Journal of Mental Health
ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20
An investigation of the implementation of NICErecommended CBT interventions for people with schizophrenia Gillian Haddock, Emily Eisner, Candice Boone, Gabriel Davies, Catherine Coogan & Christine Barrowclough To cite this article: Gillian Haddock, Emily Eisner, Candice Boone, Gabriel Davies, Catherine Coogan & Christine Barrowclough (2014) An investigation of the implementation of NICErecommended CBT interventions for people with schizophrenia, Journal of Mental Health, 23:4, 162-165, DOI: 10.3109/09638237.2013.869571 To link to this article: https://doi.org/10.3109/09638237.2013.869571
Published online: 16 Jan 2014.
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http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2014; 23(4): 162–165 ! 2014 Informa UK Ltd. DOI: 10.3109/09638237.2013.869571
ORIGINAL ARTICLE
An investigation of the implementation of NICE-recommended CBT interventions for people with schizophrenia Gillian Haddock1, Emily Eisner1, Candice Boone1, Gabriel Davies1, Catherine Coogan2, and Christine Barrowclough1 1
School of Psychological Sciences and 2Clinical Psychology Department, Manchester Mental Health and Social Care Trust, University of Manchester, Manchester, United Kingdom Abstract
Keywords
Background: The National Institute for Clinical Excellence (NICE) guidelines recommend that individual cognitive-behaviour therapy (CBT) is offered to all people with a diagnosis of schizophrenia. In addition, the guidelines recommend that family intervention (FI) should be offered to all families of people with schizophrenia who are in close contact with the service user. However, implementation into routine services is poor. Aims: To survey mental health services to investigate how many people with a diagnosis of schizophrenia and their families are offered and receive CBT or FI. Methods: A comprehensive audit of a random sample of 187 service users receiving care from one, large mental health care trust in North West England was conducted over a 12-month period. Results: The audit recorded that only 13 (6.9%) of services users were offered and 10 (5.3%) received individual CBT, while 3 (1.6%) services users were offered and 2 (1.1%) received FIs within the 12-month audit period. Conclusions: Implementation of CBT and FI is poor, particularly for FI. Reasons for poor implementation and service implications are discussed.
Cognitive-behaviour therapy, family intervention, implementation, NICE guidelines, psychosis, schizophrenia
Introduction Psychological interventions are an important part of the care that should be available to service users with a diagnosis of schizophrenia. Particular recommendations from the National Institute for Clinical Excellence guidelines (NICE, 2002, 2009) have been that individual cognitive-behaviour therapy (CBT) is offered to all individuals with a diagnosis of schizophrenia and that family interventions (FI) should be offered to all families of people with schizophrenia who are in close contact with the service user. CBT is recommended over a course of 16 sessions and FI over a course of 10 sessions. However, despite these recommendations, research suggests that national rates of implementation of CBT and FI remain below the recommended level (Krupnik et al., 2005; Mairs & Bradshaw, 2005; Prytys et al., 2011). Preliminary research findings are supported by two national surveys: the Your Treatment, Your Choice survey (Rethink, 2008) and the ‘‘No Voice, No Choice’’ review (Commission for Healthcare Audit and Inspection, 2007) which also found low levels of CBT and FI implementation for individuals with schizophrenia and their carers. The reasons for the poor implementation appear
Correspondence: Gillian Haddock, School of Psychological Sciences, University of Manchester, Zochonis Building, Brunswick Street, M17 9PT, Manchester, United Kingdom. E-mail: gillian.haddock@ manchester.ac.uk
History Received 5 November 2012 Revised 23 September 2013 Accepted 3 October 2013 Published online 16 January 2014
to be multifaceted, although a review of this area (Berry & Haddock, 2008) suggested that the barriers tended to cluster in to those related to workforce capability (e.g. level and quality of training and supervision), those related to how the service was configured (e.g. caseload size, responsibilities of care teams, managerial priorities) and those related to service user and carer barriers (e.g. a lack of desire for psychological interventions or preferring other types of intervention). It is likely that a combination of factors may contribute to implementation rather than any one in isolation, although a number of studies have shown that training staff to deliver the interventions is easily overcome, and that it is possible for staff to achieve a high level of skill in delivering these approaches (Brooker et al., 1994; Fadden, 2006; Jolley et al., 2012; Lancashire et al., 1997). Other factors which have been shown to contribute to trained staff not implementing CBT interventions following training have related to job roles not being changed to facilitate the application of these approaches (Jolley et al., 2012), lack of support and ongoing supervision and poor availability of top up training to consolidate skills. This study sought to explore the degree of implementation of NICE-recommended CBT and FI for service users and their families in one large mental health trust in the North West of England. A comprehensive audit was conducted to examine how many service users with schizophrenia had been offered CBT and FI, as well as any other psychological therapy.
