Transcript Professor Carol Harvey

Dr Scott Clarke I'd like to move on now to introduce Professor Carol Harvey. Carol's Professor in the Department of Psychiatry at the University of Melbourne and works in Northwest Area Mental Health Services and she's the Director of the Psychosocial Research Centre there. She's a researcher in epidemiology and social psychiatry and mental health services generally and has a special interest in the psychosocial aspects of prevention, treatment and recovery from mental illness, including the involvement of families in treatment and care. She's got a number of current research projects which I hope she will speak to and the title of her talk is to give us a Perspective on the Australian view of Psychosocial Rehabilitation: the evidence and the realities. Over to you.

 

Professor Carol Harvey Good morning everyone and thank you for the opportunity to share some of the Australian perspectives on this from the research we've been conducting. So Darryl and Helen have set the scene quite nicely for me, The things I want to highlight are that we've known for a long long time that recovery occurs at different rates over different outcome domains, for example, symptoms social relationships and so on and that those domains of recovery are only very loosely interrelated so you might have recovery at on one domain and not another and the fact that you've got recovery and on one domain doesn't mean that it will follow in other domains.

 

So what that really is very nicely synergistic with our evolving understandings of recovery of course where we now think about personal recovery, clinical recovery, functional recovery and so on. What it really means for us as practitioners and service deliver as if is that each of these domains need specific attention.

 

I think some of Helen’s talk has already highlighted that that each of those areas of the r person’s life needs to be attended to in terms of rehabilitation. That's nice because in our own College guidelines there is also that awareness and that acknowledgement so from the guidelines specific to schizophrenia and related disorders and as Helen said, many of the people we're thinking about here do have schizophrenia diagnosis.

 

Comprehensive care with people living with schizophrenia requires an integration of biological and psychosocial interventions. Psychopharmacology with standard case management does not address all the domains of the illness especially cognitive deficits, social complications and functional impairment.

 

So, it's good that we've got that kind of foundation within the college guidelines from which to work and I want to highlight specifically some things that we know about psychosocial interventions that make them important within the overall field of rehabilitation.

 

So, we know that they can improve sub-optimal recovery so even when people are adequately treated with medication the addition of the psychosocial intervention will improve the recovery experienced by the person. Larry Davidson in commenting on the American Guidelines, the PORT Guidelines really said that the interventions in those guidelines with the most robust effect sizes are the best the strongest evidence for effect those that supported people in occupying normative adult roles. So in other words those psychosocial interventions have the strongest evidence in the PORT Guidelines and other related guidelines including our own and of course there's also the realization that they're more beneficial in the later stages of illness and as Helen said were often coming to work with people in a rehabilitation framework at those somewhat later stages of illness even though we want to get in earlier as well as Helen said.

 

The fact that psychosocial interventions can be very beneficial even later on is a useful appreciation. Okay so I am going to talk a little bit about the National Survey of Psychosis because that tells us most about the state of play here in Australia. Those are two of the key publications, one of which Helen’s already referred to but there are many others and I'm going to go into a little bit of detail about what we know about psychosocial intervention delivery in Australia and rehabilitation. So, a very very quick overview of the methodology of the National Survey of Psychosis for those that are not familiar with it so there were seven catchment sites in five states so two here in New South Wales. The coverage was adults so there was a separate child adolescent survey.

 

Adults aged 18 to 64. At the catchment sites that were included in the survey were equivalent to ten percent of the Australian adult population. The services that were involved in the identification of people who were interviewed for the survey of psychosis, the people living with psychosis, where our clinical public mental health services and NGOs funded to support people with mental illness.

 

So course you know we have different words across Australia for the non-governmental sector so this is mental health community support services in essence we call them in record them in Victoria the PDR SS sector and so on so it's those organizations that are government funded to support people with mental illness.

 

We screened, it was a standard two stage epidemiological design so we screened people for psychosis and almost 8,000 on that screening screened positive for psychosis of which a random sample was taken for an in-depth interview and that was almost 2,000 people across Australia living with psychosis who were interviewed in-depth.

