Impact case study database

Reach and pathways to impact: SOTOF and ACS-UK have been disseminated via: publications [3.2; 3.3]; Twitter; workshops delivered at YSJU; workshops delivered on request in 4 NHS Trusts: Hull Teaching Hospital NHS Trust and York Hospital NHS Foundation Trust [5.1] (SOTOF) and Leeds and York Partnership NHS Trust [5.6] and Tees, Esk and Wear Valleys NHS Trust [5.7] (ACS-UK and SOTOF); conference presentations at national (e.g. **[3.5]**) and European conferences; invited presentation at the OT Show (2019); a stand at the European Network of Occupational Therapists in Higher Education conference in Athens (2019); and invited teaching on SOTOF in Austria on the Master of Science in Ergotherapie, in Innsbruck (June 2015; including first SOTOF 2^nd edition content validity study), and to occupational therapists at the Centre for the Rehabilitation for the Paralysed, Bangladesh (March 2017; SOTOF 2^nd ed). Twitter is a successful strategy for dissemination, for example, a tweet (posted June 2020) led to 52 SOTOF requests from clinicians and students in England, Wales, Scotland, Turkey, USA, Philippines, and Australia. SOTOF also has been requested by occupational therapists in Singapore, New Zealand, Lithuania, Poland, and Canada. Some YSJU occupational therapy students introduced the SOTOF and/or ACS-UK on practice placements leading to clinicians requesting the assessments. QR funding was awarded for research in 2020 which could not be conducted owing to the COVID-19 pandemic, so instead YSJU provided funding to print additional ACS-UK copies which have been provided free to therapists in four NHS Trusts, one independent hospital, a care home and to academics in 3 Universities (who wish to teach the ACS-UK in their curricula). Laver-Fawcett has created two databases, one for each assessment, and when people receive a copy of SOTOF and/or purchase or request information about the ACS-UK, they are invited to join the relevant database. This is used to keep colleagues updated about assessment developments and to contact colleagues regarding further research or implementation evaluation. Currently the ACS-UK database comprises 72 colleagues and the SOTOF database 98 colleagues.

Structured Observation Test of Function (SOTOF)’s impact: SOTOF 2^nd edition is published under a creative commons licence and available free of charge. It comprises a test manual, instruction protocols, record form and enlarge instructions for people with hearing deficits or benefitting from written instructions. Colleagues contact the 1^st author to request a copy, this helps to ensure it is being used by people with occupational therapy qualifications. Two role-plays and an instructional PowerPoint are provided to aid learning to use SOTOF. A Senior Lecturer from St George’s, University of London reported how SOTOF and role-plays were used with occupational therapy students on placement: ‘We had a remote peer learning placement and as the students did not have much client interaction [owing to the pandemic] we gave them all the SOTOF files and they used them to role play the assessment together. They were able to navigate it all themselves and we watched the role play videos. They also reflected on using the assessment’ [5.3]. Feedback from occupational therapists who have attended SOTOF training workshops indicated SOTOF ‘…help[s] me identify patients’ rehab. potential and to support my clinical reasoning and be more person-centred’; and SOTOF assists with ‘…being able to track change and help with insight’ and provides ‘more accurate assessment of strengths and deficits to plan … interventions’ [5.9].

Poor insight into their level of disability can hamper patients’ engagement in rehabilitation, and stroke patients gained insight into their functional problems and abilities through doing SOTOF. One patient commented: “ I was shocked actually…I thought I could do a lot more than that…I didn’t follow them [SOTOF instructions] as straight as I thought I would’ (Participant 8). The impact of stroke can lead to low mood and it is important for patients to see progression and improvements, to maintain morale during rehabilitation, SOTOF demonstrated progress with their recovery to patients, for example: ‘Simple everyday tasks become a problem...and pouring the drink [SOTOF task 3] felt as though they were coming back’ (Participant 6). Patients reported doing the SOTOF was useful, interesting, and they learnt from doing it [5.1, feedback collected through semi-structured interviews with 10 patients ].

