Measuring adherence in social recovery therapy with people with first episode psychosis.

BACKGROUND: The SUPEREDEN3 study, a phase II randomized controlled trial, suggests that social recovery therapy (SRT) is useful in improving functional outcomes in people with first episode psychosis. SRT incorporates cognitive behavioural therapy (CBT) techniques with case management and employment support, and therefore has a different emphasis to traditional CBT for psychosis, requiring a new adherence tool. AIMS: This paper describes the SRT adherence checklist and content of the therapy delivered in the SUPEREDEN3 trial, outlining the frequency of SRT techniques and proportion of participants who received a full therapy dose. It was hypothesized that behavioural techniques would be used frequently, consistent with the behavioural emphasis of SRT. METHOD: Research therapists completed an adherence checklist after each therapy session, endorsing elements of SRT present. Data from 1236 therapy sessions were reviewed to determine whether participants received full, partial or no therapy dose. RESULTS: Of the 75 participants randomized to receive SRT, 57.3% received a full dose, 24% a partial dose, and 18.7% received no dose. Behavioural techniques were endorsed in 50.5% of sessions, with cognitive techniques endorsed in 34.9% of sessions. CONCLUSIONS: This report describes an adherence checklist which should be used when delivering SRT in both research and clinical practice. As hypothesized, behavioural techniques were a prominent feature of the SRT delivered in SUPEREDEN3, consistent with the behavioural emphasis of the approach. The use of this adherence tool would be considered essential for anyone delivering SRT looking to ensure adherence to the model.

Feasibility and acceptability of integrated psychological therapy versus treatment as usual for people with bipolar disorder and co-morbid alcohol use: A single blind randomised controlled trial.

BACKGROUND: Alcohol use is a common problem in bipolar disorder (BD) and evidence indicates more promising outcomes for alcohol use than other substances. No trials have evaluated individual integrated motivational interviewing and cognitive behaviour therapy (MI-CBT) for problematic alcohol use in BD. We therefore assessed the feasibility and acceptability of a novel MI-CBT intervention for alcohol use in BD. METHODS: A single blind RCT was conducted to compare MI-CBT plus treatment as usual (TAU) with TAU only. MI-CBT was delivered over 20 sessions with participants followed up at 3, 6, 9 and 12 months post-randomisation. Primary outcomes were the feasibility and acceptability of MI-CBT (recruitment to target, retention to follow-up and therapy, acceptability of therapy and absence of adverse events). We also conducted preliminary analyses of alcohol and mood outcomes (frequency and severity of alcohol use and time to mood relapse). RESULTS: 44 participants were recruited with 75% retention to 6 and 12 months follow-up. Therapy participants attended a mean of 17.6 (SD 4.5) sessions. Therapy alliance and treatment fidelity were acceptable. Qualitative interviews indicated the intervention was experienced as collaborative, and helpful, in addressing mood and alcohol issues, although risk of overconfidence following therapy was also identified. Clinical outcomes did not differ between arms at 12 months follow-up. LIMITATIONS: As a feasibility and acceptability trial any secondary results should be treated with caution. CONCLUSIONS: Integrated MI-CBT is feasible and acceptable, but lack of clinical impact, albeit in a feasibility study, suggests need for further development. Potential adaptations are discussed.

Therapist-client relationships in a psychological therapy trial for psychosis and substance misuse.

BACKGROUND: This study aimed to explore factors associated with outcomes in a randomised controlled trial of integrated motivational interviewing and cognitive behavioural therapy for psychosis and substance misuse. METHOD: Clients and therapists completed self-report measures of alliance and clients completed a self-report measure of adult attachment. Trial therapists were also asked to identify challenges in therapy, client strengths and reasons for client making and not making changes in relation to substance misuse. RESULTS: Neither therapist-rated nor client-rated alliance was significantly related to objective outcomes. Client insecure attachment avoidance was associated with poorer symptoms and functioning at 12 and 24 months; although not changes in substance misuse. Therapists' perceptions of therapeutic processes (e.g., challenges to therapy, client strengths, client reasons for change and alliance) were consistent with previous literature. Therapists' perceptions of client improvement were associated with reductions in substance use at the end of treatment and their ratings of therapeutic alliance. CONCLUSION: Insecure adult attachment styles may be a potentially important predictor of symptom outcomes for people with psychosis and substance misuse. Trial therapists may also provide an important source of information about therapeutic processes and factors associated with outcome.

Assessing fidelity to integrated motivational interviewing and CBT therapy for psychosis and substance use: the MI-CBT fidelity scale (MI-CTS).

BACKGROUND: Guidelines for the psychological treatment of psychosis and substance use suggest integrated treatments to address both problems are necessary. One such treatment combines cognitive-behaviour therapy (CBT) and motivational interviewing (MI). While there are a number of scales to assess treatment fidelity to CBT and MI separately, none, to date, assess fidelity to integrated MI and CBT (MI-CBT) for psychosis and substance use. AIMS: This study aimed to develop a reliable and valid scale to assess fidelity to MI-CBT for people with psychosis and problematic substance use. METHOD: Items for a new scale (the MI-CTS fidelity scale) were selected from multiple relevant sources. Inter-rater reliability and validity (against the CTS-Psy and Motivational Interviewing Treatment Integrity (MITI)) scales were investigated. RESULTS: The scale had good inter-rater reliability when used to rate adherence versus non-adherence. In relation to validity, the scale related well to CBT and MI scales (the CTS-Psy and MITI). CONCLUSIONS: The MI-CTS is useful for assessing adherence to integrated MI-CBT for psychosis and substance misuse and could aid training and implementation of the approach.

Understanding factors influencing substance use in people with recent onset psychosis: A qualitative study.

This qualitative study identifies factors influencing the use of substances in young people with recent onset psychosis. A purposive sample of 19 people aged between 16 and 35 years from an Early Intervention Service in the English National Health Service (NHS) was interviewed using a semi-structured guide. All had experienced a psychotic episode and were within 3 years of first contact with the service. All were either currently misusing substances or had been doing so in the 6 months prior to first contact with the service. All participants were/had been regular cannabis users and for 13(68%) cannabis was the primary drug of use. Thematic analysis identified four key themes in participants accounts of factors influencing their substance abuse: influence of perceived drug norms on behaviour; attributions for initial and ongoing drug-taking behaviour; changes in life goals affecting drug use; beliefs about the links between mental health and drug use. These findings have clear implications for interventions at a number of levels to support young people using substances in early psychosis including public health messages, education and psychological therapies.