Implementation of CBT
DOI: 10.3109/09638237.2013.869571
Methods The audit was conducted on a random sample of 187 adult (18 and over) service users with a diagnosis of schizophrenia spectrum disorder, under the care of 45 community mental health teams (935 clinical staff) in one mental health trust in North West England, representing a large population of mixed ethnicity in both an inner city and rural location of 362 500 adults aged 18–65. Diagnosis was based on the most recent diagnosis at the time the audit was carried out. This was taken from the ICD10 codes in service users’ electronic case notes. When no code was available, CPA forms or recent letters to psychiatrists were referred to. We included all those with a diagnosis of schizophrenia or psychosis, as defined by the ICD-10 codes F20-F209 (WHO, 1992). Participants were stratified by clinical team and a random number generator was then used to select cases from each subsample. Five trained research assistants collected the data retrospectively over a 12-month period between 24 November 2009 and 24 November 2010 from the trust electronic notes system identified through random sampling. For each case identified, all case notes, letters and appointments recorded on the electronic note system during the audit were examined. In order to ensure we were not too exclusive, we engaged search criteria to look for any individual or FIs that were offered within the audit period. Following a detailed set checklist, raters recorded details of which therapies were offered, referred to or received by clients. Therapy ‘‘offered’’ was assessed through detailed inspection of all case note entries in the 12-month audit period, where any mention of therapy being offered to a client was recorded. Whether or not an individual was then formally ‘‘referred’’ was evidenced by recordings of written referrals to psychology (through the patient administration system) during the audit period. Whether or not a therapy was ‘‘received’’ was assessed through recorded appointments (via the patient administration system), If the client had an appointment but there was no evidence they were actually seen, any further details available in the notes were recorded to explain this (e.g. did not attend, waiting list, etc.). Specific attention was paid to whether therapies were recorded as individual CBT: if a therapy was recorded as individual CBT in the notes, raters then checked the notes regarding the therapeutic techniques used against a CBT checklist, to ensure the therapy could be described as CBT. In order to assess whether a FI was appropriate, service user contact with carers was examined. Through reviewing case notes, it was first established if clients’ had an indentified carer. Level of contact was then assessed from all recordings of family contact throughout client notes during the 12-month audit period. If the client had contact with more than one family member, contact was rated in terms of the family member the client saw most frequently. No recorded contact during the 12-month audit period was rated as ‘‘no contact’’; contact recorded as less than once a month (on average) over the audit period was rated as ‘‘low contact’’; contact recorded less than once a week was rated as ‘‘moderate contact’’ and contact recorded at least once a week was rated as ‘‘high contact.’’
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Raters also collected information regarding demographics; whether service users were offered FI; who delivered the therapies and how many therapy sessions were received. The process of assessing whether therapy was offered/referred/ received was the same as for CBT. Specific attention was paid to the nature of the FI: as with CBT, if the therapy was recorded as FI then the notes regarding the therapeutic techniques used were verified against an FI checklist to ensure the therapy could be described as FI. In addition, raters recorded whether or not service users had ever received any input from psychological services at any point preceding the audit. For the five raters, initial and ongoing inter-rater reliability was checked in terms of percent agreement with each other. Initial reliability for all raters averaged 91.8%, ongoing reliability averaged 96.4% and the overall average was 94.4%.