 

Although the interview response rate was only 44% there were no systematic selection biases, so we think that it's a reasonably representative picture of the state of play in 2010 and by the way of course we desperately need another survey. And those of us who were investigators in conversation with the government at the moment to try and get a third national psychosis survey underway. So, one of the things I wanted to highlight was those people living with psychosis were asked about the top three challenges they expected to face in the next year and these are them.

 

And you can see that not only are there health related challenges physical and mental health but there are a number of psychosocial challenges and in fact the most endorse three are psychosocial challenges - lack of money, social isolation, lack of employment.

 

And I agree with Helen and broadly speaking about the Australian scene the you know rehabilitation doesn't appear strongly in policy here it's very very similar to the UK in that respect but we do at least have the Australian National Mental Health Commission talking about a contributing life and defining that and I draw your attention to the domains listed at the bottom: A good home, connections to family and friends, good health and well-being, activities that provide purpose and meaning, and being free from financial stress.

 

So, there's a lot of synergy between the perspectives of the National Mental Health Commission and the leadership they play in Australian mental health policy and what participants living with psychosis are saying about the challenges they face in their lives.

Okay so for a textbook chapter we actually took those challenges there in the red boxes and thought about well what evidence is there from psychosocial interventions that could address those challenges?

 

So, the psychosocial interventions that we looked at when we wrote this chapter about five years ago. The psychosocial interventions are in the blue circles around the six challenges and the arrows represent the strength of the evidence as best we could summarize it from clinical practice guidelines available and systematic reviews.

 

And I hope you can… and the broken arrows are emerging evidence rather than strong evidence and of course in five years that would have moved on so I think we can be hearing later about cognitive remediation training and a little more depth than there's much more evidence around that now for example and supported education there's still emerging evidence.

 

But in broadly speaking I think I hope you can see that from this psychosocial interventions can place a very important role in addressing some of those challenges identified by people living with psychosis and have an important role situated within the spectrum of interventions that belong to rehabilitation.

 

So for example if you look at family psycho-education, situated out on the left-hand side there, not only can it help people improve people's symptoms but it can… there's also good evidence that you can help people get a job and that it decreases their isolation or social isolation.

 

So, these interventions being important we wanted to look at them in the National Survey of Psychosis data so this is a 2018 article that I want to share some of the findings from with you today. So we knew there wasn't much international study of the availability of psychosocial interventions and we didn't have any systematic data for Australia so our research questions were: How available are psychosocial interventions in Australia and which characteristics (demographic, clinical and service provision) help predict whether a person living with psychosis receives one of the one or more of these interventions.

 

So, what we did was we gather together the clinical practice guidelines available in the English language and fairly recent at the time that we devised this study, so they came from America from Canada from the UK and our own College guidelines. We looked for psychosocial interventions recommended in at least some of these clinical practice guidelines and we devised non-technical readily understood descriptions of those interventions for our National Survey interview schedule.

 

So that people living with psychosis when they were interviewed were asked did you receive this thing, and this is what it looks like if you drop down to the second row and look at family psycho-education and run along to the second column. So, a participant would be asked. ‘Have you and your family met together regularly with a mental health clinician to learn about mental illness and improve your communication and problem-solving skills?’ Which is the distilled essence of what family psychoeducation in its various forms is and here's our basic data.

 

So, in this study we were able to and in the interview schedule we were able to include six well supported psychosocial interventions. If you look in the first two columns headed ‘Receipt of any level that gives you the raw data so what you can see there is at most two in five people report receipt of any of these interventions and the most commonly reported is relapse prevention planning. Then if you travel along to the third and fourth columns, we applied a very simple filter to the data.

 

So, we required people who have had these six sessions of those where that was applicable. Most of the more extensive, they’re 12 sessions ten sessions and the like and the evidence in the clinical practice guidelines also talks about that. You can see then that the figures drop somewhat so really what we're looking at there about 3% of people report something like family psychoeducation in its evidence-based form and one in five report relapse prevention planning.

