Is training in psychosocial interventions worthwhile? Report of a psychosocial intervention trainee follow-up study

Trainee self-assessment of cognitive behaviour therapy competence during and after training

Large-scale cognitive behavioural therapy (CBT) training and implementation programmes, such as the pioneering Improving Access to Psychological Therapies (IAPT) initiative in the UK, aim to develop a workforce of competent therapists who can deliver evidence-based interventions skilfully. Self-awareness of competence enables CBT therapists to accurately evaluate their clinical practice and determine professional development needs. The accuracy of self-assessed competence, however, remains unclear when compared with assessments conducted by markers with expertise in CBT practice and evaluation. This study investigated the relationship between self- and expert-rated competence – assessed via therapy recordings rated on the Cognitive Therapy Scale Revised (CTS-R) scale – for a large sample of IAPT CBT trainees during training and, for the first time, at post-training follow-up. CBT trainees (n = 150) submitted therapy recordings at baseline, mid-training and end-of-training. At 12+ month follow-up, a subset of former trainees (n = 30) submitted recordings from clinical practice. There were positive relationships (r = .27 to .56) between self and expert CTS-R scores at all time points. The proportion of tapes demonstrating significant agreement between self and expert ratings (CTS-R difference <5 points) increased significantly across training and remained stable at follow-up. Findings indicate that accurate self-awareness of competence can be developed during structured CBT training and retained in the workplace. These outcomes are encouraging given the importance of self-awareness to CBT practice and accreditation. Future investigation into the development and maintenance of accurate self-awareness of competence is warranted.

Key learning aims

(1)

What IAPT CBT High-Intensity Trainees Do After Training

BACKGROUND

The UK Department of Health Improving Access to Psychological Therapies (IAPT) initiative set out to train a large number of therapists in cognitive behaviour therapies (CBT) for depression and anxiety disorders. Little is currently known about the retention of IAPT CBT trainees, or the use of CBT skills acquired on the course in the workplace after training has finished.

AIMS

This study set out to conduct a follow-up survey of past CBT trainees on the IAPT High Intensity CBT Course at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London (KCL), one of the largest IAPT High Intensity courses in the UK.

METHOD

Past trainees (n = 212) across 6 cohorts (2008-2014 intakes) were contacted and invited to participate in a follow-up survey. A response rate of 92.5% (n = 196) was achieved.

RESULTS

The vast majority of IAPT trainees continue to work in IAPT services posttraining (79%) and to practise CBT as their main therapy modality (94%); 61% have become CBT supervisors. A minority (23%) have progressed to other senior roles in the services. Shortcomings are reported in the use of out-of-office CBT interventions, the use of disorder-specific outcome measures and therapy recordings to inform therapy and supervision.

CONCLUSIONS

Past trainees stay working in IAPT services and continue to use CBT methods taught on the course. Some NICE recommended treatment procedures that are likely to facilitate patients' recovery are not being routinely implemented across IAPT services. The results have implications for the continued roll out of the IAPT programme, and other future large scale training initiatives.

Evaluating the feasibility of complex interventions in mental health services: standardised measure and reporting guidelines

BACKGROUND

The feasibility of implementation is insufficiently considered in clinical guideline development, leading to human and financial resource wastage.

AIMS

To develop (a) an empirically based standardised measure of the feasibility of complex interventions for use within mental health services and (b) reporting guidelines to facilitate feasibility assessment.

METHOD

A focused narrative review of studies assessing implementation blocks and enablers was conducted with thematic analysis and vote counting used to determine candidate items for the measure. Twenty purposively sampled studies (15 trial reports, 5 protocols) were included in the psychometric evaluation, spanning different interventions types. Cohen's kappa (κ) was calculated for interrater reliability and test-retest reliability.

