way that they are able to practise their skills in a safe, effective and sustainable way to the benefit of services users.

Action point 5: Contract for a report that examines ways to ensure that New Zealand has a clear direction for DBT moving towards a sustainable DBT training programme.

Action point 6: Include traditional therapies for Maori and Pacific peoples in the talking therapies framework.

Action point 7: Use the proposed framework in the planning and actioning of talking therapies work.

Action point 8: Follow up with the National Service Framework project manager and recommend that talking therapies are included in the final version of the NSF.

Action point 9: Document a user-friendly guide to therapies included in the framework for service users so that they are well-informed about therapy processes.

Action point 10: Contract work examining what processes enhance talking therapies for Maori (i.e. what enhances the effectiveness of Maori practitioners working with Maori clients; and, what processes might enhance the effectiveness of practitioners of other cultures working with Maori clients).

Action point 11: Te Pou to contract for best (and promising) practice guidelines for the assessment and treatment of other specific populations (i.e. similar to that completed by Dunnachie, 2008). Best practice needs to be specified for different talking therapies for population groups with different disorders and include information on assessment and outcome measurement. If prevalence and projected prevalence are clear then planning for what is needed with regard to workforce development is clearer. This will include:

• Maori • Pacificpeoples • Asianpeoples • Olderpeople • Peoplewithaddictionproblems • Refugeesandnewmigrants

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• Peoplewithphysicalandmentalhealth/addictionproblems

Action point 12: That Te Pou continues to promote and support the work of The Werry Centre.

Action point 13: Communicate the talking therapies reports to all key stakeholders.

Action point 14: Use multiple national workforce processes to enhance the mental health capability of nurses and allied health staff (e.g. Skills Matter post-entry clinical training, Let’s get real, supervision and the National Training Plan).

Action point 15: Contract a report examining ways to strengthen the psychology workforce.

Action point 16: Develop and provide a brief document specifically for mental health and addiction managers and planners and funders outlining what therapies are used, how they are effective and why they represent value for money.

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Appendix 1 people who conTriBuTed By giving informaTion To The conTenT of This reporT

Maria BakerMichael BatchelerRaine BerryDianne BlackMarion BlakeAnita BocchinoDavid BradleyRoz BroadmoreJim BurdettVicki BurnettRhona CarsonDr David ChaplowJudi ClementsDr Sunny CollingsDani CoplonMaria CotterKaren CouttsDr Oliver DavidsonDr Daryle DeeringTrudy DentVal DochertyChristine DochertyEmma Dore Dr Tony DowellDr Sarah DwyerDr Bronwyn DunnachieTina EarlJanet EdmondMonique FaleafaDr Koong-hean FooInes Ford-BruinsDr Allen FraserCorinna FriebelDr Anne Garland (and clinical staff attending her workshop)John GawithNigel GeorgeStuart GrayGail GoodfellowHelen HamerFiona HamiltonMike HamiltonGeraldine HancockDr Simon Hatcher (and the clinical research team)Audrey HolmesDr Malcolm JohnsonSuzanne JohnsonKristan JohnstonSue JoyceSelwyn KateneCate KearneyMandy LacyDr Tannis LaidlawGeraldine Lakeland

Michelle LevyDr Sue LutyJosie Goulding Andrew JonesDr Ian LambieIngo LambrechtIan MacEwanBrian McKennaDavid McNabbFiona MathiesonKarl MetzlerMind Matters NGO: service user groupMartin MolloySiobhan MolloyLeigh MurrayNew Zealand College of Clinical PsychologyNew Zealand Psychological Society (NZCCP)Ms Shoba NayarPaula NesJenny NicholsTony O’BrienMary O’HaganOtago DHB clinical leaders groupDr Choye ParkDr Chris PerkinsRoyal Australia and New Zealand College of Psychiatrists (RANZCP)Karen RamseyGraham RoperMark RoseAnna SchofieldDr Kate ScottSegar House teamDr Doug SellmanCarole SeymourVal SharpeRobyn ShearerCindy SmithMark SmithMargot SolomonPaul SolomonLindsay SpirrettMaryse StantonDr Malcolm StewartCarolyn SwansonDr Schizuka ToriiClaire ToveyMark ThorpeSue TreanorDr Samson TseEmma WoodAnnemarie WilleTania WilsonJenny Wolfe

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Appendix 2

relevanT minisTry of healTh policy documenTs

Below is a list of the key policy documents that underpin the current report.

The New Zealand Health Strategy

The New Zealand Health Strategy (Minister of Health, 2000) provides an overall framework for the health sector. It aims to ensure that health services are directed at those areas that will ensure the greatest benefits for the population and has a particular focus on reducing inequalities in health.

