Today’s Objectives

•  Discussion of why early intervention is key and works for early onset psychosis

•  Identify specific practices that have been shown to work within this population

•  Discussion of specific evidence based practice and how it is implemented within community settings

Today’s Objectives •  Identify steps in holding a standard of fidelity

for a specific EBP (CBTp) and how to maintain this in practice

•  Explore next steps to develop continued

dissemination and implementation of these approaches

•  The beginning stages of a psychotic episode •  Usually occurs between ages 15-25 years of

age •  Affects approximately 100,000 adolescents

and adults per year (McGrath, Saha, Chant, et al., 2008)

What is early onset psychosis?

The History of Early Intervention

•  First episode psychosis research began in the 1980s with randomized control trials (Crow TJ, MacMillan JF, Johnson AL.,1986; Kane JM, Rifkin A, Quitkin F., 1982)

•  Early psychosis clinical services first established in Melbourne with the development of EPPIC (Early Psychosis Prevention and Intervention Centre) (McGorry PD, Edwards J, Mihalopoulos C.,1996) and soon after expanded

•  RAISE (Recovery After an Initial Schizophrenia Episode) research was initiated in 2009 by NIMH to investigate methods for establishing specialty care programs for FEP (First Episode Psychosis) in the US

•  These findings suggested that mental health

providers can implement principals of coordinated care and compelled an argument for increased implementation in community settings throughout the US (Heinssen, R.K., Goldstein, A.B., Azrin, S.T., 2014).

The History of Early Intervention in the United States

PREP (Prevention and Recovery for Early Psychosis)

Combination of community-centered, evidence-based treatment program for clients experiencing early onset psychosis

•  A Program of Felton Institute, a community based non-profit organization

Paired with an academic partner •  University of California, San Francisco

(UCSF)

1)  Use of rigorous assessment process to determine early diagnosis (SIPS, SCID)

2)  Algorithm guided Medication Management 3)  Cognitive Behavioral Therapy for Psychosis

(CBTp) 4)  Multifamily Education Groups (PIER Model) 5)  Individualized Placement and Support

(Dartmouth Model) 6)  Cognitive Remediation through computer-

based intervention (Vinogradov, et al., 2012)

Examples of evidence-based practices used in an early intervention program (PREP)

•  Comprehensive approach needed to meet clients’ needs across settings (from the clinic to the community)

•  Challenge is holding providers accountable to standards based on research

•  Implementing these evidence-based practices in the real world to help clients build meaningful lives

Evidence-based interventions

•  Creating and holding to a standard of care •  Ongoing training to support staff learning and

growth •  Maintaining fidelity to the models through

supervision and training of staff •  Outcome accountability •  Documentation standards

Why Evidence-Based Treatment is Effective

•  Providing services to a standard is what consumers should receive as well as what we are ethically and scientifically guided to do

•  Research demonstrates these approaches are effective with this population

•  Utilizing training and ongoing supervision in order to reach, achieve, and maintain these standards

Fidelity to the model

An example of an EBP: Cognitive Behavioral Therapy for Psychosis (CBTp) •  Evidence suggests that CBTp is most

effective with individuals at ultra high risk of developing psychosis, those in the early stages of symptoms, and those with stable chronic symptoms (NICE, 2014)

•  Recommended by NICE (National Institute of Clinical Excellence) as treatment to be used in conjunction with antipsychotic medication, or by itself if medication is declined (2015)

CBT for psychosis first described by Beck in 1952 Due to prominence of medical/biological model and studies of the 1980’s on damaging effects of talking therapies for psychosis, CBT was largely overlooked as treatment option Long held assumption that positive symptoms lay outside realm of “normal psychological functioning” (Slide Source: Hardy, 2014)

History of CBTp:

How CBTp works:

•  Builds upon traditional CBT model of the relationship between thoughts, feelings, and behaviors

•  Emphasis on normalization of symptoms; A shift from how they had been conceptualized (Morrison, 2001)

•  Collaboration between client and therapist is significant piece

Goals of CBTp:

•  Provide individual with increased understanding and awareness through psychoeducation and normalization

•  Facilitate ability to identify links between environmental factors and patterns of thinking, feeling, and behaviors

•  Help individual develop their own toolbox of skills

Ensuring fidelity of the CBTp model

•  Training and orientation to the model is the first step

•  Want to track progress of implementation to ensure treatment is being implemented to a certain standard

•  A minimum standard of competence is the goal: ongoing training and supervision to achieve further advancement in how treatment is implemented

How fidelity is maintained

•  Use of validated rating scales to track and follow how interventions are implemented

•  Training and research informs how to track fidelity

•  Holds agency accountable to maintain EBP as it was meant to be delivered

An example of a fidelity tool

•  Cognitive Therapy Scale-Revised (CTS-R, Blackburn et al., 2000)

•  Likert scale format (ratings of 0-6) •  12 domains that are rated throughout a

session •  Currently one of the best measures for this

purpose

Domains of CTS-R

•  Item 1: Agenda Setting and Adherence •  Item 2: Feedback •  Item 3: Collaboration •  Item 4: Pacing and Efficient Use of Time •  Item 5: Interpersonal Effectiveness •  Item 6: Eliciting of Appropriate Emotional Expression •  Item 7: Eliciting Key Cognitions •  Item 8: Eliciting and Planning Behaviors •  Item 9: Guided Discovery •  Item 10: Conceptual Integration •  Item 11: Application of Change Methods •  Item 12: Homework Setting