RESULTS

In total, 95 influences on implementation were identified from 299 references. The final measure - Structured Assessment of FEasibility (SAFE) - comprises 16 items rated on a Likert scale. There was excellent interrater (κ = 0.84, 95% CI 0.79-0.89) and test-retest reliability (κ = 0.89, 95% CI 0.85-0.93). Cost information and training time were the two influences least likely to be reported in intervention papers. The SAFE reporting guidelines include 16 items organised into three categories (intervention, resource consequences, evaluation).

CONCLUSIONS

A novel approach to evaluating interventions, SAFE, supplements efficacy and health economic evidence. The SAFE reporting guidelines will allow feasibility of an intervention to be systematically assessed.

The development of a family intervention competency assessment and reflection scale (FICARS) for psychosis

Family intervention (FI) for psychosis has a robust evidence base. In recommending its use the revised NICE schizophrenia guideline states 'Healthcare professionals providing psychological interventions should have an appropriate level of competence'. Yet, no definitive instrument exists to outline what competences are required during and post FI training or help recruit staff with the appropriate knowledge and skill. This paper reports on the development of a Family Intervention competency assessment and reflection scale (FICARS). Using a systematic three-staged approach commonly used in health outcomes measurement development, a comprehensive literature review on UK-based FI training and commonly used assessment tools was undertaken. A FICARS draft was then constructed and revised in consultation with expert FI clinicians. Finally, a content validity study with FI trainers and students across three FI training programmes was undertaken to optimize FICARS aim to promote reflective assessment and professional development in FI skills and practice.

Implementing a structured psychosocial interventions group programme for people with bipolar disorder

It has been reported that, at any time, over half of the people with bipolar disorder are receiving no active treatment. Despite the availability of effective medications and psychotherapies, research concludes that the care of bipolar disorder in everyday practice is often deficient. Evidence base reports the effectiveness of psychosocial interventions using many of the same ideas as the recovery approach; both attempt to place clients at the heart of service delivery. This paper reports on the development and implementation of three pilot group programmes for service users with bipolar disorder, in a community clinical setting in South East England. The group programme design and development was based upon the evidence-based psychosocial interventions advocated in national clinical guidelines and research literature. The programme incorporated the key effective psychosocial interventions and self-management mechanisms within its 12 sessions spanning over 3 months, followed by three booster sessions in 6 months' time. Twenty-three service users have to date completed the programme. Participant feedback will be discussed and reported to inform further development and research implications of such innovative evidence-based interventions for service users with bipolar disorder.

Attitudes of relatives and staff towards family intervention in forensic services using Q methodology

Attitudes about family interventions have been identified as a possible reason for the poor implementation of such treatments. The current study used Q methodology to investigate the attitudes of relatives of forensic service users and clinical staff towards family interventions in medium secure forensic units, particularly when facilitated by a web camera. Eighteen relatives and twenty-nine staff completed a sixty-one item Q sort to obtain their idiosyncratic views about family intervention. The results indicated that relatives and staff mostly held positive attitudes towards family intervention. Relatives showed some uncertainty towards family intervention that may reflect the lack of involvement they receive from the forensic service. Staff highlighted key barriers to successful implementation such as lack of dedicated staff time for family work and few staff adequately trained in family intervention. Despite agreement with the web-based forensic family intervention technique and its benefits, both staff and relatives predicted problems in the technique.

What makes early intervention in psychosis services effective? A case study

A number of studies have demonstrated that Early Intervention in Psychosis (EIP) services can produce improved outcomes for service users. However, the essential elements that produce these results remain elusive. This paper considers a number of hypotheses, with a particular focus on one service in the UK, which was designed according to policy guidance. It concludes that the structure of EIP services allows for the effective implementation of evidence based psychosocial interventions, which often fail to be implemented successfully within standard mental health services.

The Meriden Family Programme: lessons learned over 10 years

BACKGROUND

Psychoeducational family approaches are effective in improving the quality of life for both those with mental health problems and their families, but implementation of these approaches within health services has been limited. The Meriden Family Programme has provided training and support for over 3,900 therapists and 242 trainers in Behavioural Family Therapy (BFT) to encourage widespread delivery of effective services for families with a member who has psychosis or other serious mental health problems.

