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Cognitive and Behavioral Practice xx (2016) xxx-xxx

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A Model to Transform Psychosis Milieu Treatment Using


CBT-Informed Interventions
Sally E. Riggs, NYC CBTp, Brooklyn, NY
Torrey A. Creed, Aaron T. Beck Psychopathology Research Center, The Raymond and
Ruth Perelman School of Medicine at the University of Pennsylvania

Although CBT for psychosis (CBTp) has been recommended as a best practice since 2002, CBTps availability is quite limited in the
U.S. Integration of CBTp-informed interventions into the milieu of the treatment settings in which the majority of the 2.4 million
Americans with psychosis receive treatment may greatly improve access to those services. This paper presents an evidence-based model for
training line staff in CBTp principles, in order that more staff throughout the U.S. might better support the recovery of people with
psychosis in this way. Examples are provided to illustrate effective strategies and approaches.

Rationale While some evidence suggests that supportive therapy


may lead to clinical gains for this population (Penn,
A PPROXIMATELY 2.4 million American adults, or about
1.1% of the population aged 18 and older in a given
year, are diagnosed with schizophrenia (Robins & Regier,
Mueser, Tarrier, Gloege, & Serrano, 2004), more rigorous,
evidence-based treatments such as CBT for psychosis
1991). Treatment and other economic costs due to may be integrated into these milieu settings to improve
schizophrenia are enormous, estimated between D32.5 outcomes for the millions of individuals receiving services
and D65 billion annually. In 2010, there were approximately (Mueser & Glyn, 2014; Pilling et al., 2002). Directly
397,200 hospitalizations for schizophrenia nationwide, and training direct care or line staff allows the milieu to move
about 88,600 (22.3%) were readmitted within 30 days from a simple safety-net to a therapeutic context in which
(Elixhauser & Steiner, 2013). all interactions hold the potential for intervention.
Large numbers of individuals with a psychotic disorder Cognitive behavioral therapy (CBT) has been included
in the U.S. receive psychological treatment solely through in good practice guidelines for the treatment of psychosis in
milieu-based interventions such as inpatient units, day both the U.K. and the U.S. (APA, 2004; NICE, 2014) based
programs, partial hospital programs, assertive community on the mounting evidence of its efficacy (Gaudiano, 2005;
treatment, and psychosocial club house (Mueser, Deavers, Grant, Huh, Perivoliotis, Stolar & Beck, 2012; Morrison
Penn, & Cassisi, 2013). Many of these programs provide et al., 2014; Pilling et al., 2002). Despite these guidelines,
only group therapy, typically delivered by paraprofes- there remains a dearth of appropriately trained mental
sionals, with few psychologists or Ph.D.-level clinicians, and health professionals to provide this treatment (Mueser &
very rarely are staff trained in evidence-based psycholog- Noordsy, 2005; Rollinson et al., 2007). In light of the
ical therapies (Kimhy et al., 2013; Mojtabai, Fochtman, scarcity of trained professionals, access to evidence-based
Chang, Kotov, Craig, & Bromet, 2009). Even when more practice remains sorely limited (Jones, 2002). Mueser
advanced clinicians are available, the bulk of interactions and Noordsy (2005) have presented a call to action
that patients have are with direct care or line staff, for clinical psychologists in the U.S. to design training
who have the least amount of training in how to interact programs in CBT for mental health professionals working
with people with psychosis or promote their recovery. with schizophrenia and other severe mental illness, and
the response to that has been rapidly growing. Given that
these services are more likely to be underresourced and
based in community mental health services by milieu line
Keywords: psychosis; cognitive behavioral therapy; dissemination;
staff (CDC/NCHS, National Health Interview Survey,
therapeutic milieu; ACCESS model
20092013), feasible strategies to implement a response
1077-7229/16/ 2016 Association for Behavioral and Cognitive must reflect the unique strengths and challenges of these
Therapies. Published by Elsevier Ltd. All rights reserved. settings.

