Community Implementation Successes and Challenges of a Cognitive-Behavior Therapy Group for Individuals with a First Episode of Psychosis

Article (PDF Available)inJournal of Contemporary Psychotherapy 36(1):51-58 · March 2006with76 Reads
DOI: 10.1007/s10879-005-9006-5
Abstract
CBT for psychosis has recently been called a best practice, suggesting that studies have demonstrated its efficacy with many populations. Community settings are encouraged to implement best practices such as CBT yet many factors can make the implementation of CBT challenging. Issues such as clinician resistance, setting, as well as client variables (refusal, denial of symptoms, etc.) come into play. Examples of successes and challenges of a community based study of CBT groups for first episodes will be described. The strategies used to overcome these challenges and the successes of the program will be presented.
Journal of Contemporary Psychotherapy (
C
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2006)
DOI: 10.1007/s10879-005-9006-5
Community Implementation Successes and Challenges of a Cognitive-Behavior
Therapy Group for Individuals with a First Episode of Psychosis
Alicia Spidel,
1
Tania Lecomte,
2,4
and Claude Leclerc
3
CBT for psychosis has recently been called a best practice, suggesting that studies have demonstrated
its efficacy with many populations. Community settings are encouraged to implement best practices
such as CBT yet many factors can make the implementation of CBT challenging. Issues such as
clinician resistance, setting, as well as client variables (refusal, denial of symptoms, etc.) come into
play. Examples of successes and challenges of a community based study of CBT groups for first
episodes will be described. The strategies used to overcome these challenges and the successes of the
program will be presented.
KEY WORDS: schizophrenia; CBT; first episodes; implementation.
The past few years have seen major progress regarding
the treatment of severe mental illness. Of these promis-
ing treatments Cognitive Behavioral Therapy (CBT) has
been recommended as a best practice for individuals with
psychosis by the American Psychological Association’s
Task Force on Severe Mental Illness (2004) as well as the
American Psychiatric Association (Lehman et al., 2004).
CBT for psychosis has been found to be effective with
many types of individuals with psychosis, particularly
with individual suffering from persistent psychotic symp-
toms (Gould & Mueser, 2001; Pilling et al., 2002) but
also with inpatients (Drury, Birchwood, Cochrane, and
Macmillan 1996), first episodes of psychosis (Lecomte,
Leclerc, Wykes, and Lecomte, 2003; Tarrier et al., 2004),
and more geriatric populations (Granholm, McQuaid,
McClure, Pedrelli, & Jeste, 2002). Though many ques-
tions remain unanswered regarding the effective ingre-
1
Department of Psychology, University of British Columbia, Vancouver,
BC, Canada.
2
Department of Psychiatry, University of British Columbia, Vancouver,
BC, Canada.
3
Department of Nursing, University of Quebec at Trois-Rivieres,
Canada.
4
Address correspondence to Tania Lecomte, Ph.D., Assistant Profes-
sor of Psychiatry, University of British Columbia, 828 West 10th Av-
enue, Room 214, Vancouver, BC, V5Z 1L8, Canada; e-mail: lecomte@
interchange.ubc.ca.
dients of this therapy and who benefits most from it
(Lecomte & Lecomte, 2002), the existing studies all re-
port positive results, either in terms of decreased positive
symptoms, diminished distress, or improved social out-
comes. As a result, the implementation of CBT in com-
munity settings is greatly encouraged by leaders in the
field. However, many reasons seem to explain why CBT
for psychosis has yet to be implemented in many com-
munity settings. For starters, many settings still do not
offer most widely accepted evidenced based treatments,
such as integrated dual disorder treatments, supported em-
ployment programs, or assertive community treatments
(Aarons, 2004; Hoagwood & Olin, 2002). There are many
reasons for this, which includes local laws, administrative
policies, funding priorities, advocates’ concerns and pro-
gram staffing (Corrigan, Steiner, McCracken, Blaser, &
Barr, 2001). Although many of these reasons are beyond
the control of individual community settings, others –such
as service providers’ resistance to implementation—can
be targeted. It is these types of implementation issues that
will be discussed here. This paper will describe the suc-
cesses and challenges related to implementing CBT for
psychosis in the community in order to facilitate a dia-
logue about this issue, bridge the gap between research
and practice, and provide health care providers with some
insight regarding our experiences in implementing group
0022-0116/06
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2006 Springer-Verlag
Spidel, Lecomte, and Leclerc
CBT for individuals with a first episode of psychosis. We
will show that despite the challenges of implementing this
treatment, many successes can be found.