AIMS

This article synthesises healthcare professionals' and carers' views on the implementation of family work and ways of increasing family involvement in services.

METHODS

During the Meriden Programme's 10th anniversary year, three Masterclass groups (n = 27) were conducted with healthcare professionals and carers involved with the programme over the past 10 years.

RESULTS

A collaborative approach between management, commissioners, BFT trainers, therapists, carers and service users encourages and ensures the delivery of family work. The most effective types of support, methods of training and organisational factors in supporting family work implementation are illustrated.

CONCLUSIONS

Best practices in implementing family work are identified to support and better inform those responsible for providing family work within their services.

A systematic review evaluating the impact of post-registration nursing and midwifery education on practice

Given the current focus on evidence-based practice, it is surprising that there is a dearth of systematic evidence of the impact on practice of post-registration nursing and midwifery education. The systematic review presented here formed part of a national review of post-registration nursing and midwifery education in Ireland [Health Service Executive, 2008. Report of the Post-registration Nursing and Midwifery Education Review Group: Changing practice to support service delivery. Health Service Executive, Dublin]. The review focuses specifically on the impact on practice from the perspective of nurses, midwives, patients, carers, education and health service providers. Sixty-one (61) studies met the criteria set. These studies were mainly of a retrospective and descriptive nature, often with small cohorts, set within one educational setting. The findings indicate that students benefit from post-registration programmes in relation to changes in attitudes, perceptions, knowledge and in skill acquisition. There is also some evidence that students apply their newly acquired attitudes, knowledge and skills. There is however limited evidence of the direct impact on organisational and service delivery changes, and on benefits to patients and carers. It can be concluded that the impact of post-registration nursing and midwifery education on practice has yet to be fully explored through a more systematic and coherent programme evaluation approach.

The contribution of nursing to public health practice in the prevention of depression

Depression is perceived worldwide as an important public health issue. Its prevalence has increased over the past 50 years. The reasons for the increase might be related, in part, to improved recognition and a greater willingness to label unhappiness or dysphoria as depression. Severe depression might be less amenable to prevention, although the identification of the stressors likely to trigger an episode in vulnerable individuals might prevent some recurrences. There is the potential, however, for the prevention of mild-to-moderate depression through action at the individual, community, and structural levels. This paper argues that nursing can make an important contribution to this prevention. At the individual level, this might be best accomplished through the development of the role of non-mental health nurses in primary care and workplace settings. At the community and structural levels, nursing as a profession can play an important role in influencing the commissioning of health care and the development of healthy public policy.

Cognitive behaviour therapy within assertive outreach teams: barriers to implementation: a qualitative peer audit

Assertive outreach is an evidence-based intervention, with over 30 well-designed randomized studies demonstrating its effectiveness, predominately in the USA. Assertive outreach teams have recently been implemented in the UK, and it has been recommended that teams should offer cognitive behaviour therapy (CBT) to service users; however, it has been reported that barriers exist in the routine delivery of CBT for psychosis (CBTp). The aim of the peer audit was to gauge current opinion from clinicians whether their experiences of barriers to implementation of CBTp reflected that outlined in the literature. A qualitative peer audit was undertaken at the National Forum for Assertive Outreach Annual Conference in 2006. The team representatives were invited to outline the barriers to the implementation of psychosocial interventions within their local areas. Teams identified organizational, managerial, supervision and local specific barriers to implementation. Specific comments included a lack of organizational investment, the structured nature of CBT, caseload issues, medication issues, application to people with sensory impairments, staff apathy and staff burnout. The analysis was limited by the metholodology employed; however, further recommendations are explored. It was evident from this peer audit that teams are experiencing barriers relating to the implementation of evidence-based therapy interventions and further research is required on the outreach model and the use of CBTp.

The implementation of the NICE guidelines for schizophrenia: barriers to the implementation of psychological interventions and recommendations for the future

PURPOSE

'Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care' was the first National Institute of Clinical Effectiveness (NICE) guidance to be produced in 2002. This guidance includes a recommendation in relation to cognitive behavioural therapy (CBT) and family interventions (FI) in schizophrenia. This review reviews this guidance and assesses the extent of their implementation in services and the barriers to this implementation.

