Introduction. Harry J. Sivec 1 Vicki L. Montesano. Mark R. Munetz 1

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1 DOI /s ORIGINAL PAPER Cognitive Behavioral Therapy for Psychosis (CBT-p) Delivered in a Community Mental Health Setting: A Case Comparison of s Receiving CBT Informed Strategies by Case Managers Prior to Therapy Harry J. Sivec 1 Vicki L. Montesano 1 David Skubby 1,2 Kristen A. Knepp 1 Mark R. Munetz 1 Received: 11 February 2015 / Accepted: 11 August 2015 Springer Science+Business Media New York 2015 Abstract This exploratory case comparison examines the influence of case management activities on engagement and progress in psychotherapy for clients with schizophrenia. Six clients were recruited to participate in ten sessions of Cognitive Behavioral Therapy for psychosis (CBT-p). Three clients who had received Cognitive Behavioral techniques for psychosis (CBt-p, a low-intensity case management intervention) prior to receiving therapy were selected from referrals. A comparison group of three clients who had received standard case management services was selected from referrals. Cases within and across groups were compared on outcome measures and observations from case review were offered to inform future research. Delivering CBT-p services on a continuum from low- to high-intensity is discussed. Keywords Cognitive behavioral therapy for psychosis CBT-p Schizophrenia Continuum of care Cognitive behavioral techniques for psychosis Introduction Cognitive Behavioral Therapy for psychosis (CBT-p) has been recommended as an adjunct to medication interventions for individuals who experience persistent psychotic & Harry J. Sivec hsivec@neomed.edu 1 2 Department of Psychiatry, Best Practices in Schizophrenia Treatment (BeST) Center, Northeast Ohio Medical University, 4209 State Route 44, P.O. Box 95, Rootstown, OH 44272, USA Department of Sociology, Kenyon College, Gambier, OH 43022, USA symptoms (see PORT; Kreyenbuhl et al. 2010; and the National Institute for Health and Care Excellence (NICE; 2014). This recommendation rests upon a series of metaanalyses reporting small to medium pre- to post-treatment effect sizes (see Wykes et al. 2008). These findings are not without criticism, as some researchers point out significantly lower effect size findings for more rigorous studies (see Lynch et al. 2010;Jauharetal.2014). Studies examining the benefits of CBT-p in routine clinical practice have reported mixed results. For example, Peters et al. (2010); Farhall et al. (2009) reported no significant added benefit of CBT-p in routine practice. In contrast, Morrison et al. (2004), Lincoln et al. (2012), and Krakvick et al. (2013) have reported positive findings in effectiveness trials. Overall, when directly compared with other interventions, CBT-p demonstrates a small but consistent effect size benefit over other approaches for positive symptoms (Turner et al. 2014). Because many clients do not have access to clinicians with specialized skills in CBT-p, one area that has received recent attention is the delivery of low-intensity CBT interventions (Bennett-Levy et al. 2010), which includes teaching non-therapist providers a modified or simplified version. Lower intensity interventions are often delivered in a stepped-care system with the express purpose of increasing access to evidence-based treatments. Such an approach may be particularly suited for individuals with severe and persistent mental illness (SPMI) when there are very few therapists available who have received formal training in CBT-p. A few studies have reported benefits associated with this approach. One of the earliest studies of this concept was tested by training mental health nurses to deliver brief CBT to individuals with schizophrenia spectrum illnesses in the UK (Turkington et al. 2002). The study yielded positive results. Specifically, as compared to the treatment as usual group, the CBT group achieved significantly greater

