Distress Brief Intervention pilot programme: evaluation

9 Conclusions

The overarching aims of this evaluation were to determine the extent to which the DBI programme was implemented as intended; identify variation and any associated impacts; and determine the impacts of the DBI programme on services, practitioners and individuals. Overall, DBI has proved to be successful in offering support to those in distress, with most individuals receiving a compassionate and practical response that has contributed to their ability to manage and to reduce their distress in the short term, and for some in the longer term. This is particularly encouraging given that the background to the development of DBI was a recognition that current supports did not meet the needs of many people, which could lead them to feel let down, vulnerable or at risk.

9.1 Meeting individuals' needs

A key strength of DBI is its flexibility to be tailored to the individual, resulting in being appropriate to the needs of a wide range of individuals in distress who present with an array of different characteristics, life circumstances and problems. It is compelling that DBI meets the needs of many, but it has worked less well for some (e.g. young adults at Level 1) and referrals were not always appropriate. Although inappropriate referrals were reduced through review and re-training, the findings suggest that there were still people who were experiencing high levels of distress, who did not meet the threshold for a more specialist service but for whom the short term DBI was not the right approach, and was not intended to be, as they require a more therapeutic intervention. This could lead to such people feeling even more stigmatised and not listened to, and suggests a persisting inequality in access to support.

Focusing efforts on delivering a compassionate response to distress appears to be having a positive impact. Individuals' perception of Level 2 practitioner compassion and care validated their feelings of distress and contributed to reductions in self-stigma. This is key to reducing inequalities in access to services that are compounded by self-stigma acting as a barrier to help-seeking. Three fifths (60%) of those accessing DBI were from the two most deprived area quintiles, indicating a further contribution of the service to reducing health inequalities. Being helped to understand why they felt distressed was also positively associated with helping them to understand why they become distressed, to recognise when they start to feel distressed, and with greater decreases in self-reported distress levels. There is also evidence that DBI may be contributing to suicide prevention.

Impacts of DBI were reported at both Level 1 and Level 2. The DBI Level 1 response had direct, immediate benefits for the individual. Most individuals thought that the Level 1 provider had helped them cope with their immediate distress. Level 2 worked well for most individuals, with nine out of ten individuals' distress levels continuing to decrease over the period of their Level 2 intervention, and the same proportion felt it had given them the tools and skills to manage their distress. We were unable to identify any demographic or DBI delivery context factors associated with changes in individuals' level of distress as a result of DBI Level 2. However, we did find that Level 2 may be working less well for women but better for younger adults in terms of their final level of distress at the end of Level 2, but the reasons for this are uncertain.

However, DBI does not work equally well for everyone. Level 1 was less successful for younger adults, those with higher levels of distress and those presenting to A&E. Some individuals who received DBI had hoped that the service would provide more intensive therapeutic intervention. Feedback from DBI providers and individuals who received DBI suggests that DBI is less appropriate for the needs of those with severe and/or enduring mental health problems and/or addictions. For individuals whose distress increased, we are not able to offer definitive conclusions as to what factors may be associated with this.

9.2 Supporting successful delivery

While not originally envisaged as a core component of DBI, the role of DBI Central in coordinating services, facilitating effective and efficient inter-and intra-agency networking, enabling open communication, information sharing, and problem-solving was an essential component of the DBI programme's success. The constructive leadership of the DBI programme manager who led DBI Central and championed the DBI programme was central to this process.

DBI delivery successfully adapted, where appropriate, to different local contexts whilst maintaining the core elements of DBI. As the DBI programme expanded within an area, the staffing numbers increased and a mix of staffing including administrative support was required to deliver the service. The guideline of a contact attempt for each referral within 24 hours was met, and around two-thirds of people referred were successfully contacted within 24 hours, rising to 86% in the following days. The 14-day Level 2 intervention guideline was met for just over half of those taking up support with length and intensity of support provided varying by pilot site.