CBT FOR FIRST EPISODES
It is standard practice following the appearance of psy-
chotic symptoms that antipsychotic medication is pre-
scribed to reduce symptom severity (Favre, Huguelet, &
Vogel, 1997). This practice, though widespread and rec-
ommended (McGlashan, 1996; Sheitman, Lee, Strauss,
Lieberman, 1997), does not guarantee full remission nor
prevention of relapse. As such, recently, researchers and
clinicians have begun to agree about the benefits of early
intervention tailored to the needs of people presenting with
psychosis (McGorry, 2005). In fact, many reasons sup-
port the need for psychosocial interventions in addition to
antipsychotic medication in order to diminish symptoms
and prevent relapse, particularly for first episodes. First,
optimal antipsychotic treatment for young people pre-
senting with a first episode is very difficult to achieve be-
cause more than 50% abandon their medication in the first
year of treatment (Kasper, 1999), and those who continue
take on average 58% of the prescribed dose (Cramer &
Rosenheck, 1998), often because of distressing side ef-
fects or because the treatment is not perceived as ef-
fective (Sheitman et al., 1997). Second, further episodes
may lead to increasing treatment resistance. Birchwood
and Spencer (2001) describe two studies where clients’
symptoms become less responsive to medication follow-
ing successive relapses; in some cases, residual symp-
toms appeared that were not present prior to relapse.
Third, a first episode typically occurs during adolescence
or early adulthood, a period during which the person’s
sense of identity and belonging can be shattered by the
psychotic experience, leading to social withdrawal or
substance abuse (Linszen, Dingemans & Nugter, 1997;
Morrison, Bowe & Larkin, 1999). Fourth, these types of
interventions may reduce illness chronicity and help the
client maintain an active and satisfying community life
(McGlashan, 1996; Sheitman et al., 1997) which is criti-
cal for first episodes. Treatment by medication alone does
not address these difficulties (Aguilar, Haas & Manzanera,
1997). As such, the use of a supplementary psychologi-
cal treatment, such as CBT with individuals presenting
with a first psychotic episode is recommended, with the
aim of helping the patient to understand the experience
of psychosis, avoiding isolation, diminishing symptoms
and preventing relapse. A randomized controlled trial was
therefore designed, and funded, in order to determine if a
tailored CBT intervention for first episodes would prove
more useful to these clients in terms of symptomatic re-
duction and other psychosocial outcomes than existing
skills training for symptom management. The preliminary
results of the CBT group were highly encouraging, with
important drops in delusions and conviction of beliefs and
increased self-esteem (Lecomte et al., 2003), and led mul-
tiple clinical sites from various countries to ask for copies
of the manualized intervention in order to implement it as
well.
One thing that has not been discussed in great detail in
previous studies or papers that encourage the use of CBT
for those with psychosis are implementation issues that
are encountered when trying to set-up CBT group treat-
ment in the community with those that have had a first
episode of psychosis. In the papers that do address these
issues it has been noted that despite the millions of dollars
and significant time spent to develop and evaluate treat-
ments for people with mental illness the service providers
are, at times, several years behind the research in actu-
ally implementing these strategies (Corrigan et al., 2001).
Many factors have been found to influence this relation-
ship. Several are pertinent here, particularly in the mental
health system that exists in Canada. In fact, many suc-
cesses and challenges were encountered when attempting
to implement and run the groups. These can be categorised
as 3 main areas: (1) the setting; (2) the clients; and (3) the
therapists. All of these will be described as many fac-
tors including the patient and system of care have been
found to affect treatment early in the course of psychosis
(Compton, 2005).
