Introduction
The Layard Report (Layard, Reference Layard2006) states that depression and anxiety account for almost a third of all disability in the UK. It is estimated that the cost to the economy in terms of lost output is £12 billion per year, or 1% of total national income, and the cost to the taxpayer is in the region of £7 billion (Layard, Reference Layard2006). The individual cost to those suffering from depression or anxiety and their families and carers is less easily calculable, but is of significant importance. The NICE Guidelines has reviewed evidence based treatments and strongly recommended CBT for depression (NICE, 2004b) and for anxiety (NICE, 2004a).
It is increasingly recognized that secondary mental health services do not have the capacity to meet the level of need in the population (Tylee, Reference Tylee2006). In a study conducted in an area of high deprivation in inner South London, less than half of all potential needs were met (Bebbington, Marsden and Brewin, Reference Bebbington, Marsden and Brewin1999). This was particularly marked for depressive and anxious states. Only just over a quarter of those with ICD-10 depressive episodes and anxiety disorders were being treated. While the public prefer psychological interventions rather than medication (Angermeyer and Matschinger, Reference Angermeyer and Matschinger1996), access to these interventions is limited, with the average waiting time for psychological treatment being 6–12 months (Lovell and Richards, Reference Lovell and Richards2000). The Improving Access to Psychological Treatments (IAPT) programme (www.dh.gov.uk) should, in time, increase the psychological resources available in the UK. For the moment, however, long waiting lists exist, together with much frustration on the part of many referrers and continued suffering of people with depression and anxiety.
Psycho-educational CBT groups constitute a low intensity treatment in terms of therapist time and resources and have been effectively used in primary care. White, Keenan and Brooks (Reference White, Keenan and Brooks1992) reported success with large scale group therapy for Generalized Anxiety Disorder with their “Stress Control” Program. Primary Care patients offered treatment improved significantly on four of six main measures of anxiety when measured immediately after treatment and at 6-month follow-up compared to a waiting list and placebo control. Using a pre-post design, Kellett, Clarke and Matthews (Reference Kellett, Clarke and Matthews2007) also found that, when compared to individual CBT and psychodynamic-interpersonal psychotherapy, psycho-educational workshops led to equivalent rates of clinically significant outcomes on depression and distress.
When members of the public have been offered the opportunity to self-refer to psycho-educational workshops, these have proved to be acceptable and popular. Brown, Cochrane and Cardone (Reference Brown, Cochrane and Cardone1999) found that Stress Management workshops that targeted people with anxiety received a very positive response, with a large number of people enquiring and attending the workshops. They were also found to be effective, leading to significant reductions in anxiety and distress among workshop participants, compared to a waiting list control group, at 3-month follow-up (Brown, Cochrane and Hancox, Reference Brown, Cochrane and Hancox2000).
However, it has been found that acceptability to the general public is important and the title of the intervention is critical. When psycho-educational “Depression” workshops were run, this resulted in a low take up and high attrition rate (Watkins et al., Reference Watkins, Elliott, Stanhope, Button, Williams and Brown2000). Given the well established link between depression and low self-esteem (Beck, Rush, Shaw and Emery, Reference Beck, Rush, Shaw and Emery1979), and the greater popularity of the term self-confidence compared to self-esteem, it was decided to change the title of the depression workshops to the non-diagnostic “Self-Confidence” workshop. This proved to be much more acceptable to a broad range of the general public and the workshops attracted large numbers, 39% of whom had not previously consulted primary care services. Additionally, these workshops led to statistically significant reductions in depression and distress, as well as improvements in self-esteem in a randomized controlled trial (Brown, Elliott, Boardman, Ferns and Morrison, Reference Brown, Elliott, Boardman, Ferns and Morrison2004).
Based on the positive results from the efficacy research, the psycho-educational workshops were mainstreamed and a series of monthly self-referral workshops, each for up to 25 people, began to be run in a community setting as part of routine practice in Southwark. Two self-confidence workshops were run in this series. This study will examine the outcome of the workshops and will describe the characteristics of those who attended and those who benefited from these workshops when they are run in routine practice.
