Recovery targets

This section is for discussion relating to the Layard report, and subsequent schemes like Improving Access to Psychological Therapies where lower intensity inteventions are offered in primary care
Bookend
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Recovery targets

Post by Bookend » Thu Aug 06, 2015 3:46 pm

I am not meeting my recovery targets and starting to get worried about my job, is anyone else strugging with this? I am a high intensity therapist, recently qualified. I'm finding the whole concept of recovery targets really stressful and quite dispiriting, I usually get very positive feedback from patients at the end of treatment, but if they haven't gone into recovery it just doesn't seem to 'count'.

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Cattius
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Re: Recovery targets

Post by Cattius » Thu Aug 06, 2015 9:51 pm

How frustrating for you :( at least you're getting good feedback - don't forget them feeling "better" may not necessarily be "recovered" but it's what matters to them :)

Have you been on any recovery training from your trust?

The training I went on talked about talking to people about their scores and checking them out for accuracy, also using them as a basis for areas that still need work. Another suggestion was to guide people who have long-term conditions, pain and such, to try and separate the pain symptoms from the mental health symptoms (almost impossible when they're unwell with both, much easier when they're feeling better mentally).

What I've always done is suggest people think of "several days" as sometimes, "more than half of the days" as often and "nearly every day" as most/all of the time. I find people often circle a 2 or 3, as they experience a problem for a small part of a few days or even every day, but it's not having an impact on their life in that time - which would be more accurately rated as a 1 or a 0, as it's asking how often have you had "problems" with x, y or z. It's massaging the language and figures a little bit though.

I'm inclined to stick to my guns and say the measure doesn't measure recovery! Have you tried disorder specific questionnaires?
Cattius.

"Go away, I'm alright" The last words of HG Wells.

Bookend
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Re: Recovery targets

Post by Bookend » Fri Aug 07, 2015 9:08 am

Cattius thank you so much for your reply! I didn't even know there was such a thing as recovery training, this hasn't been mentioned to me and I'm not aware of any but will certainly ask - thank-you. I've been wondering about ways to word the questionnaires and how other people do this, so your reply is really helpful. I find sometimes people just whip through them giving themselves '3' for everything and then tell me they are feeling much better! I do use the disorder specific questionnaires too, but probably not as much as I should do. I'm mostly worried about being put on a performance review programme or something like that, got to try and do something! Thank you again - much appreciated.

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baa
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Re: Recovery targets

Post by baa » Fri Aug 07, 2015 9:45 am

Are you sure you'll be put on performance management? I work as a therapist in an iapt service and my recovery rates were dismal last time I looked at them! But, a lot of ppeople had made significant change or I had seen some twice and referred them on (so no shift in scores),so management weren't concerned.
At least I'm not as mad as that one!

Bookend
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Re: Recovery targets

Post by Bookend » Fri Aug 07, 2015 10:01 am

Thank you baa! Performance review hasn't been mentioned to be fair, so I'm catastrophising, but I am picking up pressure from management - my recovery rates are mentioned at every supervision and eyebrows raised! Its really helpful to know others' rates vary too, the message I pick up from my service as a whole is that it is always the therapist's 'fault' if scores don't go into recovery which is pretty disheartening. I'm keeping more of a log for myself now of when people aren't recovering to try and understand if there are particular presentations where I'm falling short. Thanks again, I really appreciate your reply!

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baa
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Re: Recovery targets

Post by baa » Fri Aug 07, 2015 10:07 am

There is some formula for "significant change" which our ccg approve of (I don't know what it is). If it helps my recovery rates for the early partof tthis year were 0%, 25%, 33%, and then down again to 25%. Hah! Also, if I only discharge one person in a month (which is more likely to happen at step 3)and they haven't recovered, then it's going to look shocking ;)

I've not heard of the recovery training either, and I'm a bit toothsucky about training that focused on helping people to fill inthe questionnaires 'better'.
At least I'm not as mad as that one!

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Cattius
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Re: Recovery targets

Post by Cattius » Fri Aug 07, 2015 5:52 pm

Yeah, I spent most of it with my arms folded, saying "yeah, but" a lot, and generally being annoyed. It was more focused on us understanding and explaining the questionnaires well. Which there were a couple of good points. One being that if you just plonk it in front of them and grumble about us "having to do it", they won't take it seriously. Some people prefer for you to give them the questionnaire at the last appt, or in the waiting room, so they can fill it in properly without time pressures (actually reading the questions seems a problem for some people). I think it was pretty informal training, possibly not official training that's widely available.

Sounds like perhaps just telling people to take their time with it, telling them it's important for you to be able to measure change. I think the biggest thing, is if they're saying they're feeling much better, discussing their scores with them and highlighting what they're saying doesn't match up to what their scores are saying. I usually find it's the other way i.e.: "So I'm hearing you're very anxious and you worry about everything, but you've circled "1" on the questionnaire, do you think you're underestimating it?", "oh, yeah... urm didn't want to circle all 3s, you'd think I'm well mad".