Training and Supervision Protocol

•  20 hours of initial didactic training – Based on training model highlighted in

existing CBTp models (Kingdom & Turkington, 2008; French & Morrison, 2004)

– All clinical staff within the agency that provide therapy and case management attend training

– Program Managers also attend to support implementation

Training and Supervision Protocol

•  Weekly group consultation – Facilitated by CBTp Trainer

•  Monthly tape review – Clinicians submit one tape per month that is

reviewed by assigned trainer; goal is 3 consecutive tapes in a row to reach competence (score of 50% or better on the CTS-R scale)

Prevention & Recovery In Early Psychosis (PREP) FLOWCHART FOR ACHIEVING AND MAINTAINING

COMPETENCE IN CBT FOR PSYCHOSIS (CBTp) Developed by Kate Hardy, Clin.Psych.D, Pamela Greenberg, MFT and Erika Van Buren, Ph.D.

3  or  more  consecu+ve  tapes   0  tapes  

1  to  2  tapes  

Yes   No  

Yes   No  

Clinician  completes  training  in  CBT  for  Psychosis  

Clinician  a6ends  group  supervision  with  CBT  supervisor  

Clinician  submits  up  to  6  tapes  for  review  using  the  Cogni=ve  Therapy  Scale-­‐

Revised  (CTS-­‐R)  

Clinician  submits  up  to  3  more  tapes  for  review  using  the  CTS-­‐R  

Inform  program  manager  of  increased  intensity  of  training  and  supervision  

Clinician  a6ends  next  CBT  group  training  

Clinician  submits  up  to  3  more  tapes  for  review  

using  the  CTS-­‐R  

How  many  of  the  tapes  were  rated  as  competent  (score  of  50%  or  greater)  in  

the  CTS-­‐R?  

Were  3  consecu=ve  tapes  (out  of  9)  rated  

as  competent?    

Were  3  consecu=ve  tapes  (out  of  9)  rated  

as  competent?    

Move  to  flowchart  on  Maintaining  Competence  

in  CBT  

Move  to  flowchart  on  Maintaining  Competence  

in  CBT  

Program  Manager  

implements  performance  review  and  ac=on  plan  per  agency  

policy  

How staff were supported

•  Program managers of agency attended trainings as well as ongoing supervision

•  Incentives included stipends upon reaching competence certification and potential of being invited to be trained as a future CBTp trainer/consultant

Experiences in training and monitoring

•  Study conducted that examined the outcomes of training community clinicians with a CBTp approach

•  Research questions included whether community based clinicians could be trained to competence and whether already competent clinicians could be supported to become trainers

Findings and challenges to date:

•  Study yielded results suggesting staff turnover, resistance to CBT approach, language barriers across sites, and length of time to develop caseload were among hurdles in training clinicians to reaching competency

Findings and challenges thus far PREP  CLINICIANS  TRAINED  IN  CBTp  AND  RESULTS  

Average  number  of  tapes  to  

competence:  6    

(3-­‐18)  

Average  number  of  weeks  to  

competence:  54    

(17-­‐130)  

Average  number  of  

tapes  submi6ed:    

3  

Kate Hardy, 2014

Total  Clinicians  Trained  50  

Achieved  Competence  

17  Achieving  Competence  

13  LeW  Before  Reaching  Competence  

20  

Maintaining  Competence  

5  

LeW  Service  12  

Four  or  Less  Tapes  Submi6ed  

11  

Four  or  More  Tapes  Submi6ed  

2  

No  Tapes  Submi6ed  

8  

One  or  More  Tapes  Submi6ed  

12  

Findings and challenges thus far

•  Community clinicians can reach competency as part of an ongoing training and supervision program - turnover is one major challenge in this regard

•  Key community staff can be supported to become trainers within this area as potential incentive

•  Clinicians’ training in this approach would be most helpful once they have a caseload to work with

Future Directions to Explore

•  Impact of hiring/previous background in implementing CBTp (and other EBPs in general) as potential area of improvement

•  Relationship between clinician competence and clinical outcomes

•  Clinician demographics as predictors of achieving competence

•  Working alliance data as a mediator of clinical outcomes mediated by clinician competence

•  Differences across sites/regions – Demographic differences within populations

•  Culturally-competent and appropriate interventions – Specific sets of problems require different,

more targeted interventions (Tarrier, 2014). – May need to further target trainings according

to relevant factors and feedback

Logistical things to keep in mind

Key factors

•  Team/collaborative approach – both within the agency as well as with community partners

•  Maintaining fidelity through system of training and monitoring

•  Psychoeducation is a huge supportive piece

•  Include for case managers in High Yield Techniques

•  Specific training for specialized areas (such as interventions for suicide prevention and trauma)

•  Continued work with the community, including schools and educational institutions

•  Consider utilizing more updated rating scales more specific to psychosis and cultural factors in the future as the literature develops

Next Steps

Where to go from here:

•  Schizophrenia can be effectively treated with implementation of evidence based treatments

•  Increase accessibility of interventions such as CBTp within context of community mental health

•  Continued strategies of evidence-based program development and support is warranted in our goal of improving the lives of individuals impacted by these conditions

Take Away Points:

•  Early intervention for this population has long been studied and is still being further advanced

•  Variety of interventions exist across agencies; CBTp is one intervention that has been studied and shows strong evidence

•  Maintaining Fidelity to the model is one way of tracking how EBPs are managed and kept consistent throughout agencies

Sarah Deal, Psy.D. Staff Therapist & CBTp Trainer

PREP Monterey County 831-424-5033 x2513

sdeal@felton.org