It was predicted that attendance at the workshops would lead to a decrease in depression and distress scores among participants. The study also investigates whether this difference depends on the severity of distress at initial presentation. A naturalistic 2-year follow-up of participants (Brown et al., Reference Brown, Elliott, Boardman, Andiappan, Landau and Howay2008) found that the benefits were greatest among depressed participants (BDI scores above 14) than non-depressed participants. The second hypothesis of this study is that the outcome following the workshops would be better for those individuals with more severe distress scores at initial presentation.
The study
Design
A one group pretest-posttest design was used in this study.
Measures
The clinical outcome of the workshops was assessed using two measures.
The Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM) is a 34-item self-report questionnaire (Evans et al., Reference Evans, Mellor-Clark, Margison, Barkham, Audin, Connell and McGrath2000) that provides a measure of distress and can be used with clients with a range of psychological conditions. The Global Distress score is calculated as a mean value, and has a range of 0–4, where a higher score represents a higher level of distress. The clinical threshold is a score of 1.19 and above for males and 1.29 and above for females.
The CES-D (Radloff, Reference Radloff1977) is a self-report measure of depressive symptoms. The total score ranges from 0 to 60, with a score of ≥16 indicating the presence of clinically relevant depression (Weissman, Sholomskas, Pottenger, Prusoff and Locke, Reference Weissman, Sholomskas, Pottenger, Prusoff and Locke1977).
Both the CORE-OM and CES-D were part of a set of routine outcomes measures that were used in the NHS Trust within which the service is based. Participants also completed a brief demographic questionnaire.
Method
Self-confidence workshops were run in Southwark, a South East London Borough, as part of a series of four day-long workshop programmes. Other workshops in the series were Managing Anger, Improving Sleep, and Handling Stress. The aim of the Self-confidence workshops was to help participants improve their self-confidence and so reduce their depression. Publicity material was distributed over a period of 2 months to libraries, GP practices, counsellors, health centres, community mental health teams, local companies and leisure centres. The publicity material consisted of A5 flyers that advertised one-day workshops entitled “How to Improve Your Self-Confidence”, and invited people interested in attending to telephone or e-mail for further information.
To maximize access and reduce the likelihood of work or personal commitments affecting attendance, the workshops were free and took place on a Saturday. To reduce the possibility of stigmatization, and consequent reluctance to seek help (Hayward and Bright, Reference Hayward and Bright1997) they were held in a library rather than a mental health care setting. The workshops were run in November 2006 and March 2007. Workshops were only available to those living or working in the borough. Otherwise, there were no exclusion criteria.
All individuals who enquired and were eligible were sent an information leaflet for the workshop and a location map. Potential participants were also invited to an Introductory talk that provided further information about the workshop and the various stages involved. At the Introductory talk, potential participants were asked to decide whether or not they would like to attend the workshop, and were asked to complete the self-report measures.
Up to 25 people could attend each workshop, which was facilitated by two clinical psychologists and an assistant psychologist. The programme started at 09.30h and finished at 16.30h, with refreshment breaks during the day. The workshops used cognitive-behavioural techniques adapted into an educational programme based on previous workshop programmes (Brown et al., Reference Brown, Elliott, Boardman, Ferns and Morrison2004) and Fennell's book Overcoming Low Self-Esteem (Fennell, Reference Fennel1999). The main aims of the programme were to help participants understand how low self-confidence develops and is maintained, as well as teach techniques for improving self-confidence and self-esteem.
The day's programme was structured into four sessions. In the first session, information was given about the development of low self-confidence and its emotional components, including depression. The second session consisted of cognitive components of low self-confidence, specifically, identifying and challenging negative thoughts. Behavioural methods for improving low self-confidence, including problem-solving and assertiveness, were taught in the third session. The final session was devoted to action planning, with participants setting their own homework targets to start improving their confidence. To reduce the possibility of participants becoming bored or tired, training methods were varied and included didactic sections, large-group exercises, role-play demonstrations, and discussions of vignettes of people with low self-confidence.
Four weeks after each workshop, a 2-hour follow-up meeting was organized for participants to discuss their experiences and report back with any problems they had encountered. Participants also completed the self-report measures again at this stage. This follow-up session also incorporated a short individual session during which their scores on the self-report measures at the introductory stage were discussed with them. If appropriate, they were “signposted” to other services, including their GP and relevant voluntary organizations.