Out of 10 goals and 61 objectives, several are relevant for mental health and addiction services, with one goal in particular focusing specifically on mental health:

Goal Objectives

Better mental health • Reducetheincidenceandimpactofstress.• Reducetheincidenceandimpactofdepression.• Improvethehealthstatusofpeoplewithseveremental

illness.• Reducetherateofsuicidesandsuicideattempts.• Reducethestigmaanddiscriminationassociatedwith

mental illness.• Reducetheimpactofdementia.

Enhanced access to quality talking therapies in both primary care (e.g. Draft Policy Advice Paper: Primary Mental Health Care consultation document, April 2008) and mental health care may assist in attaining each objective above.

Our Lives in 2014: A recovery vision from people with experience of mental illness, June 2004

This publication looked at what service users expected and wanted from services in the future.

Te Tāhuhu – Improving Mental Health 2005-2015: The Second New Zealand Mental Health and Addiction Plan

Te Tāhuhu (Minister of Health, 2005) lays out the Government’s priorities for mental health and addiction services.

Te Kōkiri: The Mental Health and Addiction Action Plan 2006-2015

Te Kōkiri (Minister of Health, 2006) sets out the specific actions to meet the challenges outlined in Te Tāhuhu.

Te Hononga 2015: Connecting for greater Wellbeing

Te Hononga (Mental Health Commission, 2007) builds on Te Tāhuhu and Te Kōkiri by providing a destination picture of the mental health and addiction sector for 2015. This picture depicts what mental health in New Zealand will look like when the challenges of Te Tāhuhu are achieved.

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Te Puāwaitanga: Maori Mental Health National Strategic Framework

Te Puāwaitanga (Ministry of Health, 2002) was developed to ensure that Maori mental health services (both mainstream and kaupapa Maori) retain a discrete and prominent identity within the Government’s national health strategy.

New Zealand Suicide Prevention Strategy 2006 – 2016

The New Zealand Suicide Prevention Strategy (Associate Minister of Health, 2006) aims to reduce the rate of suicide and suicidal behaviour and reduce the harmful effect and impact of suicide and suicidal behaviour on families/whanau, friends and the wider community.

Tauawhitia te Wero – Embracing the Challenge: National Mental Health and Addiction Workforce Development Plan 2006-2009

Tauawhitia te Wero (Ministry of Health, 2005) provides national direction for workforce planning in the mental health and addiction sector. The vision of Tauawhitia te Wero is a diverse mental health and addiction workforce that is responsive to the needs of service users, their families/whanau and significant others, and confident in their positive and unique contribution to the journey of recovery. The vision and seven goals of Tauawhitia te Wero focus on workforce requirements for meeting the needs of the population who are most severely affected by mental illness.

National Mental Health Sector Standard

The National Mental Health Standard provides guidance to service providers and the people who use services and their families/ whanau as to what is expected from mental health services in New Zealand.

Blueprint for Mental Health Services in New Zealand: How things need to be

The Blueprint was produced by the Mental Health Commission in 1998. It provides guidelines for the types and levels of services required to meet the needs of people most affected by mental illness and addiction. The Blueprint espoused the recovery approach which has since permeated through mental health service provision in New Zealand.

Te Raukura: Mental health and alcohol and other drugs: Improving outcomes for children and youth 2007

Te Raukura (Ministry of Health, 2007) identifies fundamental principles for child and youth mental health and AoD services, identifies key national issues, and sets out the priorities for improving the mental health of children and young people. Maternal and infant mental health is also a growing area of focus.

The Primary Health Care Strategy

The Primary Health Care Strategy (Minister of Health, 2001) aims to strengthen primary health care and is seen as central to reducing inequalities in health. It involves a greater emphasis on population health and the role of the community, health promotion and preventive care, the need to involve a range of professionals, and the advantages of funding based on population needs rather than fees for service. The Ministry of Health views the Primary Health Care Strategy as an important opportunity for further improving delivery of mental health and/or addiction services.

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Appendix 3

suggesTed frameworks for Talking Therapies via feedBack and informaTion from The menTal healTh, addicTion and primary care secTors

Maori Models of Practice

The following descriptions of models are quoted from a document forwarded by Maria Baker (Ko te kai a te Rangatira he korero3 p. 4 -7) in response to asking for feedback on talking therapies from Te Rau Matatini.

Powhiri Poutama

Te Ngaru Learning Systems developed this framework in the early 1990s. It is based on the Poutama, a stairway pattern often depicted in the Maori traditional weaving art form of tukutuku seen in whare nui/meeting houses. The powhiri is a Maori cultural custom associated with the welcoming and hosting of manuhiri/visitors onto the marae.

