Evaluation of Training Curriculum and Service of Improving Access to Community Therapies
Phase: NA
Conditions: Depression, Anxiety, Mental Health Issue, Stress, Distress, Emotional
Sponsor: Mind Mental Health Hong Kong Limited

Research Protocol
Evaluation of Training Curriculum and Service of
Improving Access to Community Therapies
Candice LYM Powell
Patrick W.L. Leung
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Introduction
Prevalence of common mental disorders
Depression and anxiety disorders are widespread both globally and locally (Kessler et
al., 2005). In 2015, the worldwide prevalence of depression stood at 4.4%, while anxiety had
a prevalence rate of 3.6% (World Health Organization, 2017). In the context of Hong Kong,
the prevalence of major depressive disorder (MDD) reached 2.9%, whereas the prevalence
of generalized anxiety disorder (GAD) was 4.2% (Lam et al., 2015). Given the detrimental
effects of mental disorders on an individual's quality of life and productivity (Alonso et al.,
2004; Lim, Sanderson, & Andrews, 2000), the delivery of mental health services is of
paramount importance.
The psychological treatment accessibility gap
Nonetheless, the availability of psychological interventions falls significantly short of
the demand for such services. Among those with mental health issues in Hong Kong, less
than 30% utilized mental health services (Lam et al., 2015). New patients typically face a
waiting period of approximately one year before consulting with a psychiatrist. Furthermore,
consultations with a clinical psychologist occur only once every two to six months. Extended
waiting times and infrequent follow-ups may present barriers to the utilisation of mental
health services.
In addition, an imbalanced distribution of mental health resources contributes to the
gap in accessibility. A majority of resources are heavily concentrated within hospital-based
mental health services. Consequently, individuals with severe mental disorders receive a
greater share of resources from the healthcare system, while those with less severe symptoms
have limited access to resources. Moreover, waiting times for mental health services are
determined by the severity of symptoms. As a result, individuals experiencing mild to
moderate depression or anxiety face longer waiting periods before their initial meeting with a
mental health professional. In essence, those with less severe mental illnesses have access to
fewer resources and experience longer waiting times, further diminishing their access to
psychological treatments.
Improving Access to Psychological Therapies
In an effort to bridge the accessibility gap, the UK launched the Improving Access
Psychological Therapies (IAPT) programme, aimed at individuals with mild to moderate
depression and anxiety (Whiteford et al., 2013). The National Institute for Clinical
Excellence (NICE) guidelines recommend cognitive behavioural therapy (CBT) as the
primary treatment for those with lower severity mood disorders. Numerous studies have
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consistently found evidence supporting the effectiveness of traditional, high-intensity,
face-to-face CBT. Low-intensity cognitive behavioural therapy (LICBT), developed through
the IAPT programme, has received empirical backing in the treatment of MDD, GAD, panic
disorder, and specific phobia (Clark, 2011; NICE, 2004; NICE, 2009). The IAPT programme
not only fosters early identification and categorisation of mental health issues but also
enables efficient resource allocation based on severity. Individuals with less severe symptoms
receive low-intensity interventions, while those with more severe psychiatric problems are
escalated to intensive treatment.
Clark et al. (2009) showed that among participants who attended two or more
sessions, 55-56% had recovered after the intervention's conclusion, with clinical outcomes
maintained at a 10-month follow-up. Similarly, Richards and Suckling (2009) reported large
pre-post-treatment effect sizes for depression and anxiety, specifically 1.41 and 1.39,
respectively. The combined remission and recovery rates were also high for both depression
(76%) and anxiety (74%). In another extensive study, 40.3% of participants achieved reliable
recovery, and 63.7% demonstrated reliable improvement after receiving the IAPT programme
(Gyani, Shafran, Layard, & Clark, 2013). Overall, numerous investigations have indicated
that LICBT in the form of guided self-help successfully alleviates mild to moderate
depressive and anxiety disorders. According to a meta-analysis conducted by Cuijpers,
Donker, van Straten, Li, & Andersson (2010), the efficacy of guided self-help is comparable
to that of traditional CBT in treating mood disorders (Cohen's d = -0.02). The benefits of the
guided self-help approach include reduced waiting times for mental health services and the
timely provision of interventions for mild to moderate mood disorders.
LICBT is a disorder-specific intervention, it adopts different CBT intervention
strategies for different presenting problems, for example, behavioural activation for
depression, worry time and problem solving for generalised anxiety, and exposure and
habituation for panic and phobia. Transdiagnostic intervention has been gaining evidence
over the past decade to target the underlying psychological mechanism and thus treat
different presenting problems with the same set of strategies. Acceptance and commitment
therapy (ACT) is one of the well-researched intervention approaches. Meta-analysis showed
that ACT can effectively reduce the level of depression and anxiety, while brief ACT
approach also showed promising results (Bai, Luo, Zhang, Wu, & Chi, 2020; Haller,
Breilmann, Schröter, Dobos, & Cramer, 2021; Kyllönen, Muotka, Puolakanaho, Astikainen,
Keinonen, & Lappalainen, 2018).
