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The Therapeutic Community Model
in a Low Secure Setting for People
With Learning Disabilities and its
Effect on Emotional Development
Reed Cappleman
Background
• Study looks at first TC to be used in treatment for
people with LD
• Low secure unit for people sectioned under
Mental Health Act (2003)
• Twice daily community meetings, focussed
therapy groups, individual therapy, intensive staff
training, support and supervision
• Emphasis on empowering patients, joint decision
making, transparency, reflection
• Unit closed in summer 2010 due to financial
circumstances
Outline of the Study
• Case series of four men I worked with in the
hospital
• Utilising data from:
• Object Relations Technique (ORT)
• House-Tree-Person (HTP)
• Brief Symptom Inventory (BSI)
• Caution: Limited data, so conclusions to be
drawn are limited- guide future research
David
• Man sectioned due to sexual offences
• Previously underwent cognitive-behavioural
treatment: limited success
• Assessments showed
– Lack of integration, wish to disown responsibility
– Severe disturbance of object relations- strong themes
of violence and abuse on ORT, impaired sense of self
as separate due to very early traumatisation
– High score on Psychoticism dimension on BSI
David
• Re-tested following TC treatment, including
individual therapy
– Less violent/sexual content in ORT responses (though
still marked disturbance)- sense of acceptance of need
for others to keep boundaries
– HTP: Still difficulties taking responsibility, but clearer
sense of self, less omnipotent, more awareness of
issues around sexuality
– BSI: Decrease in psychoticism, but increase in
depression and hostility
• Behavioural changes- spoke in community
meetings about why detained- major shift
Other participants
• Martin- diagnosed with psychosis. Period of
being completely cut off, but then developed
more secure sense of self, more able to relate
to others
• Andrew- psychosis and violent behaviour.
Feeling safer, taking more responsibility,
decrease in apparent distress
• Dean- increase in openness, acknowledging
emotions more, but some increased
disturbance
Common Themes
• No universal improvements- treatment difficult
process
• For 3 of the 4, more positive changes than
negative
• Different aspects of TC all came in to play-
challenging, silent acceptance, belonging, place
to ‘speak the unspeakable’
• Projective tests useful for measuring progress,
but also for guiding formulation and intervention
Further Work
• Data here suggests approach worthy of more
detailed investigation- especially in light of
scandal in Bristol
– May be awhile before such a project comes along
again in current climate
– May need more evidence as to effectiveness of
psychotherapy and LD first
– Need to look at different areas of outcome-
quantitative and qualitative data, cost-offset studies
• Use of projective tests in shaping and measuring
intervention also promising- need further work
on validation
Welcome to the IPD Conference
New Ways Forward for Disability
Psychotherapy
Dr Pat Frankish
Individual case study - How does
the provision of disability
psychotherapy training to an
individual with physical disabilities
and mental health issues and
social care staff impact on the
individual’s social care support
package.
Amanda Jacques
Frankish Training
Case Study
• Alice
• 42 years old living as tenant in own home
• Lived at home until dad died
• Residential services
• Supported living
• Direct payments
• Independent Living Fund
• Social services
Frankish Training
Assessments used and type of
analysis
• Interviews
• Brief Symptom Inventory (BSI)
• General Health Questionnaire (GHQ).
• House Tree Person (HTP)
• Object Relations Technique (ORT)
• Maslach Burnout Inventory (MBI) Human Services Survey
Manual
• Fortnightly notes and three monthly interpretation
• Disability Psychotherapy joint individual and staff Training
• Extra intervention – telephone on-call
Frankish Training
Interventions
Alice Staff
– BSI • Maslach Burnout
– HTP Inventory (MBI)
– ORT Human Services
Survey Manual
– GHQ
– Therapy
fortnightly
– my visit fortnightly
– Telephone Frankish Training
Joint Intervention Disability
Psychotherapy Training
• Week 1 – Winnicott • Week 9 – Frankish Model
• Week 2 – Bowlby observation
differentiation, practicing
• Week 3 – Mahler
stages
• Week 4 – Sinason
• Week 10 - Frankish Model
• Week 5 – Freud observation early/ late
• Week 6 – Klein rapprochement
• Week 7 – Bion • Week 11 - Frankish Model
• Week 8 – Malan observation Scoring
• Week 12 – Evaluation
Frankish Training
Results and Analysis Brief
Symptom Inventory
Remained Increased in Decreased in Reduced from
above criteria symptoms symptoms clinical to non
for case clinical
1. Interpersonal 1. Obsessive 1. Depression 1. Somatization
Sensitivity Compulsive 2. Anxiety
2. Paranoid 3. Hostility
Ideation
4. Phobic
3. Psychoticism
Anxiety
4. Global
Severity
Index
Frankish Training
Symptoms Above Criteria for Case
Frankish Training
Increase
Frankish Training
Decreased
Frankish Training
Reduced from Clinical to Non Clinical
Frankish Training
Above Clinical Case As Out Patient
Frankish Training
House
Frankish Training
Tree
Frankish Training
Person
Frankish Training
ORT Blank Card December 2009
• Picture 13 -Sad and lonely because of hamster
and had cruel remarks about its death. Feeling
low and down on boxing day going to ring
somebody and will ring back. Feel broken
hearted and staff moaning about their
problems. Nobody takes any notice of me. Get
telephone number and ring them and wait for
them to speak.
