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Psychological Therapies for Psychosis

Dr Louise Johns Honorary Senior Lecturer & PICuP Coordinator at King’s College London Institute of Psychiatry Psychology & Neuroscience spoke at today’s Psychological Therapies for Severe Mental Illness conference on:

• who Should be Offered CBTp and Family Interventions?
• meeting the new national standards for early intervention
• our service in South London and Maudsley: what works?

Abstract of Dr Johns’ presentation 
Improving access to psychological therapies for people with psychosis and their carers
The SLaM IAPT-SMI Psychosis Demonstration Site

Cognitive therapy for psychosis (CBTp) is an adaptation of CBT for emotional disorders, and there is robust evidence for the effectiveness of CBTp in reducing positive symptoms and distress and improving functioning when compared to routine care. Family Intervention for psychosis (FIp) involves both the person with psychosis and their carers, with strong evidence that it reduces relapse, hospital admissions and psychotic symptoms.  In the UK, NICE recommends that people with schizophrenia are offered CBTp, and also offered FIp when they are in contact with a carer (NICE, 2009, 2014). 

Poor access to psychological interventions for people with psychosis is a clearly recognised problem (Schizophrenia Commission, 2012). Limiting factors include access for staff to adequate training, support and supervision in services. The Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI) initiative is designed to overcome these obstacles, and aims to transform existing mental health services to be better able to provide NICE-recommended psychological therapies to people with bipolar disorder, personality disorders and psychosis. 

South London and Maudsley (SLaM) NHS Foundation Trust was chosen as one of the two IAPT-SMI Demonstration Sites for psychosis. SLaM services are organised into Clinical Academic Groups (CAGS) within the King’s Health Partners Academic Health Sciences Centre. The Psychosis CAG comprises about 7,000 service users, in four care pathways: Early intervention, Acute and crisis, Recovery and Complex care. The rates of psychosis are very high, with at least 400 new cases of psychosis every year across SLaM.

SLaM was selected as a demonstration site because of its existing data collection practice and high completion rates on outcome measures, the portfolio of training opportunities, and supervision structures. Previous work on implementing the NICE Schizophrenia Guideline had identified local barriers and facilitators to psychological therapies for psychosis, leading to the publication of a 10-point Charter for teams to facilitate delivery. With the DH funding provided, our site pledged to increase access to CBTp and FIp by 50%, reduce waiting times for therapy, improve referral pathways, train new therapists and provide close and frequent supervision, provide regular assessment of progress in therapy, and assess improvement on a range of clinical and health economic outcomes.

The SLaM IAPT-SMI service spans three clinical teams: an Early Intervention team (STEP), a specialist recovery service (SHARP), and a psychological therapy team (PICuP). We selected therapists with specific CBTp and FIp competences, or trained them to competence, and have provided close and frequent expert supervision. Therapy provision is closely aligned with the MDT. From November 2012 – December 2014, we increased access by 169% per annum in terms of numbers referred to the service, and we reduced waiting times by almost 40%. The client group is representative, but selected for potential to engage with stand-alone therapy, which matches the evidence base. We have a 96% paired completion rate for therapy completers on the primary, sessional patient-reported outcome measure (PROM) and 75-85% on the PROMS given 3-monthly by independent assessors. Our outcome data show significant improvement across the measures post-therapy, with medium-large within-group pre-post effect sizes. Service user feedback on completing the outcome measures has been positive. 

To conclude, despite evidence for their efficacy, access to psychological therapies for people with psychosis and their carers is limited. Although access can be improved by training more staff to deliver high quality therapy, therapists need protected time, and on-going expert clinical supervision to deliver therapy effectively. Routine assessment of outcomes is possible in this client group with high paired completion rates. Our demonstration site shows that improving access is possible, and recommends the development of specialist therapy services, alongside or within teams, as the model of care and workforce transformation for IAPT-SMI.

