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Overcoming barriers to implementation of psychological therapies for psychosis


Overcoming barriers to implementation of psychological therapies for psychosis Dr Kathy Greenwood Sussex Psychosis Research interest Group (SPRiG) – PowerPoint PPT presentation

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Title: Overcoming barriers to implementation of psychological therapies for psychosis

Overcoming barriers to implementation of
psychological therapies for psychosis
Dr Kathy Greenwood Sussex Psychosis Research
interest Group (SPRiG)
CBTp RCTs meta-analysis (Wykes et al, 2008,
Schizo Bull, 34, 523-37)
Mean effect size on target symptoms .40 (95
CIs .25 - .55) Rigorous studies only (12
studies) .22 (95 CIs .02 - .43)
CBTp RCTs meta-analysis (Wykes et al, 2008,
Schizo Bull, 34, 523-37)
  • Significant effects (ranging from .35 .44) for
  • Positive symptoms (32 studies)
  • Negative symptoms (23 studies)
  • Functioning (15 studies)
  • Mood (13 studies)
  • Social anxiety (2 studies)

20 from UK, 5 from USA, 2 from Germany,
Australia, Netherlands, 1 from Canada, Italy,
Israel 27 individual CBTp, 7 group CBTp
Practitioners, people using Services and families
highlighted the interventions most valued
alongside medication. ?. 43 CBT. ?. 34 Peer
support. ?. 22 Exercise prescriptions. ?. 20
Family Therapy (only 10 among service
users). ?. 17 Creative therapies (art/music). ?.
14 Physical health checks. ?. 13 Self-help
strategies. ?. 12 Complementary therapies.
The most researched therapy is (CBT). Trials have
found that on average, people gain as much
benefit from CBT as from medication. Family
interventions have also been extensively
researched and many people find family meetings
very helpful.
CBTp is effective
  • 1 of the UK population (approximately 600,000
    people) have psychosis
  • 40 have persistent distressing symptoms
    (5200-8600 in Sussex alone)
  • CBTp is the only NICE recommended individual
    intervention for psychosis
  • Multiple RCTs and meta-analyses support its

So whats the problem?
  • 94 of trusts struggle to provide CBTp.
  • Fewer than 20 of service-users receive it
  • Of 187 randomly selected service users in NW
    England only 13 (6.9) had been offered CBTp
    Haddock et al. 2013
  • Of those offered it, 22-43 refuse or do not
    attend (Freeman et al. 2013 Haddock et al. 2013)

Implementation research
  • Planning
  • Educating
  • Financing
  • Restructuring
  • Monitoring Quality
  • Policy content
  • Powell et al. 2012

Investment and Access?
Talking therapy demand vastly outstrips supply
in the NHS. Urgent need for further investment
in psychological approaches to ensure that all
services come up to the standard of the best, and
so that people can be offered choice. Different
approaches suit different people. Not everyone
finds formal psychological therapy helpful, some
find it unhelpful. All staff need to be trained
in the principles of a psychological approach so
that it can inform not only formal therapy but
also the whole culture of services and every
conversation that happens within them.
Only 1 in 10 of those who could benefit get
access to true CBT (Cognitive Behavioural
Therapy) despite it being recommended by NICE
(National Institute of Health and Clinical
Excellence). ?
  • Increase access to psychological therapies in
    line with NICE guidelines.
  • Ensure commissioning of
  • services in line with NICE

Improving capacity to meet demand (Garety and
  • Mental health, learning disabilities and
    addictions services national specialist
    services large RD portfolio. 4,500 staff
  • ?Core population - 4 South London Boroughs
    1.1million inner city, very high indices of
    social deprivation
  • ?Substantially raised rates of psychosis,
    especially in ethnic minority populations (x4-9)

(No Transcript)
Conclusions (Prytys et al 2011)
  • Mapping of need
  • 10 point charter
  • Named link person in each team
  • Screening for CBT/FI eligibility
  • Training for staff
  • Limited change in implementation

Conclusions (Prytys et al 2011)
  • Audited provision remained low around 10 for
    CBTp and 5 for FIp.
  • Barriers to implementation included pessimistic
    staff views (on recovery), misunderstanding of
    who was suitable for psychological therapy, heavy
    caseload, and pressure of other tasks.
  • Need for highly trained and supervised staff.
  • No funding for implementation

So whats stopping us? Cost and Access or A war
of words, beliefs and ideologies?
Words, Beliefs, Ideologies?
Knowledge and beliefs are important
  • NICE - research aimed at behaviour change
    (individuals or population) needs to consider
    knowledge and beliefs
  • Theory of planned behaviour - requires
    implementation is desirable, associated with
    positive attitudes and perceived to be within
    behavioural control (Ajzen 1991).