Frankish Training
ORT Blank Card December 2010
• Picture 13 –I would like to meet somebody
maybe not get married, do more courses,
have a happier life and hope my health will
improve and just go from there. Can see a
future.
Frankish Training
General Health Questionnaire
Date A=Somatic B=Anxiety & C=Social D=Severe Total
symptoms Insomnia Dysfunction Depression
11th December 2 7 2 1 12
2009
24th December 2 4 2 0 8
2010
The recommended cut-off point for a positive result is 6 to 7 for each subscale.
A total score of 13 or more almost always indicates a positive psychiatric
condition
Frankish Training
Telephone calls
Total Calls to location
80
70
60
50
number of calls
total
A/H office
40
A/Coffice
Mobile week
30
mobile W/E
20
10
0
Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10
Frankish Training
Maslach Burnout Inventory
Table 1 Jan 10
Emotional Personal risk to
Month staff Exhaustion cat Depersonalization cat Accomplishment cat burn out
Jan-10 1 6 low 0 low 26 high low
Jan-10 2 28 high 0 low 31 high average
Jan-10 3 8 low 2 low 29 high low
Jan-10 4 22 average 6 low 26 high average
Total 4 64 8 112
average 1 16 low 2 low 28 high low
Frankish Training
Maslach Burnout Inventory Jan
2010
From the individual sheets Jan 2010 the highest individual score in January
2010 for emotional exhaustion was 5 equating to a few times a week. This
was for the question-
• I feel used up at the end of the workday
The highest score for depersonalization was 5 equating to a few times a week.
This was for the question-
• I worry that this job is hardening me emotionally
The highest score for personal accomplishment was 6 equating to everyday.
This was for questions-
• I can easily understand how my recipient feel about things
• I deal very effectively with the problems of my recipients
• I have accomplished many worthwhile things in this job
• I feel exhilarated after working closely with my recipients
Frankish Training
Maslach Burnout Inventory
Table 2 Jan 11
risk to
Month staff EE cat DP cat PA cat burn out
Jan-11 1 30 high 5 low 24 high average
2 17 average 4 low 26 high average
3 13 low 9 average 32 high average
Total 3 60 18 82
average 1 20 average 6 low 27 high average
Frankish Training
Maslach Burnout Inventory Jan
2011
From the individual sheets Jan 2011 the highest individual score for
emotional exhaustion was 5 equating to a few times a week. This was for the
questions-
• I feel emotionally drained from my work
The highest score for depersonalization was 4 equating to once a week. This
was for the question-
• I’ve become more callous toward people since I took this job
• I feel recipients blame me for some of their problems
The highest score for personal accomplishment was 5 equating to a few times
a week. This was for questions-
• I can easily create a relaxed atmosphere with my recipients
• In my work I deal with emotional problems very calmly
Frankish Training
My sessions
March 2010 the themes that emerged were;
• Needing a secure base environment and staff to understand
her needs relating to all the
• Pain of difference really struggling with it
• Attacks on links -me yawning were very prominent
• Thoughts on pain of unspoken transference and counter
transference
• Splitting staff group regarding me therapist manager
• As regards health the difference within the social model
medical model support
Frankish Training
My sessions
June 2010 the themes that emerged were;
• Concerns very prominent related to anger and pain associated
with disability and incompetence of professionals
• Taking part on the training course has highlighted the
differences between her and staff group
• Understanding how seeing a therapist and myself helps
indicate emotional development
• Able to accept others and the staff and the conflicts.