 

The reason you see the drop between the 40 odd percent to 20 percent of relapse prevention planning is that most people don't have a written plan and the evidence base suggests that if you're going to have something effective in terms of relapse prevention, the person, the consumer and their family should receive a written plan after the discussion.

 

Okay so we also try to predict which of our participants in the survey received at least one of these evidence-based psychosocial interventions. So, we conducted a hierarchical logistic regression to try and predict receipt and we were able to get a statistically significant model so some value in this and some meaning.

 

There were seven variables the predicted receipt of these interventions but the headline and key message for today is that the strongest predictors were service provision characteristics not clinical factors and you'd kind of expect that clinical factors and features of the individual should be driving who receives these interventions.

 

For this audience I might highlight that the strongest predictor was being assigned a psychologist as a case manager so certainly as Helen said psychologists are an important part of the mix. Accessing an NGO was fairly similar, so the mental health community support services seem to be doing their job in providing rehabilitation and recovery informed services.

 

Patients with medical registrar's as case managers were less likely to receive one of these interventions and we could perhaps discuss that we have some hypotheses about why that might be. Maybe in Q&A we can touch upon these. But these are all service provision characteristics they're not about the individual person and the individual consumer.

 

So, our key findings from this inquiry: Australians living with psychosis report limited receipt of evidence-based psychosocial interventions over the course of a year. Fewer than half received each intervention but fewer than one-fifth received anything resembling an evidence-based level.

 

What we concluded from our modelling, our regression model was not only do we need staff to be better informed and better trained in these psychosocial interventions, that's a prerequisite but effective treatment currently is not being offered to patients who might most benefit.

 

So, it rather suggested to us that systems of care should also be the target of reform we can't just expect to go out and train staff and everything's going to be hunky-dory. If we don't have systems of care that are needs-based and evidence-based in their own right, then the effective evidence-based intervention is not going to reach the people who really can benefit.

 

Okay and of course we therefore have a gap between evidence and practice and it's not only of course in rehabilitation specifically but it's across mental health and across health dare I say. Now this is a whole lot of talk, but I've put together one slide about what is some of the things we might need to think about in terms of bridging that evidence practice gap.

 

There's a whole literature there many of us have been trying to bridge that gap and I've got a lot of learnings from real-world practice. So, the first thing to say is think at all levels. You can't just think about the staff or the team. All levels of the system need to be addressed in order to bridge evidence practice gaps.

 

So, I was spoken about knowledge and skills of staff but as Helen emphasized, attitudes are also important, the therapeutic optimism and in the sphere of rehabilitation and elsewhere. There's a lot of literature that suggests that having training for managers and team leaders is also important it’s tailor training it's not the same as the three day training staff may receive.

 

But if managers and team leaders aren't on board with what is required, they're not going to be able support the implementation and sustainability of evidence-based practice. In terms of the trained staff things like supervision, the opportunity to co-work with others, having dedicated time for the practice and communities of practice seem to be good bets in terms of changing the system of practice and the system of care.

 

And I think there's emerging evidence that peer workers can play a really strong role here in advocating and supporting for change but also, we've done some local work around family psycho-education. Here workers can be involved in the training programs they can also be involved in Co-delivery of some of the psychosocial interventions, so we shouldn't forget that.

 

In terms of systems of care we have tried to transform a whole service by training all staff in a particular psychosocial intervention because of a larger systems factors that seems to be not the most efficient and now myself and colleagues who've been involved in this work advocating more for sub teams of staff being trained in a particular intervention.