The Powhiri Poutama was created to support kaimahi Maori practice in their communities. This framework has been adapted by kaimahi Maori to support their practice with whanau.

The powhiri poutama framework is as follows:Karakia Acknowledge the divine relationship.Mihi Establish relationships (personal and social). Whakapuaki To well up; identify the take, determine everyone’s relationship to the take.Whakatangi To weep, to cleanse, express pain and sorrow; emotional commitment to

common relationship.Whakaratarata The hiatus for change; expression of openness and trust in developing the

relationship.Whakaora Subscription to healthier relationships. Whakaoti The covenant of maintaining the relationship beyond physical sight.

The Poutama represents higher learning and refers to a journey that some people may undertake in discovering their potential. This imagery has been adopted by some educational institutions to represent the learning or development experience.

The Powhiri or welcome is a ritual that is enacted on the Marae, and is an important aspect of Maori protocol. Put together the Powhiri and the Poutama create a system for growth, healing and learning or social development.

Te Whare Tapa Wha

Perhaps the most well known of all Maori health models, Te Whare Tapa Wha, was presented by Durie in the mid 1980s to the Hui Whakaoranga. At this hui there was resounding support by all in attendance that this model is accepted as a Maori model of health applicable for practice in all aspects of health care.

3 ‘Te kai a te Rangatira - he korero’ translates to mean ‘The food of chiefs is communication and discussion’, this is just as relevant to Maori today as it was to our tupuna.

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A translation of Te Whare Tapa Wha reflects the four sides of a house, with each of the walls connected and inter-related (holistic). They can be used and applied in any health sphere. The four main components of Te Whare Tapa Wha are:Te taha wairua (spiritual dimension) – must be complemented with a healthy tinana (body), taha hinengaro (mental and emotional) and taha whanau (family). A healthy wairua balance between each of the taha is required as a deficit in any of the dimensions can therefore be viewed as the individual and/or the whanau being unhealthy. Te taha tinana (physical dimension) includes factors such as socio-economic and environmental circumstances which affect the capacity for optimal physical health.Te taha hinengaro (mental dimension) is the mental and emotional aspects of a person.

Durie (1998) explained that mind and body are inseparable, and that central to the concept of hinengaro is the principle of mauri, the vitality spark or life essence of a person.

Te taha whanau (family perspectives and interactions) is the extended family system that embraces all Whakapapa and contemporary/current significant (person) support ties. It is the principal social, living and learning unit in Maori society (Metge, 1995; Durie, 1998).

Te Whare Tapa Wha continues to be widely known and used by health, social service and counselling professionals, both Maori and Pakeha, in their work with Maori.

Te Wheke

This Maori model of practice has some similarities to Te Whare Tapa Wha. Te Wheke was first introduced and used in the education sector in the 1980s. Rose Pere, the initiator of this model in education uses the symbol of the octopus (Te Wheke) to illustrate the total development of the individual within the context of the whanau. Te Wheke is also based on the notion of holism and eight components have been prescribed within the model: • ThebodyandheadofTeWhekerepresenttheindividual/whanauunit • Eachtentaclerepresentsadimensionthatrequiresandneedscertainthingstohelpgive

sustenance to the whole • Thesuckersoneachtentaclerepresentthemanyfacetsthatexistwithineach

dimension • Theeyesreflectthetypeofsustenanceeachtentaclehasbeenabletofindandgainfor

the whole.

The intertwining of the tentacles represents a merging of each dimension. The tentacles portray certain Maori concepts and values (Pere, 1984; 1991):

Wairuatanga Spirituality, acknowledges one’s godlike beginning.Hinengaro The mind, which is the source of the thoughts and emotions; mental

well-being.Taha Tinana Physical state of well-being.Whanaungatanga Is based on the principle of both genders from all generations.

supporting and working alongside each other; extended familyWhatumanawa Deep emotions.Mauri Essence of the soul/life force/life principle.Mana Ake The absolute uniqueness of individual/identity.Ha a Koro ma, a Kui ma The breath of life through the heritage handed down by one’s ancestor.

taonga tuku iho/inherited strengths.

Like Te Whare Tapa Wha, Te Wheke works to support an integrated approach to understanding wellbeing for people.

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Paiheretia

First presented by Durie in 1999, Paiheretia is viewed as a move towards integrating a relational approach to health with a disease or behavioural approach.

Paiheretia recognises identity, self knowledge and behavioural patterns as reflections of an individual’s complex interaction with the environment. This assumption is considered to be consistent with Maori preference for recognising meaning through relationships.

The approach is focused on developing a secure cultural identity and facilitating access to Te Ao Maori.

