INTEGRATING REALISTIC RESEARCH INTO EVERY DAY PRACTICE Professor Nigel Beail Consultant & Professional Lead for Psychological Services. South West Yorkshire Partnership NHS Foundation Trust & Clinical Psychology Unit, University of Sheffield
Aims To challenge barriers to doing research To suggest ways of doing research To use a model from biomedical research To give examples from my own activities to illustrate research in practice.
My little bug bear Trainee clinical psychologists spend a large part of their training learning about and doing research BUT When qualified they do little, if any, research.
Another little bug bear Clinical psychology journals are filled with academic based studies and few conducted in clinical practice Practice based studies are frequently rejected
British Journal of Clinical Psychology (2016), 55 (2) 8 papers all with Academic as first author 32 authors of which 26 academic 5 academic/clinical 1 CP in practice
Having a different agenda Aspiring to do research that full time academic researchers do is not realistic. But All NHS Trusts are seen as research organisations and must be research active.
e.g. NHS constitution (2009) the promotion and conduct of research to improve the current and future health and care of the population. The NHS will do all it can to ensure that patients, from every part of England, are made aware of research that is of particular relevance to them.
NICE The National Institute for Health and Clinical Excellence guidance repeatedly highlights the lack of good quality outcome trials in the field of psychological therapy (NICE, 2011). The provision of psychological therapy is a major part of clinical psychologists core business. People with ID are excluded from effectiveness and efficacy studies (usual exclusion criteria) There is a notable lack of effectiveness research with people who have ID
The National Institute for Health Research OK to Ask campaign. In may 2013 the NIHR started a national campaign to encourage service users to ask their clinician about research opportunities
Trusts will have R&D Strategy 1. Increase research culture/embedding R&D as core business. 2. Focus research on portfolio studies 3. Strengthen links with partners 4. Increase the number of research active staff 5. Provide high quality research governance 6. Grow R&D capacity (South West Yorkshire Partnership NHS FT)
What can we do Research has to run alongside practice. Research should come from building in routine activities that contribute to research. Research needs to be seen as consisting of a wide range of activities.
Thornicroft et al. (2011) The place of implementation science in the translational medicine continuum, Psychological Medicine, 41, 2015-2012 Phase 0 Phase 1 Phase 2 Phase 3 Phase 4 Basic science (Theory, conceptual level, key processes Define intervention (define, describe, test out, pilot) Early clinical trials (Efficacy/RCT) Effectiveness (delivery in routine settings) Implementation
Realistically Off the five phases clinicians can contribute too four of them
Problems for many clinical psychologists Post course research distress syndrome I am a full time clinician, I don t have time My manager does not allow time Lack of resources Anxiety
Do Clinical psychologists have the skills 3 year doctoral training Research skills Evidence based practice Small scale projects/service evaluations Single Case Experimental design Dissertation YES
How we do it Build research into service design Through The routine collection of data approach Working in teams Collaborating with trainees
Example from my clinic: Phase 0, Basic Science Routine assessment of all service users referred for assessment or intervention can include psychometric measures Psychological Distress Mental health Behaviour BSI & PTOS PASADD BPI
Use data We have used tests designed and developed for use with the general population with people who have ID in our clinical practice. Over time the numbers accumulate and then we have tested their psychometric properties.
To date we have evaluated and published data on the psychometric properties of :- Standard Symptom Checklist 90 R Brief Symptom Inventory Rosenberg Self Esteem Questionnaire Inventory of Interpersonal Problems Novaco Anger Scale Mini Psychiatric Assessment of Adults with Developmental Disabilities
Psychometric properties example Phase 0 Basic Science Beail et al (2015). Concordance of the Mini-Psychiatric Assessment Schedule for Adults who have Developmental Disabilities and the Brief Symptom Inventory. Journal of Intellectual Disability Research, 59, 170-175
Psychometric properties Phase 0 Basic Science Vlissides, N., Golding, L. & Beail. N. (2016). A systematic review of outcome measures used in psychological therapies with adults with ID. In N. Beail (Ed). Psychological therapies and people who have intellectual disabilities. Leicester: British Psychological Society. 115-136.