SOTOF’s ability to identify functional improvements was reported by staff for example: ‘ it was a good assessment really to show that they had moved on considerably from when they were first on the ward’. SOTOF was useful to inform treatment planning: ‘ The scores show so clearly… where their difficulties are. And then we could … get together a really good programme of treatment and therapy’. [ 5.1, stroke rehabilitation ward multi-disciplinary team’s view of SOTOF collected via survey n=8 and focus group n=11]. Marrison [5.1] reported that the SOTOF identified a patient had right / left discrimination problems which had not been discovered in previously undertaken functional or cognitive assessments and stated if SOTOF had not be undertaken the deficit may have gone unnoticed. Information generated from SOTOF informs other multi-disciplinary team professionals’ practice on the stroke rehabilitation ward [5.2], SOTOF results: ‘…inform treatment techniques or treatment interventions [so]… we could get together a better programme’.

An audit of dressing practice by occupational therapists in acute stroke settings (Worthington et al, 2020) [5.4] represented 70 (of 157) stroke units in England. The authors reported that only 23.3% of therapists ‘regularly used standardised assessments, or components of standardised assessments, when assessing dressing ability’ (p.667). The SOTOF (2^nd edition) [3.1] was reported as the third most frequently used, of only five standardised assessments listed, by participants [5.4].

Laver-Fawcett (funded by Erasmus, 2016) provided a SOTOF workshop for occupational therapy Masters’ students at KU Leuven University, Belgium followed by teaching delivered virtually in 2017. A Professor at KU Leuven continues to refer to SOTOF in her teaching with occupational therapy students. This has led to the use of SOTOF by some Belgium occupational therapists. Following a request to translate the SOTOF into Dutch, a project to evaluate SOTOF’s use in practice was undertaken at Reepkaai in Belgium (with 10 neurological patients) leading to plans to implement it further in practice [5.8]. Identified SOTOF strengths included: the use of everyday objects and tasks recognised by patients; clear instructions; low cost of equipment; free assessment; that the therapist can use one test (instead of several tests); and administration can be spread over time (which helps when patients have fatigue). ‘ The dynamic element of the test provides extra information on learning or coaching style of patient, [and] effective cues…’ [5.8].

Activity Card Sort – United Kingdom (ACS-UK) impact: The ACS-UK is published by YSJU to keep costs affordable for NHS Trusts, local authorities, and care homes with limited budgets. It can be purchased from YSJU by contacting the 1^st author and is printed by a local York based printers, to support the local economy. Evaluation of the implementation of ACS-UK into older people’s mental health services in two NHS Trusts [5.7] found the ACS-UK has: ‘ …been beneficial for service users who do not have language skills anymore… [with] our more advanced dementia service users that can still look at a visual cue and …works really well’. Clinicians reported the ACS-UK ‘definitely [provides] more information’ [compared to another assessment used previously] and ‘… it helped their partner get involved as well, they … did it together and they looked at things that they could work on together’. Some people with mental illness or dementia find it hard to identify meaningful activities, and the ACS-UK helps with this: ‘When I've used it, people have said “oh no, don't really have many hobbies or anything” …and … when you go through it, you find a plethora of things to do… also you build that great rapport with people and therapeutic relationship.’ The ACS-UK provides a: ‘…detailed account of what the person used to do, now does, how much etc, and also some of the reasoning - this makes it easier to consider [the therapists’] role and possibilities in enabling the person to engage’ [5.7]. ‘ In clinical practice with people with dementia the Activity Card Sort UK (ACS-UK) has been useful in terms of talking about activity, promoting communication that is meaningful and measuring activity participation/promoting ideas for new activities to add meaning to everyday life.’ [5.6]. Following the ACS-UK implementation and evaluation project, Tees, Esk and Wear valleys NHS Foundation Trust purchased 14 ACS-UK copies to use across the Trust.

Clinicians felt ACS-UK aids reminiscence, supports goal setting, helps clients to think about what they would like to do again, ‘tease[s] out information that may not normally be covered’; ‘focuses interventions in a client centred way’ and provides results which can be used ‘to increase care home staff awareness of what the person has done previously and how best to increase their meaningful engagement’ [5.9]. An occupational therapist summarised: ‘ I think it [ACS-UK] is helpful as we are not using much by way of standardised assessments or those that help formulate goals and monitor engagement as much. It will also help make sure we address all domains, as sometimes the focus can end up being on self-care. It will also help to work collaboratively and make sure the goals are ones shared / made by the person’ [5.7].