Results
Participants
Of the 56 participants who attended an introductory talk, 40 (71.4%) went on to attend a day-long workshop. Follow-up data were collected for 31 (77.5%) of these participants.
Demographic details (n = 56)
Fifty-six people self-referred and attended the introductory talk for the “How to Improve your Self-Confidence” workshop. Participants either lived or worked in the London Borough of Southwark, which has been classified as the 12th most deprived borough in England, of 354 (Cook, Reference Cook2007). All participants completed self-report measures at this stage. Approximately two-thirds of participants were female and two-thirds were single. Just over half of participants were in paid employment. Socio-economic status was based on occupational status. A large proportion of those who self-referred were unemployed (20%) and unoccupied (21%). For those who were employed, almost a quarter fell into the Class 3 non manual category (23%), which relates to skilled non manual work, and 20% fell into Classes 1 or 2, which cover managerial or professional occupations. The mean age was 40 years. The largest ethnic groups self-referring were those who described themselves as White (57%) and Black (23%). These figures are consistent with the ethnic breakdown of Southwark's population (Cook, Reference Cook2007).
Previous consultation and/or treatment (n = 54)
Data on previous consultation for anxiety or depression were missing for two participants. Of the 54 participants who provided data, 16 (29%) had never consulted their general practitioner about anxiety or depression while 39 (70%) reported having previously tried either counselling or psychological help.
Severity of problems (n = 56)
On the CORE-OM, the overall mean Global Distress score was 1.75, with 39 participants (70%) scoring above the clinical cut-off for Global Distress. On the CES D, the mean score was 29.6, and 47 participants (86%) had scores within the clinically significant range (16 or above).
Effectiveness of intervention (n = 31)
Results will be presented for all those who provided follow-up data after 1 month (n = 31) and then only for those who scored above the clinical threshold at baseline (n = 20).
All workshop participants (n = 31). There was a significant decrease in the CORE-OM Global Distress score (Wilcoxon: N = 31, z = −2.558, two tailed p = .011) with an effect size of 0.62. There was also a significant decrease in total CES-D score (Wilcoxon: N = 31, z = −2.001, two-tailed p = 0.045) with an effect size of 0.5. This indicates a medium effect size change (Cohen, Reference Cohen1988). At the Introductory talk, 20 (65%) of these participants had CORE-OM Global Distress scores that were within the clinical range, and 26 (84%) of participants had scores within the clinical range on the CES-D.
Individual scores were investigated, in order to determine whether there was evidence for clinically significant change (Jacobson and Truax, Reference Jacobson and Truax1991). Clinically significant improvement is defined as the change from scores being in the “clinical” range to being in the “non-clinical” range. i.e. a client's pre intervention CORE-OM scores being equal to or above the “caseness” cut-offs and their post-intervention scores dropping below that point (CORE System Group, 1998). At the follow-up session, 10 participants (32%) and 6 participants (23%) showed clinically significant improvement on the CORE OM and CES-D respectively.
Participants with scores above the clinical cut-offs at baseline (n = 20). Results show that for those with CORE-OM scores above the clinical cut-off, there was a significant reduction in CORE-OM Global Distress (Wilcoxon: N = 20, z = −2.932, two-tailed p = .003) and an effect size of 1.00. For the CES D there was also a significant reduction in scores (Wilcoxon: N = 20, z = −2.596, two-tailed p = .009) and an effect size of 0.83. Both effect sizes indicate a large change.
Participants with scores below the clinical cut-offs at baseline (n = 11). For those with scores below the clinical cut-off at the introductory stage (n = 11) there was an increase in both CORE OM Global Distress (effect size = −.06) and CES-D (effect size = −0.29).
Discussion
The aim of the current study was to investigate the characteristics of those who attended the group CBT Self-confidence workshops run routinely on a self-referral basis as well as to examine the outcomes of the workshops. An additional question was whether, given the range of participants self-referring, the workshop benefited all participants equally.