2 improvements in terms of (1) overall symptoms, (2) insight, and (3) depression. Pinninti et al. (2010) described a small pilot study in which researchers trained case managers and other nonexperts in CBT. The training led to an increase in CBT services being delivered to clients with SPMI. More specifically, the percentage of clients with SPMI who received three or more CBT sessions increased from 5 % before the training to 54 % after the training, and the percentage of sessions in which CBT was used increased from 2 % before training to 7 % during follow-up. Similarly, Waller et al. (2013) reported positive results in a small exploratory study in which frontline mental health staff applied behavioral activation and graded exposure to individuals with SPMI. The 12 participants who completed assessment measures at all three time points achieved significant improvements in the following areas: (1) depressive symptoms, (2) negative symptoms, (3) delusions, (4) clinical distress, and (5) activity level, according to self-report. Additionally, individuals were able to maintain these gains at follow-up. In another exploratory study, Turkington et al. (2014) provided an intensive training to a small group of case managers in techniques derived from CBT-p, termed High Yield Cognitive Behavioral techniques for psychosis (HYCBt-p). Case managers met with their clients a total of 12 times. While the generalizability of results from the study are limited by methodological factors, the findings indicated that clients who received HYCBt-p demonstrated modest improvements in some symptom areas (e.g., medium effect size reduction in total symptoms and small effect size change in hallucinations). Low intensity interventions will be hereafter referred to as Cognitive Behavioral techniques for psychosis (CBt-p). The above studies suggest that mental health providers delivering low-intensity CBt-p interventions may lead to positive outcomes. However, it is less clear whether the delivery of low intensity interventions influence other mental health services (e.g., impact the frequency and/or quality of other services like psychotherapy or psychiatric care). The current case comparison examines the impact of delivering CBT-p in its traditional form high-intensity therapy sessions to clients who have either (1) previously received CBt-p or (2) have not engaged in CBt-p. This case comparison is guided by a model for a Community Mental Health Center (CMHC) in which clients may receive a continuum of CBT-p-related services, from lower to higher intensity, by staff who work in a coordinated fashion. In this model, case managers may directly apply CBt-p in order to help with symptom relief and also serve as liaisons between clients and other mental health staff who share the same treatment language. In this context, it would be helpful to know how CBt-p delivered by case managers might affect psychotherapy services. This case comparison examines two hypotheses about the potential impact of CBt-p delivered by case mangers: Would clients who had received CBt-p (1) be more inclined to enter the process of therapy and (2) show an enhanced response to CBT-p, as compared to clients who had not received CBt-p? Methods Setting s were recruited from a CMHC in a mid-sized city that serves more than 2000 adults with SPMI per year. The agency offers a wide range of service options, including psychiatric care, counseling, case management, homeless outreach, integrated physical and mental health care, supported employment, and other services. Some clients recruited from this agency also participated in the exploratory trial described above (Turkington et al. 2014). Participants All clients selected for this study were currently receiving services at the CMHC. Inclusion criteria consisted of (1) a DSM-IV diagnosis of a schizophrenia-spectrum disorder (i.e., schizophrenia, schizoaffective disorder, schizophreniform disorder, and psychotic disorder not otherwise specified); (2) the presence/experience of ongoing positive and/or negative symptoms; (3) receipt of antipsychotic medication; and (4) an average score of 2 on hallucination and/or delusion items of the PSYRATS (a total score of 22 on hallucinations and/or 12 on delusions). Exclusion criteria consisted of clients on a forensic status and clients who had been adjudicated incompetent and had a guardian. Additional exclusion criteria included a principal diagnosis of a substance use disorder, presence of an organic psychosis, documented IQ of less than 70, or lack of English language skills that would interfere with participation in ratings and the therapy process. s considered for the CBt-p group were selected from the group of 38 who participated in the exploratory trial (Turkington et al. 2014). The case managers trained in CBt-p who participated in this study (n = 13) were asked to make referrals from this group. The remaining case managers at the agency who were not trained in CBt-p were also asked to refer clients for the comparison group. Both groups of case managers were given a therapy referral form that included a list of the inclusion and exclusion criteria.