These are viewed as central tasks for Maori-centred counselling and recommended as a form of counselling applicable to many Maori seeking help.

Counsellors have three primary tasks: facilitating access, guiding encounters and promoting understanding by integrating new knowledge and experiences in terms that are relevant.

Pasifika Models

Three main models are described by Kingi-‘Ulu’ave, Faleafa and Brown (2007) and reported in Evans, Rucklidge and O’Driscoll (2007).

The Fonofale Model

Created by Fuimaono Karl Pulotu-Endemann in 1995 this model is depicted in a visual representation of a fale (a traditional Samoan meeting house). The house has four main posts (pou-tu) and essentially has six dimensions of health: • Thefoundation(Fa’avae)representsthenuclearandextendedfamily(Aiga). • Fa’aleagaga (the spiritual dimension: the sense of inner wellbeing, encompassing beliefs

around Christianity, traditional spirits and nature. • Fa’aletino (the physical dimension): the wellbeing of the body – the absence of illness

and pain. • Mafaufau (the mental dimension): the wellbeing of the mind. • Isimea(thedimensionoftheother):encompassesvariablessuchasfinance,gender,

age, education, sexual orientation etc. • Aganu’u (culture): the philosophical drive, attitudes and beliefs of Pacific Island culture.

The Kakala Model

Kingi- ‘Ulu’ave et al note that this model was developed by Thaman (2004) in response to growing concern that Western educational constructs, values and aims were replacing the traditional Tongan worldview and processes in educational institutions. The word kakala means garland and three processes are involved: • Toli is the gathering of material (flowers leaves etc.) which must be done at the right.

time and right place and in a respectful way. • Tui is the actual weaving of the garland and requires special knowledge and skills • Luva is the final process and involves the giving away or presentation of the kakala. It is

based on sacred values of fa (respect) and ofa (compassion).

The Tivaevae Model

This model was developed by Maua-Hodge has been incorporated into research design when researchers are from ethnically diverse groups collecting data from communities. It uses processes followed by Cook Island women to make Tivaevae or quilt. This is a group process and each woman has roles, responsibilities and a task to accomplish. The end result is a high quality garment.

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A Conceptual Model of the Predicted Influences on Family Functioning and Individual Well-being of Migrant Asian Families in New Zealand

Williams and Cleland (2007) discuss this model developed by Cleland (2004) which captures the psychology of migration and conceptualises influences in a series of boxes (cited in Evans et al, 2007). It is, however, relevant to talking therapies work, as it outlines key issues which therapists may need to be aware of in their therapeutic practice with Asian peoples.

A simplified version of this model is as follows:

→ Predictors of family functioning:Different rates of acculturation.Satisfaction with life.Age on migration.Quality of parent-child relationship.Quality of marital relations.Rigid adherence to tradition.Number of years in New Zealand.

Migratory influences

→ → Family functioning

→ Predicators of both family functioning and well-being:Access to social support.Acculturation strategies used.Extended family in New Zealand.Astronaut arrangement.Health in New Zealand.

→

→ → Individual well-being

Non-migratory influences:AgeGenderPlace of birthEducation and work skills in country of originHealth in country of origin

Predictors of individual well-being:Sense of belonging.Racism/discrimination.Language proficiency.Gender of individual.Employment status.Financial status.Cultural distance.Sense of home.

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The “MAS” three–tiered model

Feedback from several people (e.g. Michael Hamilton & the Segar House team, the Auckland regional psychology forum, March 2008, and Waitemata Health submission, March 2008) provided information on this model which was developed in the UK to assist in mental health workforce planning (MAS, 1988).

• Level1:Basicskillsinestablishingandmaintainingrelationships,simpleandoftenintuitive techniques of counselling.

• Level2:Undertakingcircumscribedpsychologicalactivities(e.g.thosedeliveredbyprotocol).

• Level3:Athoroughunderstandingofvariedandcomplexpsychologicaltheoriesandthe ability to apply these to complex problems to generate interventions.

The argument is that all three levels deserve funding to achieve best outcomes for mental health service users.

A diagnosis-based model

A clinician, who believes that diagnosis and treatment are closely linked, suggested the following approach to targeted therapeutic delivery.

“The earlier the damage to the individual and the more adverse their circumstances, the fewer strategies they have access to for coping. This does not deny resilience which personality factors etc will influence, but resilience imposed at an early age is likely to hamper flexibility in the long-term. Thus looking at this from the perspective of the health provider, the therapy offered should target the level at which the damage has occurred. Then a screening process which identifies relevant markers could perhaps be implemented and categories developed which would allow the appropriate therapy to be implemented”.

• “CategoryIcouldbegenerallyhighfunctioningbutwithaspecificissuesuchasdepression, anxiety, phobia.

