Journal of Mental Health (2002) 11, 5, 511–522
Implementing psychological treatment for symptoms of psychosis in an area mental health service: The response of patients, therapists and managers JOHN FARHALL & SUE COTTON School of Psychological Science, La Trobe University and North Western Mental Health, Melbourne, Australia Abstract The effectiveness and acceptance of a CBT for psychosis intervention that focussed on coping enhancement for voices and delusions, was studied in routine practice in an ordinary mental health service. Twenty-two of 30 referred patients received the intervention. Acceptance by the 22 patients was high, and positive symptom ratings and GAF scores improved following therapy. Eleven of 14 area psychologists availed themselves of training and support opportunities. While uptake of cases was variable, with two therapists accounting for 79% of registered cases, 50% claimed additional limited implementation of CBT principles with non-registered patients. The 14 service managers saw the therapy as effective and considered 36% of service users to be potential candidates for CBT for psychosis. However CBT was not seen as a high service priority and psychologists were generally allocated little additional therapy time. These findings raise issues about the dissemination of innovation into routine practice including management of change and the need to investigate the efficacy of more limited implementation of treatment packages.
Introduction There has been remarkable growth in the past decade in the development of cognitive and behavioural therapies designed to assist people who have psychotic disorders, particularly where symptoms such as hallucinations and delusions persist (Bustillo et al., 2001; Garety et al., 2000; Haddock et al., 1998). Controlled trials have shown that the addition of CBT for psychosis packages to routine care can lead to superior outcomes (Kuipers et al., 1998; 1997). Although the
efficacy of CBT compared with alternatives is yet to be clarified, a differential benefit after 9-12 month follow-up periods has been reported (Sensky et al., 2000; Tarrier et al., 1999). Although typically applied in residual phases of disorder, there is evidence that such approaches are also effective in reducing symptom severity and duration of in-patient care when applied in acute phases of the disorder (Drury et al., 1996a; 1996b). Treatment manuals (e.g., Chadwick et al., 1996; Fowler & Morley, 1989; Nelson, 1997; Perris, 1989) to guide therapists are readily avail-
Address for Correspondence: John Farhall, School of Psychological Science, La Trobe University, Bundoora 3086, Australia. Tel: +61 3 9479 1626; Fax: +61 3 9479 1956; E-mail:
[email protected] ISSN 0963-8237print/ISSN 1360-0567online/2002/050511-12 © Shadowfax Publishing and Taylor & Francis Ltd DOI: 10.1080/09638230020023868
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able. Common themes among the different variants of therapy include individualise d formulations, belief modification, enhancement of coping skills and development of more adaptive explanatory models of disorder by patients (Tarrier et al., 1998). Demonstrations of efficacy are central to the development of useful treatments; however, they do not guarantee that a treatment innovation will be effective when implemented routinely by ordinary mental health clinicians. Recognition of this as an issue facing mental health research in the USA has recently led to a major boost in funding (Foxhall, 2000) for evaluations of the effectiveness of interventions in services. Although some of the efficacy trials noted above recruited patients from local mental health services, the therapy was delivered by research therapists or the treatment developers rather than by ordinary mental health service clinicians, and the impact and relevance of the therapy to services was not reported. Similarly, the naturalistic study by Jenner et al.. (1998) was of patients attending a specialist university clinic for hallucinators, rather than an ordinary mental health service. The Cochrane review of CBT for psychosis (Jones et al., 2000), which concluded that CBT for psychosis has efficacy in reduction of relapse, observed that more ‘real world’ (i.e. effectiveness), trials were required. One key practical consideration for effectiveness trials is the acceptability of a treatment to service users. However, little data in relation to patient acceptability of CBT for psychosis is available: Jones et al. identified only three controlled trials reporting such data (each found no difference between the CBT and comparison condition in dropout rates). Thus, delivery of CBT for psychosis therapies by ordinary service providers in routine practice, and the acceptability of such treatments to patients, each require further study.