The worst part of it in our area, is now the counselling team are saying they won't take people with severe/severe scores, as they won't recover. RIDICULOUS.

I'm pretty sure they couldn't put you on performance review, as people's "recovery" isn't necessarily a measure of your capability as a therapist. Perhaps if it is brought up as an issue, you could reflect on the type of people you are seeing and their percentage improvements/change. But, if you've never had training on something, it can't really be a measure of your performance ;) .

Perhaps you could share with your team leader/supervisor what you find from the log you keep? IF it's an issue ;)
Cattius.

"Go away, I'm alright" The last words of HG Wells.

Alex
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Re: Recovery targets

Post by Alex » Sun Aug 09, 2015 1:10 pm

Recovery is not entirely due to the therapist's effort and skill. In fact there is much research literature that show that it is clients that make therapy work! So putting you under performance review for your recovery rates is unethical. If they did, I would get your union involved. Also, if there are raised eyebrows, I would be assertive about your efforts into therapy and that you will not take full responsibility over client's recovery but it is a collaboration. It perpetuates the idea that therapist "does things" to clients as if clients' have no personal agency or context.

On a more practical note, are you using the measures to guide intervention? You will be more effective at changing scores if you target the symptoms that are being measured. For example if they are scoring high on "Not being able to stop or control worrying" testing out with a "worry postponement period" the belief over their control to worry.

Let us know how you get on.

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Will
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Re: Recovery targets

Post by Will » Sun Aug 09, 2015 6:57 pm

For what it's worth, this sounds like a really stressful situation to be in and I can imagine it would add undue pressure to your work. I wonder if it's worth bringing up with your manager/supervisor to discuss what the policies are around this, and to (hopefully) set your mind at ease if there aren't direct consequences for individual therapists.

The suggestions made above are great - I'd also suggest thinking about wider factors influencing therapy a bit more. Perhaps it would be useful to document in your notes factors which you think might be affecting a discrepancy between how someone 'presents' and what they score on a questionnaire. For example, might there be contextual factors (e.g. health problems, situational stress, relationship breakdown...) which might make the 'here and now' scores on specific questions higher?

In addition to helping add more context to the way we measure outcomes, I think it's also important to use this therapeutically - things might be tough now, but do the people we work with feel any more able to cope with difficult circumstances as a result of the therapy?

I also think remaining aware of these things is useful for your own self-care - as others have highlighted, taking on 100% of the responsibility for change is an unhelpful path to walk. More broadly, I also think that as psychological professionals we have a duty to highlight to managers/commissioners the limitations of specific outcome measures being used and to challenge the reliance on them in determining 'recovery'. The "yes, but!" position is an important one for us to hold, in my opinion.
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LIWY
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Re: Recovery targets

Post by LIWY » Sun Aug 09, 2015 7:40 pm

Do you use mental health clustering in your service or, if not, can you try to work out yourself the clusters of your caseload using the manuals available? The MHCT is available on line.

In my experience, clusters 1 - 2 people tend to hit the numbers, a good percentage of cluster 3, once you get above that, unlikely in a short term piece of work. IAPT is full of people who are too severe for these short term interventions.

Do look up also "reliable improvement" calculations for IAPT.

It may be that you could get more improvement in your sessions or it may be that you are not actually low for your service at all, or, if you are, that others have caved in to pressure and are devoting time to ensuring the questionnaires come in at recovery whether or not the person actually does feel that way.

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baa
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Re: Recovery targets

Post by baa » Sun Aug 09, 2015 8:39 pm

Reliable improvement!! That's the term. That's been bugging me :))
At least I'm not as mad as that one!

secret squirrel
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Re: Recovery targets

Post by secret squirrel » Sun Aug 09, 2015 9:52 pm

Is the answer really to focus the therapy on the outcomes of the questionnaire?

Whose interests would that serve? The commissioners? The managers? Yours?

...the client's?

I think this is an example of how targets become horribly problematic. If there is a short term therapy being offered I think we always need to be incredibly thoughtful about how we use that time. It may be the client's only chance of help. we have an ethical responsibility to be working with their goals and hopes for therapy, rather than spending their limited time on the implicit goal of improving their questionnaire scores.

If you are getting positive feedback I would suggest you think about means of capturing that. Possibly your service already collects service-user feedback, if not perhaps you could talk to your manager about starting this, or try and redesign what's already there if it's not being used.

edit, - by the way, this was in reference to a couple of comments like this one, not the original post:
On a more practical note, are you using the measures to guide intervention? You will be more effective at changing scores if you target the symptoms that are being measured. For example if they are scoring high on "Not being able to stop or control worrying" testing out with a "worry postponement period" the belief over their control to worry.

