A clinical mindfulness service for patients and carers has now been established in the Tees, Esk and Wear Valleys NHS Foundation Trust, which serves a general population of over 2 million people. The core intervention in this new service is 8-week courses of Mindfulness Based Cognitive Therapy (MBCT) for people with recurrent depression and for stressed carers and parents. MBCT is a group-based, effective and cost-effective intervention that comprises training in meditation with elements of cognitive behavioural therapy. MBCT has been shown in systematic reviews and meta-analyses to significantly reduce relapse rates in people with recurrent depression and is a ‘key priority for implementation’ in the NICE depression guidelines. MBCT also promotes effective stress management, wellbeing and resilience and can thus be very helpful to a range of service users and carers
What We Did
A clinical mindfulness service for patients and carers has now been established in the Tees, Esk and Wear Valleys NHS Foundation Trust, which serves a general population of over 2 million people. The core intervention in this new service is 8-week courses of Mindfulness Based Cognitive Therapy (MBCT) for people with recurrent depression and for stressed carers and parents. MBCT is a group-based, effective and cost-effective intervention that comprises training in meditation with elements of cognitive behavioural therapy. MBCT has been shown in systematic reviews and meta-analyses to significantly reduce relapse rates in people with recurrent depression and is a ‘key priority for implementation’ in the NICE depression guidelines. MBCT also promotes effective stress management, wellbeing and resilience and can thus be very helpful to a range of service users and carers.
Our key values include a commitment to quality, respect, wellbeing, involvement and teamwork. Our approach is de-stigmatising, empowering and recovery-focussed. Participants self-refer; interventions take place in non-clinical community settings and sometimes in the evenings. The 8-week course involves a personal journey in which participants learn skills and apply them to their lives. Many participants describe regaining a sense of hope, meaning and self-compassion as well as symptom reduction.
We aim to focus our time and energies on the provision of accessible and helpful interventions to many and so have developed a simple but innovative service model. The service is widely publicised; interested individuals first attend a ‘taster session’; the subsequent application process is simple; assessments are brief; record keeping is concise. The service cuts across ages and service areas and is open to those with no previous or current involvement with the Trust. Carers and parents are a priority. We place great importance on the quality of our work and on respectful communication with everybody we encounter. It is essential that we live and embody the compassion and mindfulness that we teach. Many of our courses are ‘mixed’ – they include staff participants alongside service-users and carers / parents – this approach fits with our belief that service-users, carers and professionals are all ‘in the same boat’ – as humans, we are prone to suffering, we wish to be happier and to make wiser choices in our lives. The service is run by a small team of individuals with a passion for MBCT. We all comply with national good practice guidelines for MBCT therapists. These include a daily personal mindfulness practice and attendance at an annual silent retreat.
In December 2014 we submitted a business case to the Trust’s Executive Management Team (EMT). The business case proposed the development of a Mindfulness Team with the following functions:
• Clinical provision of Mindfulness-Based Cognitive Therapy (MBCT)
• Work with external organisations to generate income
• Training of Trust staff
• Evaluation and research
Key points in the business case were:
1. Courses of MBCT to be provided for people with recurrent depression – for symptom reduction as well as relapse prevention.
2. The courses also to be open to stressed carers and parents of people with mental health problems – for stress management and resilience.
3. MBCT courses to be for working age adults and older people across both primary and secondary care.
4. Service model and delivery to be de-stigmatising and recovery-focused.
EMT supported the business case and proposed that a service model should initially be developed and evaluated on a small scale. A combination of recurring and non-recurring funding was made available.
The service model for clinical provision was developed after extensive consultation, including with the following:
A focus group of service users and carers
Service user and carer members of the Mindfulness Steering Committee
A reference group of clinical colleagues
Management colleagues from the Trust
A small team was established in May 2015 and the following posts were recruited to:
• Mindfulness Lead – (0.6 WTE) – substantive
• Team Manager – (0.6 WTE) – substantive
• MBCT therapist – (0.6 WTE) – secondment
• Admin support – (0.4 WTE) – fixed term
The courses are widely advertised and promoted, with the help of professionals, carers’ groups, posters, leaflets, local press, etc, and take place in community venues. The first step is for an interested individual to attend a two hour ‘taster session’. Having attended a taster session, s/he can apply to attend the course by completing a simple application form. This is followed by a relatively brief telephone assessment.