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
2 Riggs & Creed

Implementation Process Model team provides additional supports as needed through web-
One evidence-based process model for the implemen- based training, recertification booster training, and other
tation of EBPs in community mental health has been support as needed. The final step, Study outcomes, em-
developed with the flexibility to train line staff to deliver phasized the evaluation of the implementation outcomes,
EBP-informed care within the scope of their job roles, including assessment of the number of behavioral health
as well as training of more traditional clinicians (Creed, professionals trained, retention in training, achieved com-
Stirman, Evans, & Beck, 2014; Riggs, Stirman & Beck, petency, rates of recertification, and differential outcomes
2012). The ACCESS model was originally developed to in web-based and live training.
support the implementation of an EBP with therapists in The ACCESS model has been used to train staff in more
community mental health (Stirman et al., 2010) and has than 40 community mental health programs in cognitive
been expanded into a 6-step process that can be flexibly therapy, ranging from traditional outpatient settings to
followed with therapists (the Intensive Model) or line staff nontraditional settings for cognitive therapy such as acute
(the Milieu Model) to be applied independently or inpatient care, residential treatment, school-based services,
concurrently based on needs of an organization (Creed outreach teams, and safe havens for individuals experienc-
et al., 2014). The two models share the first, fifth, and final ing chronic homelessness (Creed et al., 2013; Creed et al.,
stages of the implementation process, but diverge on the 2014; Pontoski et al., 2016). Approximately 400 clinicians
other three steps to allow for flexible adaptation to a given and 350 line staff have been trained using this model to date
setting. The first step, Assess and adapt, focuses on joining (Creed et al., under review). High rates of retention have
with stakeholders to determine the specific needs of the been demonstrated, with fewer than 8% of clinicians
setting, as well as facilitators and barriers to the withdrawing or moving to noneligible agency roles.
implementation process. A core training plan is then Participants in the training model have reported
adapted to fit the characteristics of the setting. The high acceptability of the training process and model, and,
second step, Convey the basics, relies on the use of most notably, most clinicians (79.6%) demonstrated a
experiential workshop to build the necessary foundation- high standard of competency, commensurate with those
al knowledge for participants. In the Intensive Model, demonstrated in clinical trials of CT (Shaw et al., 1999).
therapists learn about the cognitive model, case concep-
tualization, engaging individuals in the development of Overview of the Treatment Model
authentic and personalized goals, and the use of CBTp is based on the basic cognitive model, which
intervention to help individuals move toward those states that our perceptions of our experience shape our
goals. In the Milieu Model, experiential workshops focus feelings and resulting behavior (J. Beck, 2011). Additional
on the basics of the cognitive model and basic case techniques for engagement and forming a therapeutic
conceptualization to create a shared language and under- alliance are used, which include making modifications to
standing among staff, and the development of individuals traditional session structure and settings, talking about
personalized goals. These two models differ in that the delusional beliefs empathically and without colluding,
Intensive Model prepares therapists with the knowledge normalizing the symptoms of psychosis, and understand-
needed to plan and deliver cognitive therapy, whereas ing psychotic symptoms as part of a spectrum exacerbated
the Milieu Model prepares line staff to use the cognitive by stress, rather than as normal versus abnormal
model to inform their day-to-day interactions with in- (Sivec & Montesano, 2012). In addition, CBTp aims to
dividuals treated in the milieu. During the third step, instill hope, reduce distress caused by psychotic experi-
Consult, weekly consultations are held with expert ence, and improve quality of life. It uses the ABC model
instructors. Therapists in the Intensive Model focus on (activating eventbeliefconsequence) to assess beliefs
applying their new knowledge to individuals in recovery, about psychotic experiences, and uses formulation,
helping these individuals move toward their goals Socratic questioning and guided discovery, cognitive
through the use of intervention planning, case conceptu- behavioral change strategies, and homework to bring
alization, and review of work samples. Instructors in the about change (Morrison & Barratt, 2010). CBTp skills
Milieu Model use scaffolding techniques and feedback and strategies have been successfully delivered in group
to help line staff build their basic CT-informed skills. settings (Granholm, McQuaid & Holden, 2015; Hill,
Completion of training and developed skills are assessed Clarke, & Wilson, 2009; Landa et al., 2006; Romme &
in the fourth step, Evaluate work samples. In the Intensive Escher, 1989; Wright et al., 2014), which suggests that
Model, competency is assessed based on work sample transportability to a group therapyoriented milieu may be
review, and observational evaluation is emphasized in the appropriate.
Milieu Model. During the fifth step of the process, Sustain, Accordingly, there is evidence that brief CBTp inter-
ongoing practice is supported primarily through the uptake ventions delivered by nontherapists can lead to desirable
of the EBP by the agency, although the implementation client outcomes. Community psychiatric nurses working