Bookend
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Re: Recovery targets

Post by Bookend » Sun Aug 09, 2015 9:54 pm

Thank you for all the lovely replies! I'm really glad I started this thread as it has reassured me. Just to answer some points:
Alex wrote: On a more practical note, are you using the measures to guide intervention? You will be more effective at changing scores if you target the symptoms that are being measured. For example if they are scoring high on "Not being able to stop or control worrying" testing out with a "worry postponement period" the belief over their control to worry.

Let us know how you get on.
Thanks Alex - no I don't think I always do use the measures to guide intervention, I've always tended to stick doggedly to the goals the individual has identified possibly at the detriment of really looking at the symptoms. This has given me food for thought.
Will wrote: Perhaps it would be useful to document in your notes factors which you think might be affecting a discrepancy between how someone 'presents' and what they score on a questionnaire. For example, might there be contextual factors (e.g. health problems, situational stress, relationship breakdown...) which might make the 'here and now' scores on specific questions higher?


Thanks Will - I'm certainly starting to do this more, both in the notes for my own line management, recognising I need to protect myself a bit more as I'm feeling the pressure from above!
LIWY wrote:Do you use mental health clustering in your service or, if not, can you try to work out yourself the clusters of your caseload using the manuals available? The MHCT is available on line.
Thanks LIWY, we do use clustering yes, we went through the tool and excellent idea to reflect on the clusters on my caseload, thank-you. This hadn't even occurred to me, but it would really help me reflect with my supervisor some of the factors which will be affecting recovery. I know my recovery rate is well below the overall rate for my service unfortunately, I just keep wondering how on earth other people get such good rates!
baa wrote:There is some formula for "significant change" which our ccg approve of (I don't know what it is). If it helps my recovery rates for the early partof tthis year were 0%, 25%, 33%, and then down again to 25%.
Thanks baa, yep mine bump along at around the same rate!
Cattius wrote: I'm pretty sure they couldn't put you on performance review, as people's "recovery" isn't necessarily a measure of your capability as a therapist. Perhaps if it is brought up as an issue, you could reflect on the type of people you are seeing and their percentage improvements/change. But, if you've never had training on something, it can't really be a measure of your performance ;) .

Perhaps you could share with your team leader/supervisor what you find from the log you keep? IF it's an issue ;)
Thanks Cattius, really reassuring, and you're right.

Thank you so much again for all the replies, I was panicking a bit and now feel a lot better!

LIWY
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Re: Recovery targets

Post by LIWY » Sun Aug 09, 2015 10:22 pm

secret squirrel wrote:Is the answer really to focus the therapy on the outcomes of the questionnaire?

Whose interests would that serve? The commissioners? The managers? Yours?

...the client's?

I think this is an example of how targets become horribly problematic. If there is a short term therapy being offered I think we always need to be incredibly thoughtful about how we use that time. It may be the client's only chance of help. we have an ethical responsibility to be working with their goals and hopes for therapy, rather than spending their limited time on the implicit goal of improving their questionnaire scores.

If you are getting positive feedback I would suggest you think about means of capturing that. Possibly your service already collects service-user feedback, if not perhaps you could talk to your manager about starting this, or try and redesign what's already there if it's not being used.
It would probably serve the interests of all but the client - Commissioners get in trouble with the layer above them if recovery rates are too low. The Service then gets in trouble with the commissioners and risks tender - so all risk losing their jobs.

These rates are being published to the public, to me it is putting the focus on how to recover according to a few questionnaires that IAPT managed to get for free rather than really putting the patient at the heart of it. Search your IAPT service through the NHS Choices IAPT search page and many will have their recovery rates there, all are supposed to. The HSCIC produce loads of stats, although I have no idea who wades through them other than service managers, private companies looking to grab a piece of the IAPT action and stat obsessed civil servants

IAPT services have to collect the PEQ (patient experience questionnaire). So there will be feedback but its content is not yet a KPI.

OP - if you do get put on performance review, do remember that it is supposed to be a supportive process in that it is supposed to find a plan for improvement. So your target clinical contacts could be reduced for a time for instance to allow you to shadow more experienced therapists with high recovery rates or there could be some extra training. Have you read your Service's policy on performance management?

Bookend
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Re: Recovery targets

Post by Bookend » Sun Aug 09, 2015 10:23 pm

Sorry secret squirrel, missed your post! I agree with everything you've said really, I find the targets problematic. Unfortunately in my service a huge amount of pressure is loaded from above to achieve a high recovery rate, it feels uncomfortable to say the least. This whole thread has helped me feel more able to be assertive with my management about my recovery rates which I'm really grateful for, presumably if its affecting me it must be affecting others in my service also.

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