The ACS-UK was requested for a funded Valuing Active Life in Dementia (VALID) Randomised Controlled Trial which examined a community occupational therapy intervention for people with dementia and carers. Participants worked with an occupational therapist to identify meaningful activities and set appropriate intervention goals; ACS-UK was used to assist this as part of the intervention process (not used as an outcome measure). It was requested because some people with dementia struggled with the interview process and the ACS-UK activity cards, containing photographs of activities, serve as a memory prompt and could be sorted into categories without the person needing to respond verbally. The Occupational Therapist Clinical Researcher, based at the North East London Foundation Trust, commented ‘I used it mainly to support people with dementia who had expressive speech problems in particular word finding difficulties. Using the ACS-UK supported them to identify their meaningful activities, reduced stress levels (e.g., not having to rely on verbal speech output) and enabled choice in goal planning’ [5.5].

Nature of the Impact: Client Benefit

Generating sustainable practice is core to the Centre’s work. The Centre has directly influenced the lives of over 1000 service users: positively impacting their relationships, families, work, and lives. Outcomes compare well with outputs from the Government’s Improving Access to Psychological Therapies (IAPT) programme with 90% of our clients moving from moderate to minor mental distress across the course of treatment. Reach and significance is amplified through service user and partner networks, plus outcome evidence [5.2; 5.9].

Client testimonies endorse how the services have enhanced their wellbeing and mental health. Reaching clients through health and social care contacts and networks in the wider community and by ‘word of mouth’, former clients now regularly recommending it to others.

Direct impact through provision of research-informed and evidence-based interventions is epitomised in typical client feedback we receive [5.2; 5.9] - see examples below:

“I have used the services of cmhc twice in recent years (for relationship counselling and anger management). Both experiences were of a service run in a professional but compassionate way leading to constructive and positive outcomes”.

“The counselling has made a significant impact for me. Both in terms of dealing with current issues but also identifying and addressing underlying past issues that were having an impact on my life”.

“Please keep doing what you’re doing, and I know you will continue to make a difference to so many peoples’ lives”.

Shepherd’s work [3.5] proves how clients who access evidence-based anger management groups can support themselves through emotional regulation to move forward effectively and to change previous aggressive behaviour. This is also evidenced in the first client statement above. Gabriel and Wilson’s work on bereavement [3.4] has led to the development of a grief measure, AGES, which is being tested in Teesside Hospice and the Centre; importantly, the measure provides evidence for clients of how their counselling work has supported them to recover from their bereavement and loss. The measure has also been used for an online (video) COVID-19 bereavement support group; all members of the group moved from a deeply traumatised state through to acknowledgement of their situation and adjustment to their circumstances. Feedback from participants plus requests from stakeholders indicate the value of access to evidence-based bereavement support [5.8; 5.9], including a bereavement support group (pilot ran September-December 2020) and a closed social media support group (currently 400+ members) . The Centre hosted the 2020 1^st International Online Bereavement Conference, attended by several hundred UK and International delegates, generating interest in further work and events [5.7; 5.10], including being commissioned to provide consultancy to a national bereavement organisation [5.8], plus testimonies from the Hospice sector, epitomised by a ‘thank you’ letter from St Gemma’s Hospice [5.9].

Gabriel et al’s work on domestic violence and abuse (DVA) and its impact on young people and adults has drawn attention to the need for early interventions to prevent future mental ill-health or victimisation later in life [3.2]. DVA research highlighted the impact on frontline workers of exposure to violence and abuse [3.1] and influenced development of a research-informed training for frontline practitioners [3.3; 5.5]. The research has informed and supported work at IDAS, a leading UK DVA charity, and we are in the process of evaluating further groups delivered in North Yorkshire. As with many areas of work, Covid-19 has impacted on access to School contexts and pupils/parents/teachers.