Knowledge and beliefs are important
  • Conceptual models of implementation require
    change in the adopter needs, motivations,
    values, goals and skills
  • perceived relative advantage (compared with other
  • compatibility with self (ones own views, health
    and illness perceptions)
  • complexity, trialability and observability (i.e.
    seeing it as achievable, watching it in action
    and knowing that it works)

Barriers to implementationWhat CMHT staff say?
Questions What is your understanding of the
outcomes of people with schizophrenia? How do you
work with people with a diagnosis of
schizophrenia? How would you prioritise which
service users are offered therapy? Are you aware
of the NICE guidelines for schizophrenia
regarding psychological therapies? What are your
views about clinical practice guidelines such as
NICE? Prytys et al. 2010
What CMHT staff say?
Prytys et al. 2010 (n20) 16 concerned by lack of
time - the focus became more on keeping them
stable with just compliance with medication,
very little support 10 emphasised combined
medication and therapy - They have to be on
their medication obviously. If they dont take
their medication it (therapy) is not going to
work .
What CMHT staff say?
Prytys et al. 2010 (n20) 7 positive and 6
negative views re. CBTp benefits - thought for
high fx less symptomatic. 10 reported service
user refusal I dont think they would ask for
it 13 thought simple CBT techniques important
e.g psychoeducation, anxiety management, relapse
prevention 11 emphasised importance of
specialist CBT therapist in team or lack of this
as a barrier to intervention.
What CMHT staff say?
  • Beliefs about referral criteria, pathways,
  • Insight High and Low
  • Symptoms High and Low
  • Function High and Low

Uptake?What EYE project service users say..
  • Informed choice, holistic approaches,
    availability of talking therapies are
    facilitators to engagement
  • Exclusive focus on medication, lack of choice,
    lack of information are barriers
  • Uptake/engagement with psychosis interventions
    hampered by beliefs emotional barriers
    (Greenwood et al. in prep Morrison et al. 2012)

  • Uptake of interventions/CBTp affected by health,
    illness and treatment perceptions.
  • Beliefs that psychosis is transitory led to
    reduced uptake
  • Beliefs of limited personal control and
    biological causality (control/cure) led to reduce
    active engagement
  • Limited illness beliefs explored

(Freeman et al. 2013 2014 Williams and Steer
2011 Theodore et al. 2012 Lobban et al. 2004).
Illness Perception (e.g. Rogers 1983)
Uptake Interventions
  • Specific (pre-) interventions, based on illness
    perceptions, have been effective in promoting
    adherence to and outcomes from physical health
    interventions and have emphasised the need to
    tailor the intervention to health beliefs.
  • Interventions for medication adherence in
    psychosis are also common, with medication
    adherence relating to beliefs about treatment and
    illness perceptions.
  • Cameron et al 2005 Horne and Weinman et al 2002
    McAndrew et al. 2008 Petrie et al. 2002

Recent key CBTp studies
  • Turner et al 2014
  • Psychological Interventions for Psychosis A
    Meta-Analysis of Comparative Outcome Studies
  • Jauhar et al 2014
  • Cognitive-behavioural therapy for the symptoms of
    schizophrenia systematic review and
    meta-analysis with examination of potential bias
  • Morrison et al 2014
  • Cognitive therapy for people with schizophrenia
    spectrum disorders not taking antipsychotic
    drugs a single-blind randomised controlled trial

"This house believes that CBT for psychosis has
been oversold"
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Only 1 in 10 of those who could benefit get
access to true CBT despite it being recommended
by NICE (National Institute of Health and
Clinical Excellence).
The basis of clinical decisionsIsaacs and
Fitzgerald BMJ 1999
  • Eminence
  • seniority of the protagonist with a faith in
    clinical experience
  • Vehemence
  • Volume substitutes for evidence
  • Eloquence
  • Good dress sense and verbal skill
  • Confidence
  • Only applicable to surgeons
  • Evidence
  • Randomised controlled trials, meta-analyses

IAPT for Psychosis
Northwest Sussex Pilot
  • Dr Emily Gray, Principal Clinical Psychologist
  • Dr Nicola Motton, Clinical Psychologist
  • Northern West Sussex Assessment and Treatment
  • Daniel Stevens, Assistant Psychologist
  • Education and Training

With thanks to Jenefer Lofty, Art Therapist, and
Esmie Rush, Psychology Intern, Northwest Sussex
Assessment and Treatment Service
Increase capacity to offer therapy in Northwest
  • Art Therapy (group format)
  • CBT
  • Family Intervention (FI)
  • Behavioural Activation / Graded Exposure (BA/GE)