Factors that may limit the translation of an efficacious treatment innovation into improved outcomes for patients are varied and likely to arise from characteristics of the patients themselves, their therapists and aspects of the organisation through which the therapy is to be provided. Studies of the adoption of innovative therapeutic techniques by clinicians in the mental health field have sometimes been disappointing. For example, several family interventions have been consistently supported by research evidence, but have been difficult to implement widely (Fadden, 1997; Kavanagh et al., 1993). Kavanagh et al. reported a very limited uptake of their CBT based intervention, despite intensive training. While most therapists used the CBT intervention with one family, only 18% had used it with three or more families at follow-up. Reasons advanced for this low level of uptake included inadequate resources provided by the employment bodies to allow therapists to use CBT, conflict between CBT and other therapeutic approaches, and practical issues such as unavailability of evening sessions. Tarrier et al. (1999) review UK initiatives in which strategies to enhance dissemination of CBT approaches have been built into the training and supervision of mental health nurses. Such programmes select pairs of trainees (to address support issues), seek written management support and provide intensive training and supervision, in order to maximise levels of uptake of the treatment. However, these external training programmes may be limited in their ability to directly target specific organisational impediments. To date, there has been little reported research regarding the prospects for adoption of CBT for psychosis in routine mental health service practice. Little is known about demand for such services, their acceptability amongst individual practitioners and the like-
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lihood of mental health service managers introducing CBT for psychosis as a new service. Farhall & Voudouris (1996) addressed the question of demand by surveying a 355-bed hospital population for presence of persisting hallucinations. More than onethird had persisting hallucinations and of these, 53% were considered, on the basis of staff-rated communication skills and importance of the symptom, to be ‘potential candidates’ for CBT treatment. Structured interviews with a sub-sample elicited possible starting points for cognitive or behavioural therapy. Combining this information with the staff ratings led to 20% of the sample being rated as ‘good candidates’ for CBT for voices. Tarrier et al.’s (1998) controlled trial was unique in its use of a geographic cohort, identified through case records according to explicit criteria. It suggested that the therapy was applicable to significant numbers of patients with persisting positive symptoms. However, the impact of the therapy on the local mental health services was not addressed, nor was the ability of local therapists to learn and deliver the therapy. Application of CBT for psychosis in a routine treatment setting may not show results as strong as those of the efficacy trials. One study (Jakes et al., 1999) reported the effectiveness of CBT for delusions in a routine practice setting. The proportion of patients with reduced delusional conviction following treatment was lower than in the efficacy trials reviewed above. About half of the patients referred received the therapy, the others refusing, dropping out or assessed as not deluded. One third of the treated patients appeared to reduce delusional conviction in response to treatment but all reported the therapy to be helpful. In sum, it could be argued that sufficient evidence has now accumulated about the
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efficacy of CBT for psychosis, for mental health therapists and service managers to consider the introduction of such work to their mental health services. However, there is little information available to guide such personnel about the extent of need for such services, the likely degree of clinician interest in undertaking such work or of the effectiveness of these approaches in a routine service context. We report a pilot study that aimed to determine the extent to which a CBT intervention, focussed on coping enhancement for voices and delusions, might be effective and acceptable in routine practice in an ordinary mental health service, and to identify clinical and organisational issues in the implementation of the approach. The study particularly addressed the acceptance of the therapy by patients, its effectiveness in reducing the incidence and severity of positive symptoms, extent of uptake of the therapy by psychologists and its acceptance by local mental health service managers.
Method Design The study was a quality improvement initiative comprising a register of referrals, a naturalistic pre-test post-test evaluation of patients receiving the therapy, a questionnaire study of the views of area psychologist s and structured interviews with area managers. Programme development The first author convened an interest group for psychologists working in a large psychiatric hospital in metropolitan Melbourne prior to its closure and replacement by an area mental health service. By the time most of the hospital services had been devolved to community-based alternatives, the interest
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group had developed a proposal for a pilot programme which had gained the endorsement of the area mental health service management. The proposal involved the training of interested psychologists from any of the 14 facilities (comprising in-patient, community mental health, assertive community treatment, crisis assessment and clinically staffed residential services) in the area mental health service. Brief guidelines for practice were developed by the interest group and clinical assessment and patient feedback materials produced. Programme supports negotiated with management included two days of training workshops per year and monthly clinical meetings and additional supervision times for participating therapists. Participants Referrals were accepted where there was a diagnosis of psychosis and the presence of persisting hallucinations and/or delusions that were considered by the treatment team to be a management problem. Referrals were sometimes initiated by the therapist and sometimes by other members of the treatment team. Thirty-three patients were referred to the programme and 25 (76%) received some form of service. In addition to the assessment and therapy provided through this programme, all patients received the standard services of their mental health facility, which in all cases included antipsychotic medication and case management. Psychologists participating in the evaluation of the organisational impact of this programme were 11 respondents from the total of 14 psychologists employed in the area mental health services at the end of the pilot period. Participating managers comprised all 14 managers or team leaders employed across the area mental health service.
Measures In addition to the Global Assessment of Functioning Scale (GAF – American Psychiatric Association, 1994), rated by the referring agent (therapist or case manager), several measures were developed by the project for clinical assessment and local evaluation purposes: The Referral Information and Baseline Observations Record (RIBOR) documents the context and purpose of referral and baseline symptom ratings. Symptom dimensions measured included frequency (on a 1–7 scale from ‘not at all’ to ‘several times a day’, and distress and preoccupation on 1-5 scales from ‘not at all’ to ‘extreme’). Conviction was measured on a scale with five categories (from ‘convinced the symptom came from your mind’ through to ‘convinced symptom was real’). End of Therapy Record (ENDREC). Patient feedback about the therapy was recorded during the final session on a specially developed questionnaire (ENDREC), along with therapist feedback about patient response and primary techniques utilised. Psychologists’ and Managers’ Questionnaires. Feedback questionnaires were developed for participating psychologists and for managers and team leaders. The psychologists’ questionnaire sought information about level of involvement in the programme, perceived agency support, and feedback about the programme’s materials and training. The manager’s questionnaire was in the form of a structured interview probing awareness of the programme, level of involvement of psychologists from that service, estimation of prevalence of persisting symptoms amongst patients in the service and feedback about the programme and its impact. The structured interview was conducted in person by a re-
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search assistant or by the acting coordinator of the programme. Procedure Psychologists participating in the programme attended half- and one-day training workshops conducted by the senior author, read some of the relevant literature and participated in clinical discussions. The emphasis of training and discussion was around engagement strategies (Fowler et al., 1995), coping enhancement procedures (Tarrier, 1992) and a formulation by the therapist that made sense of the person’s psychosis and its symptoms in the context of his or her life (Kinderman & Lobban, 2000). The style of therapy delivered was primarily up to the psychologist involved and was heavily influenced by the nature of the service setting (long term vs. short term contact with patients, etc.). RIBOR assessments were completed as soon as practicable after referral and sent to the programme coordinator. Therapists completed a repeat RIBOR assessment and GAF at termination of therapy as well as an ENDREC questionnaire . Following completion of the pilot, the feedback questionnaire on organisational matters was mailed to all psychologists employed at that point in time in the area mental health service, regardless of whether or not they had participated as a therapist in the programme. Interviews were conducted with each manager employed at that point in time also.