Phase 1 Describe, Test out, Pilot For psychological therapies we have collected data at specified times of the treatment pathway, e.g. Pre and Post Pre, post and follow-up Pre, interval, post and follow-up Triage, pre and post
Phase one: Descriptions Case studies Beail, N. (2013). From denial to acceptance of sexually offending behavior: A psychodynamic approach. Advances in Mental Health and Intellectual Disabilities, 7, 293-299. Review of case studies Jackson, T., & Beail, T. (2013). The practice of individual psychodynamic psychotherapy with people who have intellectual disabilities. Psychoanalytic Psychotherapy, 27, 108-123.
Phase 1: Descriptions Beail, N. (in press) Individual psychodynamic psychotherapy. In J. Davies & C. Nagi (Ed.). Individual psychological therapies in forensic settings. London: Routledge Beail, N. (2016). Psychodynamic psychotherapy. In C. Hemmings & N. Bouras (Ed). Psychiatric and Behavioural Disorders in Intellectual and Developmental Disabilities. Cambridge: Cambridge University Press. Beail, N. (2016). Psychodynamic psychotherapy. In N. Beail (Ed). Psychological therapies and people who have intellectual disabilities. Leicester: British Psychological Society. Pp 22-27
Phase 1 Descriptions Beail, N., & Jackson, T. (2013). Psychodynamic Psychotherapy. In J. Taylor, W. Lindsay, C. Hatton & R. Hastings (Eds). Psychological therapies and people who have intellectual disabilities. Chichester: Wiley-Blackwell. Beail, N., & Jahoda, A. (2012). Working with people: Direct interventions. In E. Emerson, C. Hatton, K, Dickson, R. Gone, A. Caine & J. Bromley (Eds). Clinical psychology and people with intellectual disabilities. Chichester; Wiley-Blackwell. Beail, N., & Jackson, T. (2009) Psychodynamic formulation. In P. Sturmey (Ed.) Clinical case formulation: Varieties of approaches. New York: Wiley.
Phase 1 Early Clinical Trail Lindsay, Tinsley, Beail, Hastings, Jahoda, Taylor, &Hatton. (2015). A preliminary controlled trail for a trans-diagnostic programme for CBT with adults with ID. Journal of Intellectual Disability Research, 59, 360-369. Treatment versus waiting list control (triage to first appointment).
DOES RESEARCH CARRIED OUT BY CLINICAL PSYCHOLOGISTS HAVE ANY IMPACT? YES
Research on psychological therapies with people who have ID Informing care pathways Jackson, T., & Beail, N. (2016). Delivering psychological therapies: managing referrals, pathways and stepped care. In N. Beail (ed) Psychological therapies and people who have ID, Leicester, British Psychological Society.
Phase 3 Evidence base James, C. W., & Stacey, J. M. (2014). The effectiveness of psychodynamic interventions for people with learning disabilities; A systematic review. Tizard Learning Disability Review, 19, 17-24.
Phase 5 implementation Guidance Beail, N. (ed). (2016). Psychological therapies and people who have ID, Leicester, British Psychological Society. NICE (2016). Draft Guidance on Mental Health and People who have ID. NICE
Phase 5 Implementation Evaluation of services Beail, N. (in press). Evaluation of service and treatment outcome. In W. R. Lindsay, J. L. & Taylor (Eds). Handbook on Offenders with Developmental Disabilities. Chichester: Wiley.
