mindfulness-based cognitive therapy : implementation in the uk health service rebecca crane &...

Mindfulness-Based Cognitive Therapy:

Implementation in the UK Health Service

Rebecca Crane & Willem Kuyken

Mindfulness Conference, Bangor University9th April 2011

Goals & Outline

• The story so far• Current experience• Four exemplars• Next steps

The Story So Far

The MBCT Story So Far

MBSR & Stress

Reduction Clinic

Bangor Centre for Mindful-

ness Research & Practice

MBCT Manual &

RCTs

2004 & 2009 NICE

Guideline

Oxford Mindful-

ness Centre

Early NHS

projects

Mental Health

Foundation Report

© WK 5

National Institutes for Clinical Excellence (NICE) Recommendation

for Relapse Prevention (2009)

Generic Challenge of Implementation

• Research-practice gap • Uptake of research – complex and multi-

dimensional process - adopting knowledge depends on social processes including: sensing and interpreting new evidence integrating it with existing evidence reinforcement by professional networks which in turn is mediated by local context (Dopson & Fitzgerald 2005)

• Growing interest in the theory and practice of research use/implementation /knowledge mobilisation.

Core Challenges of Implementation

• Structural• Political• Cultural• Educational• Emotional• Physical and technological

(Bate et al. 2008)

How Does This Relate to MBCT?

• What are the ingredients for successful use of MBCT evidence in practice?

• What works / hasn’t worked, with whom and in what contexts?

• Can we use collective understanding to develop and disseminate best practice?

• This workshop is part of the process!

(i) What is the state of implementation within your organisation (very briefly)?

(ii)What has proved most challenging while developing MBCT services in your organisation?

(iii)What factors have proved most important in supporting the development of MBCT in your organisation?

Small Group Work

Four Exemplars

• Grassroots enthusiasm

• National or regional initiatives

• Management buy-in

• Access to training and supervision

Key Ingredients in Implementation

MBCT Implementation The North Wales

Experience

Summary

Grassroots enthusiasmAccess to training and

supervision

X management buy inX national or regional

initiatives

MBCT in secondary care – as part of community mental

health provisionInclusion criteria broadened:• recurrent depression presently in remission • residual depression• current episode of mild depression• anxiety related disorders including generalised anxiety,

recurrent panic attacks and obsessive compulsive disorder

Routine evaluation - significant change in symptoms of anxiety and depression, and

global distress(Soulsby et al. 2002 - unpublished pilot evaluation of five MBCT classes in CMHT setting)

Key challenges and achievements

• 2 classes per year delivered in local CMHTs

• Ongoing MBCT service within local oncology unit

• Pilot research on MBCT within primary care

• Strong relationship built with local GPs through current MBCT research

• Relies on the enthusiasm and time availability of individual practitioners

• Stop/start• Practitioners feel

unsupported by management

The way forward: - knowledge transfer partnership

between university and local health board - developing a strategic vision + up skilling staff at grassroots level

- pilot research on MBCT in primary care setting – dissemination and developing interest in further pilot initiatives

- Welsh IAPT - on the near horizon - clinical psychology training programme

is now ‘mindfulness orientated’ – mindfulness training built in at earlier stage

MBCT Implementation The Scottish Experience

Summary

Grassroots enthusiasmAccess to training and

supervisionManagement buy inNational or regional

initiatives

Development of mindfulness services within NHS in Scotland

2nd phase

• Underpinned by NHS Education in Scotland (NES)

• Because: NICE guidance + SIGN (Scottish Intercollegiate Guidelines Network) guidelines on psychological therapies for depression

• NES project developed the Matrix (national strategy for delivering evidenced based psychological therapies)

The NES work has entailed:

• Delivering teacher training courses• Developing a national forum of

mindfulness leads from each locality• Establishing local supervision networks

for those trained as teachers • Running supervision courses for

experienced mindfulness teachers• Specifying competencies for both

teachers and supervisors

There are now NHS professionals trained to

deliver mindfulness-based courses within

each of  the 11 mainland Scottish Health Boards

Facilitators

• small size of Scotland• grassroots

mindfulness practitioners had contacts within Scottish Government.

• centrally held strategic vision for mindfulness developments, integrated within overarching vision of increasing access to evidenced based psychological therapies

Barriers• Small funding for

training process• some managers

working outside the process

• management not always understanding the ‘why’ of the training pathway

• recent budgetary constraints

MBCT Implementation The Exeter Experience

Summary

National or regional initiatives

Grassroots enthusiasmAccess to training and

supervision

X Management buy in

Exeter: Key Elements

• Primary care and

research context

• Treatment integrity

• Therapists, therapist

training, support and

supervision

MBCT for Recurrent Depression in Primary Care

Primary Care Preventing Recurrence

Referral to MBCT Service

Person attends MBCTsessions

Ongoing contact through follow-up reunions

© MDC 2008

Pre-Post Average Depression Outcomes:

Beck Depression Inventory

severe

moderatemild

well

N>150

MBCT Implementation The Oxleas Experience

Summary!

Grassroots enthusiasmAccess to training and

supervisionManagement buy inNational or regional

initiatives

Oxleas: Key Elements

• Strategic Trust-wide approach with clear management structures

• Clear referral pathways (primary, IAPT & secondary care)

• Engagement of Trust managers and staff

• Training therapists through Bangor TDR1

Oxleas: Key Challenges & Achievements

• Resources• Competing

demands• Practical issues

(time of day, clear run of 8 groups, CDs)

• Debates with psychiatry and links with secondary care

Since 2008:•12 client groups•105 clients•8 staff groups

Summary and Close