Transcript Document

Fidelity to Manualized Psychotherapy:
Integration of Research Methods in Mental Health Clinical Training
Weronika Micula-Gondek MD, Jennifer Levin PhD, Martha Sajatovic MD
Department of Psychiatry, University Hospitals Case Medical Center, Cleveland, Ohio
Abstract
Introduction: Increase in manual based-psychotherapeutic interventions for patients with bipolar
disorder faces a challenge of integration of these interventions in psychiatry training. This is a
description of manualized psychotherapy training Customized Adherence Enhancement
(CAE) that was part of a research project and assessment of fidelity to the intervention for
trainees.
Methods: CAE has been manualized as a series of treatment modules including:
psychoeducation, modified motivational interviewing, patient training in communication
with providers, and medication routines. The learning process for trainees included: observation
of trained interventionist, videotaped practice with actors and observed intervention on pre-set
fidelity criteria. Trainees were required to meet a minimum of 80% of the pre-set criteria.
Results: Mental Health trainees included a Master’s degree psychology senior and a PGY-3
psychiatry resident. Both successfully completed the training in three months and met 80%
criteria. Trainees conducted 48 CAE sessions with sub-optimally adherent patients with bipolar
disorder. Average attendance per patient was 78.8% for trainees’ patients, similar to that of
clinical psychologist’s patients (88.8%).
Conclusions:
Standardized training in manualized psychotherapy is effective in quickly
learning and implementing a clinical research intervention. A well-designed and structured
training process facilitates integration of research methods and behavioral techniques in
psychiatry training.
Introduction
Recent years have seen an increase in manual based-psychotherapeutic interventions for
treatments of patients with bipolar disorder.
A challenge to the field is disseminating standardized psychotherapy methods, including
integration of these methods in psychiatry training and in clinical research.
This project is a description of manualized psychotherapy training and assessment of fidelity to
the intervention in psychiatry training based on Customized Adherence Enhancement CAE
study.
CAE is a manualized CBT-based psychotherapy, developed as a part of a larger research project.
It is intended to enhance treatment adherence among patients with bipolar disorder with suboptimal medication taking behavior.
This study is a pilot, prospective project of the effects of customized adherence enhancement
(CAE) when added to the medical management (usual care) of UH patients with Bipolar
Disorder.
The primary objective is to evaluate the change from baseline in treatment adherence based upon
composite Tablets Routine Questionnaire (TRQ), the Morisky Medication Scale, and of the pill
counts.
Secondary objectives are improvement in BPD symptoms, global psychopathology, overall
treatment attitudes and functional status.
Methods
CAE has been manualized as a series of the following four treatment modules:
1.
2.
3.
4.
Psychoeducation
Patient training in communication with care providers
Training in medication routines
Modified motivational interviewing to address substance abuse
Results
CAE
PSYCHOEDUCATION COMMUNICATION
WITH PROVIDER
1) Overview, symptoms,
phases of BAD
2) Chronicity, medication
management, stigma
3) Coping skills, goal
planning
MEDICATION
ROUTINES
1) Medication
1) Routine and
overview, side
schedule
effects, questions to
planning
ask
SUBSTANCE
MODULE
1) Substance use
history, negative
consequences,
motivation and
confidence
2) Behavioral
2) Barriers to
techniques, pill
communication, role box, alarm
2) Positive
playing
clocks, calendars
reinforcement
Mental health trainees included a psychology trainee during the last year of his Master’s degree
in clinical psychology and a 3rd year resident in psychiatry.
Both trainees successfully completed the standardized psychotherapy training process and met
the 80% of the pre-set criteria.
Psychiatry resident standardized training was completed in 3 months.
Trainees conducted 48 CAE sessions with sub-optimally adherent patients with bipolar disorder.
Average attendance per patient was 88.8% for clinical psychologist’s patients and 78.8% for
trainees’ patients.
Average attendance per patient
Clinical psychologist’s patients
88.8%
n = 65
Trainees' patients
78.8%
n = 13
Patients’ satisfaction data summary
4
Research patients participate in a series of four sessions conducted over a four week period
with the study interventionist who implements the module based intervention.
Each session lasts approximately 60 min.
The number of modules may differ depending on baseline adherence profile of the participant.
Intervention module selection is based upon participant’s responses on the AMSQ (Attitudes
toward mood stabilizer questionnaire) and the reasons for non-adherence on the ROMI
(Rating of Medication Influences).
3.5
CAE is useful
3
CAE covers all important
issues
CAE addresses issues
important to me
Benefit exceeds burden
2.5
2
1.5
1
0.5
0
PhD's pts (n=50)
A step-wise series of procedures for mental health trainees to learn standardized CAE
intervention included:
1) Observation of a trained interventionist conducting interviews
2) Videotaped practice with actors
3) Observation of intervention/evaluation on pre-set fidelity criteria
Trainees were required to meet a minimum of 80% of the pre-set criteria.
Trainees'pts (n=9)
Scale 0-4; 0= strongly disagree, 4= strongly agree
•
92% of clinical psychologist patients and 88.9% of trainee’s patients responded that the
number of sessions and the length of each session was just right.
• 94% of clinical psychologist patients and 88.9% of trainee’s patients thought that the timing
of each session was just right
Conclusions
CAE Training Criteria
1. Establishes and maintains constructive rapport with the participant
2. Administers the correct module in the corresponding session according to the Module
Integration Chart
3. Completes the session in 60 minutes +/- 10 minutes
4. Utilizes the treatment manual script as appropriate (rate on a scale of 0-10)
5. Completes worksheets according to the manual (0-10)
6. Identifies and addresses the main reasons for the individual's difficulties with adherence
as it relates to the module (0-10)
7. Allots sufficient time for and appropriately answers questions or describes concepts that
are unclear to the participant (0-10)
8. Sets up next follow-up time/visit, provides contact information, and reviews recommended
procedures for contacting staff in the event that future appointments need to be
rescheduled.
While there have been significant advances in CBT training techniques, dissemination of those
techniques remains problematic because of attitudes toward manualized interventions and labor
intensive training.
Our results suggest that standardized training in manualized psychotherapy that includes pre-set
fidelity criteria is quick and effective, with good patient buy-in.
Providing a well-designed and structured training process facilitates integration of research
methods as well as training in behavioral techniques in psychiatry residency training
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