Results Service users audited had a mean age of 45.0 years (SD ¼ 11.7; range ¼ 18.8–75.7). Within the 12-month audit period, 96 (51.35%) service users had high family contact equating to seeing a family member at least once per week, 22 (11.76%) had moderate contact seeing a family member less than once a week, 22 (11.76%) had low contact equating to seeing a family member less than once a month, and 22 (11.76%) had no contact with a family member. The level of family contact was unknown for 25 (13.37%) service users. In terms of treatment context, 70 (37.4%) of service users had previously received some form of psychological input and 117 (62.6%) had not, see Table 1 for an overview of other demographic and clinical characteristics of the audit sample. Individual cognitive-behavioural therapy Offered Of the 187 service users reviewed, 36 (19.3%) had evidence in their clinical notes that they were verbally offered some form of individual psychological therapy and, of those, only 13 (6.9%) were offered therapy described as individual CBT. Of the rest, 11 service users were offered one of motivational interviewing; psycho-education; group therapy based on CBT or counselling. For 12 service users, the therapy offered was unknown. Twenty four of these 36 service users were then formally referred for individual psychological therapy in writing and of those, only 12 (6.4%) were specifically referred for therapy described as individual CBT. Two were referred for group therapy based on CBT; four participants were referred to one of motivational interviewing; individual psychological support; psycho-education or ‘‘developing affective coping strategies for auditory hallucinations.’’ Six participants were recorded as being referred to a clinical psychologist although no specific therapy orientation was recorded. It should be noted that for two service users who ultimately received individual CBT, there was no record of a prior offer or referral for therapy in their electronic notes. In addition, 10 service users who were offered psychological therapy did not go on
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J Ment Health, 2014; 23(4): 162–165
Table 1. Demographic and clinical characteristics of the audit sample. Demographic and clinical characteristics Gender Male Female Diagnosis Schizophrenia Schizoaffective Other psychosis Ethnic origin White Black/black British Asian/Asian British Mixed Other Accommodation Live alone Live with family/spouse Hostel/supported accommodation House share Homeless Carer listed Parent Spouse Sibling Son/daughter Relative Friend Staff member Unknown Previously received psychological input Yes No
n (%) 116 (62.03) 71 (37.97) 159 (89.03) 18 (9.63) 10 (5.35) 124 34 16 7 6
(66.31) (18.18) (8.56) (3.74) (3.21)
69 (36.90) 60 (32.08) 50 (26.74) 4 (2.14) 4 (2.14) n ¼ 78 45 (57.69) 8 (10.26) 6 (7.70) 6 (7.70) 2 (2.56) 7 (8.97) 2 (2.56) 2 (2.56) 70 (37.4) 117 (62.6)
to be referred. However, there were no data available to explain this. Received Of those 13 participants who were offered CBT, 10 (5.3%) received it. Of those who received it, six received individual CBT from a clinical psychologist and four from other professionals such as psychotherapist, specialist counsellor, occupational therapist, or senior cognitive-behavioural psychotherapist. From the information available, the mean number of individual CBT sessions received during the audit was 7.8 (SD ¼ 5.46) with a range of 1–18 sessions, including the initial assessment by the therapist. Two service users had received additional sessions prior to the audit and three service users had therapy sessions scheduled for after the audit’s end point. Only one service user received the NICE-recommended number of therapy sessions of 16 or more and seven service users received seven sessions or fewer. Of the three service users who were referred for CBT but did not receive it during the audit period, one declined therapy and two did not attend the initial assessment session. Service user characteristics The characteristics of service users who were offered individual psychological therapy in the 12-month audit period were compared to those who were not. There were
no significant between-group differences of age, gender, ethnicity, locality, living arrangements or date of last CPA review. A trend towards a significant effect of diagnosis ( 2 ¼ 5.422, p ¼ 0.066), indicated that those with an ‘‘other psychosis’’ diagnosis were marginally more likely to be offered individual therapy than those with a schizophrenia diagnosis (OR ¼ 3.75, p ¼ 0.053). Those who had a named carer listed in the notes were also significantly more likely to have been offered psychological therapy than those who did not (OR ¼ 2.29, p ¼ 0.008). However, the small numbers involved suggest caution is needed in interpreting these results. The characteristics (age, gender, ethnicity, locality, living arrangements and date of last CPA review) of service users who were specifically offered CBT in the 12-month audit period were compared to those that were not but no significant effects were found. This may be due to the very small numbers involved. Family intervention With regard to FIs, of the 187 service users, of whom 118 were recorded as having high or moderate family contact, only three (1.6%) were offered FI therapy, with two (1.1%) receiving the therapy. From the information available, one service user received 10 FI sessions from a clinical psychologist but details of the therapy received by the other service user were unknown. The numbers of those receiving FIs were so small that exploratory investigations in relation to their characteristics were not carried out.