Because of the limited team size, provision was initially confined to three geographical patches within the geography covered by the Trust.
In January 2016 we submitted our first evaluation report to EMT – this described the development and evaluation of the new service. Detailed evaluation of early courses supported feasibility and effectiveness. Data included pre- and post-course outcome measures, qualitative feedback from course participants and a survey of TEWV clinical staff who had signposted to the service. There had also been good progress in other team functions: training, external work and evaluation / research. EMT raised some concerns in relation to geographical inequity and were keen that ‘mixed’ interventions (i.e. groups including service-users, carers and staff) should be fully explored. Non-recurring funding for the clinical team was extended for a further year.
In February 2017 we submitted our second evaluation report to EMT. By this time, a further year of clinical provision had confirmed that the service’s person-centred and recovery-focused service model is feasible and effective and fits very well with MBCT. The great majority of participants engage well with the programmes. Evaluation (see details later) revealed high levels of service user and carer satisfaction and outcome measures showed clinical benefits in keeping with national research findings. Some participants with seemingly intractable difficulties made significant progress. It was recognised that the decision to initially focus on three specific geographical patches had allowed the service model to be developed and evaluated.
The successful implementation and evaluation in these three areas argued strongly for the development of a Trust-wide service. NICE guidelines, the increasing evidence base and national and international acceptance of MBCT as a mainstream intervention all added weight to this argument. EMT agreed that the service should become Trust-wide (providing 31 clinical MBCT courses per year) and agreed to fund two additional 0.6 WTE MBCT Therapist posts together with an additional 0.25 WTE of admin time to enable this to happen.
The service fits well with the NHS five year forward view in that it is innovative, preventive, cuts across the boundaries of primary and secondary care and boundaries of physical and mental health care.
The clinical mindfulness service builds upon the success of the mindfulness service that the Trust provides for its staff. Our courses for staff promote resilience and the development of qualities such as self-awareness, emotional intelligence and compassion that are very relevant for high quality clinical care.
We work closely with a range of partners, including: Local Authorities, Primary Care Teams, Recovery Colleges, Mental Health charities (such as local branches of MIND and Age UK), service user advocacy groups, carers’ organisations and a local hospice. We have worked hard to get to know and develop relationships with partners and we keep them informed of forthcoming courses so that they can help us to promote them.
GPs are becoming aware of the clinical provision, are signposting to it and have given positive feedback. MBCT provision has been placed on the CCGs’ lists of commissioning intentions. As GPs and CCGs become more aware of the service, we are optimistic that it will be funded by CCGs in the future.
At a national level, the Trust is now an accredited training centre as a member of the ‘UK Network for Mindfulness-Based Teacher Trainers’. The Team’s Lead is an Associate of the internationally renowned ‘Oxford Mindfulness Centre’ and a member of the ‘Mindfulness Network CIC’.
Planning, establishing and delivering the service has given many opportunities for collaboration and co-production with service users and carers. Our model of service was informed by a service user focus group set up specifically for this purpose. Our steering committee includes a service user representative and a carer representative. We routinely include a service user representative on interview panels when recruiting to clinical posts within the service.
A number of service user and carer peers who have graduated from previous MBCT courses are involved in the delivery of our ‘taster’ sessions and MBCT courses and add a great deal of value by sharing their experiences about the difficulties that brought them to MBCT and how the course was helpful to them.
Verbal and written feedback from service users, carers and parents is routinely captured at end of each MBCT course and fed back through a review cycle at team meetings.
Looking Back/Challenges Overcome
Not so many years ago, MBCT was entirely unknown to the Trust. It is now a part of mainstream clinical provision as well as playing a major role in supporting staff wellbeing. There have been many challenges along the way and many that remain. Successfully introducing a new therapeutic approach (with its particular philosophy and practices) to a complex organisation that covers such a large geography has been far from easy but generally people been very open and receptive. The Trust’s communications team has been a great ally and has promoted our service to service users, carers and partner agencies through a variety of media. The dual demands of service development and service provision have meant that work has often spilled over into our own time and perhaps the greatest challenge has been to our home lives and our families!
