Improving access to psychological therapies for people with severe and enduring mental health problems: rehabilitation psychiatrists perspectives Dr Helen Killaspy Reader and honorary consultant in rehabilitation psychiatry, UCL and Camden & Islington NHS FT Chair, Faculty of Rehabilitation and Social Psychiatry, Royal College of Psychiatrists
Drivers of uptake of any intervention Evidence Adjustment Recommended Monitoring Implementation plan Resources
Family interventions and CBT for psychosis Strong evidence base Recommended by NICE, NHS Constitution Monitored by CQC, AIMS, national audit (Rethink/Centre for MH, MIND) Low uptake Implementation plan? Adequate resources? Change management issues?
Mental health rehabilitation services Focus on people with longer term, complex mental health problems Mainly psychosis Treatment resistance, negative symptoms, cognitive impairment, co-morbidities, challenging behaviours Poor social functioning 1% people with scz require inpatient rehab at any time 25-50% total mh budget Low volume, high need group
Rehabilitation Effectiveness for Activities for Life (REAL) Study Phase 1 National survey of inpatient rehabilitation services Eligibility criteria Units that admit patients from acute admission wards, secure services and can take detained patients Response 52/60 (87%) NHS MH Trusts in England in 2009 with >/= 1 inpatient rehab unit
Mental health rehabilitation units in England Unit characteristics 133 units (median 2 per Trust) 75 (59%) community based units 39 (29%) units in hospital grounds 11 (8%) hospital wards Mean 14 (SD 5) beds Service user characteristics 739 (62%) service users interviewed (range per unit = 40-100%) Mean (SD) age 40 (13) years 595 (81%) white 679 (92%) unemployed 511 (73%) scz, 57 (8%) sczaff, 59 (8%) bipolar Median (IQR) length of contact with mh services = 13 (6,22) years Median (IQR) past admissions = 4 (2,9) Median (IQR) length of current admission = 18 (9,46) months Median (IQR) length of current rehab admission = 8 (4,19) months
Staffing N=127 (%) units No access Access outside unit Works in unit Psychiatrist 0 38 (30) 89 (70) Clinical psychologist 21 (17) 65 (51) 41 (32) Occupational therapist 13 (10) 21 (17) 93 (73) Nurse 0 0 127 (100) Support worker 0 0 127 (100) Social worker 27 (21) 93 (73) 7 (6) Volunteer 67 (53) 41 (32) 19 (15) Arts therapist 66 (52) 53 (42) 8 (6) Total mean (SD) staff per unit 21 (6) Mean (SD) staff to service user ratio 1.58 (0.47)
Psychosocial interventions (n= 132 mental health rehabilitation units) Unit manager s estimate Mean (SD) Median (IQR) Number of staff trained in family psychoeducation 1.5 (2.3) 1 (0,2) Number of families receiving psychoeducation 1.0 (2.0) 0 (0,1) % families receiving psychoeducation 10 (21) 0 (0,12) Number of staff trained in CBT for psychosis 1.8 (2.1) 1 (0,3) Number of service users receiving CBT 1.7 (3.1) 0 (0,2) % service users receiving CBT 14 (27) 0 (0,18) Hours per day service users spend doing planned activities % service user who regularly participate in activities on unit % service users who regularly participate in activities in community 4 (1.6) 4 (3,5) 76 (24) 80 (63,100) 70 (31) 75 (47,100)
Rehabilitation psychiatrists perspectives
Experience of psychology input Positive: Higher resourcing (max = 2 FTE Band 7/8 for 16 beds) FI, CBT, supervision Psychometric assessment Consultation on challenging/ stuck cases Psychological input to all SUs Supporting staff in supported accom during transition as SU moves on Less positive: None or very limited psychology time Lack of clarity about the focus of the psychological approach Lack of FI/CBT Working with few SUs, eligibility criteria unclear No training/supervision of team to deliver psychological approaches No psychometric assessments Following discharged patients up for too long Having to make a referral for psychological input
What do you think are the most likely causes of inadequate implementation of Family Interventions and CBT in rehabilitation services? Psychology time Lack of training of other staff Trained staff promoted and leave Lack of supervision of trained staff Innovation fatigue SU motivation, engagement, cognitive ability, already had CBT Poor match between SU readiness and psychologist availability Not all SUs suitable no one size fits all Professional tensions who owns psychological interventions? Other staff prioritise other duties
What would you would like from your team s psychologist? Work in some way with all SUs direct delivery of FI/CBT or training and supervision of other staff in pre-engagement and other, relevant work (relapse prevention, behavioural management, activity planning) Occasional psychometric assessments Lead reflective practice group/team care planning re. SUs who are challenging/stuck More involvement in risk assessment and risk management plans
What would you be willing for your psychologist to drop in order to have more time for FI/CBT? Longer term follow-up post-discharge Taking SUs out on shopping trips Less focus on FI/CBT and more on training and supervision of rest of team in delivering psychoeducation, relapse prevention, managing challenging behaviour etc
Reasons to improve delivery of psychological interventions in rehabilitation settings SU group with highest level of needs and where first line medications are not enough to facilitate discharge Time SUs have long length of stay, 1 admission per month on average Rewarding facilitating positive outcomes for SUs who are seen as difficult by other teams Staff Low turnover Therapeutic optimism Under trained and somewhat overlooked Willing resource pool, need support
Suggestions for improving access to psychological interventions in rehabilitation settings Stop having referral systems Stop doing thing other team members tasks Assess all SUs on admission to guide intervention focus Train and supervise other staff: psychoeducation, relapse prevention, managing symptoms, anxiety management etc Facilitate some SU groups as above Facilitate reflective staff groups Occasional psychometric assessment where indicated Potentially train, but definitely supervise other staff trained in delivering FI and CBT Deliver CBT and FI to manageable number of SUs who are at point in recovery where they can use it for limited number of sessions
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