This report aims to critically appraise psychosocial interventions (PSI) that are utilised when working with complex cases. In order to do this the term complex is explored with reference to people with psychosis. Different types of complexity are discussed with a more detailed examination of a specific complexity; the relationship between substance misuse and psychosis (dual diagnosis). The effects that substance misuse and psychosis have upon the service user and their care givers are outlined.
An overview of the use of psychosocial interventions when working with complex cases is given. This discussion is then focused on particular interventions for dual diagnosis that show promise for enhancing service user and carer experience, namely a integrated treatment approach of cognitive-behavioural therapy, motivational interviewing and family therapy. These interventions are critically appraised with reference to evidence base, policy and guidelines.
Examples from clinical practice are given to illustrate potential barriers, and outcomes when implementing such interventions with service users with complex needs and their caregivers. Strategies to overcome such barriers are generated and recommendations are made.
Aliases are used within the scenarios of this report in order to maintain anonymity of the service users and carers described to illustrate points and examples.
The term complex case is referred to frequently within mental health literature, policies and guidelines but there are very few definitive explanations of what the term actually means. Griffiths & Allan (2007) discuss how the term complex case is ill defined within mental health literature summarising how the term is often used to denote circumstances where people appear to have many interrelated needs that require several, coordinated responses from multiple services. The term complex case is often used to denote needs that services do not fully understand or provide for effectively. This report aims to explore the term complexity in relation to individual cases of those with serious mental illness.
‘Made of many different things or parts that are connected; difficult to understand’
(Soanes & Stevenson 2005)
Interpreting the above definition of complex within the Oxford Dictionary of English one could describe a complex case as a service user with more than one problem or need that are connected making the case more difficult to work with. For example having a diagnosis of schizophrenia and being detained within a medium secure unit. A person fitting this example would potentially present the mental health professional with more challenges than a person with moderate depression living with their supportive family.
Wilson, Holt and Greenhalgh (2001) discuss the term complexity in relation to human health and illness. They suggest there are a number of factors (outlined in Table 1) that we all posses that makes us all complex. They go on to suggest that human illness and behaviour are not predicable and neither can be thought of as a simple cause and effect system. Again, adding to the complexity of individuals that because one individual responds one way to an event does not mean all will. Although this list of human complexities was written with medical practice in mind it applies to all and provides the baseline of those service users we work with in mental health services.
Table 1 (Wilson, Holt, Greenhalgh 2001 p685)
Factors that add the human complexity
The human body is made up of multiple interacting and self regulating physiological systems including biochemical and neuroendocrine feedback loops.
An individual’s behaviour is determined partly by an internal set of rules based on past experiences and partly by unique and adaptive reaction to external stimuli.
The web of relationships in which individuals exist contained varied and powerful determinants of their beliefs expectations and behaviour.
Individuals and their immediate social relationships are embedded within wider social political and cultural systems which can influence outcomes in entirely novel and unpredictable ways.
All of these interacting systems are dynamic and fluid.
A small change in one part of the web of interacting systems may lead to a much larger changes in another part through amplification of effects.
If we bear this in mind, that all humans are complex, then maybe the term complexity needs to be described as a continuum (Figure 1). That the more problems a person has or the more difficulties they face the further they move up a complexity continuum.
People with a diagnosis of serious mental illness (as with all people) can face a large number of problems and difficulties through the course of their lives for example, positive symptoms, negative symptoms, anxiety, depression, mania. When adding this to the complexity of an individual this produces more challenges for the health care professional, the individual and their carers/families. However, these experiences also produce problems and difficulties for the service user making their case even more complex. For example the impact of experiencing voices does not end here but effects other areas of a person’s life (see Table 2).
