Development of a tool for the Assessment of Integrated Therapy

Skills

AFT Annual Conference 2012 Bristol

Clare Brizzolara (R.M.N) Senior Lecturer

University of Sunderland

MSc in CBT and Recovery in Psychosis and Complex Mental Health

PGCert • Understanding Psychosis and Complex Mental Health Issues • CBT for psychosis • Staying well: supporting and enhancing recovery PGDip • Advanced Clinical Practice • Supporting and working with families and carers • Disseminating practice through training and supervision Masters • Research methods • Project

Supporting and working with families and carers

• Delivery of integrated therapeutic approach • Based on the Somerset model of family

interventions (Burbach and Stanbridge 2006) • Students recruited from diverse clinical areas • Consideration of the Social G.R.R.A.A.C.C.E.S.S

(Burnham et al 2008) • Broad perspective of families and include caring

systems (Asen 2002) • No marking criteria available for assessment of

audio recorded clinical sessions

My task (which I chose to accept)

• Find a tool so that students’ skills can be assessed in delivering FW to a wide variety of caring systems.

• The tool needed to reflect the module content of

an integrated therapeutic approach (ITA). • In the design of the tool, competency can be

achieved at 40%, the minimum pass mark in accordance with the policy and practices of the University of Sunderland.

Method

• Electronic literature search to identify currently available tools.

• Included those which were model specific to those contained within the I.T.A, assessed in session therapy skills, and pertained to family work.

• Excluded those which were assessing problem specific skills; individual clinical work and were not compliant with either of the models as part of the ITA.

Published and unpublished assessment tools assessing skill in therapeutic family work.

No AUTHOR TITLE

1 Pinsof (1979) The Family Therapist Behaviour Scale (FTBS)

2 Piercy et al (1983) Family Therapy Rating Scale (FTRS) 3 Breunlin et al (1983) Untitled

4 Laporta et al (1989) ‘The Behavioural Family Therapy Skills Assessment’ (BFTS)

5 Lam et al (1990) The Family Work Rating Scale

6 Lee et al (1997) Michigan State University Family Therapy Questionnaire (MSU/FTQ)

7 Briggs et al (1999) ‘Family Therapy Skills Checklist’ 8 Nelson and Johnson (1999) Basic Skills Evaluation Device (BSED) 9 McGovern et al (2000) Family Intervention Scale for Psychotic

Disorders

10 Burbach and Stanbridge (2001) ‘Assessment of Clinical Competencies’

11 Onwumere et al (2009) Family Intervention in Psychosis-Adherence Scale (FIPAS).

Lambert et al (1998) and Figley and Nelson (1989, 1990a, 1990b) informed the criteria for comparison.

• Assessment of skill within:

– Session execution

– Interpersonal skills

– Application of a theoretical model

• Assessment of formulating the family problem.

• The type of marking criteria used.

• Is it valid and reliable?

Competencies identified by Burbach and Stanbridge (2001 unpublished)

Laporta et al (1989) Behavioural Family Management

Nelson and Johnson (1999) Systemic Family Therapy

McGovern et al (2000) Cognitive Behavioural Therapy

1 Demonstrates joining skills Relationship Joining 2 Demonstrates an ability to elicit each

person’s position on the problem. Assessment and review Assessment, interventions and

hypothesising, personal skills

Planning the session with the family, goal setting and planning

3 Demonstrates an ability to identify the family’s previous attempted solutions.

Assessment and review Assessment, hypothesising and personal skills

Review of the week and review of between session tasks; initial session: identification of overall problems and needs.

4 Demonstrates goal setting skills. Rationale and teaching Joining Planning the session 5 Uses assessment tools appropriately Assessment and Review Assessment 6 Facilitates appropriate contribution from

each family member. Rationale and teaching Session management Control of session – participation and

orchestration. 7 Demonstrates basic family interviewing

techniques. Assessment and review Joining, communication skills, personal

skills and session management Review of the week; listening skills; rapport, warmth and positive feedback

8 Appropriately uses personal qualities/experiences to enhance therapeutic alliances.

Joining, communication skills and personal skills

Rapport and warmth

9 Constructs and implements session/treatment plans in a flexible and collaborative manner.

Assessment and review, rational and teaching

Joining, communication skills, and personal skills.

Planning the session with the family and planning of between session tasks.