Results Referrals and services provided Of the 33 referrals to the programme, eight (24%) received no assessment or therapy, three (9%) received assessment only, five (15%) ended prematurely and 17 (52%) completed an intervention to the satisfaction of the therapist. The intervention for one non-
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English speaking patient was a secondary consultation with residential staff, and the remaining interventions comprised one-toone therapy. The criterion that termination was premature was the therapist’s judgement that the therapy agenda had not been fully addressed and that continuation of therapy had a reasonable prospect of delivering benefits for the patient. Reasons for premature termination included therapist transfer and the patient moving out of area. Of the 11 patients receiving no service or assessment only, two left the service, three were unable to be engaged in therapy and the treatment team proceeded with a medication change (to atypical antipsychotics) in two cases as an alternative treatment. For two patients no therapist was available within a reasonable period following referral. Symptom profile of patients referred A RIBOR was completed by the case manager or therapist for 27 of the 33 patients referred to the programme; however, missing data reduces the ratings on some items to 25 or 21 patients. Twenty-seven patients received a treating team diagnosis of schizophrenia, one a diagnosis of schizophrenifor m disorder, one a diagnosis of substance-induced psychosis, and the remainder had unspecified psychoses. Eight patients (38%) were referred primarily for delusions, seven (33%) for voices, and six (29%) for both voices and delusions. Positive symptoms had persisted for more than one year for 16 (77%) of the patient group. The modal rating for frequency of symptoms, ‘several times per day’ was at the upper limit of the rating scale and was made for 15 patients (60%). The modal level of preoccupation (12 patients) was ‘preoccupied a lot’ (44%). Fortysix per cent (12) of patients were rated as being convinced the positive symptom was real. Mean GAF at referral was 33.2 (n=26, SD=12.1) with a range of 21–60.
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Therapy delivered ENDREC therapist reports were available for 19 of the 21 cases receiving face-to-face therapy. Median length of therapy was 18 sessions (n=13) with a range of 7–78. The mean duration of sessions was 10.6 months (range 2–23 months). Therapists reported the main therapeutic strategy or strategies used for each case. For the 19 cases, a total of 27 strategies were indicated. These main strategies were: coping enhancement (in 10 cases), belief modification (in nine cases) and focussing, work on explanatory model, reality testing and general CBT in two cases each. As well as addressing persisting symptoms, for most cases therapists reported addressing other significant issues in the person’s life, particularly issues of identity, relationships and practical life problems. Patient feedback Fifteen of the 21 patients receiving therapy provided feedback via ENDREC interviews with their therapists. This group comprised 13 of the 16 patients who completed therapy and two of the five cases where therapists would have preferred to conduct more sessions. The ratings suggest high levels of acceptance by those completing treatment. None said the sessions made them feel worse, two said sessions made them feel the same and 13 said they felt better as a result of sessions. Open-ended responses about gains from therapy included implications of containment regarding persisting delusions (‘Feels safer as we have controlled dangerous people’), direct reference to coping strategies (‘Different strategies to help’; ‘Help me handle the voices’), understanding of subjective experience (‘Understood me, most people don’t understand’) and reports of increased confidence or self-esteem. Of the few disappointments stated, some referred to delusional
material (‘I haven’t got rescued’), one to a premature termination due to staff change. For the six cases in which the therapy was terminated prematurely, the failure to proceed was more often due to service issues (e.g. therapist leaving) than engagement failure or patient dissatisfaction (one case). Patient outcomes Comparisons of symptom ratings between referral and termination assessments on the RIBOR were conducted using all available data. These data were from 12 of the 16 patients who completed therapy and three of the five who finished prematurely. Although the frequency, distress and preoccupation scales of the RIBOR had a descriptive anchor for each numbered point and thus may not have been strictly equal interval, they were treated as equal interval scales for ease of analysis. Symptom frequency reduced for seven patients, increased for one and remained the same for five, with the mean rating reducing from 6.3 to 4.8 (t (12)=2.86, p