Laura – Case study
Laura first started to hear voices at the age of 9 and at first these did not bother her. As she got a bit older and discovered that this wasn’t ‘normal’ her voices started to become critical of and derogatory towards her. To cope with this Laura started to experiment with Illicit drugs and alcohol as this blocked out the voices for a short time. However, this also made Laura lose her inhibitions and she would participate in sexual acts with men in her local area. This fuelled the voices and they became much more negative. So to cope Laura would take more drugs. Eventually Laura would run out of money and so would shoplift and resorted to prostitution. Her life became very chaotic and at 16 her mother kicked her out. Laura was now sleeping in neighbours gardens, sheds, anywhere she could. Laura lost touch with all her family and friends, her physical health suffered and she ended up very underweight and her voices became worse. Eventually Laura was found by the police sleeping semi-clothed in a car park under the influence of drugs and alcohol. It was at this point she was admitted to an acute mental health unit.
From the case of Laura it can be seen how not even having a diagnosis of schizophrenia, but experiencing positive symptoms can result in stigma, social exclusion and have a huge impact on a person’s life. Laura’s case was exacerbated by the use of illicit substances and alcohol demonstrating how substance misuse can add greatly to the complexity of an individual.
Within the literature it can be seen that there are many factors that add to the complexity of a person with mental health needs including: medication resistant symptoms (Tarrier et al 1993), receiving care within secure forensic units (DOH 2005), psychological reactance (Moore, Sellwood, & Stirling 2000), poor social functioning (Cather 2005, Couture et al 2006), , learning disabilities (DOH 2001a), insight (David 1990 and Buckley et al 2001), physical health (Marder et al 2003) homelessness (Randall et al 2006), and dual diagnosis (DOH 2002). These complexities have been recognised by the government and national drivers have been produced to guide mental health professionals and services to enable delivery and provision of the best services. For example ‘The National Service Framework for Mental Health’ (1999a) outlines a number of interventions for several complex groups including some of those mentioned above.
Rankin & Regan (2004) discuss how the term complexity means that there is no generic complex needs case. This therefore suggests each individual has a unique interaction between their own health and social care needs, therefore, requiring personalised responses from mental health services. Adopting an approach that incorporates psychosocial interventions could help to achieve a personalised response and provide individualised, tailored care for the service user and their care givers.
The use of psychosocial interventions (PSI) is advocated in national drivers such as ‘Schizophrenia: Core intervention is the treatment and management of schizophrenia in adults in primary and secondary care’ (NICE 2009). This guidance recommends that all service users and their families are offered psychosocial interventions as a treatment of schizophrenia. Also, documents such as ‘From values to action: The chief nursing officers review of mental health nursing’ (DOH 2006) recommends the use of psychological therapies to improve outcomes for service users and ‘The mental health policy implementation guide’ (DOH 2001b) advocates the use of psychosocial interventions through a variety of service delivery modes. Demonstrating the emphasis that is placed upon such interventions in the treatment of serious mental illness.
Mairs and Bradshaw (2005 page 28) suggest PSI is –
“… a range of evidence-based interventions for people with psychosis and their care givers. The term is generally used to include both models of service delivery such as assertive outreach and specific interventions, for example Family Intervention and Cognitive Behavioural Therapy (CBT). PSI’s aim is to reduce stress experienced by an individual with psychosis or help him or her to cope with stress more effectively.”
As a result of adopting a PSI approach an individualised service is offered to the service user to help meet their needs utilising a variety of interventions and services with great emphasis being placed upon collaboration.
Psychosocial interventions assume a complex link between biological, environmental, and sociological factors which suggests that ambient stress, together with life events may trigger onset or relapse of, mental health in some people (Gamble & Curthoys 2004). A model which displays this link is the Stress Vulnerability Model by Zubin and Spring (1977 cited in Norman, & Ryrie 2004). This model helps explain the aetiology, course and outcome of mental illness, demonstrating how stress has different effects on individuals.
The Stress Vulnerability Model (See figure 2) suggests that some people are more vulnerable to stress than others and that when an individual’s stress threshold is passed they can become unwell i.e. experience positive symptoms. In terms of a complex case it could be proposed that an individual’s complexities cause stress in themselves and/or increase a person’s vulnerability to stress. An example of how ‘The Stress Vulnerability Model’ can be illustrated to enable it to be shared with a service user with complex needs, using an easy to understand analogy can be seen in Appendix 1. As previously mentioned the aim of PSI is to reduce stress or to help cope with stress better; therefore, it can be seen how the Stress Vulnerability Model plays a central role in providing psychosocial interventions.