CHALLENGES IN IMPLEMENTING CBT FOR
FIRST EPISODES IN THE COMMUNITY
Setting
One of our biggest challenges was related to the setting.
The groups that we ran took place in primarily an urban
setting as we were collaborating with a first episode clinic
there. In order to get enough clients willing to participate
at the same time we had to recruit from many suburbs
around the city that were sometimes far away from each
other. In addition buses did not generally travel from one
suburb to the other. Therefore, they would have to go to
the city first and then back out to the location of the group.
If the bus did travel directly from their home suburb to
the other suburb where the group was, they were still
infrequent and as such missing the bus meant missing the
group. Some of the clients had cars which made things
easier but parking was often expensive.
Community Implementation Successes and Challenges of a Cognitive-Behavior Therapy Group
Another problem with the setting was finding a time and
day of the week that worked for all the people interested
in joining the group as well as the therapists. Many of
the clients had school or work at least part-time and this
affected when they were available. Other problems we
encountered were holidays and summer. As the groups
ran for three months twice a week, we frequently ran
into conflicts at some point in the group with the clients
having family vacations etc. In addition summer proved to
be particularly challenging since during the nice weather
clients frequently found other activities more appealing
or had trouble concentrating.
Finding an appropriate group location also proved to be
a problem. Many clients did not wish to go to a hospital
for the groups either because it recalled traumatic mem-
ories of their hospitalization or they feared the stigma of
“mentally ill” associated with the setting. As group spaces
were scarce and the hospital setting was sometimes the
only place that was available for the groups, a couple of
clients had to wait for the next groups to start in a differ-
ent location. Another related problem was finding a group
room that was warm, comfortable and made clients feel at
ease. Some of the rooms we were shown were dark with
no windows, uncomfortable chairs and were really more
like a lab space than a group room. It was also difficult
to reserve in advance a group room since we often did
not know until all the clients were signed up when the
group would start because we tried to accommodate the
clients’ schedules. As a result this created a last minute
scrambling in several cases to find a place to run the group
that was acceptable for all.
Clients
Other challenges related to running the groups per-
tained to the clients themselves. Some clients were partic-
ularly hard to engage for a variety of reasons. For instance,
the maturity level (or lack thereof), was sometimes an is-
sue. Although the clients were on average 22, some of
them were less mature than the average 22 year old and
would either not truly commit to the group by often miss-
ing sessions, being late, showing up in an intoxicated state,
or only wished to socialize rather than discuss the sched-
uled themes. Another problem was that of pressure from
the family or members of the treatment team for someone
to participate in the group. As such, in some cases they
attended but were either resistant or difficult to engage
as a result. Other clients were hard to engage for other
reasons. In some cases they were in denial of symptoms
or their illness and did not believe that they suffered from
psychosis. Still others had significant drug problems that
at times made them resistant to considering changes in
their beliefs or behaviours.
In addition to these problems they were general prob-
lems relating to clients that are typical to most group inter-
ventions (Yalom, 1995). These included getting everyone
to participate and at times getting them to allow others to
participate. Some clients had certain personality disorders
(i.e. borderline personality disorder) that made handling
the group more challenging, particularly in keeping every-
one focused on the theme of the day for instance. Other
clients had social phobias, obsessive-compulsive disorder,
or paranoid ideas about others –as well as other psychotic
symptoms such as continuous voices– which made par-
ticipating in the group difficult for them. In one case a
client began attending two different groups but was too
socially anxious to continue and she had to withdraw from
the group. Another challenge was that many clients have
cognitive deficits such as memory and attention problems
(Green, Kern, Braff, & Mintz, 2000). As such, for cer-
tain individuals, the therapists had to phone them prior
to every session to remind them to attend and constantly
remind them to complete the assigned homeworks. For a
few clients, medication side-effects included drowsiness,
which would sometimes result in their falling asleep dur-
ing the group or being unable to stay focused.