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
A Model to Transform Psychosis Milieu Treatment 3

in community mental health teams in the U.K. were coaching, staff were taught the cognitive model, and how to
trained to deliver 6 one-hour sessions of individual CBTp conceptualize challenging behaviors as obstacles to the
through 10 days of intensive training, followed by indi- patients recovery goals, rather than problems in them-
vidual, group, or telephone supervision. Compared with selves. Incidents of seclusion and restraints were found
treatment as usual, individuals who received the CBTp to reduce by more than half, and staff attitudes about
sessions experienced improvements in symptomatology, working on an inpatient unit with patients with psychosis
insight, and depression (Turkington, Kingdon & Turner, showed significant improvement (Chang et al., 2014).
2002). At 1-year follow-up, the improvements for insight Building upon the strength of the CBTp model
were maintained and an improvement in negative symp- (Kingdon & Turkington, 2005) and the treatment milieu
toms was also found (Turkington et al., 2006). Sub- approach taken by Beck and colleagues (A. Beck et al.,
sequently, case managers in an American community 2009; Chang et al., 2014), the implementation of CBTp
mental health system received 5 days of training plus principles facilitates a coordinated team approach for
weekly supervision in the same therapeutic approach an interdisciplinary treatment team. For milieu programs
(Sivec et al., 2015; Turkington et al., 2014). Case managers that have both licensed clinicians and support staff,
delivered CBTp in 12 meetings with individuals with an emphasis is placed on specialized formulation-driven
schizophrenia, yielding improvement in overall symptom CBTp work taking place during therapy sessions, with
burden, negative symptoms, depression, anxiety, social plans then written and shared with all staff so they can
functioning, and self-rated recovery among approximately then support and encourage no matter what time of day
60% of participants. or night. In order for this to take place, all staff, regardless
Waller et al. (2013) trained nurses and occupational of their training background, are given a working knowl-
therapists over 4 half-days in a specific recovery-oriented edge of specific skills-based strategies such as coping skills
CBTp intervention that utilized graded-exposure and for voices and behavioral interventions for paranoia and
behavioral techniques. Supervision was given on a fort- negative symptoms. Licensed clinicians may then take
nightly basis and treatment was delivered in eight weekly the lead in developing and sharing the case concep-
individual sessions, targeting anxious avoidance or low- tualization, and support staff help extend the clinical
mood-related inactivity with the aim of achieving a per- interventions into the milieu. Below, the ACCESS model
sonal goal. Eleven of the 12 participants achieved their offers a road map for implementing this framework in
personal goals and significant improvements were also a therapeutic milieu.
reported in depression, clinical distress, activity levels, Using the ACCESS Model to Train Line Staff in
negative symptoms, and delusions. Peer specialists, who CBTp-Informed Interventions
have a shared history of recovery and most commonly have
a high school diploma, have also been trained to utilize The following vignettes illustrate the implementation
CBTp-informed techniques. Perry, Murakami-Brundage, of CBTp-informed interventions across a number of
Grant, and Beck (2013) trained peers in specific strategies different settings to provide a flexible, relatable, and
that meshed with their role in recovery, including long- concrete illustration of the ACCESS model (Creed et al.,
and short-term goal setting and the use of specific cog- 2014; Riggs et al., 2012; Stirman et al., 2010). Examples
nitive and behavioral techniques to overcome barriers are drawn from the first authors experiences training
to these goals, as well as the basic cognitive model for staff in psychosis milieus in a number of public health care
conceptualization. Peers reported that the training had settings: Site Aa partial hospital program in a city-
positively influenced their work, improved their confi- funded mental health agency, recently transformed to
dence for working with people with psychosis, and helped incorporate the recovery model; Site Ban acute in-
them to better empathize and engage with their clients patient psychiatry unit in an urban public hospital setting,
(Perry et al., 2013). recently transformed to treat early psychosis in 16- to
Expanding the focus from line staff to the full treat- 24-year-olds.
ment milieu, staff in an acute urban inpatient psychi-
atric unit (i.e., nurses, mental health technicians, social Assess and Adapt
workers, an occupational therapist, a psychologist, and Success in any training initiative can be strongly linked
psychiatrists) were trained in Recovery Oriented Cognitive to staff buy-in, which can be enhanced by helping staff
Therapy (CT-R). The CT-R model promotes the engage- to anticipate how the training might be relevant to them
ment of people with psychosis in their own treatment, and (Knowles, 1980) and addressing any concerns they may
fosters staff empathy, compassion, and authenticity through have. Using open communication and emphasizing
better understanding of the psychotic experience (Beck, shared aims can also facilitate engagement with training.
Rector, Stolar, & Grant, 2009; Chang, Grant, Luther & This may be doubly important for mental health workers
Beck, 2014). Using experiential workshops and in vivo in the field of schizophrenia, who may have been working