Substance Misuse and Psychosis
Over 50% of people with a severe mental illness also use illicit drugs and/or alcohol at hazardous levels (Cleary et al 2009) and even low levels of substance misuse can have detrimental effects and cause serious complications (Barrowclough et al 2001). The combination of substance misuse and mental health problems (dual diagnosis) is associated with a range of social, behavioural, physical and psychological problems (see table 3) providing challenges for mental health services and adding to the complexity of an individual (Hussein 2002). In addition to this complexity ‘The national service framework of mental health’ (DOH 1999a) identifies patients whom misuse substances and have a diagnosis of serious mental illness as a population of greater risk of stigmatisation and exclusion from existing service provision. Demonstrating some of the factors that add to an individual’s complexity.
Complications posed by dual diagnosis (Cleary 2009, Drake & Mueser 2000, Clark 1996, Dixon, McNarey & Lehman 1995, Griffiths & Allen 2007 and Gibbins & Kipping 2006)
Increased risk of –
Poor compliance with treatment,
More inpatient stays – worsening psychiatric symptoms
HIV and Hepatitis,
Contact with criminal justice system
Prejudice and Stigma.
Negative impacts on –
Financial resources (of individual and/or family/friends)
Family Relationships i.e. increased burden, increased expressed emotion
Within literature the most commonly reported reason that people with serious mental illness use illicit drugs is to self medicate, for example, to relieve negative symptoms of schizophrenia (Littlejohn 2005). However, as Conley & Benishek (2003) report there is the additional complexity of trauma that has lead to the use of substances for various reasons including dissociation, and modelling from parents. They continue recommending that nurses working within the substance misuse field should be trained in picking up such information. If an approach adopting psychosocial interventions was utilised and therapies such a cognitive behavioural therapy were delivered then this historical information may be identified and dealt with appropriately. Therefore, leading to a different delivery of services compared to someone who uses substances to self medicate. However, the mental health professional must also bear in mind that service users also use substances for the same reasons as others (Littlejohn 2005).
Even though the NICE (2007) Guidelines, ‘Drug Misuse: Psychosocial Interventions’ recommends that CBT be offered to those with anxiety and depression who are stabilised with their drug use, but does not discuss its use with those with psychosis. There is growing literature examining the use of CBT for those with a dual diagnosis (Cleary et al 2009, Barrowclough et al 2001, Baker et al 2006, Weiss et al 2007 and Haddock et al 2003) although, as mentioned earlier the amount of literature in this area is limited. Also the CBT that is delivered to the participants within the studies has been adapted to suit the needs of those with dual diagnosis. This integrated treatment, namely C-BIT (Cognitive-Behavioural Integrated Treatment), has a number of components; Cognitive Behavioural Therapy, Motivational Interviewing and Family Interventions. C-BIT is not only about adapting psychosocial interventions to suit those with dual diagnosis but it is also about service provision and development (Thylstrup & Johansen 2009, Graham et al 2006, Graham et al 2003). Such interventions are used as part of an individualised treatment plan that incorporates the key principles of working with dual diagnosis (see table4).
Table 4 (Drake et al 1993 cited in Abou-Saleh 2004)
Principles of treatment of substance misuse in people with severe mental illness
Assertive outreach to facilitate engagement
• Close monitoring to provide structure and social reinforcement
• Integrated concurrent service
• Comprehensive, wide range of interventions
• Stable living situation
• Flexibility and specialisation (modified approaches)
• Stages of treatment: engagement, persuasion, active treatment and relapse prevention
• Longitudinal perspective for relapsing and chronic disorder
• Optimism – instilling hope in patients and carers
Motivational Interviewing (MI)
The aim of this intervention is to increase a person’s ability to recognise and do something about any problems they have (Gamble & Curthoys 2004) and that change would be desirable (Kipping 2004 and Miller & Rollnick 2002).