10 Evaluates therapeutic interventions/treatment plans.

Assessment and review Review of the week and review of between session tasks

11 Identifies and is able to elicit patterns of interaction within the family.

Assessment and review Assessment, hypothesising and interventions

Initial session: identification of overall problems and needs

12 Able to construct a genogram Assessment 13 Implements relapse prevention

strategies

Interventions Staying well

14 Sets appropriate inter-session tasks/practical goals

Handing-over Interventions Planning of between session tasks

15 Demonstrates problem solving techniques.

Rationale and teaching, and rehearsal and coaching

Interventions Giving rationales; stress management and coping; goal setting and planning

16 Demonstrates techniques for improving communication.

Rationale and teaching, and rehearsal and coaching

Interventions Giving rationales; stress management and coping; goal setting and planning

17 Shows signs of developing a wider range of therapeutic techniques for working with families.

Interventions Staying well

A comparison of the clinical competencies identified by Burbach and Stanbridge which are observable during an audio

recording of a therapy session against the clinical competencies identified by Laporta et al (1989), Nelson and Johnson

(1999) and McGovern et al (2000 un published)

DISTRIBUTION OF MARKS

0-19% Some attempt of session execution skills (which might consist of any of the essential and non essential items) or therapeutic skills but without success, and evidence of any of the interpersonal skills.

Essential items: 1a, b, c, h; plus 2a, b, c; plus 3a, b. Non-essential: 1d, e, f, g; plus 4a, b, c, d, e, f.

20-39% Evidence of 2 essential session execution skills, 1a, b, c, h; evidence of any of the interpersonal skills, 2a, b, c; and some attempt at a therapeutic skill, 3a or b. Essential items: 1a, b, c, h; plus 2a, b, c; plus 3a, b.

40-59% All of the essential session execution skills, 1a, b, c, h; evidence of two interpersonal skills, 2a, b, c; one of the therapeutic skills, 3a or b and an attempt to deliver a specific intervention, 4a, b, c, d, e, f.

Essential items: 1a, b, c, h; plus 2a, b, c; plus 3a or b. Non-essential: 1d, e, f, g; plus 4a, b, c, d, e, f

60-79% All of the essential session execution skills, 1a, b, c, h; and one non-essential session execution skill, 1d, e, f, g; evidence of all the interpersonal skills, 2a, b, c; evidence of either one of the therapeutic skills, 3a or b, an attempt at delivering an intervention, 4a, b, c, d, e, f and evidence of working within the ‘Social GRRAACCESS’.

Essential items: 1a, b, c, h; plus 2a, b, c; plus 3a or b. Non-essential: 1d, e, f, g; plus 4a, b, c, d, e, f

80-100% All of the session execution skills, 1,a, b, c, d, e, f, evidence of all the interpersonal skills, demonstration of a balance between the therapeutic skills, 2a, b, c; clear and apparent evidence of delivering an intervention, 4a, b, c, d, e, f and evidence of working within the ‘Social GRRAACCESS.’

Essential items: 1a, b, c, h; plus 2a, b, c; plus 3a and b Non-essential: 1d, e, f, g; plus 4a, b, c, d, e, f

EVIDENCE ITEM ESSENTIAL NON-ESSENTIAL

1. SESSION EXECUTION

a. Review of the week b. Agenda setting and prioritising

c. .Pacing and time allocation d. Orchestration and assignment of tasks

(if more than one family member present)

e,. Use of co-therapist (if one is present) f. Dealing with the unexpected g. Homework setting h. Session closure

2. INTERPERSONAL SKILLS

a. Active listening using feedback and summaries

b. Joining and engaging c. Collaboration and positive feedback

3. THERAPEUTIC SKILLS

a. Circular questions and systemic techniques

b. Socratic questions and guided discovery

4. INTERVENTIONS

a. Understanding the system b. Information giving

c. Formulating the problem using the cognitive interaction analysis

d. Problem solving, goal setting and recovery planning

e. Communication skills f. Relapse prevention planning

Discussion and conclusion • Caring systems are diverse (Asen, 2002 and

Bradley Report’ DoH, 2009) • And susceptible to HEE (Willetts and Leff, 1997;

Tattan and Tarrier, 2000; Barrowclough et al, 2001 and Moore et al, 2002)

• Potential to integrate therapeutic skills, as long as trainees have a foundation in systemic theory (Figley and Nelson 1989; 1990a & 1990b)

• Common denominators between therapies • Robust validity and reliability testing.

Recommendations • Comparison of the competencies produced by

C.O.R.E

• Has clinical supervision been overlooked?

• Education and training

• Analysis of the key ingredients of psychotherapeutic treatments.

REFERENCES • Asen E (2002) Outcome research in family therapy. Advances in Psychiatric Treatment. Vol8 pg 230-238

• Barrowclough C, Haddock G, Lowens I, Connor A, Pidliswyj J & Tracey N (2001) Staff Expressed Emotion and Causal Attributions for Client Problems on a Low Security Unit: An Exploratory Study. Schizophrenia Bulletin Vol 27 No 3, pg 517-526

• Burbach F and Standbridge R (2001) Assessment of Clinical Competencies. Unpublished.