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
4 Riggs & Creed

for years with minimal clinical supervision or effective the impact of training on these individual characteristics
therapeutic interventions. Cynicism and burnout are (Proctor et al., 2011).
often high, and staff can be keen to show the facilitator
all the ways the new initiative will not work (Mueser &
Noordsy, 2005). Convey the Basics
At Site B funding was initiated by behavioral health senior After the initial stage of engaging with the organiza-
administration as part of ongoing quality-improvement tion, the actual training begins. Workshops are provided
initiatives. Planning meetings took place with the medical to all staff, usually 2 to 3 hours on four occasions split over
director responsible for the unit, the associate director 4 weeks. If all staff cannot be present in the same
of nursing and the associate chief of psychiatry. Although workshop due to logistical reasons in the organization
these three administrators were able to serve as local (e.g., retaining sufficient staffing on a unit, reaching all
champions for the training, this planning might ideally staff on all shifts), it is important that each workshop
have also included unit level administrators, such as the unit includes staff from all levels of the program so that new
chief and assistant director of nursing, so that more local- opportunities for staff sharing and engagement are
level preparation was undertaken, particularly as multiple facilitated. Inclusion of a local champion in the training
training initiatives and a culture of rapid change throughout can also greatly increase the likelihood of uptake, so
the hospital were known to have had a long-term impact identification and inclusion of these team members in
on staff. training can be key (McCormack et al., 2013). Informa-
A kickoff breakfast took place at 8 A.M. on the Friday tion is presented in the workshops via a mixture of
directly preceding the start of the workshops, attended didactics, videos, role-play, and other exercises designed
by the associate chief of psychiatry, the facilitator, the to get staff thinking, participating, and learning (Riggs
unit chief, and assistant director of nursing. All unit et al., 2012; Riggs, 2015).
staff who worked the night or early morning shift were When training staff in CBTp-informed interventions
invited to attend, and those who did so heard first- for the milieu setting, it is preferred that the whole
hand about the exciting new training initiative. The program be aligned with CBTp principles, which leads
breakfast was much enjoyed, but attendance was very to a more programmatic and team-oriented approach
low, in part due to limited advertising. It cannot be across disciples, so that each team member functions in
stated enough the importance of the kickoff breakfast. his or her job role but has a common way of interacting
Providing food and drink in a celebratory atmosphere, with the individuals receiving services (informed by the
including speakers of importance from both the train- CBTp principles). Ideally, all members of the team re-
ing provider and the administration of the organiza- ceive a basic understanding of the key concepts of CBTp
tion, set the positive tone for the forthcoming initiative as a coordinating framework for care. Staff all learn to
and reward staff in advance for the time and effort they use elements of CBTp (e.g., empathy, rapport building,
are going to expend. and engagement; working within a strongly held belief
At Site A, the lead author had the opportunity for system while avoiding collusion; basic strategies for coping
continued meetings with the program manager and senior with voices, delusions, thought disorder, and negative
program staff, playing the role of ambassador. As an symptoms). In addition, line staff become familiar with
outside consultant, she was able to hear about the agency more advanced interventions that may be delivered by
program, its structure, its strengths and weaknesses, and therapists so that they can support and reinforce the use
gather stakeholder feedback about how the strategies of new skills in the milieu. For example, staff may learn
might best be delivered and targeted. She also attended about coping cards so that their use may be cued as
the program at several different points throughout the needed during daily interactions.
week, joining groups, community meeting, and drop-in For example, at Site B, training took place over a
sessions to assess the current therapeutic milieu, as well 2-month period, with workshops scheduled at different
as the content and structure of the program. When the times of the day to ensure attendance of all staff and
instructor is already employed as a staff member within make-up sessions in the second month for those who were
the organization, existing staffing structures, hierarchies, unable to complete all four workshops in a row. Four
or competing work demands can interfere and create workshops were provided to each staff member in total, of
challenges with this model. 2 hours each. As such, the facilitator ran each workshop
Engagement at this early stage can also create an three times. All staff on the unit were to be included in
opportunity to assess the staffs initial level of knowledge the training, from psychiatric technicians with a high
of the EBP, as well as their attitudes and expectations. school diploma, right up to the attending psychiatrists.
The training plan may then be adapted to address these Sixty staff were trained, including RNs, licensed creative arts
characteristics, and subsequent assessment can evaluate therapists, activity therapists, peer counsellors, psychiatry

