Psychosocial
Interventions in Psychosis
(PSI)
James Kelly
Senior Clinical Psychologist
Lancashire Early Intervention Services
Question
• What do you understand by the term
Psychosocial Interventions (PSI)?
• What has your experience been of working in
a PSI model?
EIS Shared Learning Conference
A brief look at evidence for PSI
approaches
• Cognitive Behaviour Therapy: Recommended
– 31 RCT’s reviewed, quality checks on methodology (N=3052)
– Small but clear effect on symptoms, including depression, but
not on relapse rates.
• Family Interventions (FI): Recommended
– 38 RCT’s met quality checks (5 were follow ups) (N=3134)
– 32 studies (N=2429) included in meta analysis
– FI reduces relapses consistently, improve social impairment and
reduce Expressed Emotion.
• Art Therapy: Considered for Negative Symptoms
– 7 RCT’s of art therapy
• Defeat focussed Cognitive Therapy (Grant et al, 2011)
– 1 RCT
Predictors of responsiveness to CBT
• Belief Flexibility: Garety, 1997
• Dorsolateral Prefrontal Cortex activity and its
connectivity to the cerebellum (Kumari et al., 2009).
• Psychological view of problem and potential to gain
control over them (Freeman et al., 2013).
• Neural Changes as a result of CBT: decreased activation
of inferior frontal, insula, thalamus, putamen and
occipital areas to fearful and angry expressions.
• Reduction of fMRI response in inferior frontal-insular
and occipital clusters during angry expressions
correlated directly with symptoms improvement.
Summary of Effectiveness of CBTp
• Some evidence that CBTp can improve positive
symptoms and depression.
– Some patients more likely to respond than others (Garety
et al., 2008; Dunn et al., 2012).
• Negative symptoms improve with behavioural activation
and targeting of defeat beliefs (Grant et al, 2011)
• CBTp can be helpful in EIS (Bird et al., 2012)
• CBT may be more useful than medication in prodromal
period (Morrison et al., 2012; Stafford et al., 2013)
• May be useful in those who refuse meds (Morrison et
al., 2014)
• Controversial area, claims disputed (Lynch et al., 2010)
NICE (2014) Guidelines
• Offer CBT to all people with a diagnosis of schizophrenia.
This can be started either during the acute phase or later,
including in inpatient settings.
• Offer Family intervention to all families of people with a
diagnosis of schizophrenia who live with or are in close
contact with the service user.
• Also suggests offering these to people at risk of developing
psychosis.
EIS Shared Learning Conference
Service users want
equal access to
psychological
therapies
Rethink survey (2010)
Research suggests
that only 1 in 10
access CBT, and less
than 3% of families
access structured FI,
despite NICE guidance
(Schizophrenia Commission,
2012)
THE ABANDONED ILLNESS
A report by the Schizophrenia Commission
“Research has led to a range of evidence-based
psychological treatments. We know much more about
‘what works’ than we used to... The committed individuals
who went into the mental health profession to improve
lives should be helped to do exactly that.”
Prof Sir Robin Murray
This is where IAPT-SMI comes in
November 2012
Question…
• What challenges do you think we face in
implementing PSI in Early Intervention
Services?
Why doesn’t it happen?
• Competing demands and priorities in tight financial climate.
• Lack of up to date knowledge (at all levels of the NHS)
• Insufficient therapists & supervisors with adequate
training/competences.
• Lack of appropriate, available training & supervision.
• Organisational/team philosophy and priorities.
• Workforce without specific training
• Culture hard to sustain
EIS Shared Learning Conference
69% of Trusts claim
funding challenges
for providing access
to psychological
therapies for people
with a diagnosis of
schizophrenia
94% have
encountered
obstacles in making
psychological
therapies available,
including insufficient
skilled staff
Why increase access?