Discussion The audit revealed that implementation of the NICErecommended CBT and FI for the treatment of schizophrenia was low. Implementation was lower than the previous Rethink Mental illness survey, Your Treatment, Your Choice (Rethink, 2008) and other surveys (e.g. Krupnik et al., 2005) and much lower than those within the No Voice, No Choice review of adult community mental health services (Commission for Healthcare Audit and Inspection, 2007), which recorded 46% of approximately 7500 individuals to have been offered or received CBT, and 53% of approximately 2200 people to have received FI. These discrepancies may be related to the different methods of collecting survey data and different timescales over which data were collected. There may also be differences in how CBT and FI are described, as well as discrepancies in what is written in patient notes. Based on the data from this audit alone, it is possible that some information was not documented within service users’ electronic case notes and therefore figures may be unrepresentative. This may be an issue across surveys, thereby increasingly the likelihood of variation. If this is the case, one implication of this audit might be to make recommendations about additional information that should be available within service users’ notes. Not only was the implementation of NICE-recommended CBT very low but the average number of therapy sessions received fell significantly short of the NICE guidelines
Implementation of CBT
DOI: 10.3109/09638237.2013.869571
for CBT for schizophrenia, which recommends at least 16 individual sessions. No data were available to explain why so few sessions were received. There was also no information available regarding the training and supervision of those delivering the CBT, or whether a treatment manual was followed. This supports the potential implication of this audit that additional information should be available within service users’ notes. These and previous findings suggest that only a small proportion of those eligible are receiving CBT and FI, and that those delivering the interventions tend to be a small minority of the workforce and, despite the 2009 recommendations, implementation does not seem to have improved. Reviews (Berry & Haddock, 2008; Mairs & Bradshaw, 2005) of implementation of CBT and FI have made similar conclusions and suggested the difficulties in implementation of research findings on CBT and FI are complex. During a similar time period to this audit, Haddock et al. (2013) also carried out a survey of clinical staff working in the same trust. This revealed that high proportions of staff were trained to deliver both CBT (75%) and FI (44%). This study also reported on the perceived barriers to implementation, such as lack of time. This data suggest that while training may need to be improved, it is sufficient to provide therapy to a far greater number of people than recorded in this audit. While efforts may be being made to implement the NICE guidelines, lack of resources within the trust may prevent those who are trained in CBT to deliver it to as many clients as possible. This is inline with a qualitative study of CBT and FI implementation in a London trust, which found that limited time due to caseloads, lack of resources and staff attitudes to the efficacy of psychological therapy were the most significant barriers to implementation (Prytys et al., 2011). Identified barriers to implementation therefore appear to relate to organisational factors such as how management and services are set up to deliver the interventions, workforce capability and expertise to deliver the interventions and service user factors in relation to their desire to receive the interventions rather than inability to train staff to deliver the interventions. Any implementation package may need to tackle all these areas to produce an impact. Further research is needed to explore how we can improve implementation. While this audit’s findings are extremely important, it must be considered that the audit was only conducted within one mental health trust within North West England, thus only providing a snapshot of the implementation of CBT and FI among individuals with schizophrenia. However, given that these findings are similar to those conducted in other trusts, they may reflect a need for larger audits across trusts with a greater focus on the reasons for poor implementation, as well as having potential recommendations for the information that should be made available in service users’ case notes.
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Acknowledgements We are grateful to Lucy Bateman, Adam Lawrence and Sarah Leonard for their help in extracting the audit data from case notes.
Declaration of interest This work was supported by the Manchester Academic Health Sciences Centre, specifically supported by The University of Manchester and Manchester Mental Health and Social Care NHS Trust. The authors declare no conflicts of interests. The authors alone are responsible for the content and writing of this article.
References Berry K, Haddock G. (2008). The implementation of the NICE guidelines for schizophrenia: Barriers to the implementation of psychological interventions and recommendations for the future. Psychol Psychother: Theory Res Pract, 81, 419–36. Brooker C, Falloon I, Butterworth A, et al. (1994). The outcome of training community psychiatric nurses to deliver psychosocial intervention. Br J Psychiatr, 165, 222–30. Commission for Healthcare Audit and Inspection. (2007). No voice, no choice: a joint review of adult community mental health services in England. Fadden G. (2006). Training and disseminating family interventions for schizophrenia: Developing family intervention skills with multidisciplinary groups. J Fam Thera, 28, 23–38. Haddock G, Eisner E, Davies G, Barrowclough C. (2013). An assessment of the workforce capacity to deliver NICE recommended CBT and FI in North West England. Unpublished manuscript. Jolley S, Onwumere J, Kuipers E, et al. (2012). Increasing access to psychological therapies for people with psychosis: Predictors of successful training. Behav Res Therap, 50, 457–62. Krupnik Y, Pilling S, Killaspy H, Dalton J. (2005). A study of family contact with clients and staff of community mental health teams. The Psychiatrist, 29, 174–6. Lancashire S, Haddock G, Tarrier N, et al. (1997). Effects of training in psychosocial interventions for community psychiatric nurses in England. Psychiatr Serv, 48, 39–42. Mairs H, Bradshaw T. (2005). Implementing family intervention following training: what can the matter be? J Psychiatr Ment Health Nurs, 12, 488–94. NICE. (2002). Schizophrenia. Core interventions in the treatment and management of schizophrenia in primary and secondary care. London: National Institute for Clinical Excellence. NICE. (2009). Schizophrenia. Core interventions in the treatment and management of schizophrenia in primary and secondary care. London: National Institute for Clinical Excellence. Prytys M, Garety PA, Jolley S, et al. (2011). Implementing the NICE guideline for schizophrenia recommendations for psychological therapies: A qualitative analysis of the attitudes of CMHT staff. Clin Psychol Psychothera, 18, 48–59. Rethink. (2008). Your treatment, your choice survey: final report. World Health Organisation. (1992). International Statistical Classification of Diseases and Related Health Problems, 10th rev (ICD-10). Geneva (Switzerland): WHO.
ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20
An investigation of the implementation of NICErecommended CBT interventions for people with schizophrenia Gillian Haddock, Emily Eisner, Candice Boone, Gabriel Davies, Catherine Coogan & Christine Barrowclough To cite this article: Gillian Haddock, Emily Eisner, Candice Boone, Gabriel Davies, Catherine Coogan & Christine Barrowclough (2014) An investigation of the implementation of NICErecommended CBT interventions for people with schizophrenia, Journal of Mental Health, 23:4, 162-165, DOI: 10.3109/09638237.2013.869571 To link to this article: https://doi.org/10.3109/09638237.2013.869571
Published online: 16 Jan 2014.
Submit your article to this journal
Article views: 1440
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View Crossmark data
Citing articles: 34 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmh20
http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2014; 23(4): 162–165 ! 2014 Informa UK Ltd. DOI: 10.3109/09638237.2013.869571
ORIGINAL ARTICLE
An investigation of the implementation of NICE-recommended CBT interventions for people with schizophrenia Gillian Haddock1, Emily Eisner1, Candice Boone1, Gabriel Davies1, Catherine Coogan2, and Christine Barrowclough1 1
School of Psychological Sciences and 2Clinical Psychology Department, Manchester Mental Health and Social Care Trust, University of Manchester, Manchester, United Kingdom Abstract
Keywords
Background: The National Institute for Clinical Excellence (NICE) guidelines recommend that individual cognitive-behaviour therapy (CBT) is offered to all people with a diagnosis of schizophrenia. In addition, the guidelines recommend that family intervention (FI) should be offered to all families of people with schizophrenia who are in close contact with the service user. However, implementation into routine services is poor. Aims: To survey mental health services to investigate how many people with a diagnosis of schizophrenia and their families are offered and receive CBT or FI. Methods: A comprehensive audit of a random sample of 187 service users receiving care from one, large mental health care trust in North West England was conducted over a 12-month period. Results: The audit recorded that only 13 (6.9%) of services users were offered and 10 (5.3%) received individual CBT, while 3 (1.6%) services users were offered and 2 (1.1%) received FIs within the 12-month audit period. Conclusions: Implementation of CBT and FI is poor, particularly for FI. Reasons for poor implementation and service implications are discussed.