Provision of MBCT in the Trust originally relied on a very small number of key individuals. Over the last few years, hundreds of Trust staff have participated in an MBCT course themselves and a good number of those have progressed to train as MBCT therapists, with support and supervision from the more experienced members of the Mindfulness Team.
In 2016 we ran our first in-house training for MBCT therapists within the Trust and we are to start our second training course in July 2017. Such training courses are few and far between in the NHS and the Trust is now a nationally accredited MBCT therapist training centre. Following the year-long ‘foundational’ training, the trainees further develop their skills and competencies by co-facilitating courses with members of the Mindfulness Team before we assess them as competent to run courses by themselves. They then go on to do this, in their own teams, with our supervision and support. We have thus moved from having a small number of specialist teachers towards a ‘train to teach’ model but retaining clinical supervision and a governance framework. Some of the professionals that we train are from primary care which is resulting in close collaborative relationships with these colleagues and their teams.
In this way, we are supporting the development of a good number of skilled MBCT therapists within the Trust as an investment in the future.
Evaluation (Peer or Academic)
We have carried out detailed evaluation of provision. Key data sources included electronic records, anonymous feedback forms, pre- and post-course outcome measures and on-line surveys.
In 2016 (Jan – Dec) the team delivered seventeen clinical programmes to 192 participants.
Participant characteristics and attendance were as follows:
• 76% were female
• 25% were age 65 yrs and over
• 77% had suffered repeated episodes of depression
• 30% were stressed carers / parents
• Mean attendance was 7.2 (of 9) sessions (i.e. 80% of sessions)
Anonymous participant ratings (on a scale of 0-10) given at the end of the courses were as follows:
Item Mean rating
How important has this course been to you? – 9.1
How helpful has this course been to you ? – 9.1
How convenient was the timing for you? – 8.4
How suitable was the venue for you? – 8.7
Please rate the quality of the teaching – 9.7
How helpful was it to have an expert by experience to help to deliver the course? – 8.8
Mindfulness course should be made widely available for people with mental health problems and their parents and carers – 9.8
How likely are you to recommend our mindfulness course to friends and family if they needed a mindfulness course of this kind? – 91% Extremely likely, 8% Likely
Examples of comments from anonymous feedback forms completed at end of courses are given below:
Patterns of thinking have been challenged and are gradually changing… I like myself more and am kinder to myself and have greater self-awareness.
It has been restful to live in the moment instead of constantly re-living the past and being overwhelmed by regret and guilt and worrying about the future …. It has had a real impact on mood and ability to cope with life and has improved relationships with those I care for.
I have been in therapy for depression and PTSD on and off for several years and yet this course has made more difference to every aspect of my life than I feel any CBT or counselling has.
I am so glad that this course was recommended to me and I would certainly recommend it to anyone who is suffering from depression/anxiety.
I came to the course expecting a miracle cure that never happened but what did happen was more important. I found how to be myself again and not hide away from the world imagining things that are not true. This course was a godsend.
At the beginning of the programme my mood was at rock bottom with no motivation to do anything… now I feel hopeful about the future… it has had such a great improvement in my life as a whole.
This course has changed the way I look at my life dramatically… I feel like a whole person again, able to see difficulties with a clear perspective.
The course has taught me to be kinder to myself. I originally thought the course would give me ideas to support my son, but as the course proceeded, I realised it was more beneficial for myself.
I have gained a wonderful tool to use to help me live a totally different life… I had no idea I could feel this way and it has given me a new hope.
The course has given me much needed coping skills… It has also helped me to cope better with intrusive thoughts and stress/anxiety relating to my situation and illness.
It has been really important to me in terms of making me feel much more confident about the future and being able to manage and control my depression in the long term.
It has made a big difference to my resilience to difficulties. My difficulties are ongoing as they relate to someone else but I now feel better equipped to deal with the effects on me.
The standard of teaching and care was exceptional. This course should be widely available to anyone experiencing depression or anxiety.