3 s were randomly selected from the initial pool of referrals from case managers. Once the initial pool of referrals was exhausted, additional referrals were solicited and considered in the order they were received. Case managers without training in CBt-p had difficulty identifying clients who met inclusion criteria. After an extended period of time, we solicited referrals from case managers who had received the training. As a result, one case manager with training in the techniques referred one client to the group for clients not receiving CBt-p. This case manager reported not using CBt-p with this client but there was no way to definitively confirm this report. A total of six clients were enrolled into two groups: three clients who had experience with CBt-p and participated in the exploratory trial (Turkington et al. 2014), and three clients who were not enrolled in the trial and had no prior experience with CBt-p. Informed consent was obtained from all individual participants included in this case comparison. s Who Had Received CBt-p Three clients of seven who were referred completed the therapy process (nearly 43 %). Three clients declined the opportunity for therapy and one client completed the assessment but did not meet the inclusion criteria related to symptom severity. As for demographics, this group was composed of two female clients and one male client with ages ranging from 56 to 59. All three clients reported a long history of mental illness and services within the mental health care system ([12 years for all clients). Two of the three clients had previously received psychotherapy, but not CBT specifically. In terms of educational background, two clients completed some college, and one client did not complete high school. s Who had not Received CBt-p Four clients were originally enrolled; however, one client withdrew after a single session. Three clients of 23 who were referred completed the therapy process (about 13 %). One client began the assessment but stopped prematurely due to medical issues and did not follow up; one completed the assessment and then declined therapy; eight declined therapy after referral was made; seven were determined not eligible after referral was made; and two completed the assessment but did not meet symptom criteria for enrollment (Fig. 1). This group was also composed of two female clients and one male client with ages ranging from 29 to 52. All three clients reported [12 years of services within the mental health care system. All three clients previously received psychotherapy services, but not CBT specifically. In terms of educational background, one client completed high school, one completed some college, and one client did not complete high school. At the conclusion of ten therapy sessions, clients met with their case manager and lead author to discuss skills learned, next steps, and relapse prevention plans. All clients continued to receive care by case managers and other professionals within the CMHC following therapy. Measures Psychotic Symptoms Rating Scale (PSYRATS) The PSYRATS (Haddock et al. 1999) is an interview-based rating instrument that includes 11 items designed to assess common dimensions of hallucinations (e.g., frequency, duration, loudness, distress) and six items designed to assess common dimensions of delusions (e.g., preoccupation, conviction, distress). The following scales were used: total score for auditory hallucinations (PSYRATS Tot: AH) and total score for delusions (PSYRATS Tot: DEL), plus the Emotional Characteristics factor score for hallucinations (PSYRATS EM/C: AH) and factor score for delusions (PSYRATS EM/C: DEL). The Comprehensive Psychopathological Rating Scale (CPRS) The CPRS is an interview-based rating instrument that consists of 65 scaled items that cover a wide range of psychiatric symptoms (e.g., anxiety, depression, thought disorder; (Asberg et al. 1978). A variety of subscales have been developed from the CPRS to assess more specific symptom dimensions. We looked at the subset of items used to measure negative symptoms developed by Lindstrom and Lindstrom (1996). The authors analysis suggests a subset of five CPRS items that reflect negative symptoms: (1) withdrawal, (2) reduced speech, (3) lack of appropriate emotions, (4) slowness of movements, and (5) indecision. Questionnaire of Personal Recovery (QPR) The QPR was developed to understand more about the recovery process and designed specifically to assess individuals who experience psychosis (Neil et al. 2009). The QPR consists of 22 self-reported items with two subscales: (1) intrapersonal tasks involved in recovery and (2) interpersonal factors that facilitate recovery. The QPR is most commonly used to set goals and evaluate progress.

