Rebecca Hutten University of Sheffield School of Health & Related Research ( ScHARR )

1. Patient Experience of the IAPT initiative: from health service evaluation to psycho-social research Rebecca Hutten University of Sheffield School of Health & Related Research (ScHARR) QRMH3 Conference, 27th August 2010

2. Improving access to psychological therapies

3. IAPT Anxiety and depression in the news CBT

4. SDO evaluation • Demonstration sites (Newham & Doncaster), 2005 - • 3 year evaluation looking at cost effectiveness of service model, funded by NIHR SDO R&D programme • Multi-stranded approach: • Costs and outcomes • Organizational system impacts • Patient Experience • Mixed methods: • Quantitative • Qualitative • Draft final report submitted June 2010; publication later this year, after peer review. QRMH3 Conference, 27th August 2010

5. Patient experience strand Aim: • What are service users’ experiences: • at different stages of the services? • of clients who had poor outcomes? • of changes in work status? • of clients who did not complete treatment? • of ‘stepping up’? Method: • Interviews with 77 service users who had completed treatment • Analyzed using framework method (Ritchie & Lewis 2003) • Range of participants in terms of socio-demographic indices and treatment outcomes • Topic guide for interviews covered: • acceptability of the service and treatment pathway; • service experiences; • experiences of change; • roles and responsibilities and • views of staff QRMH3 Conference, 27th August 2010

6. Initial themes used for frame

7. Framework analysis

8. Emergent themes: framework analysis • Choice • Control • Motivation • Fit with needs • Negotiation • Relationship • Confusion • Too short • Unmet needs • Impersonal • Poor communication • Power and involvement QRMH3 Conference, 27th August 2010

9. Turning psycho-social • The ‘transparent self’ problem (Hollway and Jefferson 2000) • Putting emotion back in (Clarke 2006) • Considers unconscious communication, dynamics and defences (Hoggett 2009) • Theoretically pluralist, emergent (Frosh 2003) • Uses idea of the ‘defended subject’ • Broadens the range of data considered QRMH3 Conference, 27th August 2010

10. Revisiting transcripts

11. Whole case analysis • Context, incl. service data, fieldwork notes • Audio-recordings • ‘Told story’ cf. ‘lived life’ of the interview • Anomalies, emotions, discourse • Non-verbal communication • Associative pathways • Counter-transference QRMH3 Conference, 27th August 2010

12. Changing perspectives QRMH3 Conference, 27th August 2010

13. The miner’s daughter Told story • Work-related stress, avoidance, OC(D) • IAPT telephone case management, interrupted • Puzzlement over worker qualifications • First meeting apprehension • Lack of ‘connection’, returned to GP to complain • Took up employer funded counselling, though also time-limited • I was desperate to get better • Re-started IAPT, never met 2nd case manager face to face • Found both types of treatment helpful • Got involved in local library campaign & Trade Union • Returned to work & now helps others • Some symptoms returning QRMH3 Conference, 27th August 2010

14. The miner’s daughter ‘Lived life’ • Interview interruptions, & my lack of introduction – re-enacting the IAPT experience? • No name for ‘disorder’ ….tongue-clicking, hesitations & break down • Relief at recognition of workplace problems • Strong social & family support not enough • Knows what ‘proper’ counselling is; IAPT doesn’t live up to fantasy of treatment, though it does have practical uses • Frustration with the IAPT ‘measures’ – a ‘pull’ on you improve/ not to disappoint • I think I put a better spin on than actually I’m really feeling • Motivation/ determination, and resourcefulness = striking • The patients who go and demand stuff, they live longer! • First episode of anxiety attributed to family break down during miner’s strike • Circularity of account – she loses & regains her own power & passes it on • Sense of looming isolation QRMH3 Conference, 27th August 2010

15. Emerging results from 6 cases: alternative ‘evaluation’ themes? • Resilience vs ‘heroic’ independence • Importance of restorative justice • Importance of recognition • Loss of treatment fantasies/ ideals • CBT - a gendered construction? • Social suffering & solidarity • Capacity for change & system failures to connect QRMH3 Conference, 27th August 2010

16. Questions, comments, suggestions?THANK YOU Rebecca Hutten, PhD Student r.hutten@sheffield.ac.uk QRMH3 Conference, 27th August 2010

17. Summary of Framework Analysis Findings (1) First contact with GP and IAPT service helped to identify the problem, provided hope and a way forward.. Choice was a central issue throughout. Self-referral often gave greater self-confidence and hope. Information (verbal and written) that could have helped in decision-making was often not available to patients. Good communication at all levels engagement Low intensity structured work valued, if tailored to patients’ needs. From: Parry et al, 2010 forthcoming

18. Summary of Framework Analysis Findings (2) Self-help booklets often not pitched at the right level. Some liked the freedom of telephone contacts and computerized packages; many found them problematic. Careful introduction, some one-to-one sessions and personal support helped High Intensity work was valued, but often thought to be too short. The relationship between patient and practitioner was better if the practitioner was responsive, flexible, and respectful. However, sometimes practitioners were experienced as impersonal A lack of continuity (due to staff turnover) or follow-up was problematic for patients. From: Parry et al, 2010 forthcoming