This approach conveys hope and is non-confrontational in it style (Kemp et al 1996) and is largely used within substance misuse services (DOH 1999b). This intervention is used alongside Prochaska & DiClemente (1986 Cited in Kipping 2004) Model of Change (see Figure 3) to provide a framework of which interventions should be used at which stage of change a service user is at. Motivational Interviewing is mainly used as a persuasion tool to move people from precontemplation/ contemplation to decision and active change. Four General principles are followed as outlined by Miller & Rollnick (2002); expressing empathy, developing discrepancy, rolling with resistance, and supporting self efficacy in order to facilitate this change. When a service user demonstrates that they have arrived at the decision or action stage of the cycle of change cognitive behavioural interventions are then commenced.
Cognitive Behavioural Therapy (CBT)
The aim of CBT is to lessen distress caused by negative feelings; it attempts to do this by changing the thoughts (cognitive) and beliefs that underpin them. It can also alter actions (behavioural) and circumstances that are affecting these thoughts and feelings (Nelson 2005). This approach has been written about for many years and has arguably evolved from the work of Aaron Beck, a psychiatrist whose work dates back to the 1950’s. There is a vast amount of literature examining the use of CBT with psychosis (Jones et al 2004). Generally the research and literature supporting the use of CBT for Those with serious mental illness often excludes people who misuse illicit drugs and/or alcohol for example Garety et al (2008), and Jackson et al (2008).
The topics covered within CBT sessions for those with dual diagnosis differs from that of someone who does not use substances. For example Baker et al (2006) outlines components of CBT sessions used within their trial. They include, presenting the model of problematic substance use and psychotic symptoms (Graham et al 2004), specific techniques for managing substance use, and identification of triggers and beliefs that could lead to substance use and increase psychotic symptoms. Finally a large component of CBT for dual diagnosis is around relapse prevention, identifying unhelpful thinking patterns and managing cravings.
Family Interventions (FI)
A relative of a person with a diagnosis of schizophrenia may experience negative consequences in many areas including: emotionally, socially, psychologically and economically, as they adjust to their new role as a care giver (Reader 2002). How the care giver attempts to cope with these consequences can have an effect on their relative. Research has shown that expressed emotion within families could lead to relapse in schizophrenia (Brown et al 1962, Kavanagh 1992). Often a person with dual diagnosis is only marginally engaged with services but may have regular contact with their families who provide financial and psychological support (Thylstrup & Johansen 2009). Putting them under immense strain; but also in prime position to work with mental health services to promote engagement and treatment adherence.
There is a vast evidence base to support FI for promoting recovery from psychosis (Pharoah et al 2006, Pilling et al 2002). The family dynamics of a person with a dual diagnosis is often impacted greatly due to the complexities discussed earlier and there is growing evidence to suggest how family involvement can have positive impacts on outcomes for both the service user and their families (Fischer et al 2008; Dixon, McNarey and Lehman 1995). Within integrated treatment Barrowclough et al (2001) use family interventions as a means of encouraging care givers to adopt motivational interviewing styles to improve motivation, and treatment adherence amongst other interventions. See Table 5 to illustrate how minimal family work in the form of psycho-education enhances the experience of service users and their care givers, even when staff have had no formal training.
Unfortunately, family relationships of those with dual diagnosis can often be put under vast amounts of strain that cause the family dynamics to breakdown. Leading to people losing contact with their friends and families. This therefore makes family interventions very difficult as often one or both parties (care giver(s) and service user) do not wish to accept family work. In addition to this there are service users who do not wish their care givers be informed of their illicit drug use as they are worried of the consequences this may bring, for example: negative appraisal due to the stigma surrounding substance misuse. From experience this can be overcome in some cases through normalisation and psycho-education. Providing a good rationale of why care givers should be informed and how doing this can help the situation. Although, this often takes a lot of guidance and motivational interviewing techniques.
Psycho-education with Laura and her Father.