• CategoryIIwouldbemorepervasivedifficultiessuchaspersonalitydifficultiesandunhelpful or addictive behaviours which impact on coping styles

• CategoryIIIcouldbeearlychildhoodabuseorotherearlyissueswhichimpactonthedevelopment of the person

• CategoryIVcouldbeAxisIpresentationclients”.

Treatment could then be delivered based on Category. “Thus for example: • ForCategoryIclients,CBTwouldbethetherapyofchoice. • ForCategoryIIDBTwouldbehelpful. • DBTcouldalsobeusedinamoregeneralwayforallclientswhohavehadearlyonset

difficulties as the teaching component would be valuable wherever early skill learning opportunities have been compromised.

• ForCategoryIIIamorepsychotherapeuticapproachwouldbeappropriateastherapyisfar more likely to require a long-term solid therapeutic relationship with the opportunity for slow growth and change – perhaps with a component of CBT and DBT where appropriate.

• TheCategoryIVclientswouldneedamoreeclecticapproachdependingonhistoryandpresentation. Many factors will come into play here depending on age of the client, history, presentation, meaning of the illness for the patient and level of comprehension and other strengthswhichtheclientmaybring.ClearlyCategoryIVisacomplexareawhichwould

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require a lot of thought but perhaps here sub-categories could also be identified which would enable the application of targeted therapies to such groups”.

A framework put forward by nursing

This work is a “Competence Model for Psychological Therapies” for nursing and it uses Benner’s (1984) Levels of Practice (Level 1 Beginner to Level 4 Advanced practitioner) (Adapted from Roth & Pilling, cited in Department of Health, 2007).

Competences in psychological therapyThe competencies needed to relate to people and enable the nurse to carry out any form of psychological intervention by building a good therapist/service user relationship – these are often referred to as “common or generic factors” in therapy.Mental health nurses demonstrate competencies in verbal communication skills (e.g. accurate empathy, summarizing, facilitating problem solving) and non-verbal skills (such as being with, i.e. non-possessive warmth and genuineness).

Basic psychological therapy competenciesBasic competencies in specific models of psychotherapy that create helpful change within the bio-psycho-social-spiritual-behavioural realm – many mental health nurses are currently offering this in their day-to-day work with service users and their family/whanau.

Problem-specific skillsThese interventions relate to the specific collaborative treatment plans to meet the individualised needs of each service user and their family/whanau. For example, mental health nurses working collaboratively with other professionals who are the primary therapists to co-deliver psychological strategies (e.g. chain analysis from DBT model for people with borderline personality disorder, or specific motivational interventions for service users who are ambivalent about a change in health behaviour/s).

Meta-competenciesDemonstrated by a qualified therapist to work across all levels and who adapt the evidence based model to the needs of each individual service user – an increasing number of mental health nurses are completing focused training programmes at degree or post-graduate level for specific psychological therapy models.

CBT competence framework

This framework was used as the basis for the nursing framework cited above. It was developed for the Department of Health in England by a group of clinical experts and was peer-reviewed by clinicians from the USA. In essence, it documents the activities associated with the delivery of high-quality cognitive and behavioural therapy and documents competencies required to achieve these. The document can be obtained from the Centre for Outcomes, Research and Effectiveness (CORE) www.ucl.ac.uk/CORE.

It gives very detailed information on a complex system of competencies at all levels starting with “generic therapeutic competencies” and ending with “metacompetencies”.

The stepped care model

In the recent draft policy document on primary mental health care, this model has been selected for use in primary care in New Zealand (Ministry of Health, 2008). The following is quoted from Dr Sarah Dwyer’s document:

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“Despite wide variability between service delivery models in primary mental health care, one thing they have in common is that they all introduced a new level of care previously not available to service users. Extended GP consultations, services provided by primary mental health coordinators, and packages of care all represent an additional step between traditional primary care (standard GP consultations) and secondary or specialist care. In other words, all of the models have moved towards a ‘stepped care’ approach to primary mental health service provision.

Stepped care is a system of delivering and monitoring treatments so that the most effective, yet least resource-intensive, treatment is delivered to patients first (Needham 2007). A stepped care approach to mental health care aims to enhance the efficiency of mental health service provision by providing low intensity ‘minimal interventions’, where appropriate, before providing more intensive treatment to those who do not improve with the first step. Minimal interventions are less dependent on the availability of therapists, and include patient-initiated use of evidence-based ‘health technologies’ such as books, video- and audiotapes, computer programmes and internet sites (Needham 2007). Supporting patient self-care is an important minimal intervention. Other steps include brief interventions provided within the primary care context through to more intensive, specialist mental health services.