Increase capacity to offer therapyOur approach
  • Use existing resource designated psychosis
    spaces on caseloads
  • -New training for existing staff to increase
    capacity (FI, BA/GE)
  • -Top-up training for CBT practitioners
  • -Specialist supervision CBT and FI
  • Additional resource - Assistant psychologists
    (BA/GE) and CBT trainees

Training outcomes
  • 10 members of staff trained in BA/GE to date
  • 2 currently in training
  • 6 members of staff trained in FI to date
  • 2 currently in training

Increasing offers of therapy
  • So through increasing capacity as described
    above, did the number of offers of therapy
  • A target of 82 offers of therapy was set (half of
    the caseload at baseline who were identified as
    having schizophrenia-spectrum disorders)
  • Criteria for identifying appropriate clients to
    different interventions were circulated,
    clinicians attended team meetings, circulated
    emails advertising psychosis spaces

Offers of therapy made
  • There have been 67 new offers of therapy since
    Dec 2012 (approx 42 of those with schizophrenia
    spectrum disorders on caseloads)
  • 82 towards our target of making 82 new offers of
    therapy within 2 year period

What helped increase offers?
  • Use of groups enabled a greater number of clients
    to receive art therapy
  • Positive experience of interventions from staff
    perspective more referrals
  • Staff valued opportunities to discuss potential
    referrals, availability of therapy staff and
  • Increased conversations between clinicians, and
    between clinicians and clients about

  • Movement of staff
  • Competing time demands
  • Competing clinical demands (complex trauma/PD
    also CBT slots are only 2.5 of case load)
  • Difficulty identifying appropriate clients
    (insight, medication, stability)
  • Clinicians perceptions of capacity and referral
  • Clinicians knowledge of treatment options,
    benefits, pathways

Ideas going forwards
  • Improve information for clients and staff on
    interventions available
  • Rolling training programme, whole-team training
  • Awareness-raising event(s) for staff, carers,
    clients, GPs, commissioners, etc
  • Psychosis-specific roles / protected time for
    psychosis work
  • Exploration of group interventions
  • Assertive-outreach approach to seeking out
    clients / families
  • Research study on barriers to intervention

Developing the evidence base to improve
implementation and uptake of CBT for psychosis
K Greenwood, K Cavanagh, A Field, R deVisser, R
Chandler, D Fowler, E Peters, M Hayward, P Garety
Research Questions
  • What are the knowledge, beliefs and behaviours of
    service-users and clinicians towards uptake and
    implementation of CBT for psychosis?
  • Can a pre-CBTp informed choice intervention
  • (i) knowledge, beliefs and behaviours
  • (ii) empowerment, QoL, Hope

  • The study aims to do this by
  • Identifying the knowledge, beliefs and behaviours
    associated with current provision and use of
    CBTp in service users and clinicians, and using
    this information to develop two new outcome
  • Developing two pre-CBT informed choice
    interventions, based on implementation science,
    health perceptions and phase 1 outcomes
  • Developing and assessing the feasibility of the
    interventions in two preliminary small-scale
    randomised controlled trials (RCTs) for
    Clinicians and Service-users

Method - Phase 1
  • a) Qualitative focus groups to explore
    barriers/facilitators to uptake/implementation in
  • Clinicians and
  • Service users
  • Who support or who do not value CBTp
  • b) Large-scale investigation of
    barriers/facilitators using questionnaire in 400
    service users and clinicians to clarify nature of
    problem to be addressed.

Method - Phase 2
  • Consultation to reach consensus on interventions
  • Content (modules)
  • Format (e-learning, website, booklet, video pack)
  • Intervention likely to include
  • (i) a knowledge component
  • (ii) an experiential component
  • (iii) a motivational behaviour
    change component
  • (iv) a health perceptions behaviour
    change component
  • (v) a decision aid component.

Method - Phase 3
  • Design A feasibility RCTs comparing the
    informed choice interventions (pre-CBT-IC) with
    treatment as usual (TAU) in two distinct groups
    of 40 clinicians and 40 service- users.
  • Measures at baseline post intervention and
    3-month follow-up
  • the new personal knowledge/beliefs questionnaires
    and measures of mental health and well-being,
    self-efficacy and empowerment
  • log of CBTp-related behaviour
  • Feasibility data to assess the acceptability and
    applicability of the interventions and the
    pragmatic applicability and validity of the trial

From your own experience, what are the knowledge
beliefs, attitudinal barriers to
In addition, a study we are supporting in Sussex
(Staff Attitudes Towards Guided Self-Help CBT for
Distressing Voices) will be closing shortly.
All mental health clinical staff are invited to
take part.You will be asked for your opinions
on a new psychological intervention for people
who hear voices To take part just visit the
website www.survey.bris.ac.uk/sussex/staffsurvey
Sussex Psychosis Research interest
Group www.sussex.ac.uk/spriglab
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