4 s who had received Cognitive Behavioral techniques for psychosis CBt-p (clients in original study N=38) EXCLUDED Declined therapy (n=3) CLIENTS REFERRED (n=7) ASSESSED FOR ELIGIBILITY (n=4) EXCLUDED Did not meet symptom criteria (n=1) s who had not received CBt-p CLIENTS REFERRED (n= 23) ASSESSED FOR ELIGIBILITY (n= 8) EXCLUDED Declined therapy (n=8) Determined not eligible after referral was made (n=7) EXCLUDED Began assessment but stopped prematurely and did not follow up (n=1) Completed assessment but declined therapy (n=1) Recruited into the study (n =7) Withdrew after one session (n=1) End of treatment assessment Assessed (n= 3) End of treatment assessment Assessed (n= 3) Fig. 1 Consort diagram of the recuitment and allocation of participants Personal and Social Performance Scale (PSP) The PSP was designed to assess the personal and social functioning of individuals diagnosed with schizophrenia (Kawata and Revicki 2008; Morosini et al. 2000; Nasrallah et al. 2008). The PSP consists of four domains: (1) socially useful activities (e.g., work and study), (2) personal and social relationships, (3) self-care, and (4) disturbing and aggressive behaviors (Morosini et al. 2000). The interviewer uses a 100-point rating scale that is subdivided into ten equal intervals (e.g., 31 40). The Schedule for the Assessment of Insight (SAI) The SAI is a 7-item scale measuring three hypothesized dimensions of insight: (1) awareness of illness, (2) capacity to re-label psychotic experiences as abnormal, and (3) treatment compliance (David 1990). Numerous studies have shown a positive link between dimensions of insight and treatment adherence (Chakraborty and Basu 2010). The SAI is sensitive to changes in insight and has been used in studies examining the impact of CBT-p interventions on insight (see Turkington et al. 2002). Working Alliance Inventory-Short Form (WAI-S) The WAI-S is a 12-item, self-report scale that measures therapeutic alliance as experienced by the participant (Tracey and Kokotovic 1989). The WAI-S is a simplified version of the original 36-item Working Alliance Inventory (WAI) developed by Horvath and Greenberg (1989). The WAI-S assesses three key factors of the therapeutic alliance: (1) goal (i.e., client and therapist agree on goal), (2) task (i.e., client and therapist agree on the tasks necessary

5 to achieve the goal), and (3) bond (i.e., the degree to which the client and therapist have developed a personal bond). Procedure A single, trained rater completed all assessments for this study. This rater was not involved in the design of the study and was unaware of the specific study hypotheses. The rater was aware that clients were being evaluated for an outcome study related to CBT-p. The rater was blinded to group assignment. However, this same rater also participated in ratings for the Turkington et al. (2014) study so may have recognized previously assessed clients. Two weeks prior to commencing therapy, the PSY- RATS was administered by the trained rater to determine eligibility. s who met inclusion criteria were then assessed at baseline using the CPRS, QPR, PSP, and SAI by the same trained rater. At follow-up, clients were again given the PSYRATS, CPRS, QPR, PSP, and SAI by the same trained rater. All clients enrolled in this study received ten sessions of CBT-p from the lead author. Therapy consultation was provided to the lead author on a bi-weekly basis by an expert in CBT-p. Participants were also asked to complete the WAI-S (Horvath and Greenberg 1989; Tracey and Kokotovic 1989) at the end of sessions three and seven in order to assess alliance early and later in treatment. Ethical Approval The current investigation was approved by the Institutional Review Board of the Medical University and the Research Review Committee of the Community Mental Health Agency that participated in this study. All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Results Because of the limited number of clients in each group, apparent differences between groups are not generalizable. When difference between groups are observed on the measures listed below, they are reported with caution only to be considered for future investigations. Overall, there were no clear differences between the two groups in average pre-therapy scores on most of the 10 assessment domains, with the exception of CPRS total score which tended to be higher in the non-cbt-p group. Symptom change varied by individual client and assessment domain. Early and late alliance scores tended to be higher in the non-cbt-p group. The results of the quantitative measures are summarized in Table 1. The table is organized to provide a case-by-case comparison of changes in scores from baseline to post-treatment for individual clients. Table 1 was also used to identify any patterns that may suggest future areas of study in examining the impact of pre-therapy interventions. Table 2 summarizes clients alliance scores. Clinical observations based on a review of case notes were integrated into the discussion to explore the meaning of the assessment results. Symptom and Outcome Measures Global Distress Most individuals demonstrated improvement in terms of CPRS total scores. Individuals without prior experience with CBt-p showed a greater reduction in distress; however, their pre-therapy total symptom score was considerably higher at baseline. Hallucinations There was very little