Once Laura was admitted to the rehabilitation unit where she is currently residing her father got in touch. Laura was keen to build on the relationship between her and her father and started to visit him once a week. Staff at the unit (whom are not trained in family interventions) thought it would be a good idea to spend some time with Laura and her father to help them both gain an understanding of each others situation, thoughts, feelings and behaviours. After explaining the benefits of this to Laura she consented and her dad was offered to come and have a few informal sessions with Laura and her named nurse. Lauras dad explained how he had never been given any information about schizophrenia or substance misuse and how he knew very little of how these effected his daughter. This information was shared with both Laura and her dad. The stress vulnerability model was explained to Laura’s dad with a view to building on his understanding of why his daughter experiences psychotic symptoms and providing a reason why she uses drugs. Leading on to state how this only causes more problems (all of this was discussed with Laura at an earlier date). Lauras Dad was given the opportunity to voice any concerns he had about regaining contact with Laura i.e. financial drain, crime, and ‘picking up the peices’. These problems were discussed and brainstormed with both Laura and her dad to identify ways to prevent these happening, and produce a contingency plan if either person felt they needed support. Lauras Dad reported that these sessions made it easier for him to build on lost relationships with his daughter and reduced his fears that he would have to ‘deal with it all if things went wrong’. Laura also felt much more positive as now she was starting to rebuild relationships providing more motiviation to change and sustain change. Her mood improved slightly and she had more hope for the future. Arguably the benefits Laura experienced may have inevitably occurred without staff intervention.
A small number of studies examining interventions for use with people with dual diagnosis will now be appraised.Two of the Studies are Randomised Controlled Trials (RCT’s) and are considered the gold standard method for evaluating treatment efficiency (Greenhalgh 2006). They are said to produce the least biased results as random samples are used to minimise the possibility of error in design and conduct (Roberts, 1999).
Barrowclough et al (2001) and Haddock et al (2003)
Barrowclough et al (2001) produced one of the first robust RCT’s to examine the impact an integrated intervention programme consisting of CBT,MI and FI had upon service users. The design of the trail was robust in that it was a RCT, ensured as far as possible good treatment fidelity (making certain that the treatment being delivered is the one intended (Leeuw 2009)) and the assessors in the trial were blind to group allocation (reducing the risk of bias). However there were some limitations of this study such as small numbers of participants, short follow up period, and treatment was delivered by cognitive behavioural therapists. In reality it is not possible for all service users with dual diagnosis to receive interventions from a cognitive behavioural therapist. All of these limitations question the generalisibility of the results.
Although care givers were in receipt of interventions their outcomes were not reported in this study. It would have been interesting to see these results; even those whom were in the control group received more interventions than the majority of families of substance misusers get (based on experience). One could hypothesise that the results of the two groups were not too dissimilar due to the fact that both sets of care givers were being supported.
The Haddock et al (2003) study is a follow on from the Barrowclough et al (2001) study reporting further service user outcomes, cost effectiveness and carer outcomes over an 18month period. The robustness of the study was discussed above. This study found quite significant positive outcomes of those whom received the integrated intervention programme. Results demonstrated improved outcomes for the service users general and social functioning, and reduced number of negative symptoms to a significant degree. When examining this result with experience from practice it could be hypothesised that when a service users level of functioning increases they rely less upon their care givers. Thereupon improved functioning has a positive indirect effect upon carers. There was also a small difference in the percentage of days of abstinence between the two groups with the treatment group proving more favourable. However, the clinical significance of this is questionable. Although carer outcomes were reported within the Haddock et al (2001) paper they are only briefly examined with more of an emphasis based on cost effectiveness. However, the results do show promise for care givers within the treatment programme, showing some trends towards better personal outcomes. At the 12 month follow up the treatment group demonstrated a reduction in needs and objective and subjective burden. However, these results were not statistically clinically significant. Haddock et al (2003) suggest more intensive work should be done with families due to the high rates of expressed emotion.