• Cognitive-behavioural therapy and Family Interventions for
psychosis (CBTp & FIp) are clinically and cost effective
• Improve outcomes, reduce relapse and reduce service use,
especially time in hospital
• Cost savings up to 2-4K per course of therapy
• Service users and carers like them – high satisfaction ratings
• NICE recommend CBTp (16+ weekly/fortnightly sessions)
offered to everybody with psychosis
• FIp (10+ sessions over 3-12 months) to everybody with a
caregiver
• Current provision unable to meet demand
EIS Shared Learning Conference
Lancashire Care: 3 tier model
• Whole Service Ethos of Psychosocial Care :
– Matched care or tiered approached to delivering
psychological care across whole workforce
• Education & Training :
– PSI Training: All of our staff are trained in CBT-informed
interventions (manualised, effective and accredited)
– Behavioural Family Therapy: We have 20+ staff trained
and have our own BFT trainers
– CBT & CBFI: Cohort of staff trained to Masters & Diploma
level
– REaCh: Routine Enquiry about Childhood Adversity
• Research and Contribution to Evidence-Base – E.g., LEAD Clinic, IMPACT Trial & REACT Trial
EIS Shared Learning Conference
A Matched-Care / Tiered Approach to Psychological Care
Tier 1
Psycho-social
interventions
Specific PSI
Training
Supervision/ Consultation
Formal CBT or FI,
Discrete Problems
Tier 2
Complex / multiple
problems longer term
CBT or FI
Tier 3
Case
managers/
ST&R
Staff with:
Formal CBT training
or COPE Msc
(under supervision)
Cognitive Therapists
Clinical Psychologists
North
Lancashire
Central & West
Lancashire
Aligned Therapist
Aligned Therapist
East
Lancashire
Aligned Therapist
Case Discussion and Formulation
(Therapist and Case Manager)
Core PSI Tier 1
Supervision, consultation & ongoing support from
Therapist and Team Leader
Review Outcome and Effectiveness
Psychological Assessment including Case
Manager
Formal CBT / FI
(Tiers 2 and 3)
Review Outcome
3 days of PSI training for all EIS workers & a
manual/ written resource
• To support EIS staff in the delivery of a CBT-informed
approach.
• To evaluate impact on knowledge, confidence and
application of PSI in routine clinical practice.
• To build on existing knowledge & skills.
• To include on-going supervision and support.
• Should be easily integrated into practice and
supports EI service model.
Core Competecies for Psychosis
PSI Manual
•
•
•
•
•
•
•
•
•
Engagement (MI skills)
Normalising Approaches
Maintenance Formulation
Problem lists and Prioritisation
SMART Goals & Agenda Setting
Activity Scheduling
Relapse Prevention (+ Manual)
Recovery Approach
Measuring Change
Supporting Practice Change
•
•
•
•
Monthly Formulation groups
PSI focus in clinical supervision
Ongoing weekly support from liaison sessions
Solid foundation of CBT informed knowledge
and skills within EIS
• Springboard for further CBT training
Low intensity interventions: a pilot
• Low intensity interventions: staff are trained to deliver brief,
manualised interventions.
• Helped people with psychosis to achieve personal goals
whilst targeting depression related inactivity or anxious
avoidance.
• 11 out of 12 people achieved their personal goals
• Significant improvements in depression, clinical distress,
activity levels, negative symptoms and delusions across 3
time points, no change in hallucinations or anxious avoidance
• High staff and participant satisfaction.
• Feasible therapy, needs controlled study, higher n.
• Suggests skilling a workforce with CBT skills may be feasible.
Discussion
• Reflections on this approach to delivering CBT
and FI informed Case Management.
Measuring outcome
• IAPT SMI: PROMS
– Sessional
• Choice short form
– Start, Middle, End
•
•
•
•
Work Social Adjustment Scale (WSAS)
Euroqual 5d (EQ-5D)
Psychosis Symptoms Rating Scale (PSYRATS)
Warwick Edinburgh Mental Wellbeing Scale (WEMWEBS)
– Middle & End
• Friends and Family, Patient Experience Questionnaire.
Choice
WEM
WBS
WSAS
EQ
5D
Session one
66
Session Two
PSYRATS
-
10
9
30
60
-
-
-
-
Session Three
66
70
-
-
-
Session Four
70
-
12
-
-
Session Five
70
-
-
-
-
Session Six
-
-
-
-
-
Session Seven
60
-
10
-
-
PROMS
Session Eight
-
-
-
-
-
Paired Outcomes
% Improved
% Deteriorated
CHOICE (Greenwood et al.)
Lancashire Care Trust
Final Comments & Questions