A stepped care model is one in which: • thereareinterventionsofdifferentlevelsofintensityavailabletotheserviceuser • theserviceuser’sneedsarematchedwiththelevelofintensityoftheintervention • patientsusuallymovethroughlessintensiveinterventionsbeforereceivingmoreintensive

interventions (if necessary) • thereiscarefulmonitoringofpatientoutcomes,allowingtreatmentstobe‘steppedup’if

required. • thereareclearreferralpathwaysbetweenthedifferentlevelsofintervention • theimportanceofsupportingselfcareisrecognisedasanimportantaspectofmanaging

demand” (Chapple and Rogers 1999). Another commentator notes: • “AmajoraspectofSteppedCareisawell-developedsystemofcriteriafordetermining

whether one should move from one step of therapeutic intensity to the next. • Manyifnotmostserviceshavevariedlevelsofcareintheirrepertoire.Theseareoften

defined by different therapeutic approaches but particularly by different intensities of input requirement for each level.

• Howevermostservicesdonotoperateatruesteppedcareapproachbecausethecriteriafor transitions between different levels in the service are often haphazard or poorly defined.

• Manyservicesalsodon’thaveaclearlyarticulatedsetofdiscretestepsinthecaretheyoffer.

• Thesteppedcareapproachisquiteadifferentmodelofdeliveryfrommanypeople’sconceptualisation of evidence based practice although it can also be evidence-based. Much evidence-based practice involves defining a particular model of care that is manualised and applied to all people. The stepped care approach allows for lower intensity interventions to be introduced first, before a relatively comprehensive manualised “best practice” treatment is implemented. This may be a much more feasible approach in terms of resources. These less intensive steps, however, may have their own evidence base.”

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As quoted from Dr Dwyer’s discussion paper: “Figure 2 provides a visual representation of a stepped care model. The black box around the centre of the pyramid represents the target group for primary mental health care. Patients’ needs may be matched with services of different levels of intensity. For example, the needs of service users with mild mental and/or addiction disorders may adequately be addressed through extended GP consultations, active monitoring, lifestyle advice and/or green prescriptions, e-therapies, or through libraries to access self-help resources. Patients with moderate mental and/or addiction disorders may require a more thorough assessment by a primary mental health coordinator, possibly followed by a brief (talking therapy) intervention, package of care (POC), and/or drug prescription. The Patient Health Questionnaire (PHQ) is an example of a screening tool that may be used to help primary care practitioners in their assessment of the level of patient need. A range of other screening instruments are also available” (p.14, 2008).

Finally, the model also shows the importance of a supportive environment and health promotion, relevant to the whole population. Initiatives such as the National Depression Initiative (NDI) and Like Minds, that have these population level goals, help to provide an environment in which primary mental health care is strongly supported

It is recommended that the sector adopt a stepped care approach to service delivery.

Dr Dwyer notes that in the UK, stepped care models have been gaining in popularity as their benefits are demonstrated. There is now good evidence for both their clinical and cost-effectiveness. Potential benefits of a stepped care approach include: • increasedrecognitionrates • greaternumbersofpeoplereceivingtreatmentformentalhealthandaddictionproblems • increasedrecoveryrates • reduceddisabilityandimpairmentrelatedtowork,family,andsocialparticipation • reducedsocioeconomicandethnicinequalitiesinmentalhealthandaddiction • economicandsocialbenefitsassociatedwithfewerpatientsdevelopingmoreseveremental

health and addiction problems • amorecost-effectivewayofdeliveringservices • shorterwaitingtimes • reduceddemandforspecialistmentalhealthandaddictionservices • reducedstigmaforpatients • amorerelaxedenvironmentforthepatient • increasedpatientsatisfaction • amoreholisticandintegratedapproachtotreatinghealthproblems • greateropportunitiesforpromotion,prevention,andearlyinterventioninmentalhealth

and addictions • increasedchancesofpatientsacceptingapsychiatricassessmentifitdoesnotinvolvegoing

to the hospital • enhancedcommunicationbetweenGPsandspecialists.

The stepped care model may also help to overcome some the barriers to the provision of high quality primary mental health care. Common barriers include: • culturaldifferencesbetweenGPsandothermentalhealthserviceproviders • varyinglevelsofskillsandinterestofprimarycarepractitionersinprovidingmental

health care • unclearreferralpathways • limitedspecialistsupport • lackofcoordinationofsharedcareprocesses • insufficienttimeandremunerationtoprovidementalhealthsupporttopatientswithin

the primary care context” (Draft Policy Advice Paper, 2008).