Cognitive-behaviour therapy, family intervention, implementation, NICE guidelines, psychosis, schizophrenia
Introduction Psychological interventions are an important part of the care that should be available to service users with a diagnosis of schizophrenia. Particular recommendations from the National Institute for Clinical Excellence guidelines (NICE, 2002, 2009) have been that individual cognitive-behaviour therapy (CBT) is offered to all individuals with a diagnosis of schizophrenia and that family interventions (FI) should be offered to all families of people with schizophrenia who are in close contact with the service user. CBT is recommended over a course of 16 sessions and FI over a course of 10 sessions. However, despite these recommendations, research suggests that national rates of implementation of CBT and FI remain below the recommended level (Krupnik et al., 2005; Mairs & Bradshaw, 2005; Prytys et al., 2011). Preliminary research findings are supported by two national surveys: the Your Treatment, Your Choice survey (Rethink, 2008) and the ‘‘No Voice, No Choice’’ review (Commission for Healthcare Audit and Inspection, 2007) which also found low levels of CBT and FI implementation for individuals with schizophrenia and their carers. The reasons for the poor implementation appear
Correspondence: Gillian Haddock, School of Psychological Sciences, University of Manchester, Zochonis Building, Brunswick Street, M17 9PT, Manchester, United Kingdom. E-mail: gillian.haddock@ manchester.ac.uk
History Received 5 November 2012 Revised 23 September 2013 Accepted 3 October 2013 Published online 16 January 2014
to be multifaceted, although a review of this area (Berry & Haddock, 2008) suggested that the barriers tended to cluster in to those related to workforce capability (e.g. level and quality of training and supervision), those related to how the service was configured (e.g. caseload size, responsibilities of care teams, managerial priorities) and those related to service user and carer barriers (e.g. a lack of desire for psychological interventions or preferring other types of intervention). It is likely that a combination of factors may contribute to implementation rather than any one in isolation, although a number of studies have shown that training staff to deliver the interventions is easily overcome, and that it is possible for staff to achieve a high level of skill in delivering these approaches (Brooker et al., 1994; Fadden, 2006; Jolley et al., 2012; Lancashire et al., 1997). Other factors which have been shown to contribute to trained staff not implementing CBT interventions following training have related to job roles not being changed to facilitate the application of these approaches (Jolley et al., 2012), lack of support and ongoing supervision and poor availability of top up training to consolidate skills. This study sought to explore the degree of implementation of NICE-recommended CBT and FI for service users and their families in one large mental health trust in the North West of England. A comprehensive audit was conducted to examine how many service users with schizophrenia had been offered CBT and FI, as well as any other psychological therapy.
Implementation of CBT
DOI: 10.3109/09638237.2013.869571
Methods The audit was conducted on a random sample of 187 adult (18 and over) service users with a diagnosis of schizophrenia spectrum disorder, under the care of 45 community mental health teams (935 clinical staff) in one mental health trust in North West England, representing a large population of mixed ethnicity in both an inner city and rural location of 362 500 adults aged 18–65. Diagnosis was based on the most recent diagnosis at the time the audit was carried out. This was taken from the ICD10 codes in service users’ electronic case notes. When no code was available, CPA forms or recent letters to psychiatrists were referred to. We included all those with a diagnosis of schizophrenia or psychosis, as defined by the ICD-10 codes F20-F209 (WHO, 1992). Participants were stratified by clinical team and a random number generator was then used to select cases from each subsample. Five trained research assistants collected the data retrospectively over a 12-month period between 24 November 2009 and 24 November 2010 from the trust electronic notes system identified through random sampling. For each case identified, all case notes, letters and appointments recorded on the electronic note system during the audit were examined. In order to ensure we were not too exclusive, we engaged search criteria to look for any individual or FIs that were offered within the audit period. Following a detailed set checklist, raters recorded details of which therapies were offered, referred to or received by clients. Therapy ‘‘offered’’ was assessed through detailed inspection of all case note entries in the 12-month audit period, where any mention of therapy being offered to a client was recorded. Whether or not an individual was then formally ‘‘referred’’ was evidenced by recordings of written referrals to psychology (through the patient administration system) during the audit period. Whether or not a therapy was ‘‘received’’ was assessed through recorded appointments (via the patient administration system), If the client had an appointment but there was no evidence they were actually seen, any further details available in the notes were recorded to explain this (e.g. did not attend, waiting list, etc.). Specific attention was paid to whether therapies were recorded as individual CBT: if a therapy was recorded as individual CBT in the notes, raters then checked the notes regarding the therapeutic techniques used against a CBT checklist, to ensure the therapy could be described as CBT. In order to assess whether a FI was appropriate, service user contact with carers was examined. Through reviewing case notes, it was first established if clients’ had an indentified carer. Level of contact was then assessed from all recordings of family contact throughout client notes during the 12-month audit period. If the client had contact with more than one family member, contact was rated in terms of the family member the client saw most frequently. No recorded contact during the 12-month audit period was rated as ‘‘no contact’’; contact recorded as less than once a month (on average) over the audit period was rated as ‘‘low contact’’; contact recorded less than once a week was rated as ‘‘moderate contact’’ and contact recorded at least once a week was rated as ‘‘high contact.’’