• Staff are not able to do everything for her but able to value
what is done
Frankish Training
My sessions
September 2010 the themes that emerged
were;
• An awareness of being different
• Issues of not being good enough, particularly
the staff not good enough for Alice
• Attachment issues and abandonment.
• Attacks on linking and difficulties associated
with the pain of difference
Frankish Training
My sessions
December 2010 the themes that emerged
were;
• Ending is a problem
• Not being “good enough”
• Health issues and professionals not being
good enough
• Some hope for the future
• A shift in view of relationships
Frankish Training
Response to research question-
• Individual case study - How does the provision
of disability psychotherapy training to an
individual with physical disabilities and mental
health issues and social care staff impact on
the individual’s social care support package.
Frankish Training
Welcome to the IPD Conference
New Ways Forward for Disability
Psychotherapy
Dr Pat Frankish
Age-related disability.
Therapeutic ‘holding’ of people with dementia. Analysis of
the impact of environmental change on the emotional well-
being of people with dementia living at a rehabilitation-
focused private hospital.
Liz Trubshaw
Pat Frankish Psychology &
Psychotherapy Consultancy
38
Links between early and later life
And so, from hour to hour, we ripe and ripe,
And then, from hour to hour, we rot and rot;
And thereby hangs a tale…
[Shakespeare, As You Like It, II, vii, 26-28]
39
Dementia
• Dementia is a blanket term used to describe the
symptoms that occur when the brain is effected by
specific diseases and conditions (Malloy, 2009)
• It is not a natural part of aging but is a disability that
can occur in older age
• Robs the person of memory, and, ultimately, their
identity
• Incidence on the increase. There is no cure
• Majority of sufferers live in the community, at least in
the early stages & majority of care given informally
by family
• Not enough formal care provision
40
Stages in the progression of AD
1st (Early) stage = forgetfulness phase – anxiety & depression
Emotional
• Increased irritability, lowered frustration tolerance
• Depression, anxiety, wide mood swings
• Restlessness, fatigue, lack of initiative
• loss of interest
• High activity level with incessant wandering
• Attitude of unconcern
• Excuse making
Social
• Accentuation of previous personality traits
• Apathy or euphoria
Cognitive
• Memory disturbance: significant difficulty in forming new memories
• Misplacing objects, forgetting names
• Preservation of remote well learned memories
• Disturbance of problem-solving skills: inability to solve novel, complex problems in
which old, well established skills & strategies cannot be used
• Difficulties with comprehension, expression of complex ideas, abstract thought,
making critical judgements
• Deficit of constructional skills
41
2nd (middle/intermediate) Stage = confusional phase
• Accentuation of previous emotional, social & cognitive changes
• Less able to manage personal or business affairs because of failing memory & lack
initiative
Impairment of
• Orientation (initially for time, later for place)
• Memory (especially recent memory)
• Judgement, comprehension, calculation
• Inability to organise memories in proper time sequence
• Word-finding difficulties
• Language becomes tangential, circumlocutory & perseverative. Speech is fluent
but features a lack of substantive words
• Memory for remote memories relatively intact, vocabulary largely spared
• Neurological examination still normal
Personality
• Changes become more apparent
• Heedless of personal dress & behaviour
• Unconcern for others, denial
• Wandering, restless, upset at night
• May have insight into cognitive losses, leading to secondary anxiety
• depression
42
3rd (Late) stage = dementia phase – extreme dependency
Cognitively
• More generalised loss of intellectual skills
• Loss of insight
• Inattention, distractibility
• Severe disorientation
• Motor, speech perseveration
• More distinctly aphasic: loss of spontaneous speech; anomia; echolalia; relative
preservation of repetition
• Agnosias: may mistake individuals or objects in the environment & respond
accordingly
• Apraxias: loss of motor programmes (sugar in coffee, lighting match, combing hair,
walking)
• Widespread neurological signs, abnormal reflexes
Behaviourally
• Prominent behavioural problems that challenge carers/families/peers
• Uncommunicative, apathetic, withdrawn
• Anxiety, agitation, motor restlessness, wandering
• Delusions, hallucinations, paranoid ideation
• Walking, mobility affected, eventual confinement to wheelchair & then bed
• Speech, swallowing impaired
• Incontinent
• Depression of consciousness leading to stupor, coma & then death
43
Reaching people with dementia- the obstacles
• In 1953 Freud said
“near or above the age of 50 the elasticity of the
mental processes, on which the [psychoanalysis]
treatment depends, is a rule lacking – old people are no
longer educable – and, on the other hand, the mass of
material to be dealt with would probably prolong the
duration of the treatment indefinitely” (p.264; cited in
Bender, 1993).