Motivation was also sometimes an issue for the clients.
Although most of the people in the group were truly mo-
tivated to get help and really enjoyed the group and the
social interaction, for a few clients their motivation would
sometimes come and go. For these clients their motivation
would depend on their mood, whether the topic was of in-
terest to them or whether the issues were focused on them.
Motivation could in fact largely be linked to the alliance
between the group participants and therapists (Lecomte
& Lecomte, 2002) as well as the expectancies of getting
something positive out of the group experience (Hoffman,
Kupper, & Kunz, 2000). Lack of insight into one’s illness
is often mentioned as a barrier to motivation (Ghaemi &
Pope, 1994) but has not been a barrier to participating
once in the group, but was rather a reason for refusing to
take part in the CBT group altogether.
Therapists/Organizations
In some cases there were also challenges related to
the therapists or the organization in which the therapist
worked. This may have been one of the most difficult
challenges to overcome and is not surprising given that
attitude of both the clinicians and the organizations in
which they work have been found to be one of the most
common reasons of lack of new services being provided
Spidel, Lecomte, and Leclerc
to clients (Aarons, 2004; Compton, 2005; Corrigan et al.,
2001; Moser, DeLuca, & Bond, 2004; Mueser, Torrey,
Lynde, Singer, Drake, 2003). Resistance to implement-
ing a treatment can be linked to the individual service
providers’ lack of skills and knowledge about the new
treatment, a belief that the new treatment is unneeded in
clinical practice, or that certain organizational dynamics
do not allow these innovative approaches to be imple-
mented (Corrigan et al., 2001; Stirman, Crits-Christoph,
& DeRubeis, 2004). All of these reasons for resistance
were met in the course of our study.
For instance, one of the biggest challenges in terms of
therapists was that some clinicians would be unwilling to
refer clients as they felt that their clients were still psy-
chotic and the group could be too much stress for the
clients who still experienced symptoms. Despite the fact
that, as mentioned above, the groups were meant for peo-
ple still suffering from psychotic symptoms and studies
have demonstrated to be very effective and beneficial to
the clients and despite the fact that we gave this informa-
tion to the clinicians, some were still unwilling to refer
clients. Also, as found in previous studies (Moser et al.,
2004) some therapists felt that the clients were too sick
to benefit from the treatment. Furthermore, some clini-
cians had an issue with the CBT therapy philosophy and
thought that it was best not to address psychotic symp-
toms directly and therefore did not want to refer clients to
the group. Others believed they were already doing CBT
with their clients (though their refusal to hear their clients’
beliefs and telling them what “reality” was contradictory
to the CBT philosophy) and therefore didn’t think they
needed another treatment. As a result, their attitudes to-
wards the treatment resulted in their clients not benefiting
from this new treatment, a problem that has been found in
many studies and reports on implementing new treatments
(Aarons, 2004).
Another problem was that some clinicians were less
willing to work with clients who had drug problems or
criminal records. Although these were not exclusion cri-
teria some clinicians who were running the groups did
not want these clients in their groups or want to make
other clinicians work with them. They felt that these in-
dividuals were either to difficult to deal with or would
disrupt the group too much. Since more than 75% of first
episodes are said to abuse drugs or alcohol (Linszen et al.,
1997), and close to 30% have had dealings with the law
(Spidel, Lecomte & Yuille, 2005), As a result they did
not refer these clients to the groups. All of these variables
that the therapists reported as reasons for not wanting to
refer clients may be related to other factors. For example
it has been found that job burnout is an important factor
to consider when attempting implementing new treatment
strategies as it results in undermining some staffs inter-
est in new treatments (Corrigan et al., 2001). Job burnout
is also related to many other factors that can impact the
success of new treatments being implemented including:
diminished collegial support; feeling emotional overex-
tended; and feelings of incompetence (Corrigan et al.,
2001). This is a large problem as the implementation
of many evidence-based practices necessitates the coor-
dinated efforts of the treatment team. This brings us to
problems related to the therapists’ organization.