Signposting and initiating referrals to other services following Level 2 DBI was common and was seen as an important step to support people post DBI. Going forward, consideration is needed on the availability of statutory and non-statutory services within the local community and the risks of increased demand for services and the impact on waiting lists. There was a sense of an abrupt end and loss among some individuals at the end of their DBI intervention. This suggests a need to consider a more tapered withdrawal for those who need it and/or a more co-ordinated approach to minimise the gap between Level 2 and any ongoing support - and perhaps a more consistent approach to 'supported connection', where DBI Level 2 practitioners support individuals to make contact with non-statutory services.

9.2.1 Looking forward

Areas setting up a new DBI service will have choices about the organisation of resources and modes of delivery within the core DBI delivery model that suit their local service systems. These will affect resource use. The scenarios presented in Section 6.7 outline typical pathways through DBI, illustrate their associated costs and highlight the key decision points on resource use that need to be made in the further development and rollout of DBI.

It is uncertain whether DBI will reduce demand on frontline services who will still be required to attend call-outs and to conduct appointments. However, DBI does provide them with another referral option and that - coupled with the enhanced compassion skills - may help to ease the emotional task of assisting an individual in distress.

9.3 Recommendations

Key recommendations based on our findings are set out below.

9.3.1 Roll-out

1. The national roll-out of DBI should continue, ensuring that core DBI elements (contact within 24 hours, guideline of 14-day intervention, use of D-MaP etc) are adhered to, along with the continuation of the central leadership, coordination and management function.

2. New DBI services should be aware that DBI may be perceived as a threat to, rather than complementary to, existing services. This may need to be overcome to ensure good engagement with and uptake of the programme amongst local delivery partners.

3. The evaluation findings should be used to inform the roll-out of the DBI programme and disseminated widely to share learning, encourage debate and further uptake of the DBI model.

9.3.2 DBI practitioner preparedness, training and development

4. Level 1 and 2 practitioners should not commence work on DBI until they have completed the standard DBI training.

5. DBI Level 2 training should note practitioners' previous experience and training and acknowledge practitioners' potential existing awareness and understanding of identifying distress and the importance of compassion.

6. Standard DBI training updates should be communicated to all trained practitioners, and local or service-specific buzz sessions should be encouraged.

7. It is recommended that Level 1 practitioners spend 1 hour of their paid work time to undertake regular DBI training; this should include interaction with Level 2 practitioners (where possible face-to-face).

9.3.3 DBI practice

8. To facilitate uptake and adoption of DBI, referrals to Level 2 should be incorporated within existing frontline services' processes.

9. Review the evaluation findings that the DBI Level 1 experience is not working as well for younger people and those attending A&E - and explore whether their experience can be improved.

10. Consider how DBI Level 2 is described and delivered as a brief intervention for those using the services and practitioners. Strategies such as leaving more expansive written information for the person being supported than is currently available, could be helpful in the most challenging circumstances (e.g. when individuals are highly distressed, disoriented or affected by drugs or alcohol).

11. DBI management and practitioners should continue to work to refine the appropriateness of referrals and review whether inappropriate referrals are highlighting service gaps or unmet needs.

12. DBI management and practitioners should look for opportunities to build on the finding of the importance of helping individuals to understand why they become distressed and to recognise when it starts, as this seems key to improved reduction in distress.

13. Consider whether DBI has a potential role in offering follow-up support or contact to individuals following a planned exit (i.e. because waiting for follow-up support can be a difficult time). A more tapered withdrawal may be beneficial for some and/or checking whether individuals feel able to initiate contact with follow-up services themselves.

14. Within the Level 2 services, decisions are needed on staffing composition to ensure a range of skills and experience that will meet the needs of a wide range of service users.

9.3.4 Research

15. Further research is recommended on the following: the level of uptake of follow-up services after DBI Level 2; the longer-term impact of DBI on individuals and the wider service system; whether and how DBI might help prevent some deaths by suicide; and the factors associated with increased distress among some individuals at the end of Level 2.