44
Some intra-psychic & institutional processes that give
rise to discrimination
• Kitwood (1988) function of a person with dementia could be
impeded further by poor or critical handling by family &
carers
• ‘mirroring’ of the forgetting that occurs in patients with
dementia in the organization of services, splitting off and
evacuating uncomfortable areas (Klein, 1975)
• A denial of the need to think about people with dementia
occurs – e.g. a tendency to assume that there is little or no
activity remaining in the minds of people who are losing their
memory
45
Staff defences: Horticultural approach to care
• Davenhill (2007) – the emotional meaning of tasks
such as eating and washing are often forgotten -
there is a lack of significance given to the body of an
older person, other than in a purely functional way,
yet physical care is a nonverbal form of
communication
• Impatience with a sufferer’s slowness, by over-
compensating for their perceived difficulties, may
add humiliation to their already impaired thinking
and doing (Evans, 2008)
46
‘Holding’ people with dementia
• A person with dementia is someone who becomes
increasingly isolated yet increasingly dependent.
• Frankish’s (1992) adaptation of Mahler’s stages of
emotional development, posits that (the once
individuated) people with dementia traverse
Mahler’s stages in reverse.
• As the disease progresses more losses are
experienced. When in the advanced stage the person
cannot bear to be with him/herself (Frankish, 2009).
47
Justification for conducting the current study
• It is proposed that by providing regular and
consistent contact to people with dementia
living in a long-stay hospital, emotional
deterioration will at least be static, and the
person will be therapeutically ‘held’ and
‘present’ for longer.
48
Method
• Observational, repeated measures design across two time
points (observations, HTP) of patients
• Contact with each person (tactile & verbal) for 5 minutes,
twice a week
• Staff completed the Ward Atmosphere Scale at baseline and
at twelve months
Measures
• House-Tree-Person (HTP) test – projective personality test
(Buck 1948)
• Frankish’s (1992) adaptation of Mahler’s stages of emotional
development (observation tool)
• Ward Atmosphere Scale (WAS) – Form R (Real)
49
Mahler’s (1975) phases of emotional development
• Differentiation – ability to recognise that there are parts of
itself that are different.
• Practising – begins to practice behaviours that come with
development – e.g. walking & talking. Repetitive.
• Rapprochement – experiments with increasing physical &
emotional distance between self & primary carer but still with
regular & consistent checking that the carer is vigilant.
• Individuation – the final stage – ability to be separate & away
from the primary carer without obvious anxiety.
50
Measurement of Emotional Development – Frankish,
1992
• Observe for 20-seconds, code for 40-seconds coding, observe again
for 20-seconds. Complete this procedure for 40-minutes.
• For each minute = three observations (Behaviour, Orientation,
Interaction).
• Behaviour is allocated as:
– P to represent passive
– A to represent active behaviour
– R to represent repetitive behaviour
– V to represent varied behaviour
• Orientation is allocated as:
– S for orientation to self
– O for orientation to objects
– P for orientation to person
Interaction Y = present; N = absent
51
Frankish’s Mahler’s Phase
Code
Passive, Self, No 1 Differentiation
Active, Self, No 1
Active, Objects, No 2 Practising
Active, Person, Yes 3
Repetitive, Self, No 1
Repetitive, Objects, No 2
Repetitive, Person, No 2
Repetitive, Person, Yes 3 Rapprochement
Varied, Self, No 1
Varied, Object, No 2
Varied, Object, Yes 3
Varied, Person, Yes 4 Individuation
52
Ward Atmosphere Scale – Moos 1974
Relationship Dimensions
1 Involvement How active & energetic patients are in the program
2 Support How much patients help & support each other & how supportive the staff is
toward patients
3 Spontaneity How much the program encourages the open expression of feelings by
patients & staff
Personal Growth Dimensions
4 Autonomy How self-sufficient & independent patients are in making their own decisions
5 Practical Orientation The extent to which the patients learn practical skills & are prepared for
release from the program
6 Personal Problems The extent to which patients seek to understand their feelings & personal
Orientation problems
7 Anger & Aggression The extent to which patients argue with other patients & staff, become
openly angry, & display other aggressive behaviour
System Maintenance Dimensions
8 Order & Organization How important order & organization are in the program
9 Program Clarity The extent to which patients know what to expect in their day to day routine
& the explicitness of program rules & procedures
10 Staff Control The extent to which the staff use measures to keep patients under necessary
controls 53
Procedure
• Spent 5-minutes twice a week with each patient on the unit.