Link to the presentations from our latest open day in March 2015:
http://www.iapt.nhs.uk/smi-/smi-demonstration-sites-open-days-2013/

Key Learning Points

i)    It is both feasible and acceptable to staff, service users and therapists to deliver NICE-recommended psychological therapies for people with psychosis within an IAPT-model, with high rates of paired outcome completion, and of carer and service-user satisfaction, and promising improvements in clinical and service use outcomes. 

ii)    Dedicated, ring-fenced, funding and time has been essential for these therapists to deliver high quality psychological therapies, including time for regular and frequent clinical supervision in addition to client contact. However, the right service context (existing critical mass of staff, appropriate care and referral pathways, supervision and support – at managerial, clinical, administrative and business/finance levels) needs to be in place to ensure the resource translates rapidly into increased delivery.

iii)    Service models need to safeguard ring-fenced time dedicated to therapy delivery. Depending on the team/service configuration, this may need therapists to spend some of their time at one remove from the team setting. 

iv)    To ensure delivery and throughput, referral pathways need to prioritise service users who are more likely to be able to attend and engage. Those who need more flexible engagement are better suited to being seen in a community team context. 

v)    Routine measurement of outcomes, including sessional outcomes, is feasible and acceptable in this setting, providing that they are carefully chosen to suit the particular population, and that sessional measures are brief.

vi)    The use of independent assessors (psychology assistants) has a number of advantages: it is cost-effective (compared to using therapist time to assess); improves efficiency and throughput, by early engagement, and by triage of those who are hard to engage or choose to opt out; ensures assessment completion is prioritised and timely, and that timing is not subject to therapist influence; facilitates the routine and reliable provision of detailed feedback reports for GPs and teams; and offers service users the opportunity to provide ratings at one remove from therapist demand.

Dr Johns’ full PowerPoint presentation is available for download at the end of this page.

Dr Louise Johns is a consultant clinical psychologist and the IAPT-SMI project lead at South London and Maudsley (SLaM) NHS Foundation Trust. She previously worked at the Psychological Interventions Clinic for Outpatients in Psychosis (PICuP) in SLaM, providing individual cognitive behaviour therapy for psychosis (CBTp) and supervising qualified clinical and counselling psychologists in CBTp. She has recently taken up a post as consultant academic clinical psychologist within the Early Intervention in Psychosis Service, Oxford Health NHS Foundation Trust. Dr Johns is also an honorary senior lecturer at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London.

Dr Johns received a BA (Hons) in natural sciences, specialising in psychology, at Cambridge University in 1991. She went on to complete a Doctor of Philosophy (DPhil) at the University of Oxford. Her Doctorate in Clinical Psychology (DClinPsy) was completed in 1998 at the Institute of Psychiatry. She also received a Postgraduate Certificate in Academic Practice (PGCAP) at King’s College London in 2003.

Dr Johns is a chartered psychologist and an accredited cognitive behavioural therapist with the British Association of Behavioural and Cognitive Psychotherapies (BABCP). Since qualifying as a clinical psychologist in 1998, she has worked continuously in a clinical and research capacity in the field of psychosis. She has published over 50 articles on psychosis, including papers and chapters on cognitive behavioural treatments.

Future conferences of interest:

Implementing the national objective to end Prone/Face Down Restraint: Examining Restraint Positions in Practice
Tuesday 22 September 
ICO Conference Centre, London

Adult Safeguarding Enquiries & Safeguarding Adults Reviews
Monday 12 October 
Hallam Conference Centre, London

Improving Mental Health Crisis Care
Thursday 15 October 
Hallam Conference Centre, London

Smoking Cessation in Mental Health
Tuesday 20 October 
Hallam Conference Centre, London

Safe Staffing for Nursing in Mental Health Inpatient Units
Monday 16 November 
Hallam Conference Centre, London

Improving the Quality of Perinatal Mental Health Services
Tuesday 1 December 
Hallam Conference Centre, London

Psychological Therapies in the NHS
Wednesday 3 February — Thursday 4 February 
Millennium Conference Centre, London


Download: louise-johns_1085.pdf

1 July 2015

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