However as we know “primary mental healthcare is very different from secondary mental healthcare” (Dowell et al, 2007). Some commentators have noted that some of the factors inherent in stepped care may be of use to people who use secondary services, but: “A substantial research

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agenda needs to be fulfilled before a judgment can be made as to whether stepped care might be an efficient method of delivering psychological services” (Bower & Gilbody, 2005).

Sarah Dwyer noted that every primary mental health practitioner should have the following knowledge and skills:

1. Engaging with patients and their families/whānau. 2. Screening, diagnosis and assessment of mental health and addiction problems.3. Psycho-education. 4. Cultural awareness and promoting whānau ora (2008, p.27).

In the Model of Care discussion document Dr Dwyer also lists the knowledge and skills required by every practice team and by every provider of more intensive primary mental health (psychosocial) interventions.

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Appendix 4

examples of Talking Therapies-relaTed workforce developmenT and Training as reporTed By regional workforce coordinaTors (rwcs)

SouthRWC: Stuart Gray

• In2008thereisaregionalinitiativeusingunder-spend,whichwillseearound30CBT workshops being delivered at local level by Wayne Froggatt. They will be two-day workshops open for health professionals from adult mental health and addiction services, and health professionals from the primary health sector working with adult mental health and addiction.

• ThelearningoutcomesarearoundgainingknowledgeandawarenessofCBTanditsuses, plus the ability to incorporate selected CBT techniques to practice. It is aimed at adult sector as there is recognition of the value of training provided by the Werry Centre to CAHMS.

CentralRWC: Janet Edmond

Hawke’s Bay Health: Eastern Institute of Technology (EIT) offered training in CBT & DBT on an annual basis and the DHB had a number of staff complete this training.

Hutt Valley Health: “Currently we are in the process of training our Service in DBT. We sent eight of our staff recently to the Gathering Conference and the DBT workshop held in Auckland. The approach we are adopting is to train a group of clinicians who will in turn apply this training to all our Mental Health Service staff. All the Clinical Psychologists working for our DHB have post graduate training in a number of talking therapies, and continue to update their training through their membership of professional associations and during supervision. These talking therapies include Motivational Interviewing, Cognitive Behavioural Therapy, Rational Emotive Behaviour Therapy, Acceptance and Commitment Therapy, Cognitive Analytical Therapy etc. In our region, for other staff, Cognitive Behavioural Therapy (CBT) training has been available, and Dialectical Behavioural Therapy (DBT) training is currently available” (Sue O’Connor Training Co-ordinator, personal communication April 2008). Capital and Coast: This DHB has supported people to attend CBT training, DBT training, motivational interviewing and Interactive Drawing Therapy (IDT).

Wanganui District Health Board supports clinical staff to complete training courses as outlined below: • RationalEmotiveBehaviouralTherapy–WayneFroggatt’scourses,Hawke’sBay. • CognitiveBehaviourTherapy–OtagoUniversity’sWellingtoncampus. • DialectalBehaviourTherapy–NZPsychologicalSociety–NZCollegeofClinical

Psychologists. • AcceptanceandCommitmentTherapy–NZPsychologicalSociety–NZCollegeof

Clinical Psychologists. • MindfulnessandTherapeutichypnoses–AustralianSocietyofHypnosesandNZ

Society of Hypnoses. • MasseyClinicalPsychology’sPostgraduateDiplomainCognitiveBehaviourTherapy. • MotivationalInterviewing. • RiskyBusiness–WorkingwithPersonalityDisorders–RegionalPersonalityDisorder

Team.

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• TraumaTherapy. • EyeMovementDesensitisationandReprocessing. • DomesticViolenceWorkshop. • FamilyViolenceWorkshop. • WorkingwithVictimsofRape. • NationalSuicidePrevention. • PostgraduateCertificateinAddictions.

In the last 12 months: • TwocommunitypsychiatricnursesfromchildandfamilyhavecompletedtheOtago

University’s postgraduate diploma in CBT. • TwocommunitypsychiatricnursesfromcommunitymentalhealthteamsandAoD

have enrolled in this course this year. • SevenclinicalstaffhavecompletedRiskyBusiness. • FourclinicalstaffhavecompletedMI. • TwoclinicalstaffhavecompletedPrinciplesofTraumaTherapy. • TwoclinicalstaffhavecompletedaFamilyViolenceWorkshop. • OneclinicalstaffmemberhascompletedaWorkingwithPeopleExperiencingSleep

Disorder Workshop. • TwoclinicalpsychologistshavecompletedNZCollegeofClinicalPsychologistTherapy

Workshops. • OneclinicalpsychologisthascompletedanAustralianSocietyofHypnoses,

Mindfulness and Hypnosis Workshops. • OneclinicalstaffmemberhascompletedaDomesticViolenceWorkshop. • OneclinicalstaffmemberhascompletedaVictimsofRapeWorkshop. • OneCPNhascompletedaNationalSuicideWorkshop. • TwoAoDclinicianshavecompletedaPDCertificateinAddictions.