Building Impact Impetus: Influencing Communities and Professionals

The Centre’s research and training practice not only influences local and national communities, citizens, and practitioners [5.1; 5.2], it also provides life and work-related experiences for new practitioner generations and roles in frontline mental health practice - not least in the form of real-life and meaningful research and practice at the frontline of mental health services. Since opening, over 100 trainee practitioner opportunities and research associate roles have created work-related administrative, management and Advisory Board placements for undergraduate and postgraduate students, plus five Graduate Interns furthered their careers. Employment for local students has been generated, with two students currently employed as Office Administrators. All former employees have secured jobs, internships, funded PhDs, or tenured academic Graduate Teaching Assistant (GTA) posts.

The Centre’s research contributes to and informs the International Pluralistic Practice Network (https://pluralisticpractice.weebly.com/links.html\). The network draws international academics and researchers from the field of integrative therapy practice. A 2016 textbook captures research-based and evidence-informed work and research from the network; see https://uk.sagepub.com/en-gb/eur/the-handbook-of-pluralistic-counselling-and-psychotherapy/book243250#contents which includes a chapter from Gabriel (2016, pages 300-313) and is used by UK and European Pluralistic training programmes (including University counsellor training programmes at Queens, Abertay, Roehampton, South Wales, Oslo).

Gabriel’s work with the British Association for Counselling & Psychotherapy and research-based textbooks on ethics have influenced practice ethics. Relational Ethics in Practice, an edited text https://www.routledge.com/Relational-Ethics-in-Practice-Narratives-from-Counselling-and-Psychotherapy/Gabriel-Casemore/p/book/9780415425919 and Speaking the Unspeakable

https://www.routledge.com/Speaking-the-Unspeakable-The-Ethics-of-Dual-Relationships-in-Counselling/Gabriel/p/book/9780203086933 a research-informed exemplar text on dual and multiple role relationships in counselling and psychotherapy, have enhanced the clinical, training and research work in the clinic, as well as the counselling professions more widely, with citations in International journals plus use as resources within counsellor training sites [5.5]. Gabriel Chairs BACP’s Ethics and Good Practice Guidance Committee, responsible for the development and enhancement of the Associations Ethical Framework for the Counselling Professions, plus production of ethics resources available through multiple media, including online and print-based [5.1]. The synergies of professional knowledge and evidence derived from the Centre’s work and research, concurrent with development work with the BACP Committee, provide a fertile context and impetus for advancing evidence-informed practice; with updating of the Ethical Framework due in 2021, providing a context to innovate UK and International practice ethics.

Gabriel’s ethics research informs BACP good practice guidance resources; her Good Practice in Action GPiA044 resource is one of the top downloaded documents ( over 900 downloads January-November 2020, plus over 2000 views of an online e-resource on ethical decision-making), providing research and practice-based informed guidance for counselling professionals. In early 2020, Gabriel worked closely with the Association to identify and provide key online evidence-based resources for upskilling practitioner members [5.1] during the Covid-19 crisis. One resource focussed primarily on safeguarding and managing risk online whilst the other supported supervisors to prepare them for challenges they may encounter when working with supervisees online [5.1]. These online resource events were attended by over 2,000 practitioner members of BACP including International members. Gabriel’s work supported BACP to venture into delivering remotely recorded online events to large numbers of Association members [5.1].

Research and practice outputs reached York and North Yorkshire communities through York Mix (a monthly column across 2019) and broadcasts on Radio York. A paper on domestic abuse, published in 2020 in The Conversation [5.4], generated an increase in domestic violence referrals to the Centre and the development of a partnership with York Women’s Centre.

Arising from the Covid-19 pandemic, to enable access to the research-based Centre services, practitioners were provided with training on working through online video and telephone platforms. We are now seeing increased referrals from across the UK and, to support our practice and research into online therapy, a rapid review is underway with RTCC members ( the review involves Open University plus Abertay, Salford, Newman, Roehampton and York St John Universities) on the effectiveness of online counselling. The review has an approved Prospero registration. A second RTCC research phase will see analyses of its national minimum dataset - with national and international impact for the delivery of humanistic and pluralistic psychological therapies. Additionally, York St John University have invested in growth of the Centre though the provision of bespoke premises at 32-34 Clarence Street, York (due to open Autumn 2021) to enable expansion of research projects, knowledge production and exchange, and evidence-based research and practice placements.