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Raters also collected information regarding demographics; whether service users were offered FI; who delivered the therapies and how many therapy sessions were received. The process of assessing whether therapy was offered/referred/ received was the same as for CBT. Specific attention was paid to the nature of the FI: as with CBT, if the therapy was recorded as FI then the notes regarding the therapeutic techniques used were verified against an FI checklist to ensure the therapy could be described as FI. In addition, raters recorded whether or not service users had ever received any input from psychological services at any point preceding the audit. For the five raters, initial and ongoing inter-rater reliability was checked in terms of percent agreement with each other. Initial reliability for all raters averaged 91.8%, ongoing reliability averaged 96.4% and the overall average was 94.4%.
Results Service users audited had a mean age of 45.0 years (SD ¼ 11.7; range ¼ 18.8–75.7). Within the 12-month audit period, 96 (51.35%) service users had high family contact equating to seeing a family member at least once per week, 22 (11.76%) had moderate contact seeing a family member less than once a week, 22 (11.76%) had low contact equating to seeing a family member less than once a month, and 22 (11.76%) had no contact with a family member. The level of family contact was unknown for 25 (13.37%) service users. In terms of treatment context, 70 (37.4%) of service users had previously received some form of psychological input and 117 (62.6%) had not, see Table 1 for an overview of other demographic and clinical characteristics of the audit sample. Individual cognitive-behavioural therapy Offered Of the 187 service users reviewed, 36 (19.3%) had evidence in their clinical notes that they were verbally offered some form of individual psychological therapy and, of those, only 13 (6.9%) were offered therapy described as individual CBT. Of the rest, 11 service users were offered one of motivational interviewing; psycho-education; group therapy based on CBT or counselling. For 12 service users, the therapy offered was unknown. Twenty four of these 36 service users were then formally referred for individual psychological therapy in writing and of those, only 12 (6.4%) were specifically referred for therapy described as individual CBT. Two were referred for group therapy based on CBT; four participants were referred to one of motivational interviewing; individual psychological support; psycho-education or ‘‘developing affective coping strategies for auditory hallucinations.’’ Six participants were recorded as being referred to a clinical psychologist although no specific therapy orientation was recorded. It should be noted that for two service users who ultimately received individual CBT, there was no record of a prior offer or referral for therapy in their electronic notes. In addition, 10 service users who were offered psychological therapy did not go on
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Table 1. Demographic and clinical characteristics of the audit sample. Demographic and clinical characteristics Gender Male Female Diagnosis Schizophrenia Schizoaffective Other psychosis Ethnic origin White Black/black British Asian/Asian British Mixed Other Accommodation Live alone Live with family/spouse Hostel/supported accommodation House share Homeless Carer listed Parent Spouse Sibling Son/daughter Relative Friend Staff member Unknown Previously received psychological input Yes No
n (%) 116 (62.03) 71 (37.97) 159 (89.03) 18 (9.63) 10 (5.35) 124 34 16 7 6
(66.31) (18.18) (8.56) (3.74) (3.21)
69 (36.90) 60 (32.08) 50 (26.74) 4 (2.14) 4 (2.14) n ¼ 78 45 (57.69) 8 (10.26) 6 (7.70) 6 (7.70) 2 (2.56) 7 (8.97) 2 (2.56) 2 (2.56) 70 (37.4) 117 (62.6)
to be referred. However, there were no data available to explain this. Received Of those 13 participants who were offered CBT, 10 (5.3%) received it. Of those who received it, six received individual CBT from a clinical psychologist and four from other professionals such as psychotherapist, specialist counsellor, occupational therapist, or senior cognitive-behavioural psychotherapist. From the information available, the mean number of individual CBT sessions received during the audit was 7.8 (SD ¼ 5.46) with a range of 1–18 sessions, including the initial assessment by the therapist. Two service users had received additional sessions prior to the audit and three service users had therapy sessions scheduled for after the audit’s end point. Only one service user received the NICE-recommended number of therapy sessions of 16 or more and seven service users received seven sessions or fewer. Of the three service users who were referred for CBT but did not receive it during the audit period, one declined therapy and two did not attend the initial assessment session. Service user characteristics The characteristics of service users who were offered individual psychological therapy in the 12-month audit period were compared to those who were not. There were
no significant between-group differences of age, gender, ethnicity, locality, living arrangements or date of last CPA review. A trend towards a significant effect of diagnosis ( 2 ¼ 5.422, p ¼ 0.066), indicated that those with an ‘‘other psychosis’’ diagnosis were marginally more likely to be offered individual therapy than those with a schizophrenia diagnosis (OR ¼ 3.75, p ¼ 0.053). Those who had a named carer listed in the notes were also significantly more likely to have been offered psychological therapy than those who did not (OR ¼ 2.29, p ¼ 0.008). However, the small numbers involved suggest caution is needed in interpreting these results. The characteristics (age, gender, ethnicity, locality, living arrangements and date of last CPA review) of service users who were specifically offered CBT in the 12-month audit period were compared to those that were not but no significant effects were found. This may be due to the very small numbers involved. Family intervention With regard to FIs, of the 187 service users, of whom 118 were recorded as having high or moderate family contact, only three (1.6%) were offered FI therapy, with two (1.1%) receiving the therapy. From the information available, one service user received 10 FI sessions from a clinical psychologist but details of the therapy received by the other service user were unknown. The numbers of those receiving FIs were so small that exploratory investigations in relation to their characteristics were not carried out.