One notable result was that participants who attended the self-confidence workshops reflected the general population in the Borough of Southwark, attracting a representative proportion of Black and ethnic minority (BME) participants. Several studies have found that Black people consulting their GP were less likely than Whites or South Asians to be referred to specialist services and more likely to present in crisis, often at Accident and Emergency as first point of contact (Bhui et al., Reference Bhui, Stansfeld, Hull, Priebe, Mole and Feder2003). Without further research, it is only possible at this stage to speculate why the workshops did attract these difficult to engage groups. It may be that self-referral workshops could offer an alternative means for this group to access mental health services without needing to consult their GP, whom they may perceive as having a more biological model of mental health problems. Or it may be that non-diagnostically labelled workshops may be less threatening and more congruent with their view of mental health difficulties. Alternatively, it may be the non mental health settings in which the workshops were run that are more acceptable.
Individuals who self-referred to the workshops had high levels of distress and depression: 70% scored above the clinical cut-offs for Global Distress (CORE OM) and 86% scored above the clinical cut-offs for depression symptomatology (CES-D). This supports earlier findings that those who self-refer to psycho-educational workshops are not just the “worried well”, but that the workshops attract individuals with diagnosable or recurrent psychiatric problems (Brown, Boardman, Elliott, Howay and Morrison, Reference Brown, Boardman, Elliott, Howay and Morrison2005). Twenty-nine percent of participants had not previously sought help for their psychological problems, indicating that these self-referral workshops allowed individuals who had not sought help from their GPs to seek help through these workshops.
The workshops were associated with significant reductions in levels of self-reported distress and depression at 4-week follow-up, with moderate effect sizes of 0.62 for self-reported Distress (CORE OM) and 0.5 for self-reported depressive symptomology (CES D). This supports a previous efficacy study examining CBT-based self-confidence workshops in targeting depression (Brown et al., Reference Brown, Elliott, Boardman, Ferns and Morrison2004).
Some participants benefitted more than others. Those individuals with distress scores in the clinical range at the introductory stage showed most improvement following the workshops. However, individuals with CORE-OM and CES-D scores within the non-clinical range seem to gain little or, at worst, may even feel more distressed after attending the self-confidence workshop. This is consistent with results obtained from a previous 2-year follow-up study of self-confidence workshops, which demonstrated that whilst those who had significant depression maintained their improvement at follow-up, those with scores below 14 on the BDI did not seem to show improvement (Brown et al., Reference Brown, Elliott, Boardman, Andiappan, Landau and Howay2008). It may be that those who had scores below the threshold had experienced depression or anxiety in the past. These results would imply that future Self-confidence workshops should be offered only to individuals with scores on the CORE-OM and CES-D that fall within the clinical range.
There are a number of limitations to this evaluation. First, the number of participants in the present study was relatively small. Second, there is the possible effect of a regression to the mean, which may lead to incorrectly concluding that a significant difference or effect is due to the treatment. Third, while this study had a short-term follow-up of only 4 weeks duration, a 2-year follow-up of workshop participants found that for those with high depression scores, improvements achieved at 3-month follow-up were largely maintained (Brown et al., Reference Brown, Elliott, Boardman, Andiappan, Landau and Howay2008). Additionally, non specific effects of being part of a group may have affected participant outcome. However, given the psycho-educational approach taken in the present study, we would expect group interaction to have been minimal. Finally, as the workshops took place in an area of high deprivation in inner London; this could affect the generalizability of the findings to other areas.
To establish the efficacy of these workshops, for maximum methodological rigour, future studies would usefully include a placebo group or control group consisting of an equivalent group treatment, in the context of a randomized control trial (RCT). Future research looking at self-confidence workshops would also usefully include an economic evaluation of their effectiveness. The cost of using two qualified psychologists and an assistant psychologist could be considered as it has been suggested that actors or professional presenters might be used as leaders. However, during the workshops, clinicians delivering workshops have had to field numerous questions and comments from participants. This has required considerable expertise and an applied understanding of CBT models and techniques, which is something that trained psychologists are well placed to provide.
In summary, these workshops catered for up to 25 people, attracted a large number of self-referrals and led to significant reductions in self-reported distress and depression. In the current climate where NHS resources for psychological interventions are scarce and waiting lists are long, such a large scale intervention offers an important, potentially cost effective means of disseminating psychological interventions to a large number of people. These self-referral psycho-educational workshops in routine practice helped to reach individuals who would not otherwise access psychological help. Once they accessed help, significant changes were obtained on measures of distress and depression for approximately half of participants. The greatest change was demonstrated in clients who had scores above the clinical cut-off, indicating that this intervention should be directed towards those with a degree of distress.
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