• Baseline emotional level was recorded and assessed every
four months, over a 12-month period.
• House-Tree-Person drawings were requested at Time1 and
Time 4.
• Unit staff completed the Ward Atmosphere Scale (WAS) Form
R, to describe their experience of working on the Unit.
• Inter-rater reliability = 1 service user and her carer who had
both completed level 2 of the DDP course. They did not know
the participants.
54
Results
55
Time 1 Time 2 Time 3 Time 4 HTP comment
Jan 2010 May 2010 Sept 2010 Jan 2011 1&
2
Alan Schizophrenia 2 2 2 2 No No HTP
Brian Korsakoff’s 3 3 3 3 Yes Improvement on HTP –
still disturbed but
more presence
Gordon Frontal Lobe 1 2 2 2-3 (20 Yes Detero’tn on HTP
Dementia each) Some practicing
behvrs, some
rapprochement
James Frontal Lobe 2 2 2 2-3 1 Time 121 x 2, 19 x 3 at
Dementia T4. Some
rapprochement.
HTP – helpless,
vulnerable
John Alzheimer’s 2 2 2 2 Yes Major Deterioration &
shrinkage in cog
ability.
Tom Korsakoff’s 2 2 2 2 Yes No person Time 2.
Smaller not as detailed.
Differentiation/practicing
Trevor Alzheimer’s - 1 2 2 1
56
Brian - Time 1 (Korsakoff’s )
Brian – Time 2
58
• Brian - Time 2
59
• Brian – Time 2
60
Gordon – Time 1 (Frontal Lobe)
Gordon – Time 1
Gordon – Time 2
Gordon – Time 2
Gordon – Time 2
John – Time 1 (Alzheimer’s)
John – Time 1
John – Time 1
John – Time 2
John – Time 2
John – Time 2
Ward Atmosphere Scale Profile (Form R). Staff
experience of the Unit at 1 month & 12 months
Discussion
• Emotional level static for most patients using Frankish’s tool
• HTPs demonstrated
– Improvement
– Stability
– Deterioration
• Ward Atmosphere Scale
– Staff experience of the Unit had deteriorated over the 12
months
• Some patients therapeutically held by contact despite
instability of the Unit
73
Limitations
• Confounders
– My presence
– Extraneous variables
– Only twice a week for 5 minutes
– Unconscious desire for the patients to continue to be
psychically well, initially by me, but also by other raters
74
Conclusion
• Enhancing the quality of care is much needed, particularly
finding ways to understand the patient’s experience and to
better communicate
• Real and ordinary contact with people right to the end is what
is required.
Recommendations
• Unit & hospital wide training to Level 2 of the DDP
• Daily, regular, consistent, real and ordinary contact
75
References
• Davenhill, R. (2007). (Ed.). Looking into later life.
London: Karnac Books.
• Evans, S. (2008). ‘Beyond forgetfulness’: How
psychoanalytic ideas can help us to understand the
experience of patients with dementia.
Psychoanalytic Psychotherapy, 22(3), 155-176.
• Frankish, P. (1992). A psychodynamic approach to
emotional difficulties within a social framework.
Journal of Intellectual Disability Research, 36, 559- 563.
• Malloy, L. (2009). Thinking about dementia – a
psychodynamic understanding of links between early
infantile experience and dementia. Psychoanalytic
Psychotherapy, 23(2), 109-120.