In trying to implement the current treatments, there
were also some problems related to the therapist’s orga-
nization. As a matter of fact Corrigan et al. (2001) found
that many factors related to an organization can influence
a teams’ or therapists’ ability to implement new treat-
ments, such as: poor leadership, a climate that is adverse
to change, insufficient collegial support, and bureaucratic
constraints. A few of the clinics were unwilling to free
up the clinicians’ time from their regular caseload so that
they would be able to prepare and run the groups. Al-
though the clinicians were willing to run a group and
wanted their clients to get the therapeutic benefit of the
treatment, many mental health clinics made it difficult for
them to participate. This may be a result of a number of
factors mentioned above as barriers in the Corrigan et al.’s
(2001) study. As a result, in some cases we had to pay
for a replacement therapist (since the person running the
group could not have as big an individual caseload) even
though the research team was already paying for train-
ing the therapists and offering our own co-therapists. This
lack of support, as mentioned before, can lead to demor-
alization and job burnout (which in fact happened in one
instance), which creates a vicious cycle within the orga-
nization resulting in an inability to implement innovative
treatments.
Perhaps one of the greatest challenges to our groups
came from competing groups. As this project took place
in an area that already had several groups in place for
the clients, there was some resistance from the people
running the other groups. Although this group was com-
pletely different than the ones that were currently running
(which were mostly psychoeducational or family groups)
some of the individuals that were in charge of the other
groups seemed to be threatened by our presence and even
attempted to discourage clients from attending. This has
been found in different areas as in some sites staff ei-
ther felt that they were providing many of the elements
of the treatment or feared being negatively compared to
our group, and were therefore resistant to the new models
(Moser et al., 2004). Although the clients would have ben-
efited from participation in both groups these therapists
felt that they should only attend one or the other and that
Community Implementation Successes and Challenges of a Cognitive-Behavior Therapy Group
it should be their group. This was very difficult to deal
with as some of these clinicians tried to veto our group by
blocking referrals from other clinicians or by giving neg-
ative descriptions of our group to the parents of potential
clients who were asking about it. Despite all these difficul-
ties, on a more positive note, there were many successes
with the groups that we experienced.
SUCCESSES IN IMPLEMENTING CBT FOR
FIRST EPISODES IN THE COMMUNITY
Setting
Some of the successes were directly related to the set-
ting. Despite all the problems mentioned above we did
manage to get everyone to groups! This was accomplished
using a variety of techniques. In some cases clients would
car pool together taking turns driving. Other times we
would pick up the clients ourselves and bring them to
the group. We also gave clients free bus tickets and free
parking to make it a bit more desirable to attend the group
and to alleviate any financial barriers to their attending
the groups. In addition, we managed, in several cases to
get the parents involved to bring the clients to the groups.
As a result of this technique, in some settings an informal
parent group started in the waiting room, where parents
could share with each other their experiences, concerns,
and successful strategies. The ability to involve the par-
ents in treatment of the clients is of particular importance
as it has been found that good family support is an impor-
tant facilitator in outpatient treatment (Compton, 2005;
McGorry, 2004). In terms of schedules we did our best to
accommodate clients’ schedules and managed to not have
anyone excluded due to schedule conflicts. This was quite
an achievement considering the varying schedules that we
were working with.
Clients
There were other successes in the group related to
the clients themselves. For one the retention rates in our
groups were 75%, which was great given the targeted pop-
ulation that we were working with and some of the chal-
lenges mentioned above. In addition many of the clients
developed friendships with one another that lasted above
and beyond the group’s termination. Furthermore, as men-
tioned above, the preliminary results were positive with
significant decreases in overall symptomatology, halluci-
nations, delusions, and conviction in irrational beliefs, as
well as increases in self-esteem (Lecomte et al., 2003).