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
A Model to Transform Psychosis Milieu Treatment 5

residents, psychologists, social workers, and staff specialists (Aubrey & Gillespie, 2007) illustrate beautifully how and
in behavioral interventions to deescalate violence, from why we work within a delusional belief system, and how
all three shifts both day and night. Training was funded the delusion also often holds specific meaning for the
in-house. Staff who worked shift patterns were paid over- person in question. For those unfamiliar with this movie, a
time for remaining 2 hours past the end of their shift or man shows up on his brother and sister-in-laws doorstep
for coming in early. Nine-to-five staff attended workshops accompanied by a slightly shocking delusion. He has a
during this time period and were released from regular life-sized doll that he believes is alive, and with whom he
duties during this time. Funding was also provided for has fallen in love. The brother and his wife are distraught
workshop materials, including handouts and binders. As they catastrophize and blame themselves. However, they
the instructor was an employee of the hospital, and had are able to take the young man to the town internist who, in
previously worked on a similar inpatient unit, she was her wisdom, points out that the delusion must be functional
known to some of the staff and was very familiar with all or meet some need for the man, even if they dont yet
the different staff roles and the politics of working in the know how. The internist suggests that they must therefore
hospital, which may have facilitated staff buy-in. go with it (i.e., work within the delusional belief system).
Concerning CBTp-informed interventions for the ther- The family enlists the support of the town in this en-
apeutic milieu, two elements are emphasized during the deavor, with some initial resistance. Ultimately, the function
workshops to enhance everyday interactions between staff presents itself and the delusion resolves. In a related but
and individuals being served in the milieu: empathy and real-life example, Eleanor Longdon, a British clinical psy-
working within a patients delusional belief system (Riggs chologist and voice hearer, speaking about her experiences
et al., 2012). In these brief therapeutic conversations, the with the behavioral health system in the U.K. (Longdon,
emphasis is on staff providing empathic support to people 2011), offers a wonderful example of how recovery from
with psychosis that does not challenge their beliefs, schizophrenia is possible to a much higher level than
but also does not collude. This is a central concept in people think. Dr. Longdons video also provides firsthand
CBTp and one that is often misunderstood. Challenging information about what it feels like to be treated by a
beliefs head-on makes them stronger. Anecdotally, all regular mental health system, which can help line staff
people hold strong beliefs about such issues as religion to better understand how their daily interactions can have
and politics, and when an acquaintance with opposing a positive or negative impact on people with psychosis.
beliefs attempts to challenge us, we more than likely try
to convince them to the contrary. Not only does this
lead us to reiterate all the reasons we hold our beliefs, Consult
but if the conversation continues, we may even discover Following the intensive workshops, the consultation
new evidence for our beliefs to support our argument. phase begins. During this time, the instructor visits the
Further, we may end the conversation feeling frustrated program for hourly case consultation discussions, in which
or misunderstood. None of these outcomes are desirable staff bring real-life examples from their program, and
in engaging a person around their beliefs. Many of us these are discussed in an attempt to formulate them using
also have experience with working with people with the CBT for psychosis model. These are scheduled as
psychosis and may have tried to disprove a belief that was frequently as the funding agency will allow, ideally offering
obviously not true, to little effect (the patient who believes contact at least once per week for each staff member.
they are pregnant or HIV positive in the face of repeated The consultation phase is where change really begins
negative blood tests, for example). In CBTp, thoughts to happen (Miller, Yahne, Moyers, Pirritano, & Martinez,
are not challenged, and may only be caught, checked, 2004; Sholomskas et al., 2005). At Site B the workshops
and changed if they are found to be inaccurate or un- were followed-up with a 1-year consultation phase, during
helpful (Granholm, McQuaid, Auslander & McClure, 2004) which the facilitator attended the unit for a 1-hour weekly
much later in therapy. case consultation meeting. The timing of this meeting
These concepts are taught to staff during the workshop was also rotated so that staff from the two daytime shifts
phase of the training using particular exercises and role- could attend. (Unfortunately, due to logistical reasons,
plays (Riggs et al., 2012). In particular, this workshop it was not possible for a case consultation meeting to be
delivery leans heavily on the work of Hazel Nelsons (2005) scheduled for the night shift.) To begin with, the weekly
concept of working within the delusional belief system, case consultations were poorly attended, particularly by
as well as utilizing an exercise for increasing empathy, nursing staff. Despite partnership in planning the timing
first put forward by McLeod, Deane, and Hogbin (2002). of the sessions across all disciplines, it was typical for
The first author also uses video clips to help line staff relate clinical staff to be available to meet, while nursing staff
to the experiences of the individuals receiving services. were already assigned other important duties at that time.
For example, clips from the movie Lars and the Real Girl However, with repeated emails the assistant director of