Baker et al (2006)
Baker et al (2006) also produced a RCT to examine the impact a series of sessions of CBT and MI has upon service users with a dual diagnosis. This study was not as robust as the Barrowclough et al (2001) study in relation to randomisation and assessor blindness. Within this study participants were paid for their expenses and time attending assessments. Although the authors suggest this was not enough to influence responses, this procedure was not carried out in similar studies such as the one by Barrowclough and colleagues (Barrowclough et al 2001 and Haddock et al 2003) which should be considered when comparing results. Another negative to this study as with that of Barrowclough et al(2001) was that the interventions were carried out by highly trained psychologists; Echoing the argument of generalisability. On a positive note this study did have a larger number of participants almost double that of Barrowclough et al (2001). Baker et al (2006) suggest both this trial and the one carried out by Barrowclough and colleagues suggest improvements in substance misuse. However from the results these improvements appear minimal. Baker et al (2006) also report that there was no significant difference in improvement of functioning or positive symptoms; providing opposite and contrast results of the Barrowclough et al (2001) study.
Baker et al (2006) conclude that this study demonstrates that this challenging case group (service users with dual diagnosis) is able to engage in CBT and demonstrate positive results. Although this ‘excellent therapy-attendance’ could be questioned due to the use of payment for time and travel.
Graham et al 2006
This study carried out by Graham et al (2006) differs from those discussed above in that it is not a RCT, it is a preliminary evaluation of the impact of C-BIT training on 3 assertive outreach teams and service user outcomes and is not an RCT. Care co-ordinators from 5 assertive outreach teams were allocated to two groups. One of which received immediate C-BIT training and the other groups training was delayed. Results of the training demonstrated increased confidence of care co-ordinators in working with substance misuse and mental illness. Graham et al (2006) suggest these findings illustrate the effectiveness of such training and highlights the extent to which implementation actually occurs. They suggest their findings add evidence to the recommendations made for implementation of interventions for this client group presented in Mental Health Implementation Guide: Dual Diagnosis Good Practice (DOH 2002).
Graham et al (2006) also discuss the impact of such training upon service user outcomes. The results highlighted an improvement in engagement, reduction in alcohol use and a reduction in positive alcohol related beliefs. Demonstrating that this team approach to C-BIT shows promise. This report does not measure impact on care giver outcomes.
All of the reports mentioned here suggest further research is needed to establish a firm evidence base for integrated treatment programmes that use interventions such as CBT, MI and FI. Nonetheless, they do provide a good grounding for recommending that such interventions show promise for enhancing service user and carer experience. In order to do this there may need to be a change in service provision. For example for a change within treatment philosophy of a team may mean that all staff must be trained preferably at the same time (Graham 2004). This causes barriers on numerous levels such as cost implications of all staff receiving training, back fill of their hours, cost of trainer and venue etc.. Potential barriers may occur when implementing these newly acquired skills and knowledge due to feelings of diminished confidence as part of the learning process (Atherton 2008).
Substance misuse services separated for mental health services some time ago (Conley & Benishek 2003) and as a result mental health professionals have limited training and experience in working with people who misuse substances. In addition, many drug and alcohol workers have only had minimal education in mental health issues (Frankel 1996). This could result in mental health professionals and substance misuse workers feeling unequipped in working with people with a dual diagnosis; resulting in them receiving inadequate care. A way to overcome this is for more health professionals to acknowledge their deficits in knowledge and attend training.
Perhaps as a result of having minimal education in the field of substance misuse, negative attitudes towards those who misuse substances is still present (Howard & Chung 2000 and Richmond & Foster 2003). This can take the form of moralistic and stereotypical attitudes leading to mistrust, suspicion and avoidance on both sides. Evidence indicates that when such attitudes are held problems of substance misuse are often overlooked and not dealt with or referred on (Howard & Chung 2000).
Luke – Case Study
Luke was brought up in a deprived area of a large city and often experimented with illicit substances with his friends. He had a very poor relationship with his mother and siblings (although he did reside with them) and never saw his father. Luke started to hear voices at the age of 18 and was soon admitted to an acute unit where he commenced anti-psychotic medication. Luke was discharged from hospital back to his home. Luke’s motivation was draining and he was experiencing little enjoyment in life. it wasn’t long before he stopped taking his anti-psychotic medication because it was making him put on weight and causing side effects. L