 

It's more efficient and you can target the support to that sub–team. You don't want us to totally separate team though because that runs the risks of marginalizing the practice. You need to consider suitable delivery vehicles and I'll speak for just a few moments about that shortly and the systems of care need to have incentives built in so position descriptions have to be redesigned, KPI's have to be developed to make sure the practice is happening and monitoring of those KPI's needs assessments need to be built-in as you saw because we're not addressing the identified needs of people living with psychosis. In terms of the intervention itself you can't expect to introduce evidence-based interventions without having some basic practices right so what we found in trying to introduce family psycho-education was the one that wasn't enough basic family involvement or even we didn't have proper information about carer’s telephone number for example.

 

If you don't have those things in place you can't expect to leap to an evidence-based practice. And the other very interesting area is an emerging area is thinking about either practice elements so that's the Chorpita and colleagues work. Which is breaking down the psychosocial interventions into elements of practice which are in common across a number so an example might be problem-solving is in common across a number of psychosocial interventions: teach that sub-skill and deliver that to people and build from that.

 

It's a more teachable element and the other type of approach, Tonia Lecomte and colleagues is talking about is merging evidence-based practices so there's… we'll probably hear more about this later, but there's examples such as cognitive remediation training within a supported employment or IPS program.

 

And there’s studies coming out about how cognitive remediation training can add value to a supported employment program and that's of course of high relevance to rehabilitation consumers because of the multiple difficulties they face that Helen’s already outlined.

 

So that's a very quick Cook's Tour of bridging the evidence practice gap - another talk, another time. So, what do I mean my delivery vehicle well by delivery vehicle I mean an appropriate model of care to deliver the parcels in this visual but when we talk about parcels we of course mean evidence-based practice rehabilitation and psychosocial interventions.

 

So briefly we did an evidence check review for your New South Wales Ministry of Health a few years ago. Our question was what can be identified from the national and international literature regarding optimal models of care both hospital based and community based care for people with severe and enduring mental illness. So, our target group of people who need rehabilitation. This is just a table from that evidence check review which I'm sure you can find on the Ministry of Health website.

 

What I want to briefly draw your attention to is two vehicles that are well supported in the evidence, especially assertive community treatment of course also called mobile support teams or mobile intensive support teams, different terminology across Australia, as a vehicle for delivery of psychosocial interventions and rehabilitation practice and as Helen might talk to you later, many of them assertive community treatment teams that were in existence in the UK have been disbanded or rebranded into community rehabilitation teams perhaps making this point in a different way that assertive outreach approach to people in their own homes can be a tremendously good vehicle for offering these other interventions that people require and similarly with the housing first or supported housing approach which is in this an outreach approach to people living in their own homes which Helen's also talked about supported housing, housing first, floating outreach, these are all terms that encompass different aspects of that model.

 

Okay so what else can we learn from the National Survey of Psychosis about rehabilitation and recovery informed service provision. So, this is a very very brief summary of 2016 article in which we aimed to describe people living with psychosis that were in receipt of public clinical community mental health services.

 

Those with there's NGO or mental health community support services and those without because we hypothesized the people we're most interested in working with are the people living with complex psychosis would be receiving both sets of services by rights that MH mental health community support services are targeted to people who need rehabilitation. And that these people would report that they were receiving rehabilitation recovery focused interventions. If they were receiving both services more often than those purely receiving clinical services.

 

So, in brief we were able to develop a statistically significant model to project people who were in both these groups. The group receiving only clinical services and then the group receiving clinical and NGO services. Now importantly the model could be improved by the entry of functioning a disability variable, suggesting that people who were receiving both sets of services were actually being targeted or because of their functioning and disability status so that's encouraging because functioning is so much a part of people's problems and difficulties that need to be addressed in terms of rehabilitation service delivery.

 

So, the people who were in receiving both sets of services were significantly more likely to be never married, living with greater disability, living in group accommodation and to report experiences of childhood trauma. Again, suggesting they have many of the characteristics of the complex psychosis group that Helen described.

 

They were significantly more likely to report receipt of rehabilitation and recovery focused services. So not only supported employment and those evidence-based psychosocial interventions but other rehabilitation interventions might help to look after yourself and your home.