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
6 Riggs & Creed

nursing on the unit began to schedule for nursing staff voices, such as arguing about the voices (which could lead
to arrive an hour early for their shift or to stay late and the young man to defend himself and his experience),
attendance rocketed. It is really important, as with the colluding with the hallucination (which may become
workshops, to ensure that all disciplines are represented further evidence to him that the voices have power or
at these meetings with the emphasis on sharing and are important), trying to ignore the voices (which is
learning from each other. Generally, these meetings another way of paying attention to them, often increasing
took the form of presenting 1 or 2 patients from unit, his experience of them, as well as his sense that they are
formulating their psychotic experiences from a CBTp uncontrollable), and so on. By focusing on the environ-
perspective, and sharing ideas about interventions. The ment rather than internally, the volume knob on the
facilitator attempted to model a collaborative, Socratic voices is turned down. In an elegant intervention, the
questioning approach throughout. tech may then help the young man pay attention to the
At Site A, weekly consultation sessions were provided meaning he makes from this experience. If the voices
over a 6-month period. Consultation took place for an recede when he focuses elsewhere, what does that tell
hour once a week, with all staff mandated to attend. Staff him about how powerful or uncontrollable the voices are?
presented case examples for feedback and troubleshoot- (See Riggs, 2015, for more details of the CBT model as
ing. The instructor then presented a review topic with applied to these symptoms and more information about
an experiential exercise, followed by new intervention this and other strategies.)
setting and summary. Topics initially flowed from didactic Consultation may also be particularly valuable in sup-
workshops, but quickly became based on requests from porting the coordinated efforts among treatment team
staff for troubleshooting and additional information. members. For example, a psychologist may work with a
Initially a role-play between pairs of staff members was woman to identify beliefs she holds about herself, based
always included. However, because staff had been on past experiences, including Im broken, or Im a
disengaging during the role-play, this was revised to failure. The psychologist may then work with the woman
watching the instructor role-play with a member of staff, to identify and engage in new mastery between sessions
and team-by-team case presentation with whole group to build evidence against those beliefs. At a day program,
discussion. In addition, the instructor attended each for example, the woman may offer to teach other inter-
teams meeting on a three weekly rotation, at which staff ested individuals to sew, creating opportunities for her
presented a particular participant they were struggling to to experience herself as capable and successful. Support
work with. A CBTp-based formulation was constructed, staff can then watch for these and other moments, and
and interventions were suggested. Finally, the instructor help draw her attention to the successes she might other-
was on-site informally 1 hour a week, interacting with wise miss or discount. Consultation may be particularly
consumers, modeling good practice interventions, and helpful in facilitating communication among disciplines
able to answer additional staff questions. to support and extend these experiences. Special care
Staff are also encouraged to practice coaching indi- should be paid to communication across shifts, as cross-
viduals in specific strategies to help diminish voices, delu- shift communication may be observed to be a particular
sions, and negative symptoms. For example, staff may challenge. Integration of key information into shift-change
offer individuals the point-look-name strategy (Riggs, updates, treatment team meetings, and documentation
2015) for reducing voices. In this strategy, a psychiatric may be particularly effective, but effective approaches will
technician (tech) on an inpatient unit may observe that need to be adapted to each setting.
a young man looks distracted and upset, and based on
her knowledge of the young man, hypothesize that he
may be reacting to an auditory hallucination he fre- Evaluate Work Samples
quently experiences. After inquiring about the young When implementing any EBP, evaluation of work sam-
mans experience, she reminds him of his past successes ples allows direct measurement of the extent to which
with the look-point-name strategy to shift his focus from trainees have learned to deliver the intervention as the
the critical voice he is experiencing to the environment treatment developers intended (Proctor et al., 2011).
around him. The tech asks the young man if he is willing Fidelity in standard CBT is often typically measured using
to find out whether he might find that strategy useful the Cognitive Therapy Rating Scale (CTRS; Young &
again currently (empathic, collaborative). With guidance Beck, 1980) to rate audio- or video-taped sessions, and
as needed, the young man begins to look around the many modified versions exist for training individual cli-
room, point at specific objects, and name what he is nicians to do full CBTp: Cognitive Therapy Scale for
pointing out, engaging several systems in his brain and Psychosis (Haddock et al., 2001); Cognitive Therapy in
refocusing away from the auditory hallucinations. This Psychosis Adherence Scale (Rollinson et al., 2008); Cogni-
strategy is in contrast to the tech engaging around the tive Therapy Scale Revised for Psychosis (Munro-Clarke,

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
A Model to Transform Psychosis Milieu Treatment 7