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Mental Health in Hong Kong
Due to the huge success of the IAPT programme, its concept is worth borrowing and
applying to Hong Kong. Mind Mental Health Hong Kong (Mind HK) has launched a
programme named Improving Access to Community Therapies, or ‘iACT’ for short. iACT
was developed in accordance with the IAPT programme and incorporated the principles of
low-intensity psychological intervention and ACT principles. In this programme, Mind HK
will train 30 bachelor’s degree holders to study a low-intensity psychological intervention
programme. The study programme consists of 120 hours of intensive training and a 9-month
placement in community settings, including non-government organisations, schools, and
private clinics. The trained psychological well-being practitioners (PWPs) will provide
low-intensity acceptance and commitment therapy (LIACT) to around 300 adults who are
screened with mild to severe depressive or anxiety symptoms without imminent risk.
Individuals will later receive LIACT offered by PWPs and complete guided self-help
workbooks with guidance. PWPs will be trained and supervised for providing LIACT. In
addition to the 120-hour training, they received regular supervision from recognised
supervisors, including clinical psychologists, social workers, and experienced counsellors.
Aspects of case management and clinical skills will be covered during supervision. Despite
the promising results of the IAPT programme, the effectiveness of LIACT in a local context
has yet been examined.
Aims of the study
The current study aims to conduct a comprehensive evaluation of a training
curriculum designed for teaching low-intensity psychological interventions to bachelor's
degree holders, specifically focusing on principles of Acceptance and Commitment Therapy
(ACT) and its intervention effectiveness. This evaluation is divided into two integral parts. In
the first part, the curriculum, which encompasses a 120-hour intensive teaching block
followed by a nine-month placement, will be evaluated. To assess the trainees' competencies
in applying the principles of ACT, a series of role-play examinations will be administered at
various
time
points,
including
pre-training,
pre-placement,
mid-placement,
and
end-of-placement. Focus groups will be conducted.
The second part of the evaluation is to examine the outcomes of low-intensity
psychological interventions, delivered by the trainees, targeting adult individuals (age >=18)
screened with mild to severe symptoms of depression and anxiety. To achieve this, a series of
questionnaires will be administered at several stages: pre-intervention, during each session,
and at a three-month follow-up. Outcome measures will include the assessment of depressive
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and anxiety symptom severity, quality of life, functional impairment, therapeutic alliance, and
the level of experiential avoidance. Individual exit interviews and focus groups will be
conducted.
Hypotheses
It is hypothesised that the competency level of the training participants will increase
after the intensive training block and the placement. It is hypothesised that after receiving the
low-intensity psychological intervention based on the Acceptance and Commitment Therapy
(ACT) principle, the depression and anxiety scores, functioning impairment, and experiential
avoidance level will reduce, and quality of life and therapeutic relationship will improve.
Methodology
Training Participants
Participants from the Psychological Wellbeing Practitioners (PWPs) Programme will
be invited to participate in the research. The PWPs are degree holders who will undergo 120
hours of intensive training block, followed by 9 months of placement to practise the learnt
skills. Given therapist competency will be part of the programme, this research will request
the participants to consent to the use of the data collected in the programme.
Service Participants
Individuals with depression or anxiety symptoms will be sampled in this study.
Participants will be recruited from the placement organisations and promotions on social
media, web pages, and at mental health centres. The sample size is estimated to be 300
individuals for initial screening for LIACT-guided self-help services.
Inclusion criteria
1.
Adults aged 18-65
2.
Adults with a specific set of presenting problems
3.
Anxiety problems (including social, generalised, health anxiety, work anxiety)
4.
Mild to moderate depression
5.
Other
emotional
challenges
include
(but
not
limited
to):
Low
self-esteem,
perfectionism, mild anger issues, interpersonal or relational challenges, low motivation,
lack of purpose, and numbness
Exclusion criteria
1.
Adults with the following features/presentations are not eligible for the PWP
programme and should automatically lead to an onward referral:
2.
High severity on depressive score (PHQ9 >= 20)
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3.
High or imminent risk (according to scores on PHQ9 question no. 9 and information
emerging at triage assessment, including indication of plan and action or the lack of
protective factor)
4.