An on-line survey of Trust clinical staff who had sign-posted participants to the service was conducted. It included quantitative and qualitative elements. The questions and ratings are given below:
Please rate the degree to which the mindfulness service seems to have been helpful for your client: – 18% helpful, 82% very helpful
How likely are you to recommend the mindfulness service to other suitable clients in the future? – 100% very likely
Comments from the staff who did the signposting included the following:
It has had a huge impact upon his recovery and he uses the practices every day… he continues to say on every visit how important it has been to his recovery.
The client had previously had numerous episodes of low mood/depression, culminating in an attempt on his life… the course appears to have given him something new… a way of self-monitoring… and a greater insight into the negative thinking which has previously led to low mood.
My client spoke very highly about the group and stated she is continuing to use the skills she has developed in daily life with a very positive effect. Many thanks.
This client has already accessed mental health services on a number of occasions in addition to 7 years of private counselling…. she now understands that some of the ‘answer’ she is seeking may be within her own grasp, and the skills and understanding of Mindfulness she has gained can be used going forward.
The members of the Mindfulness team delivering the service have been by the motivation and hard work of most of the participants. Some participants with seemingly intractable difficulties made great progress. Our impression is that the service model fits well with the ‘skills development’ approach of MBCT, putting participants at the centre of clinical processes and encouraging them to take responsibility for their journey of recovery.
The courses include a heterogeneous mix of participants: some currently depressed, some between episodes, stressed carers, stressed parents, working age adults, older people, those involved with secondary care mental health services, those not. Our impression is that this heterogeneity is de-stigmatising and helps to emphasise the importance of ordinary mental processes that are common to us all – processes that we can become more familiar with and learn to work with more skilfully.
Outcomes were measured by pre- and post-course questionnaires assessing low mood, anxiety and wellbeing:
We calculated mean pre-course and post-course scores for PHQ 9 (low mood), GAD 7 (anxiety) and SWEMWBS (wellbeing)
PHQ9 (post) 6.3
PHQ9 – mean reduction of 5.6
GAD7 (pre) 10.7
GAD7 (post) 4.9
GAD7 – mean reduction of 5.8
SWEMWBS (pre) 19.7 – below 25th centile.
SWEMWBS (post) 25.1 – between 50th and 75th centiles
SWEMWBS mean increase 5.4
We calculated pre and post figures for ‘caseness’ (ie above clinical threshold) according to PHQ 9 & GAD 7
(Caseness: PHQ ≥ 10; GAD ≥ 8)
PHQ caseness (pre) 67%
PHQ caseness (post) 19.8%
GAD7 caseness (pre) 70%
GAD7 caseness (post) 19.8%
We calculated figures for recover and reliable recovery
(reliable change indices: PHQ9 ≥ 6; GAD7 ≥ 4)
Recovery – 67%
Reliable Change – 74%
Reliable Recovery – 64%
We are passionate about MBCT and about the service model that we have developed. This strength of feeling leads us to tell others about our service at any opportunity! Within the Trust we appear frequently in in-house publications and electronic media. We have given numerous presentations (long and short) to various audiences (large and small) in recent years. The most high profile setting was at a meeting of an All Party Parliamentary Group in the Houses of Parliament. Team members have presented at local, regional, national and international conferences.
Is there any other information you would like to add?
A well designed randomised controlled trial in the Lancet (Kuyken et al, 2015) which compared MBCT to maintenance antidepressant medication over a two year period and found no difference in the rates of relapse (44% in the MBCT group; 47% in the medication group).
A systematic review and meta-analysis of 1,250 patients in nine randomised controlled trials (Kuyken et al, 2016) strongly supported MBCT’s effectiveness.
A report by an All Party Parliamentary Group in 2015 recommended considerable expansion of MBCT within the NHS (in line with NICE guidelines) and the training of many more MBCT therapists. Team members have contributed to the planning of a national roll out of MBCT therapist training that is currently being developed.
Team members are also playing a significant role in the design and delivery of a high profile Wellcome Trust funded randomised controlled trial (MYRIAD) about the primary prevention of depression, which involves training secondary school teachers to deliver mindfulness courses to their pupils.
The Team has been commissioned by a Local Authority to provide course of MBCT for its stressed staff members – 4 courses a year over a three year period.
Other ‘external’ work has included workshops and MBCT courses for external organisations, including other Local Authorities, Universities and the regional and national NHS Leadership Academy.