difference between the two groups. One individual in each group did not endorse hallucinations at the post-test. This suggests significant improvement or possibly reluctance to talk about hallucinations during the final assessment. Delusions Both groups showed similar levels of reduction in symptoms. Negative Symptoms Items from the CPRS can be used to estimate negative symptoms. From this sample, the sum total score for clients with prior experience with CBt-p decreased from 11 (baseline) to 3 (post-treatment) in which lower scores indicate a reduction in symptoms. In contrast, the sum total score for clients with no prior experience with CBt-p decreased from 7 (baseline) to 4 (post-treatment). Measures of Functioning QPR The QPR does not have a set cutoff score for improvement. Instead, the measure is often used qualitatively for the client to identify areas of improvement. We examined each of the 22 items to identify a 3-point change in items from

6 Table 1 Case comparison: change in scores from baseline to post-treatment for assessment domains Measure Group mean total symptom (pre-therapy) CBt-p prior to therapy (change scores) Group mean total symptom (pre-therapy) No CBt-p prior to therapy (change scores) CPRS total PSYRATS AH a a PSYRATS EM/C AH a a PSYRATS DEL PSYRATS EM/C del CPRS negative symptoms QPR intrapersonal QPR interpersonal PSP SAI Scores are based on difference between baseline and posttest. Scores with a positive valence indicates change in the direction of improvement Measures: CPRS The Comprehensive Psychopathological Rating Scale and subscale for negative symptoms, PSYRATS Psychotic Symptoms Rating Scale and subscales, AH total auditory hallucinations, EM/C emotional characteristics, DEL delusions, QPR Questionnaire of Personal Recovery, PSP Personal and Social Performance Scale, SAI the Schedule for the Assessment of Insight a s reported no voices at post-test Table 2 Alliance ratings early and late in treatment Measure CBt-p prior to therapy No CBt-p prior to therapy WAI-S Early alliance? WAI-S Late alliance? WAI-S Working Alliance Inventory-short form? Range is 12 (min) 84 (max); (Early = session 3; Late = session 7) baseline to post-treatment assessment. This degree of change was considered unlikely to occur by chance and to represent a significant change. Using this criteria, one client in the CBt-p group and two in the non-cbt-p group showed changes in scores suggestive of significant improvement. No clients showed evidence of changes in scores suggestive of significant decline. PSP The PSP is another measure used to assess personal and social functioning. Total scores for clients were compared at baseline and after treatment. A score change of ten or greater was identified for two clients from each group. One client demonstrated no change on this measure, but the baseline score was already higher than other clients. Insight and Alliance Insight: SAI Individuals in the CBt-p group demonstrated an increase in insight scores of 26 %. Individuals in the non-cbt-p group showed a 16 % increase in scores with more variability (see Table 1). Alliance: WAI-S High scores on the measure of therapeutic alliance were found in five of six clients (see Table 2). The client with the lowest WAI scores throughout the therapy process also showed the least amount of symptom improvement by the end of treatment.

7 Discussion The current study is largely exploratory and the sample size is too small for broad generalizations. However, the following clinical observations may inform future research. One hypothesis for the current study was that clients receiving CBt-p may be more inclined to consider entering psychotherapy. One finding from the referral data seems to support the initial hypothesis. That is, it took very few clients who had previously received CBt-p (i.e., seven) to achieve the referral goal of three clients who completed therapy compared to clients who had not received CBt-p (i.e., twenty-three). One reason may be that CBt-p in some way helped prepare clients for receiving additional, high intensity interventions. There is a small but noteworthy literature related to preparing individuals with schizophrenia for therapy. The work of Prouty (1990), referred to as pre-therapy, comes from the person-centered therapy tradition and posits that pre-therapy conceptualizes psychological contact as the functions necessary for therapy to occur (p. 651). The outcome literature is quite limited in this area, but like CBtp, pre-therapy interventions aim to develop readiness skills for engagement in therapy (Dekeyser et al. 2008). The case of client 3 may support the idea that CBt-p helps to develop readiness for therapy. 