Any of the following presentations or situations: diagnosis or features of a mental
health problem that is not suitable for low-intensity intervention, obsessive compulsive
disorder, post-traumatic stress disorder, bipolar disorder, schizophrenia and other
psychotic disorders, dissociative disorders, personality disorders, eating disorders,
gender dysphoria, paraphilic disorders, anger issues as primary presenting concern
(without anxiety or depression), sleep issues as primary presenting concern (without
anxiety or depression), psychotic experiences (e.g. hallucinations), substance-related
disorders, history of trauma or abuse that is considered highly relevant to the current
presenting problem they are seeking support for, planned changes to psychotropic
medication during the period of PWP intervention, currently receiving regular
psychological counselling or support from another practitioner for at least twice a
month, diagnosis of a learning disability, cognitive impairment or neurodevelopmental
condition that would impair their ability to engage with a structured, manualised
intervention (e.g. untreated ADHD or moderate-severe brain injury), clear safeguarding
concerns requiring multi-agency support (e.g. concerns about domestic abuse)
Research design
For training evaluation, given the current training programme has already consists of
therapist competency assessment to ensure the quality of the training participants. A record of
role-play videos will be rated the ACT therapist competency by trained psychologists at
pre-training, after intensive training block, mid-placement and post-placement. A consent
form will be sent to the training participant to authorise the use of data for analysis. Repeated
measures design will be adopted for this study.
Repeated measures design will be adopted for this study. Individual guided self-help
LIACT service, eligible participants will receive 6-8 sessions of guided self-help LIACT over
three to four months. Clinical outcomes (depression and anxiety levels) will be measured at
every session, it will take around 5 minutes to complete these two routine outcome measures.
Other primary and secondary outcome measures, including general well-being, functioning
and activity impairment, psychological flexibility, experiential avoidance, and therapeutic
alliance will be at 3 time points, namely pre-treatment, post-treatment (at the end of the last
session) and 6-week follow-up. Participants will take around 20 minutes to complete the full
package of assessments. These outcome variables will be additionally measured after each
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session to avoid missing data if participants drop out. Recovery rate and reliable
improvement rate will also be used as indicators to evaluate the efficacy of LIACT. Focus
groups will be conducted on participants who drop out and complete the programme to
understand their experience and journey.
Curriculum
The LIACT training curriculum is designed by registered clinical psychologists with
consultation from local ACT experts from the Association of Contextual and Behavioural
Science (Hong Kong Chapter). There are 5 modules in the intensive training block including
introduction, professional and ethics issues, application of ACT low-intensity intervention,
troubleshooting and preparation for clinical placement. The LIACT protocol is also piloted
and revised by clinical psychologists to ensure its adaptability to local situations. After 120
hours of intensive training, the training participants will attend a role-play exam to ensure
their competency to proceed with the 9-month placement. During the 9-month placement,
each PWP is expected to see at least 15 direct service beneficiaries to provide LIACT. During
which, supervision will be provided regularly to ensure the quality of service delivery and
risk management. There will be a mid-placement review and final placement review, and the
training participants will submit audio recordings for supervisors to rate for their competence.
Focus groups will be conducted for the training participants to understand their learning
experience.
Treatment
Guided self-help LIACT will be provided to eligible participants. For individual
guided self-help LIACT service, intake assessment will be conducted to assess the presenting
problem of the participants at pre-treatment to ensure the suitability to receive LIACT
service. Participants will be given the LIACT self-help workbook collaboratively with a
PWP. Between each session, clients will read through the workbook and complete the
exercises suggested in the workbook. In subsequent sessions, PWP will guide clients to
overcome the difficulties in performing the LIACT exercises.
Therapists
PWPs will be responsible for providing LIACT to the participants. PWPs have
completed a 120-hour intensive training and pass the role play examination prior to
placement provision. The training was provided by experienced clinical psychologists and
counsellors. Moreover, PWPs are under regular supervision by clinical psychologists,
experienced counsellors, or social workers with extensive ACT training.
Outcome Measures
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Training evaluation.
1. General counselling skills - ENhancing Assessment of Common Therapeutic factors
rating scales (ENACT; Kohrt et. al., 2015): The 18-item ENACT scale assesses the
levels of common factors in psychotherapeutic settings. The domains covered include
non-verbal and verbal communication, rapport and self-disclosure, collaborative
processes, problem-solving, assessing functional impairment etc. Each item is rated
on a scale from 1 (“needs improvement”) to 3 (“done well”).
2. ACT competency - The ACT Fidelity Measure (ACT-FM; O’Neill et. al., 2019):
ACT-FM is a 25-item measure evaluating the clinicians’ fidelity to ACT according to
four key aspects: Therapist Stance, Open Response Style, Aware Response Style and
Engaged Response Style. The measure focuses on the therapists’ frequency of desired
and unpreferred therapeutic behaviour. It is possible for therapists to demonstrate both
ACT-consistent (e.g. “Therapist helps the client to notice thoughts as separate experiences
from the events they describe” ) and -inconsistent (e.g. “Therapist imposes their own,
other’s or society’s values upon the client”) behaviours to co-exist, therefore, the
scores are calculated into two separate subscales - ACT Consistency Score and ACT
Inconsistency Score, both range from 0 to 36 marks.