METHODS

The review draws on data from empirical studies specifically focused on the NICE guidance for FI for schizophrenia, papers discussing implementation issues in relation to other psychological therapies in schizophrenia and empirical studies investigating the implementation of similar evidence-based guidelines in Australia and the USA.

RESULTS

Although there is relatively limited research investigating implementation of the NICE guidelines, the available evidence suggests that people with schizophrenia still have poor access to psychological interventions. Barriers to implementation involve factors associated with: mental health professionals, the needs of service recipients and of organizations.

CONCLUSIONS

In order to improve the implementation of the updated version of the schizophrenia guidance due to be published in 2009, it will therefore be necessary to target barriers at all of these levels. There are also problems associated with the way in which the NICE guidance, generally, and those for psychological interventions in schizophrenia in particular, are developed. It will be necessary to address these in order to facilitate successful implementation.

The compatibility of psychosocial interventions (PSI) and assertive outreach: a survey of managers and PSI-trained staff working in UK assertive outreach teams

In recent years, there has been an increased emphasis on providing psychosocial interventions (PSI) and assertive outreach (AO) for people with severe and enduring mental illness living in the UK. This paper presents the findings of a telephone survey conducted with managers and PSI-trained staff working for AO teams in the Northwest of England. The aim of the study was to gain an insight into staff attitudes regarding the compatibility of PSI and AO. The survey also gathered more general information about the nature of the AO teams and the number of PSI-trained staff working within them. The results indicate that, although PSI-trained staff believe that PSI and AO are compatible, AO is not immune to the barriers to PSI implementation that exist in other service areas. There also appears to be a question regarding the extent to which teams are maintaining fidelity to the original AO model that was outlined by Stein and Test.

The transfer of CBT education from classroom to work setting: getting it right or wasting the opportunities?

Recent policy, service and financial drivers that are aimed at improving access to psychological services with a particular focus on cognitive behavioural approaches have resulted in a number local and national service planning initiatives. The extent to which these developments ought to be informed by theory and research regarding the transfer of classroom-based learning to the work setting is made clear. The existing evidence base has implications for how education providers develop collaborative curricula with NHS employers in order to prepare students for the practice setting, and for how service providers support the students' knowledge, skills development, skills transfer and consolidation of these within the practice setting. The dangers of assuming that the dissemination of the clinical evidence base is straightforward within complex organizations and the structure of the NHS are also critically discussed.

An evaluation of education and implementation of psychosocial interventions within one UK mental healthcare trust

Psychosocial interventions (PSI), though recommended in the NICE guidelines for schizophrenia and bipolar affective disorder, are not routinely available to people with a serious mental illness in the UK. Education and training initiatives to equip mental health professionals with skills in PSI have grown over the last decade; yet the literature indicates serious problems in implementation of PSI in routine service provision. This paper examines on a local level the factors which support and limit the education and practice of PSI in one UK mental healthcare trust. It reports on a survey of trainees and their managers which aims to evaluate the impact of a PSI training programme and practice development strategy on staff, managers and service provision. The key findings are: a high rate of implementation of PSI by PSI-trained staff in the Trust; a strong association between PSI training and career progression for staff; and the support mechanisms which are most effective in the education and implementation of PSI. The paper concludes that certain measures and support mechanisms have facilitated the successful implementation of PSI with positive outcomes for staff and service provision. Further recommendations are made identifying measures which facilitate the implementation of PSI through an integrated education and practice development strategy owned by all stakeholders.