As indicated on the clients’ comments following the last
group session, the clients stated that they enjoyed and ben-
efited from the groups in multiple ways. When asked how
your situation has changed since coming to the groups
some of the answers included: “I know myself better; I
deal better with stress; I look for alternatives for my be-
liefs; I am in a better situation and I have noticed I am
doing well and don’t worry about the past; I was able to
preserve my health using the stress vulnerability model;
I feel better able to deal with problems; and I feel better
about myself in general. These results further support the
usefulness of a group CBT intervention, particularly for
first episodes. One thing that the participants found partic-
ularly useful was the manual itself. Though not mentioned
in most studies, the use of manuals can greatly improve
participants’ attendance and help diminish fears linked to
the group by allowing participants to anticipate what will
be addressed in the group. Thus, the manual was not only
a source of information that one could go back to when-
ever needed once the group was finished, but also served
as a type of reassuring contract between the therapists and
the group members ensuring that the content of each ses-
sion could not be changed from what was written in the
manual. Each participant was given a copy of the manual
at the first session.
Typically, CBT is offered in individual therapy, once
or twice a week for up to nine months (Lecomte &
Bentall, 2004). However, this format is not mandatory
in order to obtain positive results. Other studies have also
demonstrated positive results. Wykes, Parr and Landau
(1999) showed a significant decrease in hallucinations
and an increase in self-esteem in individuals presenting
a first episode of schizophrenia after only six weeks of
CBT in group format. Lecomte, Cyr, and Lesage (1999)
and Leclerc, Lesage, & Ricard (2000) also obtained sig-
nificant results on positive symptoms after an intensive
24 meetings group, using some CBT principles. Levine,
Barak, and Granek (1998) significantly decreased delu-
sions in participants with paranoid schizophrenia after
only six CBT group meetings, using cognitive disso-
nance. Moreover, the group format increases socialization
by helping clients meet others who have similar issues
and see that they are not alone. In addition, schizophre-
nia and psychosis being highly stigmatized, a group set-
ting gives people a chance to make new friends and feel
less alienated. It is important to realize the groups are
not simply run by therapists but are in fact led in great
part by the clients themselves, who by speaking of their
own experiences offer each other alternatives for each
other’s irrational beliefs and ways to seek facts to dis-
prove some distressful thoughts. For some clients, knowl-
edge that comes from others their own age and peers can
Spidel, Lecomte, and Leclerc
have more impact than if it came from a mental health
professional.
Therapists/organization
Another area where they were successes was in terms of
the therapists. Although it is generally believed that those
who provide CBT need to be highly skilled, Durham and
colleagues (2004) found that clinicians, such as nurses,
who are trained in real world conditions, can use this
approach. Several authors have noted that to implement
successful treatment, training needs to be comprehensive
and take into account the practitioners that require train-
ing (Moser, DeLuca, Bond, & Rollins, 2004). The lack of
knowledge and skills by clinicians that is required to as-
similate the implementation of evidence-based practices
such as CBT has been found to be one the biggest obsta-
cles to it’s incorporation into the regular treatment within
clinics (Corrigan et al., 2001). In order to overcome this
obstacle, the group CBT intervention was manualized and
clinicians interested in offering the groups were trained
in using the manual and in following the CBT philosophy
(see Lecomte et al., 2003 and Lecomte & Bentall, 2004,
for details). For example, in order to create a collabo-
rative relationship, facilitate normalization and avoid the
expert-therapist model, the manual describes the themes
of each session with open-ended questions that both ther-
apists and clients respond to together. The CBT concepts
have also been simplified so that participants, both ther-
apists and clients, can easily understand and apply them.
