A process evaluation to determine the barriers and facilitators to implementation of a cognitive behavioural therapy for psychosis treatment programme in a high secure setting

Abstract

Aims Up to 80% of patients in a high secure hospital in Scotland have a diagnosis of schizophrenia or other psychosis. However, despite limitations in delivering cognitive behavioural therapy for psychosis (CBTp) in forensic settings, clinical guidelines continue to recommend that all patients who experience persisting psychotic symptoms and /or depression, or who are in remission, should receive CBTp. A process evaluation was therefore conducted to understand the barriers and facilitators to delivering a bespoke forensic CBTp intervention in this setting.

Method The study had three distinct phases. Phase 1 was a retrospective review of case notes (n=60); Phase 2 involved interviews with therapists (n=9) who were providing CBTp, and Phase 3 was a Delphi survey of experts informed by phases 1 and 2.

Results There was poor adherence to the current psychological intervention. There were three main barriers: manual related factors (e.g. manual complexity); therapist related factors (e.g. preparedness of therapist to deliver CBTp); and environmental factors (e.g. negotiating security or risk issues). Facilitators also included factors related to the therapist (e.g. receipt of clinical supervision) and factors related to the manual (e.g. acceptability to patients). Expert consensus was much in keeping with the established evidence base and clinical guidelines for CBTp delivery in non-forensic settings.

Conclusion To support consistent implementation of a manualised CBTp treatment intervention in a forensic setting: a clearly structured and accessible treatment manual for therapists is required; therapists’ training requires to be updated and repeated on a regular basis; it is necessary to ensure governance and supervision structures are in place; and it is advisable to utilise a CBTp adherence scale to support therapist development. Potentially it may also be appropriate for this type of intervention to be delivered by a small group of specialist practitioners, rather than a larger group of generalist practitioners.