Discussion The audit revealed that implementation of the NICErecommended CBT and FI for the treatment of schizophrenia was low. Implementation was lower than the previous Rethink Mental illness survey, Your Treatment, Your Choice (Rethink, 2008) and other surveys (e.g. Krupnik et al., 2005) and much lower than those within the No Voice, No Choice review of adult community mental health services (Commission for Healthcare Audit and Inspection, 2007), which recorded 46% of approximately 7500 individuals to have been offered or received CBT, and 53% of approximately 2200 people to have received FI. These discrepancies may be related to the different methods of collecting survey data and different timescales over which data were collected. There may also be differences in how CBT and FI are described, as well as discrepancies in what is written in patient notes. Based on the data from this audit alone, it is possible that some information was not documented within service users’ electronic case notes and therefore figures may be unrepresentative. This may be an issue across surveys, thereby increasingly the likelihood of variation. If this is the case, one implication of this audit might be to make recommendations about additional information that should be available within service users’ notes. Not only was the implementation of NICE-recommended CBT very low but the average number of therapy sessions received fell significantly short of the NICE guidelines
Implementation of CBT
DOI: 10.3109/09638237.2013.869571
for CBT for schizophrenia, which recommends at least 16 individual sessions. No data were available to explain why so few sessions were received. There was also no information available regarding the training and supervision of those delivering the CBT, or whether a treatment manual was followed. This supports the potential implication of this audit that additional information should be available within service users’ notes. These and previous findings suggest that only a small proportion of those eligible are receiving CBT and FI, and that those delivering the interventions tend to be a small minority of the workforce and, despite the 2009 recommendations, implementation does not seem to have improved. Reviews (Berry & Haddock, 2008; Mairs & Bradshaw, 2005) of implementation of CBT and FI have made similar conclusions and suggested the difficulties in implementation of research findings on CBT and FI are complex. During a similar time period to this audit, Haddock et al. (2013) also carried out a survey of clinical staff working in the same trust. This revealed that high proportions of staff were trained to deliver both CBT (75%) and FI (44%). This study also reported on the perceived barriers to implementation, such as lack of time. This data suggest that while training may need to be improved, it is sufficient to provide therapy to a far greater number of people than recorded in this audit. While efforts may be being made to implement the NICE guidelines, lack of resources within the trust may prevent those who are trained in CBT to deliver it to as many clients as possible. This is inline with a qualitative study of CBT and FI implementation in a London trust, which found that limited time due to caseloads, lack of resources and staff attitudes to the efficacy of psychological therapy were the most significant barriers to implementation (Prytys et al., 2011). Identified barriers to implementation therefore appear to relate to organisational factors such as how management and services are set up to deliver the interventions, workforce capability and expertise to deliver the interventions and service user factors in relation to their desire to receive the interventions rather than inability to train staff to deliver the interventions. Any implementation package may need to tackle all these areas to produce an impact. Further research is needed to explore how we can improve implementation. While this audit’s findings are extremely important, it must be considered that the audit was only conducted within one mental health trust within North West England, thus only providing a snapshot of the implementation of CBT and FI among individuals with schizophrenia. However, given that these findings are similar to those conducted in other trusts, they may reflect a need for larger audits across trusts with a greater focus on the reasons for poor implementation, as well as having potential recommendations for the information that should be made available in service users’ case notes.
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Acknowledgements We are grateful to Lucy Bateman, Adam Lawrence and Sarah Leonard for their help in extracting the audit data from case notes.
Declaration of interest This work was supported by the Manchester Academic Health Sciences Centre, specifically supported by The University of Manchester and Manchester Mental Health and Social Care NHS Trust. The authors declare no conflicts of interests. The authors alone are responsible for the content and writing of this article.
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