2015). However, when training staff in therapeutic milieu may be lost to the milieu. For example, within the first 6
enhancement, recording the daily interactions that con- months of the consultation phase of training at Site B,
stitute most of the interventions is often not feasible. approximately 50% of the staff who had attended the
Instead, work may be evaluated indirectly during weekly initial workshops had taken new jobs outside of the
consultation discussion, through evaluation of staff skills hospital or been floated or transferred to a different unit
during role-plays, or through in vivo observation of staff or program within the hospital. When the resources are
in the milieu. Direct observation of skills in the treatment available, didactics may be offered to new staff members
milieu may offer the best of these options, as observation after the end of the consultation phase, helping orient
provides the most accurate data about staff skills and new staff, and inciting fresh enthusiasm in the whole
feedback can be provided instantaneously. However, staff team, but access to ongoing training may not always
may find the observation distracting or uncomfortable, be possible for organizations. The milieu staff offer an
so subtlety during the observation may be particularly excellent source of ideas and information for feasible
important. sustainability strategies within their system, with direct
Several measures of integration of CBT into the milieu knowledge of the resources and barriers of their context.
are under development. An observational measure of the CBTp-trained milieu staff have suggested and enacted
integration of a goal-oriented CBT into the treatment strategies for sustaining the CBTp culture on their units,
milieu is currently being piloted in a large-scale imple- including access to written materials and information
mentation of CBT in community mental health (Creed such as books or papers kept in a centrally available
et al., 2015). In addition, Sivec and colleagues (Sivec, library (including both established resources, and re-
2015) have been developing a modified checklist version sources developed and updated by the team), video
of the CTRS to be used to measure the fidelity of case training material for new staff and for caregivers, and
workers being taught to use CBTp-informed interventions access to instructors for consultation on a case-by-case
in Assertive Community Treatment team settings. When basis. The use of web-based training has also evidenced
available, this may be usefully applied to milieu settings great utility in replenishing trained staff after turnover
as well. (Creed et al., 2014), allowing new staff to access the
At Site A the instructor was able to attend the program necessary foundational knowledge as they enter the
every Friday morning, at least an hour of which was organization. Their growing skills are then supported by
dedicated to spending time solely in the milieu, interact- the daily flow of the CBT milieu.
ing with consumers, modeling good practice, observing At Site A the instructor provided an additional work-
staff interactions, and giving live feedback and shaping. As shop after the end of the 6-month consultation period to
the 6-month consultation progressed, it was notable that bring new members of staff up to speed with the material
modeling and live feedback was required, not only praise and initiative. This was largely driven by staff request
and reinforcement of good practice. as they had noticed how important the initiative was to
the program and wanted to get up to speed as fast as
possible. In addition, each of the three staff teams was
Sustain led by a masters-level clinician who had been trained in
Many different factors may facilitate the implementa- a previous initiative in individual CBT and who became
tion of an EBP in the earlier stages of implementation, important local champions for CBTp-informed milieu
but the influence of those factors may change over time, interventions and greatly supported both their teams
potentially limiting the long-term impact of implementa- and the program, with long-term sustainability of the
tion (Massatti, Sweeney, Panzano, & Roth, 2008; Scheirer, interventions. One of these three undertook additional
1990; Seffrin, Panzano, & Roth, 2008). Research targeting training in group CBT interventions for voices and para-
the best approaches to improve or sustain EBPs is still noia, another undertook further supervision for her
in its very early stages, and the ideal strategies remain individual client work with patients with psychosis using
pressing areas of research (Proctor et al., 2015). Among the CBTp model, and the third was promoted to clinical
the emerging literature, much has focused on national or lead of the program and continued to champion CBTp-
statewide initiatives, with little guidance for local mental informed interventions from this level. At Site B, because
health systems or individual behavioral health organiza- the instructor was an employee of the hospital, sustain-
tions that are implementing EBPs more independently ability was conceptualized within the framework of an
(Stirman et al., 2015). ongoing in-house expert. This was further reinforced by
Turnover is a particularly salient issue in community hiring a new psychologist to the unit who had also had
mental health, typically ranging from 30% to 60% previous training and experience in using CBTp. In
annually (Mor Barak, Nissley, & Levin, 2001). When both instances, long-term investment in the infrastruc-
staff are trained and then lost to turnover, those resources ture by management (i.e., support for additional training,