The use of manuals has been found to be an important
factor in making evidence-based practices more likely to
be used and implemented by staff (Corrigan et al., 2001;
Stirman et al., 2004). In addition, in order to ensure that
manuals are used by the health care providers, they must
be user friendly and not use jargon and principles that
are familiar only to those in academic settings (Corrigan
et al., 2001). In the context of our study, each group was
therefore run by two novice therapists –in terms of CBT
for psychosis—one hired as part of the research team
and the other being part of a community mental health
team. Both therapists were closely supervised by one of
the study’s investigators (T.L. or C.L.) as all the sessions
were videotapes and rated by two independent research
assistants for treatment fidelity. We were able to train all
of the co-therapists in two days with an average of 80%
fidelity rating for each session according to Young and
Beck CBT fidelity scale (1980). This demonstrated that
this type of training could be given to clinicians from
various professional backgrounds successfully and with
little time commitment, making it a very cost effective
treatment strategy. In fact, many opponents of the CBT
for psychosis approach cite the length of training needed
to become competent and the lack of funds to hire CBT-
trained psychologists as a reason to not implement CBT
for psychosis. In addition the clinicians reported that they
were able to feel competent in running the group, which
was in part because the group utilised a structured man-
ual for the clinicians and a workbook for the clients. One
of the reasons for the success of our treatment program
seemed to stem from the user friendly manual as those
who used them expressed satisfaction with its structure
and content.
Another success was the ability to gain clinicians’ en-
thusiasm. After hearing about the groups or seeing its
impact on their clients, many clinicians asked to receive
training in the group CBT approach and many asked to run
a group themselves. One clinician ran two CBT groups, as
she was so enthusiastic after the first one. This is crucial as
it has been found that “an optimistic attitude on the part of
health professionals is an essential ingredient” (McGorry,
2004) for therapy to be effective, regardless of the change
of the illness. During the course of the study, any mental
health clinic that referred clients to the study would re-
ceive free training in the approach for all of its interested
clinicians at the end of the study. However, many mental
health clinics wished to get trained before the end of the
study and therefore contracted the trainers (T.L. & C.L.)
to give the CBT training, as long as clinicians wouldn’t
interfere with the study (i.e. not target first episodes). Var-
ious mental health workers, namely psychologists, psy-
chiatric nurses, social workers, occupational therapists,
and even some psychiatrists received a three-day group
CBT training. Not surprisingly, the mental health teams
who expressed the most enthusiasm regarding the CBT
training were also the ones who quickly conducted a CBT
group, who were most open to the study and who referred
the most clients. Though most team directors also received
the training, those who were most resistant to the approach
also made it the most difficult for anyone in their team to
run a group and would most likely have benefited from
more gradual and varied dissemination strategies (Mueser
et al., 2003; Stirman et al., 2004). As such, simply by as-
sessing the team director’s attitude and the presence or
not of a champion in the mental health team, it is possible
to predict which settings will continue conducting CBT
groups and those that will probably never run a single one.
In conclusion, in this paper we wished to demonstrate
some of the issues in play when trying to implement an
evidenced-based practice such as CBT for psychosis in
the community. Though the implementation was linked to
a study, most of the successes and challenges met are gen-
eralizable to other settings without a research component.
Despite the many challenges faced we found that group
Community Implementation Successes and Challenges of a Cognitive-Behavior Therapy Group
CBT for first episode clients is possible even when un-
dertaken in non-urban settings. Moreover, those who par-
ticipated (both the clinicians and the clients) enjoyed the
groups and found it beneficial as has been shown by both
the quantitative and qualitative findings presented earlier.
In addition many clinicians learned new techniques and
a new treatment philosophy and it is hoped that they will
continue to run groups independently at their respective
clinics. Lastly and perhaps most importantly we found
that most challenges can be overcome with creativity and
by garnering support from those involved with the clients
be it the families or treatment teams. As mentioned by sev-
eral authors (Corrigan et al., 2001; Mueser et al., 2003;
Stirman et al., 2004), the successful implementation and
dissemination of best practices such as CBT for psychosis
rely on multiple factors, both individual and systemic, all
of which needing to be addressed properly if one wishes
for the treatment to be more than a transient fad.
