Work

Training Community Mental Health Agencies in Cognitive Therapy for Schizophrenia.

Year: 2012

Type: article

Abstract: Based on the demonstrated effectiveness of Cognitive Therapy (CT) with patients with schizophrenia (Pilling, et al., 2002) CT has been included in good practice guidelines for the treatment of schizophrenia in both the UK and the US (APA, 2004; NICE, 2002). Despite these guidelines, and in the face of growing evidence (Gaudiano, 2005; Grant, Huh, Perivoliotis, Stolar, & Beck, 2011) Jones (2002) describes a “scarcity of trained professionals able to deliver CT for psychosis”. In addition, Mueser and Noordsy (2005) present a “call to action” for clinical psychologists in the US to design training programs in CT for mental health professionals working with schizophrenia and other severe mental illness. The dissemination of evidence-based psychosocial treatments (EBTs), the theme for the 2011 ABCT conference has gained much ground in the last ten years, albeit haphazardly (McHugh & Barlow, 2010). Dissemination research shows us that workshops and one-time trainings do not provide sustained change in clinician practice to the suggested degree of competence and fidelity (Miller, Yahne, Moyers, Pirritano, & Martinez, 2004; Sholomskas, et al., 2005). It has also provided us with models for training community-based clinicians that include strategies to facilitate implementation (Stirman, et al., 2010); Kauth, et al., 2010). Although CT for schizophrenia may be different to CT for other types of disorders in some respects (Nelson, 2005) it is important that we refrain from reinventing the wheel in our training efforts, as we push forward with this very necessary work. However, in our dissemination efforts, it is also vital to consider what is different in CT for schizophrenia, and one of the primary differences is how and by whom services are delivered. People with schizophrenia often receive therapeutic intervention in inpatient, partial hospital or community based therapeutic settings, and this intervention is rarely limited to one-to-one therapy. Master’s level therapists may be available, but interventions are also provided by bachelor’s level or peer support workers. Of paramount relevance here is the therapeutic milieu, and considering how CT for schizophrenia can be utilized at this level. Furthermore, direct therapeutic interventions may only be on a group basis. How to train clinicians to deliver CT for schizophrenia in a group format is also crucial. Empathy has been highlighted repeatedly to be of central importance to therapeutic engagement (Reynolds, Scott, & Jessiman, 1999) and is routinely cited to be crucial in the psychological treatment of schizophrenia (Kingdon & Turkington, 1994; Nelson, 2005). However, another key difference in CT for schizophrenia is that empathy may not be profuse. McLeod, Deane and Hogbin (2002) suggest that attitudinal factors (such as beliefs that schizophrenia cannot be successfully treated or that working with people with schizophrenia will impede career prospects and job satisfaction), could inhibit empathy. This research also highlights the potential for a lack of empathy due to clinicians’ lack of personal experience of psychotic symptoms. A second fundamental skill for working with schizophrenia from a cognitive behavioral perspective is that of “suspending disbelief” or “working within the patient’s belief system” (Nelson, 2005). Again this is subtly different to standard CT and clinicians who have some previous knowledge of CT often misunderstand the cognitive aspect of intervention in relation to schizophrenia, thinking that the primary objective is to change or challenge the person’s delusional beliefs. Others who have been trained that one must not collude with delusions to avoid strengthening them, often extrapolate that one cannot talk about delusions at all. Helping clinicians to understand the concept of working within a delusional belief system, as a middle ground between these two alternatives, is vital. In 2007, the Beck Initiative, a partnership between the University of Pennsylvania and the city of Philadelphia’s Department of Behavioral Health and Mental Retardation (Stirman, Buchhofer, McLaulin, Evans, & Beck, 2009), was formed to provide training in CT to providers in the Philadelphia community mental health system. As part of this initiative, a specific training in CT for schizophrenia for staff in a Recovery oriented, partial hospital program was designed. Staff at all levels of the organization (peer support, bachelor’s, master’s) were involved in training, which focused on group based interventions and the general therapeutic milieu, with a particular emphasis on improving empathy and working within a patient’s belief system. This paper presents details of the development of the training, according to the ACCESS model: assess and adapt, convey basics, consult, evaluate work samples, study outcomes, sustain (Stirman et al., 2010). It will highlight elements of this model that are particularly relevant to CT for schizophrenia and provide details of specific components of the didactic and consultation elements, to provide ideas and guidance for future dissemination of CT for schizophrenia.

Source: PubMed

Authors: Sally E Riggs, Shannon Wiltsey-Stirman, Aaron T Beck

Institutions: Kings County Hospital Center, Boston University, VA Boston Healthcare System, National Center for Post Traumatic Stress Disorder, University of Pennsylvania

Language: English

Topic: Schizophrenia research and treatment

Subfield: Psychiatry and Mental health

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: green

Funder: National Institute of Mental Health

Awards: Influences on the Sustainability of Evidence-Based Psychotherapies, Influences on the Sustainability of Evidence-Based Psychotherapies