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
8 Riggs & Creed

establishment of local champions, hiring the instructor as Next Steps


in-house staff) helped to create stability and demonstrated CBTp can effectively reduce the distress experienced
administrator commitment to CBTp. The availability of due to positive and negative symptoms, and can improve
in-house resources, in turn, created an opportunity for the quality of a persons life (Wykes, Steel, Everitt, &
the penetration of CBTp to expand. Tarrier, 2008). A programmatic approach to CBTp offers
a vehicle for transforming the therapeutic milieu within
Study Outcomes which many people with psychosis are supported, and
may increase access to the evidence-based approach. As
The ACCESS model highlights the importance of an organizing principle, delivery may be conceptualized
studying outcomes in collaboration with the agency, according to three levels, or tiers. As an intensive,
but this may be difficult to do in a formal or controlled formulation-driven therapy, full CBTp can be provided
fashion (Seiber, 2008). Outcomes can be difficult to on a one-to-one weekly basis by masters-level clinicians or
define with agencies, especially when interventions are above who have received lengthy and specialist training,
not targeted to specific individuals, but rather the milieu sometimes referred to as Tier 3. Such trained clinicians,
as a whole. Standardized measures may be administered with supervision, could be able to work with anyone with
to staff to assess changes in attitudes, burnout, or other psychosis, regardless of diagnosis or symptom presenta-
characteristics, but the time and effort required for tion. However, at Tier 2, clinical staff can be taught to
data collection and analysis may be beyond the scope provide targeted CBT-pspecific CBTp interventions
of smaller or less-resourced organizations. On a related targeting a specified mechanism or symptom (such as
note, not all organizations are equipped to support the command hallucinations or sleep for people experienc-
Institutional Review Board applications that are required ing paranoia) and that typically follow an evidence-based
to conduct research, so data collection may be limited to manual, but for which both length of training and number
routine program evaluation. of treatment sessions is shorter. At Tier 1, line staff within
Although collection of data can be a very labor- milieu settings may use CBTp-informed interventions,
intensive task, with those administering the question- such as increased empathy, and understanding of how
naires often required to provide support to individuals to work within a persons delusional belief system, as well
as they complete the questions, checking for legibility and as specific skills-based coping strategies, to improve out-
incomplete data, and reminding staff of the assurance comes for people with psychosis.
on confidentiality of the data, the labor leads to objective CBTp is finally getting some buzz in the U.S. now
information about the impact of the implementation. among clinicians, service providers, and mental health
Questionnaires to consider include: The Ward Atmo- agencies, and many more people are being trained.
sphere Scale (WAS-R; Moos, 1974), The Staff Attitudes However, the need for caution remains. Evidence-based
Survey (McLeod et al., 2002), The Community Oriented practices need to be implemented in a way that is also
Programs Environment Scales (COPES; Moos, 1972), evidence based, increasing the likelihood of changing
The Community Assessment of Psychic Experiences staff practices. Those investing in training need to know
scale (CAPE; Stefanis et al., 2002), the View of the that their money is being usefully spent, and to know
Therapeutic Environment (VOTE; Laker et al., 2012), what kinds of changes they can expect in return. This
and the Competency Assessment Inventory (CAI; Chinman model suggests one way in which Tier 1 CBTp can be
et al., 2003). Data being collected as part of standard implemented according to the research base, to have a
care may also be accessed (with appropriate permission) major impact on not just the lives of people with psychosis,
to assess the impact of implementation on events on the and on those who are involved in their care, but also
unit. For example, rates of seclusion, physical restraint, potentially their families, friends, and society as a whole.
critical incidents, or intermuscular medication use may be
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137143. http://dx.doi.org/10.1111/j.1468-2850.2008.00122.x The authors would like to acknowledge the contribution of Shannon
Shaw, B. F., Elkin, J., Yamaguchi, J., Olmsted, M., Vallis, T. M., Dobson, Wiltsey-Stirman, Ph.D., for her ongoing mentorship and expertise in
K. S., . . . Imber, S. D. (1999). Therapist competence ratings in training and dissemination. They would also like to thank the Beck
relation to clinical outcome in cognitive therapy of depres-
Community Initiative, the Philadelphia Department of Behavioral
sion. Journal of Consulting and Clinical Psychology, 67, 837846.
Health and Intellectual disAbilities, and New York City Health +
http://dx.doi.org/10.1037/0022-006X.67.6.837
Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Hospitals who supported this work. Finally, thank you to JCR for the
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A dissemination trial of three strategies of training clinicians Address correspondence to Sally E. Riggs, DClinPsy, NYC
in cognitive-behavioral therapy. Journal of Consulting and Clinical CBTp, 142 Joralemon Street, Suite 5F, Brooklyn, NY 11201; e-
Psychology, 73, 106115. http://dx.doi.org/10.1037/0022- mail: sallyeriggs@gmail.com.
006X.73.1.106
Sivec, H. J. (2015, November). Cognitive Behavioral Therapy for Psychosis
(CBT-p): Training mental health providers using the Best Centers Received: July 28, 2015
Approach. Paper presented at the 49th Annual ABCT Convention, Accepted: August 9, 2016
Chicago, IL. Available online xxxx

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001