76
Welcome to the IPD Conference
New Ways Forward for Disability
Psychotherapy
Dr Pat Frankish
Evaluation of the Impact of using a
Disability Psychotherapy Approach
with Five Training Clients
Amanda Shackleton
Clinical Psychologist 2 days
Tameside Learning Disability Service
Why
• From a behavioural background – previously rely
on behavioural reduction as indicator of clinical
success
• Training has been incredibly powerful
• completely changed my thinking
• have seen changes over and above reduction of
referral issue
• Passionate about continuing and developing
practice now training completed
• Need data to support continuing to use approach
• To allow consolidation of training process for self
Method
• Examined impact on 5 clients with learning disabilities
• Range of length of therapy 12 month to 2 years – still ongoing
• 3 mild LD, 1 moderate and one severe LD
• Retrospectively tried to establish data set for each client
– File review looking for indictors of change over and above
referral issue
– Key informant interview based on file review
– Behavioural incident reports
– Projective tests used in assessment repeated
– House Tree Person
– Object Relations Test
Therapeutic Approach
• Approach – radical change from previous working
– Provision of safe base – dynamic administration
– Using ideas of Winnicott, Klien and Bion re provision of a
containing and facilitating experience that can help
process of thinking development
– Growing awareness of counter transference and
projections as a therapeutic tool and guide
– Helping person make links between past and present and
defences.
– Supervision by Linda Arkwright
Mr A
• 29 years old, lives with adoptive parents,
• Referred for agitation, aggression, anxiety
• Birth mother drug user, found alone at 6
weeks in filthy, emaciated state. Thought
cerebral palsy. Fostered until 13 months then
adopted.
• 26 attempts to get service engagement since 9
years old
Therapy Mr A
– WAIS-3 –IQ 69 – presents as much more able.
– BADS – significant frontal lobe difficulties identified
• extremely poor initiation, planning and problem solving.
• Therapy work 21 months to date
– 38 weekly sessions – lots of AWOL periods and DNA’s
– Key themes –
• anger at birth mother and also adoptive mother’s
‘invasiveness’ - missing attunement / false self
• Cognitive assessment results – understanding self
• Wanting to move on and progress in life – previously not
able to think possible
Outcomes Mr A
• File review key changes
– Decrease in incidents – first 12 months= 9, last 9 months = 1
– Thinking longer term consequences of actions on impact on others
– Wants to work - referral to supported employment – been disappointed by
loss of workers and poor service progress
• Key informant – mother – issues re seeing - not been able to collect data from her
• ORT
– increased richness in answers and more emotional content
– increase in ability to describe consequences
• 8 Don’t Know to ‘what will happen next?’ vs 1 at repeat
– themes re aggression / drinking / groups - currently going out with old
friends / processing issues
• HTP
– Slight increases in detail of pictures but not size.
– not as significant as seen in other clients
Client age Referral issue Therapy Incident ORT HTP File and key
length reports informant
to date
Ms L 58 Anxiety, 16 mths n/a Not Much Better
depression, over repeated richer boundaries;
dependence due to detail in all assertive;
reaction drawings thinking of
to inital solutions
Ms D 43 Increase in 2 years Staff report Refused to Refused to Increased
aggression decrease repeat repeat empathy, sense
but of humour,
unreliable seeking
data independence
Mr D 27 Acute anxiety, 18 mths Self report Richer, Much More
agitation decrease ‘complete’ developed independence,
answers then sorting out
declined own problems,
more assertive
Mr P 31 Challenging 18 mths Data n/a More No key
behaviour – incomplete developed informant
aggression, – repeated then available –
refusal staff declined qualitative
turnover changes in
and moves sessions -
reverie
Overall Conclusions
• All clients show indications of positive change in
therapy
– Difficulties with obtaining complete data sets
• Overall review massively helpful – goes beyond reviews
for supervision
• Highlighted how vulnerable clients are to service and
life changes,
– Those supported by staff – longest time people worked
with them 2 years
– Everyone receiving services has had some service
disruption or worker change
• Indications of impact on measures used.
Further Work on this Project
• To use present data set as base line and follow up after
completion of therapy
– especially useful to compare with those who have had previous
behavioural approaches
• Look at time/cost involved with previous approaches
• To routinely assess and evaluate therapy work
– establish protocol with as wide a range of measures as possible.
– To include outcome measures used by Beail and others
• Brief Symptom Inventory; Inventory of Interpersonal Problems
– To look at client thoughts on therapy work
• Continue to contribute to growing evidence for this approach
as feel is far superior in terms of benefits and changes for
people able to access.
• Thank you for listening and any questions or
comments??