Phase 5 Implementation Audit/Routine evaluation Provide population profiles from your data base to service managers Provide service reports on your outcomes to service managers
Routine monitoring system Collects routine biographic, intervention type and psychometric information at the points of assessment and outcome/discharge. Information is stored and analysed using a statistical database (SPSS)
Routine Monitoring Biographic age, sex, relationship status, employment, presenting problem Intervention type psychological assessment or therapy approach Psychometric information at referral, pre treatment & outcome
Pre - post scores of Psychological distress (BSI subscales)
Back to Phase 0 A Current Project Development and evaluation of The Psychological Therapies Outcome Scale for people who have intellectual disabilities (PTOS-ID)
COLLABORATORS Nikolaos Vlissides, Tom Jackson & Ryan Lawty Respond UK Merseycare NHS Foundation Trust
Why bother measuring outcomes? To see if what we do is any good To see if we re any good at what we do To demonstrate change to service users To justify our services to commissioners (PBR) To fulfil obligations/expectations within contracts To contribute to the evidence base.
What does the literature tell us? There is a lack of reliable and valid outcome measures for people who have learning disabilities (Vlissides et al 2016). Some appropriate single trait measures have been developed (e.g. GDS, GAS) Multi-trait measures have greater utility in service settings
Scope of the new measure (Consultation with 110 psychologists attending BPS Faculty for ID events) Anxiety Anger Depression Psychological Wellbeing Interpersonal functioning
Development of an item pool Diagnostic manuals: WHO, ICD-10, DSM-IV Published studies of psychometric evaluations of mental health assessments Found considerable overlap and repetition across manuals and tools (not surprising) Looked for items that had best psychometric properties in published studies with adults who have ID
(Item Pool cont.) Identified 30 items that had good psychometric properties in other studies (Face Validity, Construct Validity, Reliability etc.) Initial 5 scales: Depression (7 items) Anxiety (6 items) Anger (6 items) Interpersonal wellbeing (5 items) Psychological wellbeing/self worth (6 items)
Response format Carried out a frequency analysis of scale points in 493 completed Brief Symptom Inventories Found Quite a lot was used infrequently. Decided on 0-3 scale with supporting visual aid.
Psychological Therapies Outcome Scale (PTOS) example questions Over the past week Not at All A little bit Sometimes A lot 1 Have you been interested in doing things or meeting people 0 1 2 3 2 Have you felt sad? 0 1 2 3 3 Have you felt angry 0 1 2 3
Psychometric properties Measure completed in routine practice by 175 people with ID attending outpatient services for assessment or therapy Mean age 29.43 Years (17 to 62 years) 91 men & 84 women
Data analysis (now we need more help) Exploratory factor analysis (Construct Validity) Cronbach's Alpha (internal consistency/ reliability ) Correlation with the BSI (concurrent validity
Factor analysis Three interpretable factors derived Anger & Mood Anxiety Wellbeing (all wellbeing items) Two items failed to factor
Internal consistency Anger and Mood = 0.82 Anxiety = 0.76 Wellbeing = 0.81
Concurrent validity Correlation with the Global Severity Index of the BSI with index based on all psychological distress items in the PTOS-ID r = 0.85, p<.001
Recommendations for clinical use/interpretation Psychological Distress (Anxiety, depression and anger items) Cronbach's alpha = 0.85 Psychological Wellbeing Cronbach's alpha = 0.81
Carer/informant version Following feedback from services that the measure could not be used with all clients with id we developed a carer/informant version Preliminary analyses show a good correlations with the self report version Psychological Distress = 0.758 p<.0001 Psychological Wellbeing = 0.623 p<.0001
Summary of the PTOS Outcome scale developed specifically for people with LD Appropriate for people receiving a range of psychological therapies Measures both negative/distress and positive/wellbeing aspects Easy to administer Good face validity Shows good internal reliability
Conclusions Clinical psychologists are one of the most equipped professions after training to undertake research in health and social care settings However the profession does not seem to embrace research post qualification Research is now a core element of health care delivery.
Conclusions Our research skills need to meet the needs of the clients and services in which we work. We work with under researched populations By offering research activity to clinicians, NHS Trusts are showing dedication to improving the skills of the workforce. Offering research to our service users shows a dedication to improving health.
PROFESSOR NIGEL BEAIL Nigel.beail@swyt.nhs.uk