Service evaluation.
1.
Depression level: The PHQ-9 (Patient Health Questionnaire-9) is a widely-used
self-report screening tool designed to assess the severity of depressive symptoms in
individuals. The PHQ-9 contains nine items, each corresponding to one of the major
depressive disorder criteria. Respondents are asked to rate the frequency with which they
have experienced each symptom over the past two weeks on a 4-point Likert scale,
ranging from 0 (not at all) to 3 (nearly every day). The total score ranges from 0 to 27,
with higher scores indicating greater severity of depressive symptoms.
2.
Anxiety
level:
The
GAD-7
(Generalised
Anxiety
Disorder-7)
is
a
self-report
questionnaire designed to assess the severity of generalised anxiety disorder symptoms in
individuals. It comprises seven items, each reflecting a symptom of generalised anxiety
disorder as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Respondents are asked to rate the frequency with which they have experienced each
symptom over the past two weeks on a 4-point Likert scale, ranging from 0 (not at all) to
3 (nearly every day). The total score ranges from 0 to 21, with higher scores indicating a
greater severity of anxiety symptoms. The GAD-7 is widely used in clinical and research
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settings for screening, diagnosis, and monitoring treatment outcomes in patients with
anxiety disorders.
3.
Well-being: The World Health Organisation - Five Well-Being Index (WHO-5) is a
questionnaire that measures current mental well-being, originally developed to assess
both positive and negative well-being. This five-question version uses only positively
phrased questions to avoid symptom-related language. Response options are indicative of
the frequency of particular feelings (e.g. “I woke up feeling fresh and rested.”) in Likert
format, ranging from 0 (“at no time”) to 5 (“all of the time”).
4.
Functioning impairment: The Work and Social Adjustment Scale (WSAS; Mundt et. al.,
2002) is a self-report measure developed to assess functional impairment in daily life
across five domains: work, home management, social leisure, private leisure, and family
relationships. Each domain is rated on a 9-point Likert scale, ranging from 0 (no
impairment) to 8 (very severe impairment), with higher scores indicating greater
functional impairment. The total score ranges from 0 to 40. The WSAS is commonly
used to evaluate the impact of psychological disorders on an individual's daily
functioning and to monitor treatment progress.
5.
Psychological flexibility: The Acceptance and Action Questionnaire (AAQ-2; Bond et.
al., 2011) is a widely-used measure designed to assess psychological inflexibility, which
is a central concept in Acceptance and Commitment Therapy (ACT). In this 7-item
self-report scale, participants choose from 1 (“never true”) to 7 (“always true”) to depict
the relevance of the statements and themselves.
6.
Therapeutic alliance: The Working Alliance Inventory (WAI) was developed by Horvath
and Greenberg in 1989. The brief revised version (Brief Revised Working Alliance
Inventory; BR-WAI) consists of 12 items available multilingually (including Chinese).
The scale is rated on a 5-point Likert scale, ranging from 1 (never) to 5 (always).
7.
Experiential avoidance: The Brief Experiential Avoidance Questionnaire (BEAQ; Gámez
et. al., 2014) is a shortened 15-item self-report measure designed to assess experiential
avoidance, or the avoidance of uncomfortable or distressing thoughts and emotions.
These statements are scored on a scale ranging from 1 (strongly agree) to 6 (strongly
8.
Work Productivity and Activity Impairment: Work Productivity and Activity Impairment
Questionnaire: General Health (WPAI) was developed by Reilly et. al. (1993) to measure
impairments in both paid work and daily activities due to health-related problems. The
domains covered include work time missed, impairment at work, productivity loss and
activity impairment.
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9.
Data analyses
For individual service, only the data of participants who have attended two or more follow-up
sessions will be included for analysis. The first assessment session will not be counted for
this requirement. Firstly, inter-correlations among all outcome measures will be assessed with
Pearson’s correlation coefficients. Secondly, the changes in outcome variables between
pre-treatment, post-treatment and 3-month follow-up will be evaluated with repeated
measures ANOVA. Cohen’s d will be calculated to assess the relative effect sizes.
Furthermore, reliable significant improvement will be computed according to the method
recommended by Jacobson & Truax (1991), which is the division of pre-post treatment score
difference by the standard error.
Compliance
The protocol of this study complies with the Declaration of Helsinki, IGH-GCP and
research ethics principles to protect the rights, safety and well-being of participants.
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