Training in CBT has two staff members currently enrolled as mentioned above. Further training is scheduled in conjunction with staff completing a yearly performance and training review. Issues are the service’s ability to release staff and building the provision of these therapies to staff job descriptions. The provision of suitably qualified supervisors is also stretched.

MidlandRWC: Amanda Lacy

Bay of Plenty DHB: Mental Health and Addiction Services fund an in-service programme that includes core competencies (e.g. restraint training) and annually purchases specific skills training like motivational interviewing, clinical supervision training and solution-focused therapy training.

Waikato DHB: Waikato purchases training via Blueprint Centre for Learning. In 2008 they have a five-day programme on dual diagnosis plus a range of introductory workshops on topics such as: recovery principles and competencies, working with suicidality and self harm, working effectively with people with borderline personality disorder, motivational interviewing, and the strengths model, problem-solving and working with consumers as colleagues.

Lakes DHB: Over the last 12 months the major focus for workforce development and training as been a pilot for career development and AoD scholarships. Individually clinicians have sought talking therapies training.

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Taranaki DHB: This DHB offers DBT and CBT 1-3 day courses offered to all staff of mental health and addiction services. Plus inpatient staff have an in-service programme which includes a range of topics from CPR through to talking therapies. For example: • Psychologicalinterventionsforpsychosis. • DBTskills. • CBT. • Motivationalinterviewing. • Solutionfocusedtherapy.This DHB also has a programme for first year nurses that is led by the nurse educator and this programme has been approved by the nursing council to use for those returning to the workforce.

Tairawhiti DHB: This DHB also has a range of workforce development options including: • Anewgraduateprogrammefornurses. • Recovery,culturalandclinicalworkshopsviaTeRauMatatini,MatuaRakiandthe

Werry Centre. • Clinicalandculturalsupervisiontraining. • CBT,DBTandfamilytherapytraining. • Culturaltherapytraining(e.g.TahaWairua/Tohunga(fromlocalpeople).

NorthernRWC: Emma Wood (at time of writing report)

Auckland DHB: Mike Hamilton (taking over from John Thorburn) is leading a formal stock-take and gap analysis of psychological therapies used in all adult services. In addition “We have and continue to support staff with access to training in motivational interviewing, CBT and DBT. Some of this training is in house some is provided by training institutions.WeprovideinhousetrainingforclinicalstafftoparticipateintheHearingVoicesandBeliefs therapeutic groups (which are a talking therapy) and also reinforce this training in the key worker training. The key worker training is based on the Re-Covery Spiral, in which talking therapies are well enshrined”. Waitemata DHB: Information was forwarded by Tina Earl, Psychology Advisor. She noted that they are currently undertaking a Psychological Therapies Review which is not yet completed. Tina stated the therapies undertaken by clinicians in the DHB (similar to all those previously mentioned in this document). She noted that a team of 10 staff was sent for intensive DBT training from adult mental health services and CADS plus a number of multidisciplinary teams did in-house training on DBT core principles and skills. She also noted the need for a formal coordinated approach between mental health services, NGOs and PHOs as lack of this leads to ad hoc development of services and training in talking therapies, duplication of resources and a lack of targeted and best use of funding. Tina also thought that la formal DBT coordinator position to facilitate DBT training and development would be useful.

Northland DHB: The Funder has contracted the Blueprint Centre for Learning (BCL) to deliver both CBT & DBT (to NDHB-contracted NGOs and Provider Arm employees) in 07/08 year. In addition the Funder has contracted BCL to deliver a Talking Therapies Programme for 08/09 detailed as below: • CognitiveBehaviouralTherapy(onestream,sevendays). • DialecticalBehaviouralTherapy(onestream,sevendays). • RiskingConnection(twostreams,threedayseach). • MotivationalInterviewing.

Note: “Risking Connection was developed by trauma specialists in response to working with people who have difficult-to-treat, suicidal, and self-injuring symptoms. The authors of this programme suggest that when mental health workers have the skills to understand the psychological consequences of early trauma, combined with state-of-the art treatment practices, mental health care becomes more clinically effective and demonstrates significant cost savings”.

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In addition to this the provider arm will have four workshops across mental health and primary care in 2008 on Problem Solving Therapy.

Summary

The work of Regional Workforce Coordinators will be supported by: • thesuggestedframeworkfortalkingtherapies • theNationalTrainingPlanwillalsoprovideacoordinatedapproachsothatanational

approach is available but local training needs are met.

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