• Burbach F and Stanbridge R (2006) Somerset’s family interventions in psychosis service: an update. Journal of Family Therapy. Vol 28 pg 39-57

• Burnham J, Alvis Palma D & Whitehouse L (2008) Learning as a context for differences and differences as a context for learning. Journal of Family Therapy. Vol 30 pg 529-542

• Breunlin D, Schwartz R, Krause M and Selby L (1983) Evaluating family therapy training: the development of an instrument. Journal of Marital and Family Therapy. Vol 9 No1 pg 37-47.

• Briggs K, Fournier D, Hendrix C (1999) Evaluating Trainees’ Skill Development: The Family Therapy Checklist. Contemporary Family Therapy Vol21 No 3 pg 353-371

• Department of Health (2009) The Bradley Report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. London. Department of Health.

• Figley C & Nelson T (1989) Basic family therapy skills, I: conceptualization and initial findings. Journal of Marital and Family Therapy Vol 15 No 4 pg 349-365

• Figley C & Nelson T (1990a) Basic family therapy skills, II: Structural family therapy Journal of Marital and Family Therapy Vol 16 No 3 pg 225-239

• Figley C & Nelson T (1990b) Basic family therapy skills, III:Brief and Strategic Schools of Family Therapy. Journal of Family Psychology Vol 4 No 1 pg 49-62

• Lam et al (1990) The Family Work Rating Scale, adapted by Catherine Gamble.www.thorn-initiative.org.uk/FileStore/Filetoupload,37078,en.pdf

• Lambert M, De Julio S & Stein D (1978) Therapist interpersonal skills: Process, outcome, methodological considerations and recommendations for future research. Psychological Bulletin Vol 85 No 3 pg 467- 489

• Laporta M, Falloon I, Shanahan W & Graham-Hole V (1989) The NIMH behaviour family therapy skill assessment: reliability and validity. Paper presented at the World Congress of Psychiatry, Athens, cited in: Falloon I, Laporta M, Fadden G & Graham-Hole V (1993) Managing Stress in Families. Routledge.

• Lee R, Emerson S and Kochka (1997) Using the Michigan State University Family Therapy Questionnaire for training. Contemporary Family Therapy Vol 19 No 2 pg 289-303.

• McGovern J, Barrowclogh C and Haddock G (2000) Family Intervention Scale for Psychotic Disorders. Unpublished.

• Moore E, Yates M, Mallindine C, Ryan S, Jackson S, Chinnon N, Kuipers E & Hammond S (2002) Expressed Emotion in relationships between staff and patients in forensic services: Changes in relationship status at 12 month follow-up. Legal and Crimminal Psychology Vol 7 pg 203-218

• Nelson T and Johnson L (1999) The Basic Skills Evaluation Device. Journal of Marital and Family Therapy. Vol 25 No 1 Pg 15-30

• Onwumere J, Kuipers E, Gamble C, Jolley S, Smith B, Rollinson R, Steel C, Fowler D, Bebbington P, Dunn G, Freeman D & Garety P (2009) Family Interventions in Psychosis: a scale to measure therapist adherence. Journal of Family Therapy. Vol 31 No 3 pg 270-283

• Piercy F, Laird R and Mohammed Z (1983) A family therapist rating scale. Journal of Marital and Family Therapy. Vol 9 No 1 pg 49-59

• Pinsof W M (1979) The Family Therapist Behavior Scale (FTBS): Development and Evaluation of a Coding System. Family Process. Vol 18 No 4 pg 451-461

• Tattan T and Tarrier N (2000) The expressed emotion of case managers of the seriously mentally ill: the influence of expressed emotion on clinical outcomes. Psychological Medicine Vol 30 pg 195-204

• Willetts L E & Leff J (1997). Expressed emotion and schizophrenia: the efficacy of a staff training programme. Journal of Advanced Nursing 26, No 6 pg 1125-1133.

Acknowledgements

• With thanks to Dr John Fulton and Dr Judith Kuit for their supervision and guidance. I would also like to thank my colleagues from the Health Team at the University of Sunderland for their encouragement and moral support.

• Special thanks to my colleagues Tonia Ellett, Paul Jackson

and Kevin Hawkes, and students from the Year 2 cohorts (MSc in CBT and Recovery in Psychosis and Complex Mental Health) for their feedback and input in to the development of the assessment tool; and extra special thanks to Frank Burbach for his feedback and guidance, and without whom I would not have been inspired to create the assessment tool in the first place.

Clare Brizzolara University of Sunderland Faculty of Applied Sciences Dale Building, Room 105 City Campus Chester Road Sunderland SR1 3SD • Tel: 0191 515 2172 • Email: clare.brizzolara@sunderland.ac.uk