 

ADL's interventions that come from that are led by OTs, financial and housing assistance that can be crucial for people living day to day with complex psychosis and they were more likely to have participated in some form of rehabilitation or day therapy program so that all that was terribly encouraging in terms of the mental health community support sector doing its job in enhancing what we offer in clinical but there's a caveat here because when we looked at the individual indicators of disability and functioning and complexity.

 

We found that many people who are only receiving clinical services, the right-hand column. Many people in that group had significant disability so if you run along the bottom row significant extreme disability our target group for sure 28% were receiving both sets of services but 23% of people in public clinical services also rated as having significant extreme disability so our day to day experience in clinical services we're seeing these people and they're not necessarily in 2010 getting NGO MHCSS type interventions.

 

So that's very very important and of course now as Helen said we're in NDIS land so I'm going to finish up with a few comments about NDIS.  Could and does the NDIS help us to bridge this evidence practice gap or not. First to summarize: There was evidence there was a complex group of people living with psychosocial disability who were receiving both clinical and NGO services but many people living with severe psychosocial disability didn't access NGOs in 2010. And if you think about the data I've already presented about evidence-based interventions and rehab and recovery focused intervention, their needs may not be well addressed in solely clinical service provision.

 

So, what about the NDIS? Well we know it offers choice and increased control and it is designed to help people get the support they need so their skills and independence improve over time. So, it is concerned with functional recovery and it overlaps with the rehabilitation approach, but psychosocial rehabilitation is not equivalent to psychosocial support.

 

Rehabilitation includes some supports which are funded under the NDIS and also various treatments and interventions which are not within the NDIS, so that's a challenge and further challenges: many NGO programs and services in being required to align with the NDIS as part of their provision of support have dropped the treatment programs they had, so for example we in my service in Victoria were running through an NGO a family psycho-education program which is no longer in existence because of the NDIS.

 

So, but the NDIS assumes these rehabilitation treatments are already available in Australia but that's contrary to the evidence I've shown you. There are challenges associated with choice of course. We understand that few consumers so far have chosen supports to get a job in the NDIS despite good evidence for supported employment.

 

And ultimately, we know the big question is how much funding will there be, how many people will be supported? There is promise, there's improved planning supports including training for planners which might help. There's a psychosocial disability service stream coming in, there's there will be an item for a recovery coach which could be very helpful and the NDIA are very aware of the need for an assertive outreach to help some of the people who are most disadvantaged to link in with the NDIS and help them link on if they're to other services if they're ineligible.

 

So, what else can we do to advocate for change? Well I want to finish in talking briefly about the World Association for Psychosocial Rehabilitation mentioned earlier by both Daryl and Helen. So, there's… this is an international NGO comprised of interdisciplinary mental health professionals and people with lived experience.

 

The mission of WAPR is to disseminate the principles and practices of psychosocial rehab and recovery so it's very much in our domain of interest today and we've recently re-invigorated the Australian branch and what we're focusing on is raising awareness, advocating for rehabilitations, psychosocial rehabilitation and recovery and training efforts so that's where we will almost certainly be collaborating through the section in the college in terms of what training can we get up and get accredited. And here's some of the questions we think are very important for the Australian branch which hopefully encapsulates some of the things I've already said. How can psychosocial rehabilitation including clinical interventions and treatments be strengthened and extended within state-run mental health services to better meet the rehabilitation needs of those Australians with psychosocial disability who are not engaged in community managed programs or the NDIS?

 

So how can we assist our state-run services and work with our state run services to improve rehabilitation provision. Regardless of whether those people we're working with access to the NDIS or the community managed sector.

 

How and where will the rehabilitation needs of those Australians living with disability are not covered by the NDIS been met? Many of us worry about that. That the NDIS is not going to reach everyone who could really benefit and how can we in Australia develop a hold of system approach?

 

You know that we know there's endless reference to the fragmentation of our system. So how in this sphere of rehabilitation and recovery can we develop whole of system approach? And I will finish there.

 

Applause