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    • "There is some literature that looks specifically at first episodes. What is known with first episode and treatment adherence is that less than 50% take their medication as prescribed (Birchwood & Spencer, 2001) and less than one-third engage in relapse prevention treatments (Spidel, Lecomte, & Leclerc, 2006). The problem is particularly severe in the case of first episode clients since the absence of treatment adherence , psychosocial and pharmacological, can lead not only to relapses but also to more severe symptoms, violence, heightened suicidal risks and increased risk for homelessness and drug overdoses (McGlashan, 1996; Pepper & Ryglewicz, 1984). "
    [Show abstract] [Hide abstract] ABSTRACT: In predicting treatment compliance in individuals with severe mental illness, research has focused on variables such as substance abuse, personality, history of child abuse, and symptomatology, although these relationships have not been investigated in great detail in individuals at the onset of mental illness. To better understand these correlates of treatment compliance, two samples were examined: a sample of 117 individuals presenting with a first episode of psychosis and a more chronic forensic sample of 65 participants recruited from a psychiatric hospital. These samples were investigated for service engagement in terms of violence history, substance abuse, symptom severity, psychopathic traits and history of childhood abuse. Linear regressions performed for the first episode sample revealed that childhood physical abuse was the strongest predictor of poor service engagement, followed by problems with alcohol, a history of physical violence, any history of violence and higher psychopathic traits. Linear regression revealed for the forensic group that a lower level of service engagement was most strongly predicted by a history of childhood abuse and a higher score on the Brief Psychiatric Rating Scale (BPRS). Results are presented in light of the existing literature and clinical implications are discussed. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Feb 2015
    • "There is some literature that looks specifically at first episodes. What is known with first episode and treatment adherence is that less than 50% take their medication as prescribed (Birchwood & Spencer, 2001) and less than one-third engage in relapse prevention treatments (Spidel, Lecomte, & Leclerc, 2006). The problem is particularly severe in the case of first episode clients since the absence of treatment adherence , psychosocial and pharmacological, can lead not only to relapses but also to more severe symptoms, violence, heightened suicidal risks and increased risk for homelessness and drug overdoses (McGlashan, 1996; Pepper & Ryglewicz, 1984). "
    Full-text · Article · Jan 2015 · International Journal of Law and Psychiatry
    • "Unfortunately, only 14 participants answered the interview at each follow-up, resulting in insufficient statistical power to compare quantitative data at follow-ups 1 and 2. Although significant attrition rates are somewhat typical of this clientele (Spidel, Lecomte, & Leclerc, 2006), we wonder if people who dropped out of the study or who refused to receive services would have shown different paths of recovery. Furthermore, 9 months is a relatively short period of time to capture the process of recovery and we did not control for the duration of untreated psychosis. "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives This study sought to explore the links between recovery stages, symptoms, function, and narrative development among individuals with a recent onset of psychosis.DesignA qualitative longitudinal study was conducted including quantitative data at baseline.Methods Forty-seven participants were administered the Indiana Psychiatric Illness Interview three times over 9 months and content analysis was performed. Participants also completed the Social Functioning Scale, the Brief Psychiatric Rating Scale – Expanded, the California Verbal Learning Test, and the Trailing Making Test at baseline. Descriptive discriminant analysis was performed.ResultsResults suggested that participants were mostly in the first two stages of recovery (moratorium, awareness) and that being in the awareness, rather than moratorium, stage was associated, to a different extent, with richer narrative development, better levels of psychosocial function, less negative and positive symptoms, and more years of education. Furthermore, recovery appeared to be a stable process over the assessment period.Conclusions Recovery is a complex concept including objective and subjective aspects. In the recovery path of persons recently diagnosed with psychosis, social engagement, narrative development, and occupational functioning seem to be particularly important aspects. This study is a first step, and future research is needed with larger and more diverse participant pools, and assessments conducted over longer periods of time.Practitioner pointsAs greater level of social engagement was the most robust predictor of membership in the awareness versus moratorium stage, treatment of early psychosis should include interventions targeting social relations and social skills.As greater narrative development was the second most robust predictor, enhancing it via psychotherapy could be a pertinent clinical goal.
    Full-text · Article · Aug 2014
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