3 presented with a significant history of avoiding treatment, other than case work and psychiatric care. Participation in CBt-p was likely pivotal in enlisting the client to participate in psychotherapy. Of note, the client s baseline early alliance scores were the lowest among all clients in this study, suggesting that from the beginning the working relationship was rated at a lower level than others in this cohort. In contrast, all clients who did not receive CBt-p, but completed therapy, showed high alliance ratings early. One possible consideration is that clients with psychosis who show high alliance scores early in the treatment process (regardless of prior interventions) may be more inclined to engage in psychotherapy (i.e., they already possess the psychological contact or readiness necessary to benefit from therapy), compared with symptomatic clients who exhibit low, early alliance scores. Consistent with this hypothesis, a recent study by Goldsmith et al. (2015) revealed that higher scores on client-rated therapeutic alliance produced better treatment outcomes in individuals treated with CBT, as well as supportive counseling. The research showed that a stronger therapeutic alliance was causally related to symptomatic outcome. Associations among capacity for early alliance, provision of low intensity techniques, and therapy engagement can be operationalized and evaluated in future studies. A better understanding of this relationship may help to streamline the process of identifying clients with psychosis who would be most likely to benefit from CBT-p. Another possible explanation for the relative ease of referrals is that the CBt-p clients who participated in the Turkington et al. (2014) exploratory trial represented a group that is simply better screened since they completed the referral, assessment, and intervention phase of a prior study. In contrast, clients in the non-cbt-p group were not pre-screened and did not have a similar record of recent engagement in psychosocial treatment (e.g., seven clients in the non-cbt-p group were not included due to issues related to inclusion/exclusion criteria, which seems to reflect pre-screening factors more than preparation of the client). Another related hypothesis is that because of the initial exposure to CBt-p, individuals may show an enhanced response to therapy (e.g., move more quickly into key client issues). Although this outcome is difficult to operationalize, there are some clinical observations that suggest CBt-p may have favorably predisposed individuals to better outcomes. s who had received CBt-p identified primary targets involving improved self-confidence (competence and appearance) and socialization. In contrast, clients in the group not receiving CBt-p identified primary targets involving symptom reduction (e.g., coping with hallucinations, self-injurious behavior; stress/anxiety). One possibility is that by virtue of the fact that clients who engaged in CBt-p previously worked on targets related to symptoms and were prepared to work on other quality of life goals during the therapy process. For example, upon completion of the previous CBt-p exploratory trial, client 2 reported reduced distress associated with hallucinations. As a result, at the outset of therapy in the current case comparison, the client expressly stated a desire to improve self-confidence and increase socialization. In addition to experiencing symptom relief, client 2 also already possessed a basic understanding of the cognitive model. Therefore, the client was able to undertake more intensive exploration of automatic thoughts and underlying assumptions fairly rapidly, leading to positive changes in behavior and progress toward personal goals. By comparison, clients 4, 5, and 6, who did not receive CBt-p previously, focused primarily on ways to reduce symptoms and distress. While therapy appeared to help reduce distress associated with symptoms, these clients did not progress to more intensive work on underlying beliefs during the ten sessions of therapy. Another way to think about an enhanced response has to do with the potential for the case manager to extend the benefits of therapy (see Pinninti et al. 2014). In this case comparison, all three clients who received CBt-p prior to

8 therapy continued to work with their case manager on techniques after therapy. Two of the three clients in the non-cbt-p group identified specific activities that could be carried out with the case manager after therapy was completed. For one case, the transition back to case management services was more tentative. It is not clear if experience with CBt-p prior to receiving therapy would have helped this transition. The current investigation provides some observations about the way lower and higher intensity CBT-p interventions work together. The hope is that this work will stimulate further discussion on employing a continuumbased approach to CBT-p. In contrast to providing training in CBT-p to a small sample of therapists in CMHAs, this approach advocates a broader training to a wider range of professionals. The continuum model may fit better with the reality of direct care for schizophrenia in CMHAs in which case managers typically spend far more time with clients than do other mental health professionals. With this approach, low-intensity CBt-p services may be used to engage clients, to prepare those who may need high-intensity therapy, and extend the benefits of therapy following completion of a high-intensity intervention. In addition, the low-intensity interventions may achieve aims desired by clients without requiring high-intensity interventions. Finally, CMHAs tend to have very few staff trained in evidenced-based treatments, including CBT-p for individuals diagnosed with schizophrenia. From a workforce development standpoint, employing a continuum approach to CBT-p services would not only direct training to a wider range of staff but also potentially allow agencies to reach more clients with better coordinated care across the service delivery system. 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