The Thorn Course: rhetoric and reality

The Thorn Course that provides psychosocial interventions and family work training for UK mental health professionals was founded in 1992. Since this time policy, service provision and needs have changed. The aim of this study was to examine the Thorn Course through relevant literature, in order to establish whether research and policy have been integrated into practice within training and services. A search of professional journal databases was conducted. Keywords used were 'Thorn Course' and 'psychosocial intervention training'. The resulting body of literature was reviewed. Five main themes emerged which were examined: needs identified, delivering the Thorn Course, training outcomes, implementing interventions and user and carer involvement. There is a distinct lack of research studies evaluating any aspect of the Thorn Course. There is little evidence that user and carer involvement has moved beyond rhetoric and community mental health nurses continue to lack opportunities and support to implement psychosocial skills acquired in training.

The long-term outcome of 2 family intervention strategies in schizophrenia

The different family-based interventions that have proven to be effective in treating people with schizophrenia present some therapeutic elements in common and differ in certain other respects, although to date, none of the proposed approaches have demonstrated to be clearly superior to each other in reduced relapse and readmission rates. Although the approaches based on relatives group therapies save considerable amounts of time, some data reveal better short-term results when the intervention focuses on the family unit and the participant patient.

OBJECTIVE

The aim of this study was to determine whether the clinical and social benefits observed in the short term would be maintained 5 years later.

METHOD

Follow-up study over a 5-year period on 87 patients diagnosed with schizophrenia and their families taking part in a cognitive behavioral therapy, assigned at random either to (a) a family unit including the patient or (b) a group of relatives.

RESULTS

The statistical contrast between the 2 survival curves reveals that they are not significant with regard to relapse (log-rank test, 1.30; P < .2538) nor readmissions (long rank test, 0.03; P = .8547). Results after analyzing other variables were also similar in both groups, with slight differences for the strategy where the patient was not present.

CONCLUSIONS

Both types of interventions have similar long-term impact with a clear tendency to loose benefits acquired during the intervention. This finding suggests that it might be possible for some subgroups of patients to conduct a 12-month therapy followed by a support group, hoping that long-term benefits would be maintained.

Stepping out of the box: broadening the dialogue around the organizational implementation of cognitive behavioural psychotherapy

The dissemination and uptake of cognitive behavioural interventions is central to the evidence-based mental health agenda in Britain. However, some policy and related literature, in and of itself social constructed, tends to display discursive naïvety in assuming a rational basis for the dissemination and organizational integration of cognitive behavioural approaches. Rational constructions fail to acknowledge that the practice settings of key stakeholders in the process are likely to be socially constructed fields of multiple meanings. Within these, the importance of evidence-based interventions may be variously contested or reworked. To illustrate this, a case example from the first author will discuss the hypothetical introduction of a cognitive behavioural group for voice hearers in a forensic mental health unit. This will highlight contradictions and local organizational problems around the effective utilization of postgraduate cognitive behavioural knowledge and skills. A synthesis of social constructionist with organizational theory will be used to make better sense of these actual and anticipated difficulties. From this basis, specific ways in which nurses and supportive stakeholders could move the implementation of cognitive behavioural psychotherapy agenda forward within a postmodern leadership context will be proposed.

Implementing family intervention following training: what can the matter be?

Family interventions (FI) have been established as an effective treatment for psychosis. Training in this intervention is now widely available in the UK. This paper reports a review of published literature that investigates whether, following this training, graduates provide this evidence-based treatment for individuals with psychosis and their caregivers. It further seeks to identify the barriers to implementation in cases where the treatment is not provided and assess benefits for service users and carers when it is. The review was conducted using the MEDline, PsycINFO, CINAHL and Embase databases. Studies that have attempted to evaluate the rates of implementation of FI by graduates of FI training programmes were identified, retrieved and reviewed. Six studies investigating the rates of implementation upon graduation were identified. The findings of these six studies were generally consistent. Rates of implementation by graduates of training programmes are usually low and a small number of graduates work with most of the families who are seen. The studies reviewed failed to assess service user and carer outcomes or consider the full range of likely impediments to the implementation of this evidence-based intervention. A key barrier to the implementation of FI is the reliance upon professionally developed and facilitated approaches. Alternative models that are service user and carer-led may provide a potential solution to the problem of implementation. Implications for future research and practice are considered.